Summary of COVID-19 medicines guidance: Cardiovascular system disorders

Eimear Maguire, Senior Medicines Information Pharmacist, North West Medicines Information CentrePublished

This page summarises and signposts to medicine related guidance we’re aware of from professional and government bodies relating to coronavirus and cardiovascular system disorders.

Our advice is constantly reviewed as the pandemic situation evolves.

Whilst we have tried to ensure that the information on this page is complete, please report a concern if you feel anything is omitted or inaccurate.

To see our professional guidance summaries for other clinical areas, click here

Advice in this area includes:

NHS England/ NHS Improvement: Clinical guide for the management of cardiology patients during the coronavirus pandemic

Last updated 20 March 2020 [Re-added 25 November]

  • Issues requiring admission and ongoing management will be prioritised eg myocardial infarction, class IV heart failure, arrhythmias (such as uncontrolled AF or VT), endocarditis; pathways must be expedited to allow rapid treatment and discharge.
  • All elective admissions and day cases should be deferred unless absolutely necessary.
  • For outpatients, consideration should be given to the urgency of appointment, the requirement for diagnostics and the need for face-to-face contact; where possible, appointments should be conducted remotely and non-urgent appointments deferred, particularly those requiring diagnostics for surveillance.
  • Advises on specific areas of cardiology services e.g. bradycardia pacing, ICD and CRT implants, elective and primary PCI, ablation etc.

NHS England/ NHS Improvement: Clinical guide for the management of anticoagulant services during the coronavirus pandemic

Last updated February 2021 [Re-added 25 November 2021]

  • Take the opportunity to review if long-term warfarin therapy is still indicated eg in patients with prior DVT or PE for whom the risk of recurrence is now considered low.
  • Consider if patients taking warfarin are suitable for treatment with a DOAC instead; if a DOAC is unsuitable, could they be switched to LMWH instead? (Note that in view of recognised supply issues with LMWH, these should only be used if there are no other appropriate options).
  • Consider prioritising patients with poor control of INR as this cohort will need the most frequent INR checks. Address non-adherence if this an underlying reason for poor INR control.
  • Consider if patients could be trained to self-test INR in their own homes.
  • As a last resort, for individual patients for whom INR testing is not possible and therefore warfarin cannot be dosed safely, warfarin therapy could be temporarily stopped after weighing the benefit and risk and discussion with the patient. Regular review should be undertaken with a view to restarting warfarin therapy as soon as it is safe to do so. (Note: patients’ with mechanical heart valves MUST be initiated on, or stay on warfarin).

NICE: COVID-19 rapid guideline: acute myocardial injury

Last updated 23 April 2020

  • The purpose of this guideline is to help healthcare professionals who are not cardiology specialists identify and treat acute myocardial injury and its cardiac complications in adults with known or suspected COVID-19 but without known pre-existing cardiovascular disease.
  • Be aware that treatments that may be used in COVID-19, such as azithromycin and hydroxychloroquine, may prolong the QTc interval and lead to arrhythmia (at the time of publication (22 April 2020), azithromycin and hydroxychloroquine can only be used to treat COVID-19 as part of nationally approved randomised controlled trials).

NICE: COVID-19 rapid evidence summary: angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) in people with or at risk of COVID-19

Last updated 21 May 2020

  • The purpose of this review is to assess the best available evidence to determine If there is any increased risk of developing COVID-19 due to ACEIs or ARBs and if ACEIs or ARBs can lead to an increased risk of developing more severe symptoms of COVID-19.
  • The review identified 2 retrospective observational studies that met the inclusion criteria; these studies found no increase in risk of developing COVID-19 or more severe disease. However, the studies were of poor quality and subject to bias and confounding.
  • Therefore, conclusions cannot be drawn on whether ACEIs or ARBs increase the risk of developing COVID-19 or developing more severe COVID-19.

Royal Pharmaceutical Society: Guidance for the safe switching of warfarin to direct oral anticoagulants (DOACs) for patients with non-valvular AF and venous thromboembolism (DVT / PE) during the coronavirus pandemic

Last updated 26 March 2020

  • Includes information on how to decide if it is appropriate to switch individual patients to DOACs, choice of DOAC, monitoring etc.
  • Advice on how to manage patients considered unsuitable for a DOAC.
  • Includes a counselling checklist for patients commenced on a DOAC.

British Cardiovascular Society: COVID-19 Clinician’s Resource Hub 

Last updated 14 January 2021

  • Includes a ‘COVID-19 Clinicians Resource Hub’ that is updated with cardiovascular articles pertaining to coronavirus from relevant organisations and publications.

