European Association of Percutaneous Cardiovascular Interventions Position Statement During the Pandemic

This document emerges from the assembly of the European Association of Percutaneous Cardiovascular Interventions (EAPCI) and the Acute Cardiovascular Care Association (ACVC).

Both associations gathered their most prominent experts, including people who worked in the European areas most affected by COVID-19.

Their aim was to modify diagnostic and therapeutic algorithms to adapt the evidence collected over many years to these unprecedented times.

Various clinical scenarios were described in order to reorganize the management of acute cardiac patients during the pandemic.

Myocardial injury: the role of biomarkers

• Myocardial injury, quantified as troponin T/I concentration, can occur in a setting of both COVID-19 infection and other pneumonias. Troponin levels correlate with disease severity and prognosis.
• Mild elevations in troponin T/I ( <2 or 3 times the reference limit), particularly in older patients with pre-existing cardiac disease, do not require invasive management for suspected type 1 infarction, unless the angina symptoms and the electrocardiographic results are too obvious.
• Such mild elevation can usually be explained by stress injury related to the infection.
• Elevations >5 times the normal limit may indicate the presence of severe respiratory failure, tachycardia, systemic hypoxemia, shock as part of COVID-19, Takotsubo syndrome, or type 1 infarction triggered by the infection. If there are no symptoms or ECG changes suggesting type 1 infarction, echocardiography can be used to clear any doubts.

Clinical scenarios

• It is critical to differentiate type 1 infarction from other causes of troponin elevation and ECG changes without a coronary cause.
• At the beginning of this pandemic, there was a reduction in the number of visits for ST-segment elevation infarction, followed by an increase in the number of visits due to cardiogenic shock and mechanical complications from an infarction.
• Patients with acute coronary syndrome must be managed as COVID-19 positive patients. They should be admitted through entry points different from those for the general population and they should be hospitalized in dedicated areas within the hospital.
• Patients requiring a computerized tomography (CT) due to a pulmonary condition and presenting troponin elevation can make the most of their situation and undergo a CT coronary angiography. Site resources should obviously be taken into account.
• Suspected epidemiology should be considered, particularly in aerosol-generating procedures.

ST-segment elevation infarction: primary angioplasty or thrombolysis?

• All ST-segment elevation patients must be managed as if they were COVID-19 positive cases.
• Primary angioplasty is the preferred choice if conducted within the first 120 minutes.
• If there are no contraindications, fibrinolytic therapy can be considered in case of delay of more than 120 minutes for primary angioplasty.
• Complete revascularization can be considered if indicated and appropriate (which is mostly left at operator’s discretion).
• Experts also recommend a left ventricular angiogram as opposed to echocardiography to assess ventricular function. Ventricular function can be underestimated during the acute event; we flood the patient with contrast and volume, etc. We believe this is a quite controversial issue, and this study can be perfectly replaced by an echocardiography before discharge. Of course, this last option obviously implies moving equipment and exposing more staff members, both technicians and physicians.

Non-ST-segment elevation infarction

• Extremely high-risk ST-segment elevation infarction cases must be managed early and invasively.
• Extremely high-risk patients managed invasively must be tested for COVID-19 before undergoing a coronary angiography.
• Intermediate-risk patients can be initially handled non-invasively. The ideal method, if available, is CT coronary angiography.
• You may consider adding CT coronary angiography to the CT protocol of COVID-19 positive patients.

Original Title: EAPCI Position Statement on Invasive Management of Acute Coronary Syndromes during the COVID-19 pandemic.

Reference: Alaide Chieffo et al. European Heart Journal (2020) 41, 1839–1851 doi:10.1093/eurheartj/ehaa381.

We are interested in your opinion. Please, leave your comments, thoughts, questions, etc., below. They will be most welcome.