تشخیص و درمان ایسکمی حاد میوکارد در بیماران مبتلا به COVID-19

نوع مقاله : مقاله مروری

نویسندگان

1 استاد، گروه قلب، دانشکده‌ی پزشکی، دانشگاه علوم پزشکی اصفهان، اصفهان، ایران

2 بخش همودیالیز، بیمارستان نور و حضرت علی اصغر (ع)، دانشگاه علوم پزشکی اصفهان، اصفهان، ایران

چکیده

در عفونت COVID-19، ایسکمی حاد میوکارد می‌تواند به دو صورت انفارکتوس حاد میوکارد (Acute myocardial infarction یا AMI) نوع 1 و 2 رخ دهد. در AMI نوع 1، عفونت می‌تواند سبب التهاب گردد و التهاب موجب ترشح و افزایش سیتوکین‌هایی مانند اینترلوکین (Interleukin یا IL) 1، 6 و 8 و نیز Tumor necrosis factor (TNF) در جریان گردش خون می‌شود. این مکانیسم منجر به ترشح کلاژناز از ماکروفاژهای فعال می‌شود و مجموع این واکنش‌ها، پیش‌درامد پارگی پلاک، افزایش انعقادپذیری و تشکیل ترومبوز است. این مکانیسم بر روی پلاک آترواسکلروز، ایجاد AMI نوع 1 می‌کند. در این بیماران، Primary Percutaneous Coronary Intervention (PPCI) (بر خلاف نظریه‌ی اولیه که لیتیک‌تراپی را درمان اصلی پیشنهاد کرده بود) روش اتنخابی درمان می‌باشد. در شرایط کرونایی، زمان انجام PPCI از 120 تا 180 دقیقه افزایش می‌یابد. اگر برای انجام PPCI به بیش از 180 دقیقه زمان لازم بود، در این صورت لیتیک‌تراپی پیشنهاد می‌گردد. در AMI نوع 2، بیماران از نظر بالینی اغلب آنژین ندارند و تروپونین به صورت ملایم (کمتر از 2 برابر حد طبیعی) بالا می‌رود و تغییرات الکتروکاردیوگرام که نشانه‌ی ایسکمی است را ندارند. البته بیماران مبتلا به COVID-19، درد قفسه‌ی صدری پایدار با و یا بدون نکروز میوکارد را دارند. در عفونت کرونایی حاد، به دلیل آزادی IL، Tumor necrosis factor (TNF)، کاتکول آمین‌ها و همچنین، وجود هایپوکسی، اسیدوز، پرفشاری خون و یا کاهش فشار خون، بین اکسیژن‌رسانی و نیاز به اکسیژن میوکارد، اختلال به وجود می‌آید و AMI نوع 2 رخ می‌دهد. در این بیماران، درمان‌های حمایتی انجام می‌شود و درمان بیماری حاد زمینه‌ای مانند درمان با داروهای ضد التهابی استروئیدی و ضد ویروسی، درمان اصلی است.

کلیدواژه‌ها

عنوان مقاله [English]

Diagnosis and Treatment of Acute Myocardial Ischemia in Patients with COVID-19 Infection

نویسندگان [English]

  • hassan shemirani 1
  • RAZIEH JAFARI 2
1 Professor, Department of Cardiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Hemodialysis, Noor and Hazrat-e-Ali Asghar Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
چکیده [English]

Acute myocardial ischemia during coronavirus disease 2019 (COVID-19) infection can occur in two forms of acute myocardial infarction type І and II. In acute myocardial infarction type І, infection can cause inflammation, and inflammation causes the secretion and increase of cytokines such as interleukin 1, 6, and 8, as well as tumor necrosis factor (TNF) in the circulation. This mechanism causes the secretion of collagenase from activated macrophages, and the results of these reactions is a precursor to plaque rupture, increased coagulation, and thrombus formation. This mechanism causes acute myocardial infarction type І on atherosclerotic plaque. In these patients, primary percutaneous coronary intervention (PCI) is the treatment of choice, contrary to the initial theory that lytic therapy was the main treatment. In COVID conditions, the primary PCI time increases from 120 minutes to 180 minutes, and if the primary PCI takes more than 180 minutes, then lytic therapy is recommended. In acute myocardial infarction type II, patients usually do not have angina clinically, troponin rises slightly (less than 2 times normal), and do not have electrocardiogram changes as a sign of ischemia. However, patients with coronary heart disease have persistent chest pain with or without myocardial necrosis. During COVID-19 infection, due to release of interleukin, tumor necrosis alpha, and catecholamine, as well as hypoxia, acidosis, hypertension and/or hypotension, oxygen delivery and myocardial oxygen demand become disturbed, so acute myocardial infarction type II may occur. Supportive therapies are performed in these patients, and the treatment of acute underlying disease such as treatment with steroidal anti-inflammatory drugs and antiviral drugs is the main treatment.