British Cardiovascular Society (BCS) with the British Society for Heart Failure (BSH): Joint statement on ACEi or ARB in relation to COVID-19

Last updated 19 March 2020

  • Both the BCS and the BSH share the view of the European Society of Hypertension and the Renal Association that patients should continue treatment with ACEI and ARB unless specifically advised to stop by their medical team.
  • The BCS and the BSH recommend that patients taking ACEIs or ARBs and presenting unwell with suspected or known COVID-19 infection should be assessed on an individual basis and their medication managed according to established guidance.

British Heart Foundation (patient information): Coronavirus and heart medication

Last updated 24 December 2020

  • There is no evidence that ACEI/ARBs increase the risk of catching coronavirus, or make COVID-19 worse.
  • It’s really important that patients continue to take their cardiac medicines, including ACEI/ARBs, low-dose aspirin and heart transplant medicines as prescribed, even if they catch coronavirus, unless told differently by their doctor.
  • Paracetamol is the first choice of medicine to treat a fever caused by any infection and is the best choice to treat COVID-19 symptoms.

British Heart Foundation (patient information): Coronavirus vaccine: your questions answered

Last updated 16 February 2021 [Added 21 January 2021]

  • This webpage answers questions about the coronavirus vaccines, such as their safety for people with heart conditions and those taking anticoagulants.

British Society for Haematology: INR testing for out-patients on warfarin during COVID-19 restrictions

Last updated 26 March 2020

  • Advice for out-patient INR testing during COVID-19 restrictions.
  • Assess whether a DOAC that does not require monitoring can be used instead of warfarin. Note that antiplatelet therapy is not an effective alternative to anticoagulation.
  • Patients who are stably anticoagulated on warfarin with a time-in-therapeutic range of >60% can generally have long INR test intervals of 8 weeks or in some cases longer.
  • Patients in self-isolation because of possible COVID-19 exposure who are stably anticoagulated and would be due a routine test, can usually have the test safely postponed until after the period of isolation

British Society for Heart Failure: BSH position statement on the roll out of COVID-19 vaccinations 

Last updated 8 January 2021 [Added 21 January 2021]

  • People with heart failure are at increased risk of severe COVID-19.
  • The British Society for Heart Failure strongly recommends that all those eligible accept vaccination, if offered.

Cardiomyopathy UK: COVID-19 and Cardiomyopathy

Last updated 7 January 2021

Cardiomyopathy UK answers FAQs from patients, including:

  • Should I avoid non-steroidal anti-inflammatory medication like Ibuprofen?
  • I take an ACEI/ARB; should I stop?
  • I am taking immunosuppressant medications (e.g. prednisolone) for the management of my cardiomyopathy, should I stop?
  • Do any other cardiac medications cause harm?

European Society of Cardiology: Position Statement of the European Society of Cardiology Council on Hypertension, ACE-Inhibitors and Angiotensin Receptor Blockers

Last updated 13 March 2020

  • The Council on Hypertension of the European Society of Cardiology have highlighted the lack of evidence supporting harmful effect of ACEI and ARBs in the context of the pandemic COVID-19 outbreak; they strongly recommend that patients should continue treatment with their usual anti-hypertensive therapy.
  • There is evidence from studies in animals suggesting that these medications might be protective against serious lung complications in patients with COVID-19 infection, but to date there is no data in humans.

European Society of Cardiology: ESC Guidance for the Diagnosis and Management of CV Disease during the COVID-19 Pandemic

Last updated 10 June 2020

  • Guidance from the European Society of Cardiology on the diagnosis and management of cardiovascular disease during the COVID-19 pandemic.
  • Has management/treatment pathways for cardiovascular conditions, including STEMI, NSTEMI, cardiogenic shock, heart failure, valvular heart diseases, hypertension, pulmonary embolism and arrhythmias.
  • Also has a section on considerations on the use of anticoagulants in COVID-19 Patients.

European Society of Cardiology: Chloroquine and cardiovascular side effects

  • There has been increased interest in the use of chloroquine and hydroxychloroquine in the context of COVID-19 which is currently under evaluation in trials. There are potential cardiovascular side effects associated with their use.
  • The ESC have summarised output from their meetings and relevant journals.

European Society of Hypertension: Statement of the European Society of Hypertension (ESH) on hypertension, Renin-Angiotensin System (RAS) blockers and COVID-19

Last updated 15 April 2020

  • The currently available data on COVID-19 infections do not a support a differential use of ACEI or ARBs in COVID-19 patients.
  • In COVID-19 patients with severe symptoms or sepsis, ACEI or ARBs and other blood pressure lowering drugs should be used or discontinued on a case-by-case basis, taking into account current guidelines.
  • Further research analysing the continuously increasing data on the impact of hypertension and blood pressure lowering drugs, particularly RAS blockers, on the clinical course of COVID-19 infections is warranted.

