Dr Karl-Friedrich Kreitner, Professor of Radiology at the Department of Diagnostic and Interventional Radiology of Johannes-Gutenberg University in Mainz, Germany, will focus on the prevalence of pulmonary embolism in COVID-19 patients, discuss the hypotheses which can explain cardiac involvement in the course of the disease, and help delegates understand imaging findings of cardiovascular complications. The “Non-pulmonary aspects of COVID-19” session on July 16 will aim to provide an overview of pathology research on COVID-19 disease, describe the many clinical manifestations of the infection and introduce the concept of multi-organ involvement. Alongside Dr Kreitner’s presentation on cardiac issues, other contributors will look at neurologic manifestations, and the disease in paediatric patients.
Speaking to Healthcare in Europe ahead of his presentation, Dr Kreitner stressed that while the virus uses the ACE-2 receptor predominantly located in the lung tissue for getting into humans, the receptor is also present elsewhere in the body. “It is also in up to 10% of myocardial cells and in endothelial cells of arteries and veins,” he said. “If you are aware of this then you come to the conclusion that the infection is not exclusively localised in the lungs, but can affect other organs as well, including the heart and pulmonary vasculature.”
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Among hospitalised patients who ultimately die of the disease, he said evidence shows that not all are dying from the destruction of lung tissue but of other causes too, notably pulmonary. He pointed to lab data that can help clinicians assess the risk of COVID-19 patients sustaining thromboembolic disease, in particular checking the D-dimer or fibrin degradation products (FDP) as markedly-elevated D-Dimer and FDP are common in non-survivors of COVID-19.
Recommendations suggest that patients with a D-dimer level below 1 have a lower risk of thromboembolism than those presenting with a level over 1. He said: “In these newer recommendations there is some risk stratification; that with a D-dimer between 1 and 2 you should think of controlling this value and do pulmonary embolism imaging in the further course of the disease. If presenting with values above 2, you should immediately test to see whether patient suffers from pulmonary embolism or not. Generally, if values are below 1, you can treat these patients with a prophylactic dose of low molecular weight heparin and where the value is above 2, you should consider a therapeutic dose of low molecular weight heparin.”
One presented with a typical viral myocarditis and the second with dilated cardiomyopathy like appearance with signs of inflammation, so the phenotypes of cardiac involvement have a great diversityKarl-Friedrich Kreitner
He said the challenge is weighing up lowering the risk of thromboembolism with the increased risk of haemorrhage and that it was very important to look at these values when the patient is admitted to hospital. He continued: “With cardiac involvement, COVID-19 patients suffering from a cardiovascular disease have a much higher risk of dying from the condition. This is perhaps because their cardiovascular system is not fit enough to face the challenges of this SARS-CoV-2 infection.” In these cases, clinicians should turn to cardiac biomarkers, especially high-sensitivity troponin and the NT-pro BNP, as when they are elevated the individual is at a greater risk.
While much of the evidence of this has come from China, Italy and the United States, Dr Kreitner will discuss two patients from his department presenting with different forms of COVID-19 myocarditis. “One presented with a typical viral myocarditis and the second with dilated cardiomyopathy like appearance with signs of inflammation, so the phenotypes of cardiac involvement have a great diversity.”
He will also discuss a study conducted in the Institute of Legal Medicine in Hamburg following autopsies on the first 80 patients that died from COVID-19 in the city, where it was found that 40% had thromboembolisms. Dr Kreitner said in the cases of suspected thromboembolism, timely imaging should be initiated.
In summing up the key take home message from his presentation, he said: “The main points are that cardiovascular involvement has a significant impact on prognosis for in-patients and it is absolutely necessary to control for D-dimer, fibrin degradation products, hi-sensitivity troponin and the NT-pro BNP during admission and the course of the hospital stay. This is especially for D-dimer and FDP; when they are elevated an anti-coagulative therapy should be considered and the amount – or whether it is a prophylactic or therapeutic dose – depends on the D-dimer value.”
Dr Karl-Friedrich Kreitner is Professor of Radiology at the Department of Diagnostic and Interventional Radiology of Johannes-Gutenberg University in Mainz, Germany. He has published more than 200 articles in peer reviewed journals and 29 contributions to books. He is co-editor of the books Cardiac Imaging: A Multimodality Approach and Radiological Differential Diagnosis and Great Vessels.