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To the Editor,
We read with great interest the paper by Pagnesi et al1 who described the echocardiographic findings in 200 non-critical patients with novel coronavirus (COVID-19) infections, highlighting the role of echocardiography in these patients.
Recent lines of evidence pointed out two main issues underscoring the pivotal role of cardiologists in managing patients with COVID-19 infections.
First is the clinical interpretation of increased troponin levels, described to be common and related with worse prognosis. Investigations combining echocardiographic assessment and troponin measurements reported that serial echocardiograms (and electrocardiograms) failed to detect signs of myocarditis in patients with elevated troponin both in mild2 and severe COVID-19 disease.3 Ruling out coronary ischaemia, cardiologists should interpret troponin elevation in COVID-19 disease as multifactorial,4 related to right ventricle (RV) increased intraventricular pressures (due to lung disease/RV dysfunction). A direct relationship was reported between troponin and C reactive protein.3
Second is the central role of RV assessment and pulmonary systolic arterial pressures by echocardiography in COVID-19 disease. In a series of 28 patients with COVID-19 disease requiring intensive care unit (ICU) admission, serial echocardiograms documented that systolic pulmonary arterial pressures were increased in all patients on ICU admission but significantly decreased during ICU stay. In patients with milder disease, the incidence of pulmonary hypertension was lower (31%),2 suggesting a relationship between systolic arterial pressure and disease severity. In agreement with these findings, Pagnesi et al1 observed that pulmonary hypertension was associated with a more severe Acute Distress Respiratory Syndrome (ARDS). In COVID-19 disease, increased systolic arterial pressures may be due mainly to lung disease severity (ie, parenchymal consolidations) and hypoxic vasoconstriction which may be treated by appropriate ventilation strategies. Pulmonary embolisms/thrombosis, not infrequent in COVID-19 disease, can represent a contributing factor.
In patients with COVID-19 disease, the clinical interpretation of echocardiographic findings by cardiologists is complex since it should contemplate the assessment by disease severity (indicated by P/F ratio and/or PaO2), the kind of ventilation (non-invasive versus mechanical ventilation) and ventilatory parameters due to their influence on intrathoracic pressures. Further research is needed to evaluate whether pulmonary arterial hypertension and RV dysfunction may represent therapeutic targets in COVID-19 disease.
Contributors CL wrote the draft of the document. MB and AP critically revised it.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; internally peer reviewed.
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