Diagnosis and treatment strategy of coronavirus disease 2019 with cardiovascular disease in elderly patients

31.2% of COVID-19 patients are reported to be over 60 years old, 81% of the dead patients are elderly patients over 60 years old.1 Up to 24:00 January 22, 2020 there were 425 confirmed cases of COVID-19 as reported by the National Health Commission of the People’s Republic of China.1 Furthermore, 162 (or 38.1%) of these patients were older than 65 years and 40% of this older age group were complicated with cardiovascular disease. The mechanisms of heart injury caused by viral pneumonia are as follows2: the virus directly damages the myocardium, resulting in viral myocarditis; at the same time, viral infection leads to an inflammatory storm that causes cardiovascular events, such as acute coronary syndromes and arrhythmias. According to the research,3 these cardiovascular complications could persist for a long time, even for more than 10 years. Even with advanced medical examination methods and powerful medical data analysis for reference, it is still very difficult to select diagnostic strategies for patients with pneumonia and cardiovascular diseases because the pulmonary imaging features of these two diseases are complicated. For example, ground-glass shadow and septal thickening are shared features of the two diseases. Therefore, clinical experience is very important in such cases.

Even with advanced medical examination methods and powerful medical data analysis for reference, it is still very difficult to select diagnostic strategies for patients with pneumonia and cardiovascular diseases because the pulmonary imaging features of these two diseases are complicated. For example, ground-glass shadow and septal thickening are shared features of the two diseases. Therefore, clinical experience is very important in such cases.

| PROG RE SS IN E ARLY D IAG NOS IS OF COVID -19 WITH C ARD I OVA SCUL AR D IS E A S E S IN ELDERLY PATIENTS
In China, the diagnosis of COVID-19 goes through three stages.
In the first stage, suspected cases are tested for the new coronavirus nucleic acid with real-time fluorescence-based polymerase chain reaction or virus-gene sequencing is carried out. In the second stage, the clinical diagnosis is added, and pulmonary

| Problems
At present, the supply of COVID-19 nucleic acid testing kits varies greatly among different cities in China. Clinicians not specializing as cardiologists have little knowledge of cardiovascular diseases, and their clinical experience varies greatly.
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| E ARLY RIS K S TR ATIFI C ATI ON AND THE S IG NIFIC AN CE OF MULTIDISCIPLINARY TE AMWORK
Risk stratification in the early stage plays a great role in predicting prognosis and developing treatment strategies. As novel interventions are introduced constantly, risk stratification is also updated. Multiple

| Issues
In spite of significant progress that has been made in the assessment of heart failure, it is undeniable that non-cardiologists lack cardiovascular knowledge. Furthermore, the way of clinical thinking of cardiologists and non-cardiologists is different. In addition, the diagnosis and treatment vary by geographic regions. Thus, there is an area for development. The multidisciplinary team consultation system can bridge the gap in the application of various clinical guidelines in different disciplines and promote the optimization of treatment strategies.

| Medication directions for the elderly
The total amount of liquid and excessive speed of infusion should be appropriately limited. Generally, infusion speed < 0 mL/h or <1400 mL/24 h (except for fluid resuscitation with additional capacity) has little impact on cardiac function of the elderly with cardiovascular disease. At the same time, it is necessary to guard against aspiration pneumonia and heed nutrition support.

| S TATUS OF C ARDIOPULMONARY REHAB ILITATION AND S ECONDARY PRE VENTI ON
Pulmonary rehabilitation includes exercise training, patient education, and behavior change. It aims to change the physical and mental state of patients with chronic respiratory diseases, improve patients' compliance with long-term healthy behaviors, alleviate symptoms, and reduce disability.
Effective cardiac rehabilitation is very important to help patients improve their quality of life, and to prevent reinfarction and sudden cardiac death. 8 Different plans are made for the acute and convalescent phases. Cardiac rehabilitation starts from admission, including acute phase (4-7 days after onset), convalescence (7 days-4 weeks in early convalescence, 2-6 months in late convalescence), and maintenance phase (6 months to lifetime). 9 Secondary prevention is the key to reducing the recurrence rate and mortality of cardiac events. The current problem is an overall decline in the use of cardiovascular medications after discharge according to longterm follow-up. So, it is significant for doctors to develop individualized treatment and conduct early and close follow-up. It is necessary to note that patients with viral myocarditis may develop malignant arrhythmia or exacerbation of atrioventricular block within 2-4 weeks of onset.
To sum up, doctors should conduct standardized diagnostic stratification and rational medication, especially in the early stage.
It is worth emphasizing that the multidisciplinary team consultation system could shorten the course of treatment and reduce the occurrence of critical illness and multiple organ failure.

CO N FLI C T S O F I NTE R E S T
Nothing to disclose.