A clinical bulletin released by the America College of Cardiology (ACC) addresses the cardiac implications of the novel Wuhan coronavirus (COVID-19). Additionally, the bulletin provides background on the epidemic, which was first reported in late December 2019, and examines early cardiac implications from case reports. COVID-19 is a betacoronavirus, like severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) that presents as viral pneumonia. The ACC states that COVID-19 originated in Wuhan, China, and healthcare experts believe that COVID-19 may possess a greater infectivity capability compared with SARS and MERS, and may have a lower fatality rate. The clinical bulletin also emphasizes that 99% of all cases are in mainland China, where, despite aggressive containment attempts, case counts continue to soar swiftly. 

According to Mohammad Madjid, MD, MS, FACC, FSCAI, assistant professor of cardiovascular medicine at McGovern Medical School at The University of Texas Health Science Center at Houston and an expert advisor of the ACC clinical bulletin, “In geographies with active 2019-nCoV transmission (mainly China), it is reasonable to advise patients with underlying cardiovascular disease of the potential increased risk and to encourage additional, reasonable precautions.” The bulletin states that COVID-19 is a rapidly moving epidemic with an uncertain clinical profile, and providers should be prepared for guidance to change as more information becomes accessible. The ACC plans to update the bulletin as needed.

The bulletin was reviewed and approved by the college’s Science and Quality Oversight Committee. “This bulletin provides background on the epidemic, which was first reported in late December 2019, and looks at early cardiac implications from case reports,” the ACC notes in a press release. “It also provides information on the potential cardiac implications from analog viral respiratory pandemics and offers early clinical guidance given current COVID-19 uncertainty.”

Additionally, the bulletin examines some early cardiac implications of the infection. For example, early case reports indicate that patients with underlying conditions are at greater risk of complications or mortality from the virus, with up to 50% of hospitalized patients having a chronic medical illness. Other findings in the clinical bulletin include the following:

• Nearly 40% of hospitalized patients confirmed to have the virus have cardiovascular disease (CVD) or cerebrovascular disease.
• In a recent case report on 138 hospitalized COVID-19 patients, 19.6% developed acute respiratory distress syndrome, 16.7% developed arrhythmia, 8.7% developed shock, 7.2% developed acute cardiac injury, and 3.6% developed acute kidney injury. 
• Rates of complication were found to be universally higher in ICU patients.
• The first reported death was a 61-year-old male with a long history of smoking who succumbed to acute respiratory distress, heart failure, and cardiac arrest.
• Early, unpublished first-hand reports imply that at least some patients develop myocarditis.
The clinical bulletin also provides the following clinical guidance related to COVID-19:  
• COVID-19 is transmitted via droplets and can live for considerable periods outside the body; containment and prevention using standard public-health and personal strategies for preventing the spread of communicable disease continues to be the priority.
• In geographic areas with active COVID-19 transmission (primarily China), it is reasonable to advise patients with underlying CVD of the potential expanded risk and to encourage additional, reasonable precautions.
• Older adults are less likely to present with fever; therefore, close evaluation for other symptoms, such as cough or shortness of breath, is warranted.
• Some experts have recommended that the rigorous use of guideline-directed, plaque-stabilizing agents (statins, beta blockers, ACE inhibitors, acetylsalicylic acid) could offer added protection to CVD patients during an extensive outbreak; however, such therapies should be tailored to individual patients.
• It is vital for patients with CVD to remain up-to-date with vaccinations, including the pneumococcal vaccine, given the augmented risk of secondary bacterial infection; it would also be judicious to receive influenza vaccination to avert another source of fever, which initially could be confused with coronavirus infection.
• For CVD patients in locations without widespread COVID-19, emphasis should remain on the threat from influenza, the importance of vaccination and frequent hand-washing, and continued adherence to all guideline-directed therapy for underlying chronic conditions.

The clinical bulletin states that due to the ongoing outbreak of COVID-19, as healthcare providers concentrate on this virus, there is a possibility that the hallmark symptoms and presentation of acute myocardial infarction may be missed and result in underdiagnosis. In addition, the ACC has reached out to its partners and colleagues in China, expressing support as they work to address the mounting epidemic.

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