ABC | Volume 114, Nº5, May 2020

Review Article Costa et al. The heart and COVID-19 Arq Bras Cardiol. 2020; 114(5):805-816 QTc >500ms (or >530-550ms if QRS >120ms), azithromycin should be discontinued or the HCQ dose, reduced, and ECG performed daily. If the ECG changes remain, the risk/benefit of maintaining the medication should be reevaluated. For outpatients, who may be less at risk for complications from QT interval prolongation, baseline ECG should be acquired 2-3 hours after initiating HCQ and on day 3 of therapy. If QTc increases by >30-60ms or absolute QTc >500ms (or >530- 550ms if QRS >120ms), consider discontinuing therapy. 36 Transthoracic echocardiogram should be the initial choice for assessing cardiac function in those patients, and ideally performed at the emergency department by use of the point- of-care or dynamic method. Transthoracic echocardiogram can show systolic and/or diastolic left ventricular impairment and provides hemodynamic information to support the management of patients, in addition to enabling the diagnosis of pericardial changes. It should be considered for all risk groups or those requiring hospitalization. Patients with ventricular dysfunction are more likely to need mechanical ventilation and be of worse prognosis. 13 Critical patients should be followed up with daily echocardiogram, as well as strict assessment of hemodynamic parameters and biventricular function. In addition, the detection of ventricular dysfunction is an indication for invasive hemodynamic monitoring and will guide the treatment with inotropic and/or circulatory support. In critical cases, dynamic echocardiogram should be acquired daily and at every hemodynamic change. Magnetic resonance imaging should be considered in stable patients and can support the differential diagnosis of ventricular dysfunction etiology, which might be related to myocarditis or stress-induced systolic dysfunction. The diagnosis of myocarditis follows the classic criteria already validated for other viral etiologies, in which myocardial edema and non-ischemic myocardial late enhancement can be observed. 37-39 Management of the patient with COVID-19 Initial approach and intensive support. The mean time of symptom onset is 4-5 days, and 97.5% of contaminated individuals will have symptoms in up to 11.5 days from exposure. 32 Most patients (81%) have mild symptoms, the most common being fever (88%) and cough (67.7%). Other less frequent are diarrhea, myalgia, headache and runny nose. Approximately 20% of the patients with COVID-19 will have the severe form, with dyspnea, tachypnea, oxygen saturation ≤93%, and pulmonary infiltrate, while 5%will have the critical formof COVID-19, with signs of shock and respiratory failure. 1,40 Most of asymptomatic or olygosymptomatic clinically stable patients require no hospitalization, which is mandatory for those with severe symptoms and unfavorable evolution. Figure 3 - Flowchart for cardiac assessment of patients with suspected COVID-19. *Advanced age, coronary artery disease, cerebrovascular disease, arterial hypertension, diabetes mellitus, cardiomyopathy or arrhythmia. COVID-19: Coronavirus disease 2019; CVD: cardiovascular disease; ECG +: supraventricular or ventricular tachycardia, new repolarization changes suggestive of acute ischemia; ECG -: electrocardiogram without acute changes; ECHO: echocardiogram; mod: moderate; Tropo +: troponin levels above the 99th-percentile upper reference limit; Tropo -: troponin levels below the 99th- percentile; ICU: intensive care unit. 810