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Management strategies for patients with heart, kidney, and mental chronic diseases under the epidemic, one article get!

 Last Update: 2023-02-01
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Clinical medication, individualization is still the focus!

In the last issue, we talked about the interaction and use strategies between new crown antiviral drugs and commonly used cardiovascular disease treatment drugs (click to view the original article).

As mentioned earlier, China's cardiovascular disease, chronic kidney disease (CKD), stroke and other chronic diseases have a huge base, and these patients have already received double clinical attention
as a high-risk group of the new crown.
So for patients with myocarditis, CKD, and stroke who have high clinical attention, what are the management strategies during the epidemic?

Covid + myocarditis

How likely are you to have it?

During the epidemic, acute myocarditis related to new crown infection was firmly in the hot search
.
Indeed, the new crown infection can affect the cardiovascular system, especially myocarditis, which can aggravate the patient's condition
.
However, in fact, the prevalence of the disease is low, about 2.
1~4.
1/1000 people ^[1].
So we don't have to panic too much, the focus is to understand how to diagnose and manage new crown combined myocarditis!

Diagnosis of new crown-related myocarditis ^[2]
The diagnosis of new crown combined myocarditis is basically the same as myocarditis, and clinically its diagnostic criteria are divided into three levels: suspected diagnosis, probable diagnosis, and confirmed diagnosis

Suspected diagnosis: (1) cardiac symptoms (such as chest pain, dyspnea, palpitations, syncope); (2) elevated cTn; (3) Abnormal ECG and/or echocardiogram results, but no acute myocarditis was found on endocardial biopsy or cardiac magnetic resonance (CMR), or biopsy and CMR
were not performed.

Probable: consistent with suspected (1)(2)(3) manifestations, with abnormal follow-up CMR and/or biopsy results within 6 months of new crown infection
.

Confirmed: consistent with suspected (1), (2) (3) manifestations, with new crown infection concurrent with CMR and/or biopsy showing active myocarditis
.

The management of new crown complicated myocarditis ^[3]
treatment depends to a large extent on the clinical presentation and severity of the patient, and the general principle is individualized treatment
according to the severity of the disease.

After infection with the new crown, once patients develop symptoms such as chills, fever, cough and sputum, muscle aches, etc.
, antiviral drug treatment
should be started as soon as possible.
Effective antiviral treatment helps prevent severe pneumonia and myocarditis
after coronavirus infection.
Currently available small molecule drugs include: (1) Paxlovid, recommended for viral infection within 5 days, dose of 150 mg x2 + 100 mg x1 q12 h, treatment course of 5 days; Creatinine clearance greater than 60ml/min is fully applied, creatinine clearance between 30-60ml/min is reduced to 150mgx1+100mgx1 q12h, creatinine clearance less than 30ml/min is not recommended; ② Molnupiravir； (3) Azvudine tablets
.

For patients with new crown complicated myocarditis, symptomatic and supportive treatment should be actively taken, mainly including maintaining quiet rest, regular life, and light diet
.
During the period, nasal cannula, mask oxygen or mechanical ventilation positive pressure oxygen can be given according to the patient's condition to improve myocardial energy metabolism
.
Severe patients need to maintain hemodynamic stability, pay attention to fluid supplementation, and physical cooling or drug cooling in the case of high fever, but nonsteroidal anti-inflammatory drugs are not recommended, and glucocorticoids
are used.

In terms of immunomodulatory therapy, it is recommended to use: (1) glucocorticoids, preferably dexamethasone, the recommended dose is 5-10mg/d, the course of treatment is 5-7 days, methylprednisolone 40-80mg/d, the course of treatment is 5-7 days, the dose reduction regimen depends on the clinical situation; (2) Immunoglobulin (IVIG), it is recommended to be used in combination with glucocorticoids, or alone, the recommended dose is 0.
1-0.
3g/kg/d, and the course of treatment is 5-7 days; (3) Use new crown-specific immunoglobulin or monoclonal immunoglobulin, such as interleukin-6 (IL-6) monoclonal antibody
.

In particular, attention needs to be paid to the management of new crown combined with fulminant myocarditis, and it is recommended that such patients adopt a comprehensive treatment plan based on life support as soon as possible, and if hemodynamic instability occurs, life support therapy
should be given as soon as possible.
In addition, antiviral therapy and immunomodulatory therapy are also very important
.

CKD patients after "impotence"

How is antiviral therapy done?