کلیدواژه‌ها [English]

  • COVID-19
  • Myocardial Infarction
  • Myocardial Ischemia
  • Percutaneous Coronary Intervention
  • Troponin

مراجع

  1. Zhou P, Yang XL, Wang XG, Hu B, Zhang L, Zhang W, et al. A pneumonia outbreak associated with a new coronavirus of probable bat origin. Nature 2020; 579(7798): 270-3.
  2. Wu F, Zhao S, Yu B, Chen YM, Wang W, Song ZG, et al. A new coronavirus associated with human respiratory disease in China. Nature 2020; 579(7798): 265-9.
  3. Lu R, Zhao X, Li J, Niu P, Yang B, Wu H, et al. Genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding. Lancet 2020; 395(10224): 565-74.
  4. Nishiga M, Wang DW, Han Y, Lewis DB, Wu JC. COVID-19 and cardiovascular disease: From basic mechanisms to clinical perspectives. Nat Rev Cardiol 2020; 17(9): 543-58.
  5. Donnelly CA, Ghani AC, Leung GM, Hedley AJ, Fraser C, Riley S, et al. Epidemiological determinants of spread of causal agent of severe acute respiratory syndrome in Hong Kong. Lancet 2003; 361(9371): 1761-6.
  6. Goyal P, Choi JJ, Pinheiro LC, Schenck EJ, Chen R, Jabri A, et al. Clinical Characteristics of COVID-19 in New York City. N Engl J Med 2020; 382(24): 2372-4.
  7. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020; 382(18): 1708-20.
  8. Parasher A. COVID-19: Current understanding of its Pathophysiology, Clinical presentation and Treatment. Postgrad Med J 2021; 97(1147): 312-20.
  9. Lang JP, Wang X, Moura FA, Siddiqi HK, Morrow DA, Bohula EA. A current review of COVID-19 for the cardiovascular specialist. Am Heart J 2020; 226: 29-44.
  10. Ganatra S, Dani SS, Shah S, Asnani A, Neilan TG, Lenihan D, et al. Management of cardiovascular disease during coronavirus disease (COVID-19) Pandemic. Trends Cardiovasc Med 2020; 30(6): 315-25.
  11. Guo T, Fan Y, Chen M, Wu X, Zhang L, He T, et al. Cardiovascular implications of fatal outcomes of patients with coronavirus disease 2019 (COVID-19). JAMA Cardiol 2020; 5(7): 811-8.
  12. Sala S, Peretto G, Gramegna M, Palmisano A, Villatore A, Vignale D, et al. Acute myocarditis presenting as a reverse Tako-Tsubo syndrome in a patient with SARS-CoV-2 respiratory infection. Eur Heart J 2020; 41(19): 1861-2.
  13. Musher DM, Abers MS, Corrales-Medina VF. Acute Infection and Myocardial Infarction. N Engl J Med 2019; 380(2): 171-6.
  14. Fox SE, Akmatbekov A, Harbert JL, Li G, Quincy BJ, Vander Heide RS. Pulmonary and cardiac pathology in African American patients with COVID-19: An autopsy series from New Orleans. Lancet Respir Med 2020; 8(7): 681-6.
  15. Dominguez-Erquicia P, Dobarro D, Raposeiras-Roubin S, Bastos-Fernandez G, Iniguez-Romo A. Multivessel coronary thrombosis in a patient with COVID-19 pneumonia. Eur Heart J 2020; 41(22): 2132.
  16. Chen L, Li X, Chen M, Feng Y, Xiong C. The ACE2 expression in human heart indicates new potential mechanism of heart injury among patients infected with SARS-CoV-2. Cardiovasc Res 2020; 116(6): 1097-100.
  17. Puelles VG, Lutgehetmann M, Lindenmeyer MT, Sperhake JP, Wong MN, Allweiss L, et al. Multiorgan and renal tropism of SARS-CoV-2. N Engl J Med 2020; 383(6): 590-2.
  18. Rosenberg ES, Dufort EM, Udo T, Wilberschied LA, Kumar J, Tesoriero J, et al. association of treatment with hydroxychloroquine or azithromycin with in-hospital mortality in patients with COVID-19 in New York State. JAMA 2020; 323(24): 2493-502.
