Debra L. Beck and Eugene Braunwald, MD
Published: April 13, 2020
The coronavirus pandemic has made the provision of routine medical care challenging, and acute care more challenging yet. The Chinese Society of Cardiology (CSC) has written a consensus statement on the management of cardiac emergencies during the COVID-19 pandemic.
The statement was developed by 125 experts, including cardiologists and infectious disease specialists, including 23 physicians currently working at the front line of the pandemic in Wuhan, China.
The authors emphasized that three overarching principles guide their recommendations: 1) the highest priority is prevention and control of transmission (including protecting staff); 2) patients should be assessed both for COVID-19 and for cardiovascular issues; and 3) all interventions and therapies provided should always be in concordance with directives of infection control authorities.
Because asymptomatic patients can be a source of infection and transmission, all patients with severe emergent cardiovascular diseases should be managed as suspected cases of COVID-19, particularly in places where the disease is more prevalent.
Individuals presenting with acute cardiovascular events should be assessed for both COVID-19 infection and their cardiac needs simultaneously. Until COVID-19 status is known, a single-bed room should be utilized, patients should be closely monitored for signs of the disease, and efforts made to limit the risk of infection to healthcare workers.
Risk assessment that weighs the relative advantages and disadvantages of treating the cardiovascular disease while preventing transmission can be considered, wrote Han et al. Other recommendations include limiting transfers both within the hospital and between hospitals to the extent possible.
Utilizing select laboratory tests with definitive sensitivity and specificity for disease diagnosis or assessment. These include CT angiography for patients with suspected acute aortic syndrome or acute pulmonary embolism; D-dimer and deep vein ultrasound testing for suspected acute pulmonary embolism is suspected; and electrocardiography and standard biomarkers of cardiac injury for those with suspected acute coronary syndrome.
As well, all patients should undergo lung CT examination to evaluate for imaging features typical of COVID-19. Chest X-ray is not recommended because of a high rate of false negatives. Care should be paid to avoid misdiagnosing patients with pulmonary infarction as COVID-19 pneumonia.
Medical therapy should be optimized in patients presenting with acute cardiac needs, with invasive strategies for diagnosis and treatment used with caution.
For the duration of the pandemic, while risk of infection is high for healthcare workers and resources are stretched, they recommend that invasive management should be reserved for only the following conditions: ST-segment myocardial infarction (STEMI) with hemodynamic instability, life-threatening non-STEMI, Stanford type A or complex type B acute aortic dissection, bradyarrhythmia complicated by syncope or unstable hemodynamics mandating implantation of a device, and pulmonary embolism with hemodynamic instability in patients for whom intravenous thrombolytics are contraindicated.
In an intervention is to be done, negative-pressure ventilation should be used in the catheterization laboratory or operating room, with strict periprocedural disinfection and high-level use of personal protection equipment (PPE). Even in areas with low incidence of COVID-19, interventions should be used sparingly and with higher than standard levels of disinfection and PPE.
If negative-pressure ventilation is not available, air conditioning (e.g., laminar flow and ventilation) should be stopped.
The authors concluded that “[I]ndividualized diagnosis and treatment measures tailored to specific local epidemic situations should be developed.” As well, patients should be encouraged to not delay presenting to a hospital in the event of an acute cardiac emergency.
References
Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine features a unique update program by Dr. Braunwald, creating a “living textbook” by featuring twice monthly updates including “Hot off the Press” and Late-Breaking Clinical Trials (links to authors’ presentation slides are also included).
Learn more about Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, 11th Edition. Download a free chapter here.
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