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

1. Biomarker Elevation Suggesting Cardiovascular Conditions in Patients with COVID-19 Infection


  • Cardiomyocyte injury, as quantified by cTnT/I, and haemodynamic stress, as quantified by BNP and NT-proBNP, may occur in COVID-19 infections, the level of those biomarkers correlate with disease severity and mortality
  • cTnT/I and BNP/NT-proBNP concentrations should be interpreted as quantitative variables


Cardiac Troponin I/T


  • Cohort studies showed that 5–25% of COVID-19 patients had elevations in cTn T/I, elevations more common in patients admitted to the ICU and among those who died.  In non-survivors, troponin levels progressively increased in parallel with the severity of COVID-19 and the development of ARDS
  • Mild elevations (e.g. < 2–3 times the ULN), can be explained by the combination of possible pre-existing cardiac disease AND/OR the acute injury related to COVID-19 and do NOT require work-up or treatment for T1MI, unless strongly suggested by angina chest pain and/or ECG changes
  • Marked elevations (e.g. > 5 times the ULN) may indicate the presence of shock; in the absence of symptoms or ECG changes suggestive of T1MI, echocardiography should be considered in order to diagnose the underlying cause; patients with symptoms and ECG changes suggestive of T1MI should be treated according to ESC-guidelines irrespective of COVID-19 status




  • As quantitative markers of haemodynamic stress and HF, concentrations of BNP/NT-proBNP in a patient with COVID-19 should be seen as the combination of the presence/extent of pre-existing cardiac disease AND/OR the acute haemodynamic stress related to COVID-19
  • Release of BNP/NT-proBNP seems to be associated with the extent of right ventricular haemodynamic stress




  • D-dimers indicate presence of thrombin formation, unspecific acute phase response, or disseminated intravascular coagulation associated with shock. Markers of activated coagulation or impaired fibrinolysis might contribute to acute myocardial injury. Therefore, markers of haemostasis should be monitored.
  • Elevations of D-dimers have been associated with poor outcome.
  • Despite low specificity for diagnosis of acute PE, algorithms combining pre-test probability and D-Dimer can be used in suspected acute PE.


2.  Which Biomarkers Should be Measured and When?


  •  cTnT/I concentrations should be measured whenever on clinical grounds T1MI is suspected
  • ESC hs-cTn T/I 0/1-h algorithm is recommended
  • higher percentage of patients remaining in the observe zone expected, detailed clinical assessment including chest pain characteristics, assessment of COVID-19 severity, hs-cTn T/I measurement at 3 hours, and cardiac imaging including echocardiography are the key elements for the identification of MI in this heterogeneous subgroup
  • BNP should be measured whenever on clinical grounds HF is suspected
  • In patients who are not critically ill, rule-in cut-offs for HF maintain high positive predictive value
  • in contrast, currently recommended cut-offs should not be applied in critically-ill patients, as most critically-ill patients have substantial elevations in BNP/NT-proBNP, most likely due to the near-universal presence of haemodynamic stress and HF in these patients
  • routine measurements of cTnT/I and/or BNP/NT-proBNP in patients with COVID-19 given the current very limited evidence for incremental value for clinical decision-making is discouraged