  19. Vakhshoori M, Heidarpour M, Shafie D, Taheri M, Rezaei N, Sarrafzadegan N. acute cardiac injury in COVID-19: A systematic review and meta-analysis. Arch Iran Med 2020; 23(11): 801-12.
  20. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020; 323(11): 1061-9.
  21. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020; 395(10223): 497-506.
  22. Zeng J, Huang J, Pan L. How to balance acute myocardial infarction and COVID-19: the protocols from Sichuan Provincial People's Hospital. Intensive Care Med 2020; 46(6): 1111-3.
  23. Skulstad H, Cosyns B, Popescu BA, Galderisi M, Salvo GD, Donal E, et al. COVID-19 pandemic and cardiac imaging: EACVI recommendations on precautions, indications, prioritization, and protection for patients and healthcare personnel. Eur Heart J Cardiovasc Imaging 2020; 21(6): 592-8.
  24. Chieffo A, Stefanini GG, Price S, Barbato E, Tarantini G, Karam N, et al. EAPCI position statement on invasive management of acute coronary syndromes during the COVID-19 pandemic. Eur Heart J 2020; 41(19): 1839-51.
  25. Shi S, Qin M, Shen B, Cai Y, Liu T, Yang F, et al. Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China. JAMA Cardiol 2020; 5(7): 802-10.
  26. Sandoval Y, Januzzi JL, Jaffe AS. Cardiac troponin for assessment of myocardial injury in COVID-19: JACC Review Topic of the Week. J Am Coll Cardiol 2020; 76(10): 1244-58.
  27. Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, et al. Fourth universal definition of myocardial infarction (2018). J Am Coll Cardiol 2018; 72(18): 2231-64.
  28. Schiavone M, Gobbi C, Biondi-Zoccai G, D'Ascenzo F, Palazzuoli A, Gasperetti A, et al. Acute coronary syndromes and COVID-19: Exploring the uncertainties. J Clin Med 2020; 9(6).
  29. Sandoval Y, Smith SW, Sexter A, Schulz K, Apple FS. Use of objective evidence of myocardial ischemia to facilitate the diagnostic and prognostic distinction between type 2 myocardial infarction and myocardial injury. Eur Heart J Acute Cardiovasc Care 2020; 9(1): 62-9.
  30. Sandoval Y, Thygesen K. myocardial infarction type 2 and myocardial injury. Clin Chem 2017; 63(1): 101-7.
  31. Bhatraju PK, Ghassemieh BJ, Nichols M, Kim R, Jerome KR, Nalla AK, et al. Covid-19 in critically ill patients in the seattle region - case series. N Engl J Med 2020; 382(21): 2012-22.
  32. Inciardi RM, Lupi L, Zaccone G, Italia L, Raffo M, Tomasoni D, et al. cardiac involvement in a patient with coronavirus disease 2019 (COVID-19). JAMA Cardiol 2020; 5(7): 819-24.
  33. Landesberg G, Jaffe AS, Gilon D, Levin PD, Goodman S, Abu-Baih A, et al. Troponin elevation in severe sepsis and septic shock: the role of left ventricular diastolic dysfunction and right ventricular dilatation. Crit Care Med 2014; 42(4): 790-800.
  34. Landesberg G, Levin PD, Gilon D, Goodman S, Georgieva M, Weissman C, et al. Myocardial Dysfunction in Severe Sepsis and Septic Shock: No Correlation with Inflammatory Cytokines in Real-life Clinical Setting. Chest 2015; 148(1): 93-102.
  35. Moore JB, June CH. Cytokine release syndrome in severe COVID-19. Science 2020; 368(6490): 473-4.
