One of the first statements in this document points out these are not “regular guidelines” developed after thorough analysis of all the available evidence published since the last update. Instead, they are meant to provide temporary basic management pointers on how to handle different scenarios of cardiac patients in the context of the COVID-19 pandemic.
Not only is COVID-19 capable of producing viral pneumonia, but also several major complications to the cardiovascular system.
Patients with classic risk factors (male sex, old age, diabetes, hypertension, and obesity) and also patients with diagnosed cerebral and cardiovascular disease, are especially vulnerable to the new coronavirus.
In addition to the possibility of COVID19 presenting as artery or venous thrombosis, with the consequent acute coronary syndrome or venous thromboembolism, the new coronavirus can produce myocarditis and therefore plays an important role in patients with cardiac failure.
A big spectrum of arrhythmias has been reported along the course of the COVID-19 infection, including many produced as adverse effects of medication used in an attempt to treat the infection or its complications.
As an effect of resource redistribution, the access to emergency treatments (such as primary PCI) could be negatively affected depending on pandemic severity at local level. This is exacerbated by the concern raised by deferred consultation, since patients are afraid of catching the disease in the process.
For all these reasons, the European Society of Cardiology (ESC) has published this document with the most relevant aspects of our cardiovascular patients in the context of the pandemic.
This document, of over 100 pages, goes over all cardiology care aspects, but we deem essential that we focus on patients in need of immediate treatment, aiming at:
- Increasing the health system’s capacity to treat COVID-19 patients
- Reducing unnecessary exposure to hospital environment (both for patients and their families)
- Reducing health care staff exposure to asymptomatic patients potentially infected with COVID-19.
These patients should be handled according to risk stratification and should immediately receive a diagnostic COVID-19 test, regardless the ACS strategy. This information will let healthcare staff take adequate protection measures.
Patients can be categorized into four risk groups: very high, high, intermediate and low risk.
Those with troponin elevation, but with no acute clinical signs of instability (change in EKG or recurrent angina) can be managed conservatively at first. A CT angiography could greatly improve stratification times, avert the cath lab, and prompt early discharge.
For high risk patients, we should take all clinical and pharmacological measures to stabilize them and plan an early invasive strategy (<24 horas). This time could extend in case of positive COVID-19 patients, who should be transferred to dedicated correctly equipped centers.
Intermediate risk patients should be carefully assessed looking at alternative diagnosis such as myocarditis or myocardial injury in the context of COVID-19 infection. If available, again a CT angiography can be of great help for effective management.
In times of high infrastructure demand, conservative management with early discharge should be considered together with a follow-up plan, ideally via tele-health.
This pandemic should not compromise MI patient access to early reperfusion. All specific guidelines remain valid, making sure the exceptional operator protection protocols are met.
Since there is not time to wait for COVID-19 test outcomes, all patients admitted to the cath lab should be handled as positive.
The longest between MI diagnosis and reperfusion should be 120 minutes, providing the following requirements are met:
- Primary PCI continues to be the preferred strategy, if available, and operators should follow all protection protocols
- Primary PCI could be delayed by local transport hassle, depending on the country.
- If the target time cannot be met, we should immediately prescribe an antithrombotic, unless counter indicated. It might even be the first line of treatment in areas with systems saturated by the pandemic.
All patients undergoing an ST elevation MI must be tested for COVID-19 as soon as possible and regardless the reperfusion strategy implemented, or its success. If there were other lesions, consider immediate revascularization to prevent rehospitalizations and shorten hospital stay.
All physicians involved in the management of MI patients should be familiarized with antithrombotics indication and counter indication. In many institutions where primary PCI used to be standard, their physicians might not have the proper experience for the correct use of antithrombotics.
Patients with chronic coronary syndromes
- These are in general patients at low risk of cardiovascular events whose diagnostic and therapeutic studies can be deferred, in most cases.
- Medical treatment should be optimized and intensified
- Telemedical follow-up should guarantee clinical status changes requiring a change of strategy will be identified.
For symptomatic patients suspected of CAD with a pre-test probability between 5% and 15%, we initially recommend a functional test with imaging or CT. In regions where the health care system is saturated by the pandemic, these tests might be put off in most cases and, if necessary, we should favor CT angiography.
This can also be a problem given CT service saturation, because of the high request of pulmonary CTs as a consequence of COVID-19.
In symptomatic patients with a high clinical chance of having obstructive CAD, we habitually use the direct invasive strategy. However, these patients can be initially handled conservatively in the context of the pandemic, with close clinical watch.
PCI or CABG can be put off in most cases. According to the local epidemiological circumstance, coronary unit beds should be available for COVID-19 patient management.
The guidelines also provide recommendations for electrophysiological procedures, patients with cardiac failure, arrhythmias, hypertensives, structural cardiology, etc. WE have recently published in our web a summary of guidelines for the management of structural cardiomyopathies in the context of the pandemic which does not conflict this document’s recommendations.
As mentioned at the beginning of this article, these are only temporary guidelines to handle this extraordinary situation and in no way replace the criteria of physicians in charge or healthcare policies in any region.
We are interested in your opinion. Please, leave your comments, thoughts, questions, etc., below. They will be most welcome.