Cardiovascular Testing Considerations

Electrocardiography/Telemetry

See Penn QTc Monitoring Pathway

Indications

Recommendations

  • Obtain baseline electrocardiogram in all patients diagnosed with COVID-19 >50 years old, with history of cardiac disease, or on any QT prolonging drug
  • Repeat electrocardiogram if new concern for cardiovascular complication
  • Consider utilization of telemetry to minimize need for serial/frequent electrocardiograms which require significant close bedside contact

Echocardiography

Indications

Echocardiography may be employed to evaluate COVID-19-associated cardiovascular complications, including Acute Cardiac Injury, Acute Coronary Syndrome, Arrhythmia, Myo/Pericarditis, cardiac injury related to Cytokine Release, or Cardiomyopathy/Heart Failure/Cardiogenic Shock, or non-COVID-19 associated acute/chronic manifestations of cardiovascular disease.

Special Considerations

  • To limit potential exposure of sonographers and providers, limited echocardiograms are preferred, and when possible point-of-care ultrasound (POCUS) should be considered for initial evaluation.
  • Transesophageal echocardiography in particular is a potentially aerosolizing procedure, exposing staff to a high level of risk. When possible, alternative lower-risk modalities can be considered (eg. cardiac CT for evaluation of left atrial appendage thrombus).
  • At UPHS, the intensive care units are equipped with in-room video cameras, enabling sonographers and cardiologists to guide point-of-care echocardiogram image acquisition and interpretation in real-time. See sample workflow below:

Sample Workflow

Cardiac Biomarkers

Cardiac biomarkers in general refer to troponin, however in specific clinical circumstances may include measurement of creatine kinase and subfractions and/or BNP/NT-proBNP (eg. evaluation of Cardiomyopathy/Heart Failure/Cardiogenic Shock).

Indications

Recommendations

Coagulation Biomarkers

Typically includes CBC with differential, PT/INR, aPTT, D-dimer, fibrinogen; consider blood smear

Indications

  • Evaluate COVID-19-associated Thromboembolic Disease/Coagulopathy
  • Provide prognostic information about COVID-19 progression and survival (see Thromboembolic Disease/Coagulopathy)
  • Evaluate non-COVID-19-associated thromboembolic/hematologic disease (eg. deep venous thrombosis, pulmonary embolism, coagulopathy, disseminated intravascular coagulation, hemolysis)

Recommendations

  • Consider baseline D-dimer, PT/INR, aPTT, fibrinogen for initial risk stratification
    • Consider serial evaluation every 2-3 days in hospitalized patients for prognostic purposes
  • Repeat testing if concern for new complication

Inflammatory Biomarkers

May include ferritin, non-cardiac CRP, ESR, LDH; under specific circumstances molecular testing of inflammatory cytokine levels may be indicated (if available)

Indications

  • Evaluate COVID-19-associated Cytokine Release
  • Provide prognostic information about disease progression and survival
  • May provide information about eligibility for clinical trials

Recommendations

  • Consider baseline ferritin, non-cardiac CRP, ESR, LDH for risk stratification
    • Consider serial evaluation every 2-3 days in hospitalized patients for prognostic purposes
  • Consider molecular testing of inflammatory cytokines/markers (eg. IL-6), natural killer cell activity, soluble IL-2 receptor) in discussion with hematology if concerned for Cytokine Release

Deferral of Non-urgent Testing/Procedures

This section provides guidance from the ACC regarding non-urgent cardiovascular testing and procedures that may be deferred, by specialty.

Stress Testing and Imaging

  • Stress testing (ECG alone or with imaging [echocardiography, radionuclide, MRI]) for suspected stable ischemic heart disease (outpatient and inpatient)
  • Cardiopulmonary exercise testing for functional assessment (outpatient and inpatient)
  • Transthoracic echocardiograms (outpatient)
  • Transesophageal echocardiograms in stable patients (outpatient and inpatient)
  • Cardiovascular computed tomography (CT) (outpatient)
  • Cardiovascular magnetic resonance imaging (MRI) (outpatient)
  • Nuclear cardiac imaging (SPECT and PET) (outpatient and inpatient)
  • Vascular imaging for asymptomatic carotid artery disease (outpatient and inpatient)
  • Vascular imaging for claudication (outpatient and inpatient)
  • Imaging for screening purposes (e.g., coronary calcium score, screening ultrasound to assess for an AAA) (outpatient and inpatient)

