The COVID-19 pandemic has changed the practice of cardiology as we know it, leading to supplies shortages, delayed procedures, and an at-risk patient population fearful of the road ahead. How has the outbreak affected cath labs? A new joint statement from the American College of Cardiology (ACC) and Interventional Council and Society of Cardiovascular Angiography and Intervention (SCAI) addressed that very subject, providing guidance for healthcare providers throughout the United States.
The statement, published online in the Journal of the American College of Cardiology, was written by Frederick G.P. Welt, MD, University of Utah Health Sciences Center, and colleagues from both the ACC Interventional Council and SCAI.
“COVID-19 has placed an enormous strain on the healthcare systems of the nations where it has spread widely, with specific implications of the disease on practice in the catheterization laboratory,” Welt et al. wrote. “These implications include how we might modify practice for standard cardiac patients, those who are suspected COVID-19 patients, and those patients with COVID-19 who have either unrelated cardiac conditions or cardiac manifestations of the disease. It merits emphasis that this is a dynamic situation and one for which there are limited data. In addition, local conditions may vary considerably.”
A moratorium on elective procedures is already in place in much of the country, one of many ways providers are hoping to prevent at-risk patients from being exposed to the disease. The authors emphasized that, “under any circumstance,” elective procedures should be avoided if the patients has “significant comorbidities,” the length of stay is expected to last longer than two days, or if the use of an intensive care unit would be required.
Percutaneous coronary interventions (PCIs) for stable ischemic heart disease and patent foramen ovale closures are listed as specific examples of elective procedures that can be delayed.
“Case decisions should be individualized, taking into account the risk of COVID-19 exposure versus the risk of delay in diagnosis or therapy,” the authors explained.
When patients have a confirmed COVID-19 diagnosis and ST-segment elevation myocardial infarction (STEMI), fibrinolysis “can be considered an option” if the patient is “relatively stable.” When primary PCI is to be performed on a COVID-19 patient, “appropriate personal protective equipment” is necessary, and cath labs “will require a terminal clean following the procedure” that could delay the treatment of other patients.
For patients with non-ST-segment elevation myocardial infarction (NSTEMI) who could have the disease, on the other hand, “timing should allow for diagnostic testing for COVID-19 prior to cardiac catheterization, and allow for a more informed decision regarding infection control.” Unstable NSTEMI patients, the authors noted, may be viewed under the same guidelines as STEMI patients if their “instability is due to the acute coronary syndrome (rather than other factors).”
Welt and colleagues also wrote about how providers should handle patients who require intubation, suctioning, and CPR, scenarios that “likely result in aerosolization of respiratory secretions.”
“Patients who are already intubated pose less of a transmission risk to staff given that their ventilation is managed through a closed circuit,” the authors wrote. “Patients with COVID-19 or suspected COVID-19 requiring intubation should be intubated prior to arrival to the catheterization laboratory. Further, the threshold to consider intubation in a patient with borderline respiratory status may need to be lowered in order to avoid emergent intubation in the catheterization laboratory.”
Staff shortages, limited resources are expected
Cath labs should anticipate shortages, both due to the possibility of infected or quarantined staff and because of personal issues such as school closings. This could also lead to certain procedures typically performed in the cath lab—pulmonary artery catheter placement, for instance—to be treated as bedside procedures for a considerable time.
The joint statement also addressed the known shortage of N95 masks and the “emerging reports” of shortages of gowns, gloves and even regular surgical masks.
“This supports the deferral of elective cases and a reduction in the number of people who scrub into procedures,” the authors wrote. “This is particularly relevant for teaching institutions where multiple physicians often scrub into cases.”