Heart UK – The Cholesterol Charity: Information for GP’s and prescribers on how best to manage cholesterol during the coronavirus pandemic

  • Contains advice for healthcare professionals on management of patients with suspected familial hypercholesterolaemia, management of patients experiencing statin side effects and deferral of follow-up cholesterol tests following statin initiation.
  • Patients due to have a follow-up cholesterol test after starting statins who are symptom-free may have to have their appointment deferred depending on service capacity, but they should continue their medication.
  • Patients experiencing side effects should be offered a telephone appointment to review their symptoms, their dose and/or type of statin.
    Patients with suspected familial hypercholesterolaemia should be started on a statin as recommended in NICE CG71; the recommended minimum for most otherwise healthy individuals is atorvastatin 20mg daily.
  • Patients due to have a follow-up cholesterol test following lifestyle changes may need to have their treatment decision delayed. They should, however, continue with lifestyle changes, unless their most recent result met the criteria for familial hypercholesterolaemia screening. These patients would usually be prescribed atorvastatin 20mg daily.
  • Has specific COVID-19 protocols for medications such as PCSK9i, volanesorsen and lomitapide; users must log in to view this, but can sign up to a free professional membership area.

Medicines and Healthcare products Regulatory Agency (MHRA): Coronavirus (COVID-19) and high blood pressure medication

Last updated 27 March 2020

  • There is no evidence from clinical or epidemiological studies that treatment with ACE-I or ARBs might worsen COVID-19 infection.
  • It is vitally important that patients taking ACEI or ARBs to treat high blood pressure continue their usual treatment.
  • The MHRA are working closely with the Commission on Human Medicines and other regulatory bodies and will respond with further advice on this issue, should any new data emerge.

Medicines and Healthcare products Regulatory Agency (MHRA): Warfarin and other anticoagulants – monitoring of patients during the COVID-19 pandemic 

Last updated 13 October 2020

  • The MHRA are advising of reports of an increase in the number of patients taking warfarin found to have elevated international normalised ratio (INR) values during the COVID-19 pandemic. Reasons for this are likely to be multifactorial: most, but not all, of these patients had suspected/confirmed COVID-19 infection, while others had recently been treated with antibiotics. Other causes may have been changes to diet due to lockdown (e.g. access to green leafy vegetables, increased alcohol consumption), while the psychological impact of social distancing and bereavement may have affected adherence to regular medications.
  • Advice is provided for healthcare professionals, including:
    • acute illness may exaggerate the effect of warfarin and necessitate a dose reduction. Therefore, continued INR monitoring is important in patients taking warfarin or other vitamin K antagonists (VKA) if they have suspected or confirmed COVID-19 infection, so they can be clinically managed at an early stage to reduce the risk of bleeding.
    • some patients taking warfarin may have been switched to direct-acting oral anticoagulants (DOACs) during the pandemic to avoid regular blood tests for INR monitoring – like VKA, DOACs also interact with several medicines. Patients with COVID-19 may be treated with antibiotics/antivirals. Healthcare professionals are therefore reminded of the potential for drug-drug interactions between oral anticoagulants (i.e. VKA or DOACs) and certain antibiotics/antivirals and are advised to follow existing advice in product information; this includes advice on the need for INR monitoring in patients taking VKA who have recently started taking new medications.
    • the MHRA is also aware of a small number of patients in whom warfarin treatment was continued after starting treatment with DOACs. To reduce the risk of over-anticoagulation and bleeding, healthcare professionals should ensure that warfarin treatment is stopped before DOACs are started.
  • Advice is also provided for patients taking VKA. Patients should be reminded of the need to carefully follow the instructions for use for their anticoagulant and asked to let their GP and healthcare team know:
    • if they have symptoms of or confirmed COVID-19 infection, because it is important that they continue to have their INR monitored while they are ill;
    • of any recent changes to their diet (including alcohol consumption) or lifestyle
    • if they are ill with sickness or diarrhoea or have lost their appetite, or are unable to attend their next scheduled blood test for any reason, including because they feel unwell.
  • This information is also available in Drug Safety Update [Added 28 October. Last updated October 22]
  • This information, aimed at patients, is available at: Warfarin and other blood thinners – reminder on safe use during COVID-19 pandemic [Added 28 October. Last updated October 13]

Primary Care Cardiovascular Society: COVID-19 Learning Bites

The Primary Care Cardiovascular Society has produced a number of COVID-19 ‘learning bites’, including:

  • Maintaining anticoagulation efficacy and safety during the COVID-19 crisis – should I be switching my warfarin to a DOAC?
  • Assessment of hypertension in primary care in a time of COVID-19.
  • Treatment of hypertension in primary care in a time of COVID-19.
  • Practical considerations around the diagnosis and management of patients with heart failure during the COVID-19 crisis.

Administration update (17th February 2021): Added to “NHS England/ NHS Improvement: Clinical guide for the management of anticoagulant services during the coronavirus pandemic” that patients with mechanical heart valves must be initiated on warfarin.