CKD patients are also at high risk of severe / critical disease in the new crown, and there are 132.
3 million CKD patients in China ^[4], so under the siege of the new crown epidemic, its diagnosis and treatment and management have also become the focus
.
So how should CKD be identified and treated if it develops into a severe new crown infection? Do hormones, immunosuppressants and other drugs originally used by CKD patients need to be adjusted? Look down!
Treatment strategies for new coronavirus infection ^[5]
According to the "Novel Coronavirus Pneumonia COVID-19 Treatment Manual (8.
1 Edition)" issued by the Japanese Ministry of Health and Welfare, because the cause of death by new crown is mostly respiratory failure, usually according to respiratory symptoms and oxygen saturation (Sp O₂) to distinguish between four categories
.

In terms of treatment, when the patient is infected, the viral load is significantly increased, and antiviral therapy
should be actively carried out at this time.
When viral load decreases, that is, in the later stages of infection, basic treatment such as adequate oxygen, thromboembolism prevention, and support for symptomatic treatment
should be noted.

Figure New crown virus infection treatment strategy
, but it should be noted that for patients with different degrees of new crown infection, their management strategies also have their own focus ^[5]:

1.
Lightweight

Respiratory management
Antiviral drugs such as remdesivir, Veklury, monapigravir, Lagevrio, nimetrevir/ritonavir, Paxlovid
Neutralizing antibodies
Immunomodulators
Anticoagulants

2.
Medium I.
:

Antiviral drugs

3.
Medium II:

Oxygen therapy, including nasal cannula high-flow oxygen therapy (NHF), with membrane-filtered CPAP and NPPV if necessary
Hormones, such as dexamethasone
JAK inhibitors, such as baricitinib, Oiumiante, etc
IL-6 receptor monoclonal antibodies, such as tocilizumab, Actemra, etc
Patients are recommended to breathe in a prone position with positive postural changes

4.
Heavy duty:

Intubation, artificial respiration, ECMO
hormone
JAK inhibitors
IL-6 receptor monoclonal antibody
Use prone breathing and positive positioning
Blood purification therapy: CRRT or PMX-DHP with filters equipped with inflammatory mediators such as cytokines can be used in the initial stage of progression of multi-organ failure, reducing excessive inflammatory response
.
Blood purification therapy requires attention to prevent bloodstream-related infections
Antithrombotic therapy: severe infection and respiratory failure are intermediate risk factors for deep vein thrombosis, and it is speculated that new crown patients will have cytokine storm and vascular endothelial damage, which can lead to hypercoagulation and fibrinolytic inhibition, so antithrombotic therapy
is recommended.
Heparin anticoagulation is recommended for patients with obesity, lying still, and D-D polymers rising to more than 3-4 times normal, but the prophylactic dose of unfractionated heparin is not clear, and it is recommended to start with a small amount (10,000 / day), and monitor activated partial thromboplastin time measurement (APTT) and platelet count

It should be noted that hormones need to be used according to the patient's clinical condition and drug characteristics, such as when the patient's sodium and water retention is more obvious, dexamethasone is more suitable for use; If the blood glucose is high, methyl strength
is more appropriate.

Adjustment of immunosuppressants and related treatment strategies
in patients with CKDWhen patients with CKD have symptoms related to new crown infection, the use of immunosuppressants needs to be adjusted according to the specific situation, as shown in the table below
.

Table Adjustment strategy of immunosuppressants in patients with new crown and CKD^[6].
The recovery of immunosuppressant use should be based on the comprehensive decision of chest CT and clinical improvement, starting from the reduction of the dose of CNI drugs, and the blood trough concentration in the early stage of recovery should be controlled at tacrolimus 4-6 ng/mL and cyclosporine 50-80 ng/mL, and gradually adjusted to the target plasma concentration according to the recovery ^[6].

Since some antiviral drugs may interact with immunosuppressants commonly used in patients with CKD, it is necessary to decide whether to adjust the use of
immunosuppressants according to the patient's situation when concurrently administering antiviral therapy and symptomatic treatment of CKD.

For example, Paxlovid has significant interactions with CNI drugs, and attention needs to be paid to medication protocol adjustment
when selecting.
In particular, ritonavir is a potent inhibitor of CYP3A, which can increase the plasma concentration of immunotherapy drugs metabolized by CYP3A, such as cyclosporine, tacrolimus, dexamethasone, etc.
, so the dose of some immunotherapy drugs needs to be adjusted during Paxlovid ^{medication [7].}

What issues do stroke patients need to pay special attention to when coping with the new crown? The experts in the gods have advice!

For stroke patients, we should mainly do 3 points:

Standardized vaccination: stroke is not a contraindication to vaccines, stroke patients are recommended to actively vaccinate, 6 months after this wave of the epidemic, continue vaccination is still encouraged to complete the standard full vaccination ^[8].

