ABC | Volume 114, Nº5, May 2020

Review Article Costa et al. The heart and COVID-19 Arq Bras Cardiol. 2020; 114(5):805-816 trial – a multicenter study with 440 patients proposed by the Teaching and Research Board of Fiocruz Amazonas – that has included 50 patients so far; and b) an assessment of the safety and clinical efficacy of HCQ in association with azithromycin for patients with SARS-CoV-2 pneumonia – a multicenter study with 400 patients proposed by the Brazilian Israeli Beneficent Society Albert Einstein – waiting to start recruiting. Since March 25, 2020, the Brazilian Ministry of Health has adopted that drug as an adjuvant for the treatment exclusively of the severe forms of COVID-19, while also maintaining the other supportive measures. The indication considers that there is no other effective specific treatment available at the present time and that the recommendation can be modified at any time, depending on new evidence. On March 31, 2020, in a preprint study, without peer review, a Chinese group showed the superior efficacy of HCQ for mild pneumonia in 62 patients assessed (with a control group). 55 That should be confirmed in a study with higher sample power and stricter methodology. Other drugs being analyzed are glucocorticoids, immunoglobulins, interferon, and tocilizumab. Cardiopulmonary resuscitation. When patients with COVID-19 have a cardiorespiratory arrest, special care should be taken, with special attention to airway management, because of the higher risk of contamination of healthcare workers performing aerosol-generating procedures. 56,57 All healthcare professionals in contact with patients with COVID-19 should follow the local and national orientations for infection control and use of personal protective equipment, which should be readily available. 58,59 SARS-CoV-2 infected patients at risk for acute deterioration or cardiac arrest should be identified early, as should those for whom a ‘do not attempt cardiopulmonary resuscitation’ applies, and that should be based on local guidelines. 58 Hypoxia is the most probable cause of cardiorespiratory arrest among patients with COVID-19; however, all causes should be taken into account (hypoglycemia, acidosis, coronary thrombosis). The algorithms already validated should be applied according to the identification of shockable and non-shockable rhythms. 56,57 Airway should be manipulated by experienced and skilled professionals. Healthcare professionals caring for patients with COVID-19, including physicians, nurses and physical therapists, are at higher risk of infection. 60,61 Aerosol-generating procedures, such as non-invasive ventilation, high-flow nasal cannula therapy, and bag-valve-mask or bag-tracheal-tube ventilation, pose a particularly high risk. 62 Bag-valve-mask or bag-tracheal-tube ventilation should be avoided, because of its elevated risk of aerosolization and contamination of the team; moreover, that type of ventilation has not proven to be superior to the mechanical one. 56 If bag-valve-mask ventilation is necessary, the mask should be properly sealed, which requires more than one professional. In addition, the use of filters between the mask and the bag is mandatory. For those patients, the establishment of advanced airway should be prioritized and conducted by skilled individuals. 56 If intubation fails or is impossible, other devices should be used, such as laryngeal tube or mask, to enable closed-circuit mechanical ventilation until definite access to airway is obtained, by either tracheal intubation or cricothyroidostomy. 57 In case of cardiorespiratory arrest of patients on mechanical ventilation, to prevent aerosol contamination from cardiopulmonary resuscitation maneuvers and ventilation, the patient should remain connected to the mechanical ventilator in a closed-circuit system, maintaining FiO 2 at 100%, asynchronous mode, and respiratory rate of 10-12 bpm (Figure 4). 56 Thrombosis prevention and management The literature provides suggestive evidence that the exacerbated systemic inflammatory response present in COVID-19 causes endothelial dysfunction and increased procoagulant activity, which, in association with lower oxygen supply, might contribute to coronary plaque instability or to thrombus formation on a ruptured coronary plaque, and, thus, to plaque vulnerability. 10,11,63 It is worth noting the importance of the differential diagnosis of obstructive coronary artery disease from type II myocardial infarction. 64 Patients with COVID-19 can present with acute coronary syndrome due to a mismatch in myocardial oxygen supply and demand, being diagnosed with type II myocardial infarction. The cases should be analyzed individually, because a large part should be managed conservatively, considering that 7% of the patients with COVID-19 and acute coronary syndrome might have type II myocardial infarction or myocarditis. 64 The approach to acute coronary syndrome in patients with COVID-19 should consider the availability of local resources, such as structured catheterization laboratories, coronary care unit and/or ICU beds, and adequacy of the environment to the protectivemeasures against SARS-CoV-2. 64 A Chinese report has suggested that thrombolysis should be the first-choice therapy for patients withCOVID-19. That is a controversial recommendation, especially where primary angioplasty can be performed, respecting all the safety rules for protection of healthcare professionals and hospital environment (personal protective equipment, negative pressure room, proper cleaning). 64 The treatment of cardiovascular complications should be based on the ideal and careful use of the therapies recommended in the guidelines. Therapy with ACEI, ARB, beta-blockers, antiplatelet agents and statins should abide by the recommendations in the guidelines, respecting the contraindications related to hemodynamic stability and presence of other organic dysfunctions. 21 Patients with COVID-19 are at a higher risk of venous thromboembolism, because of their prolonged physical inactivity and their abnormal coagulation parameters. 4 The use of non-pharmacological prophylaxis strategies is recommended for all in-patients with COVID-19. Pharmacological strategies should be considered, such as the use of unfractionated or low-molecular-weight heparin, taking into account the latter’s contraindications and the patient’s creatinine clearance. Venous thromboembolism should be suspected based on clinical criteria, in situations such as maintenance of high d-dimer levels and refractory hypoxemia, or in the presence of echocardiographic signs of pulmonary hypertension and right ventricular dysfunction. 812