4 Managing myocardial injury in patients with suspected or confirmed COVID-19

4 Managing myocardial injury in patients with suspected or confirmed COVID-19

4.1 For all patients with a suspected or confirmed acute myocardial injury:

  • monitor in a setting where cardiac or respiratory deterioration can be rapidly identified

  • perform continuous ECG monitoring

  • monitor blood pressure, heart rate and fluid balance.

4.2 For patients with a clear diagnosis of a myocardial injury:

  • seek specialist cardiology advice on treatment, further tests and imaging

  • follow local treatment protocols.

4.3 For patients with a high clinical suspicion of myocardial injury, but without a clear diagnosis:

  • repeat high sensitivity troponin (hs-cTnI or hs-cTnT) and ECG daily, as dynamic change may help to monitor the course of the illness and establish a clear diagnosis

  • seek specialist cardiology advice on further investigations such as transthoracic echocardiography and their frequency.

4.4 Discuss the risks, benefits and possible likely outcomes of different treatment options with patients, families and carers using decision support tools (where available) so that they can make informed decisions about their treatment wherever possible.

4.5 Be aware that treatments that may be used in COVID-19, such as azithromycin and hydroxychloroquine, may prolong the QTc interval and lead to arrhythmia.
At the time of publication (22 April 2020), azithromycin and hydroxychloroquine can only be used to treat COVID-19 as part of nationally approved randomised controlled trials.

4.6 Start all critical care treatment with a clear plan of how the treatment will address the diagnosis and lead to agreed treatment goals (outcomes). For recommendations on critical care treatment, see the NICE COVID-19 rapid guideline: critical care in adults.

4.7 Review critical care treatment regularly and when the patient's clinical condition changes (see recommendations 4.1 and 4.2). Include in the review an assessment of whether the goals of treatment are clinically realistic.
For support with decision making, see ethical guidance from the British Medical Association, the Royal College of Physicians and the General Medical Council.

4.8 Stop critical care treatment when it is no longer considered able to achieve the desired overall goals (outcomes). Record the decision and the discussion with family and carers, the patient (if possible) or an independent mental capacity advocate (if appropriate).