Early antiviral treatment: If stroke patients are unfortunately infected with the new crown, antiviral therapy should be carried out as soon as possible to relieve the symptoms of lung disease in time and better improve the prognosis
of stroke.

Pay attention to secondary prevention: Secondary prevention of stroke should not be relaxed, and more attention should be paid to the management of risk factors, such as antithrombotic therapy and blood pressure management, to avoid the recurrence and initial occurrence
of stroke.

In addition to stroke, many "Xiaoyang people" also reported losing their sense of smell, taste, and even neurological symptoms
such as "brain fog" after recovery.

At present, the mechanism of smell and taste failure in new crown patients is still unclear, and there may be some local mechanism, similar to the swelling of the nasal mucosa and nasal congestion in the nose after a cold, causing the destruction
of receptors.
Some studies have also found that the new crown has a certain impact on the olfactory nerve and even on the area of the brain responsible for smell ^[9].
Failure of smell and taste usually does not cause serious consequences, and most patients recover within four weeks, although some patients have been reported to take more than a year to recover ^[9].

Another popular word recently is "brain fog", which is mainly manifested as inability to concentrate, which may be related to inflammation caused by infection, and may also be related
to poor rest, tension and anxiety, and life stress.
Brain fog also generally does not cause particularly serious consequences, can recover within two weeks, or may take longer, patients should reduce unnecessary anxiety, maintain a comfortable mood, regular routine ^[10].

Summary Cardiovascular disease, CKD, stroke patients are currently the new crown epidemic under the population of much concern, for such patients, it is still recommended not to stop the original basic treatment, if necessary, can reasonably use new crown antiviral drugs (such as Paxlovid, azvudine) or new crown symptomatic drugs, while paying attention to the interaction between drugs, according to the patient's personal situation and drug characteristics, Follow the doctor's advice to adjust, and do not stop or reduce the drug
by yourself.

This article reviewers (in no particular order):

Professor Sun Ningling, Peking University People's Hospital

Professor Chen Nan, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine

Professor Li Yong, Huashan Hospital Affiliated to Fudan University

Professor Jiang Hong, Xinjiang Uygur Autonomous Region People's Hospital

Professor Fang Kun, Huashan Hospital Affiliated to Fudan University

Professor Wenchao Ou, The Second Affiliated Hospital of Guangzhou Medical University

Professor Wang Shang, Beijing Tiantan Hospital, Capital Medical University

Professor Xiong Fei, Wuhan First Hospital

Professor Zhang Junjun, The First Affiliated Hospital of Zhengzhou University

Professor Zhong Ming, Qilu Hospital of Shandong University

References: [1] Ammirati E, Lupi L, Palazzini M, et al.
Prevalence, Characteristics, and Outcomes of COVID-19-Associated Acute Myocarditis.
Circulation.
2022; 145(15):1123-1139.
[2]GLUCKMAN T J, BHAVE N M, ALLEN L A, et al.
2022 ACC Expert Consensus Decision Pathway on Cardiovascular Sequelae of COVID-19 in Adults: Myocarditis and Other Myocardial Involvement, Post-Acute Sequelae of SARS-CoV-2 Infection, and Return to Play: A Report of the American College of Cardiology Solution Set Oversight Committee [J].
J Am Coll Cardiol, 2022, 79(17): 1717-56.
[3] Brief recommendations for the diagnosis and treatment of myocarditis associated with novel coronavirus infection (first edition)[4]GBD Chronic Kidney Disease Collaboration.
Global, regional, and national burden of chronic kidney disease, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017.
Lancet.
2020; 395(10225):709-733.
[5] "Novel Coronavirus Pneumonia COVID-19 Treatment Manual (8.
1 Edition)" [6] Organ Transplantation Branch of Chinese Medical Association.
Guidelines for National Organ Donation and Transplantation during the Novel Coronavirus Pneumonia Epidemic (adopted on February 23, 2020)[J].
Organ Transplantation, 2020, 11(2):6 [7] "Nirmatevir tablets/ritonavir tablets combination package insert" [8] National Health Commission.
Technical guidelines for new coronavirus vaccination (first edition)[J].
Infectious Disease Information, 2021, 34(2):2 XU Hongwei, LIU Fanghui, WAN Beibei.
Research progress on olfactory disorders in patients with novel coronavirus pneumonia[J].
Chinese Journal of Otorhinolaryngology-Head and Neck Surgery, 2021, 56(6):6 [10] ZHAO Yan, CHENG Siqi, DUAN Yaxin, et al.
Relationship between novel coronavirus and cognitive dysfunction[J].
Chinese Journal of Neuroimmunology and Neurology, 2021, 028(006):475-478

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