Electrophysiology

  • In-person cardiovascular implantable electronic device (CIED) checks/interrogations (outpatient) and absent new cardiovascular symptoms (inpatient)
  • Cardioversions in stable, asymptomatic patients (outpatient and inpatient)
  • Tilt table test (outpatient and inpatient)
  • Implantable loop recorder (ILR) implant absent cryptogenic stroke (outpatient and inpatient)
  • Pacemaker implant for stable sinus node dysfunction or second-degree AV block without syncope (outpatient and inpatient)
  • ICD placement for primary prevention in stable, low-risk patients (outpatient)
  • Upgrade to cardiac resynchronization therapy (CRT) in stable patients (outpatient and inpatient)
  • Atrial fibrillation ablation in stable patients (e.g., without refractory heart failure) (outpatient and inpatient)
  • Atrial flutter ablation in stable patients (e.g., without refractory heart failure) (outpatient and inpatient)
  • SVT ablation in stable patients (outpatient and inpatient)
  • PVC ablation in stable patients (outpatient and inpatient)
  • Left atrial appendage closure/occlusion (e.g., Watchman) (outpatient and inpatient)
  • Lead extraction unrelated to infection or symptomatic lead failure (outpatient and inpatient)

Heart Failure/Transplant

  • Cardiopulmonary exercise testing for functional assessment (outpatient and inpatient)
  • Right heart catheterization (outpatient)
  • Surveillance right heart catheterization and cardiac biopsy post cardiac transplant (outpatient)
  • Surveillance coronary angiography post cardiac transplant (outpatient)
  • Hemodynamic monitor implant (e.g. CardioMEMS) (outpatient and inpatient)

Interventional Cardiology

  • Coronary angiography ± intervention for stable ischemic heart disease (outpatient and inpatient)
  • Coronary angiography ± intervention for non-cardiac preoperative evaluation (outpatient and inpatient)
  • Chronic total occlusion (CTO) intervention (outpatient and inpatient)
  • Coronary brachytherapy (outpatient and inpatient)
  • Surveillance coronary angiography post cardiac transplant (outpatient)
  • Right heart catheterization (outpatient)
  • Pulmonary angiography (outpatient)
  • Balloon pulmonary angioplasty for CTEPH (outpatient and inpatient)
  • Renal angiography ± intervention (outpatient and inpatient)

Structural Heart Disease

  • PFO/ASD closure (outpatient and inpatient)
  • Transcatheter aortic valve replacement (TAVR) in asymptomatic patients (outpatient and inpatient)
  • Percutaneous mitral valve repair (e.g., MitraClip) or replacement (e.g., valve-in-valve) (outpatient)
  • Left atrial appendage closure/occlusion (e.g., Watchman) (outpatient and inpatient)

Cardiac Surgery

  • Coronary artery bypass graft (CABG) surgery for stable ischemic heart disease (outpatient and inpatient)
  • Valve repair/replacement in asymptomatic patients (outpatient and inpatient)
  • Repair of asymptomatic ascending aortic aneurysm (<5.5 cm) among those without additional risk factors (e.g., family history) (outpatient and inpatient)
  • Surgical treatment of atrial fibrillation (including convergent procedure) (outpatient)

Vascular

  • Upper extremity angiography ± intervention (outpatient and inpatient)
  • Lower extremity angiography ± intervention for claudication (outpatient and inpatient)
  • Lower extremity surgical revascularization for claudication (outpatient and inpatient)
  • Lower extremity angiography ± intervention for non-healing wounds (without impending limb/tissue loss) (outpatient and inpatient)
  • Lower extremity surgical revascularization for non-healing wounds (without impending limb/tissue loss) (outpatient and inpatient)
  • Carotid angiography ± intervention in asymptomatic patients (outpatient and inpatient)
  • Transcarotid artery revascularization (TCAR) or other surgical revascularization in asymptomatic patients (outpatient and inpatient)
  • Renal angiography ± intervention (outpatient and inpatient)
  • Creation of dialysis access (AV fistula) (outpatient)
  • Repair of asymptomatic ascending aortic aneurysm (<5.5 cm) among those without additional risk factors (e.g., family history) (outpatient and inpatient)
  • Endovascular or open treatment of an unruptured abdominal aortic aneurysm (AAA) ≤5.5 cm (outpatient and inpatient)
  • Endovascular or open treatment of an unruptured thoracic aortic aneurysm (AAA) ≤5.5 cm (outpatient and inpatient)
  • Venous ablation (outpatient and inpatient)
  • Venous stenting (outpatient and inpatient)

Rehabilitation

  • Cardiac rehabilitation, phase 1 (inpatient) and 2/3 (outpatient)
  • Pulmonary rehabilitation (outpatient)
  • Vascular rehabilitation (outpatient)