Heart attack in COVID-19 patients NICE guideline

Diagnosing acute myocardial injury in patients with suspected or confirmed COVID-19-NICE guidelines

3.1Be aware that acute myocardial injury and its complications:

3.2Be aware that acute myocardial injuries in patients with COVID-19 include:

  • acute coronary syndromes
  • arrhythmias
  • cardiac arrest
  • cardiogenic shock
  • cardiomyopathy
  • heart failure
  • myocarditis
  • pericarditis and pericardial effusion.

3.3Be aware that symptoms suggesting acute myocardial injury in patients with COVID-19 include:

  • chest pain
  • palpitation
  • severe fatigue
  • shortness of breath.

Diagnostic tests

3.4In patients with symptoms or signs that suggest acute myocardial injury, measure high sensitivity troponin I (hs-cTnI) or T (hs-cTnT) and NT-proBNP, and perform an ECG.

Use the following test results to help inform a diagnosis:

  • evolving ECG changes suggesting myocardial ischaemia
  • NT-proBNP level above 400 ng/litre
  • high levels of high sensitivity troponin (hs-cTnI or hs-cTnT), particularly levels increasing over time.

3.5Be aware that elevated troponin levels may reflect cardiac inflammatory response to severe illness rather than acute coronary syndrome, and should be considered in the clinical context.

BAME and SAAD

In the extraordinary circumstances of the COVID-19 coronaviurus pandemic we are worried about doctors and health workers becoming infected with COVID-19, expecially BAME-that is Black, Asian and Minority Ethnic community. There is a recorded excess death in this cohort. A group of Greater Manchester GPs, led by Dr Jiva, produced a tool to gauge risk, the Safety Assessment and Decision scorecard (SAAD),-authors have compiled a scorecard following review of many research papers and guidance available. In some cases, there has been a lack of available data to make a clear recommendation and accordingly the group has reflected on the data available and used their clinical experience to propose a pragmatic approach. The system has been developed for all staff within General Practice including both clinical and non-clinical staff. This is also applicable to all ethnicities within the practice.

SCORE CARD

Staff name:                                                         Manager name:                                                      Date:

Points
 
1
234High RiskRow score
Age40-4950-5960-69 70 and above 
EthnicityWhite Chinese Mixed originIndian  Bangladeshi Pakistani Middle EastBlack  
*BAME Other: Any staff that do not fall into one of the categories above, score according to other ethnicities above 
Gender  FemaleMale    
Obesity (BMI) kg/m2 Appendix 1Over 23 (exclude white/ Chinese/ mixed) Over 30 (white/ Chinese/mixed)  Over 30 (exclude white/ Chinese/ mixed)Over 40 (All groups) 
Pregnancy   Under 28 weeks  Over 28 weeks 
Medical Conditions- Appendix 2One condition  Two conditionsThree or more conditions 
Vitamin D nmol/L Appendix 330-50Under 30    

NICE guidelines for ASTHMA

In the rapid guidance on ASTHMA produced by NICE in light of Covid-19 gives recommendations on treatment for adults aged 17 years and over, children and young people aged 5 to 16 years, and children under 5 years. The tables give dosages for adults aged 17 and over and children aged 5 to 11 years, because these reflect the age categories used in most UK marketing authorisations. In practice, the prescriber will choose dosages for children under 5 years and young people aged 12 to 16 years taking into account factors such as the severity of the condition being treated and the person’s size in relation to the average size of people of the same age.

The smallest dosage should be used to obtain optimal control: people with asthma should usually use the smallest dosage of ICS that provides optimal asthma control, to reduce the risk of side effects. The MHRA advises that steroid treatment cards should be routinely provided for people who need prolonged treatment with high dose ICS.

Chloroquine Hydroxychloroquine suspended as treatment for CoronaVirus COVID-19

The medical journal The Lancet 22 May 2020 has reported being unable to confirm a benefit of hydroxychloroquine or chloroquine, when used alone or with a macrolide, on in-hospital outcomes for COVID-19. Each of these drug regimens was associated with decreased in-hospital survival and an increased frequency of ventricular arrhythmias when used for treatment of COVID-19. Hydroxychloroquine is a drug that is most commonly used as an antimalarial.

Nearly 800 GP practices across the UK are now recruiting patients onto the trial, led by the University of Oxford. The trial investigating coronavirus (Covid-19) treatments via GP practices known as the PRINCIPLE trial has been halted recruitment following concerns about the safety of hydroxychloroquine. PRINCIPLE ‘is a flexible, platform trial of interventions suitable for use in the community that may prevent hospitalisation and speed recovery from Covid-19 illness

World Health Organisation (WHO) has initiated the temporary suspension of global trials that include hydroxychloroquine.