Table 2

Potential mechanisms of myocardial injury and diagnostic limitations due to COVID-19

Potential mechanism of myocardial injuryStandard method of diagnosisLimitations to diagnostic modalities in setting of COVID-19 pandemic
Acute coronary syndromeTrajectory of troponin and ECG changes;
coronary angiography
Risk for healthcare worker exposure; higher threshold before taking patients to cardiac catheterisation lab in setting of myocardial injury
Cytokine release syndrome-induced myocardial dysfunctionInflammatory and cardiac biomarker testing (often need to exclude coexisting cardiac diagnoses)Minimal exposure with biomarker testing if timed with other blood draws; but limited by risk for exposure when excluding underlying cardiovascular disease
MyocarditisCardiac MRI for tissue characterisation (Lake Louise criteria);
trajectory of cardiac biomarkers;
endomyocardial biopsy in selected cases
Risk for exposure during transport and contamination of MRI scanner; risk for healthcare worker exposure in cases requiring biopsy
Progression of existing cardiovascular disease or demand ischaemiaReview of prior medical records and clinical history;
cardiovascular disease-specific testing
Limited by risk for exposure if assessing for underlying cardiovascular disease
Stress-induced cardiomyopathyAccurate clinical history taking for physical and psychological stressors;
cardiac imaging patterns of wall motion abnormality that typically do not fit within a coronary distribution;
diagnosis of exclusion (typically after excluding coronary artery disease)
None directly, but limited by risk for exposure when excluding underlying cardiovascular disease