  36. Deng Q, Hu B, Zhang Y, Wang H, Zhou X, Hu W, et al. Suspected myocardial injury in patients with COVID-19: Evidence from front-line clinical observation in Wuhan, China. Int J Cardiol 2020; 311: 116-21.
  37. Jiang F, Yang J, Zhang Y, Dong M, Wang S, Zhang Q, et al. Angiotensin-converting enzyme 2 and angiotensin 1-7: novel therapeutic targets. Nat Rev Cardiol 2014; 11(7): 413-26.
  38. Qiu H, Wu J, Hong L, Luo Y, Song Q, Chen D. Clinical and epidemiological features of 36 children with coronavirus disease 2019 (COVID-19) in Zhejiang, China: an observational cohort study. Lancet Infect Dis 2020; 20(6): 689-96.
  39. Verdoni L, Mazza A, Gervasoni A, Martelli L, Ruggeri M, Ciuffreda M, et al. An outbreak of severe Kawasaki-like disease at the Italian epicentre of the SARS-CoV-2 epidemic: an observational cohort study. Lancet 2020; 395(10239): 1771-8.
  40. Riphagen S, Gomez X, Gonzalez-Martinez C, Wilkinson N, Theocharis P. Hyperinflammatory shock in children during COVID-19 pandemic. Lancet 2020; 395(10237): 1607-8.
  41. Kermani-Alghoraishi M. A review of coronary artery thrombosis: A new challenging finding in COVID-19 patients and ST-elevation myocardial infarction. Curr Probl Cardiol 2021; 46(3): 100744.
  42. Attia ZI, Kapa S, Yao X, Lopez-Jimenez F, Mohan TL, Pellikka PA, et al. Prospective validation of a deep learning electrocardiogram algorithm for the detection of left ventricular systolic dysfunction. J Cardiovasc Electrophysiol 2019; 30(5): 668-74.
  43. Shemirani H, Khoshavi M. Correlation of echocardiographic epicardial fat thickness with severity of coronary artery disease-an observational study. Anadolu Kardiyol Derg 2012; 12(3): 200-5.
  44. Shemirani H, Pourrmoghaddas M. A randomized trial of saline hydration to prevent contrast-induced nephropathy in patients on regular captopril or furosemide therapy undergoing percutaneous coronary intervention. Saudi J Kidney Dis Transpl 2012; 23(2): 280-5.
  45. Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2018; 39(2): 119-77.
  46. Shemirani H, Tavakol S, Atapoor A, Golshahi J. The Role of Inflammatory Processes in Occurrence of Left Ventricular Failure in Patients with Chronic Kidney Disease. Adv Biomed Res 2017; 6: 13.
  47. Shemirani H, Separham KH. The relative impact of smoking or hypertension on severity of premature coronary artery disease. Iran Red Crescent Med J 2007; 9(4): 177-81.
  48. Ghazal A, Shemirani H, Amirpour A, Kermani-Alghoraishi M. The effect of intracoronary versus intralesional injection of eptifibatide on myocardial perfusion outcomes during primary percutaneous coronary intervention in acute ST-segment elevation myocardial infarction; A randomized clinical trial study. ARYA Atheroscler 2019; 15(2): 67-73.
  49. Shemirani H, Khosravi A, Eghbal A, Amirpour A, Roghani F, Hashemi-Jazi SM, et al. Comparing efficacy of receiving different dosages of eptifibatide in bleeding after percutaneous coronary intervention in patients with myocardial infarction. ARYA Atheroscler 2019; 15(4): 185-91.
  50. Daniels MJ, Cohen MG, Bavry AA, Kumbhani DJ. Reperfusion of st-segment-elevation myocardial infarction in the COVID-19 era: Business as usual? Circulation 2020; 141(24): 1948-50.

فایل ها

سابقه مقاله

  • تاریخ دریافت: 19 تیر 1400
  • تاریخ بازنگری: 11 آبان 1403
  • تاریخ پذیرش: 17 فروردین 1401

هم رسانی

ارجاع به این مقاله

آمار