key: cord-0883669-wgtoc544
authors: Awad, Wael I.; Idhrees, Mohammed; Kennon, Simon; Bashir, Mohamad
title: Coronary artery bypass grafting surgery versus percutaneous coronary intervention: What is the clinical decision framework amid COVID‐19 era?
date: 2020-07-11
journal: J Card Surg
DOI: 10.1111/jocs.14833
sha: 60da2ff75d7f7c667b5786c0ead416ee3cddeecd
doc_id: 883669
cord_uid: wgtoc544

nan

In response to pressures on global health services, the elective component of our work has been reduced. Emergency and urgent patients, however, will continue to need care and thus, we need to provide the best local solutions to maintain the appropriate management of these patients without increasing the risk of disease propagation, while still protecting resources for the response to Coronavirus.

In an investigation of the prevalence of SARS-CoV-2 within hospitals, the virus was widely distributed in the air and on object surfaces in both the ICU and general wards, implying a potentially high infection risk for medical staff and patients alike. 1 The contamination was greater in the ICU than in the general wards and the transmission distance of SARS-CoV-2 might be 4 m. As patients undergoing cardiac surgery will spend longer periods in hospital and ICU than patients undergoing percutaneous coronary intervention (PCI), this will ultimately influence the choice of intervention recommended by clinicians and chosen by patients. The median incubation period is considered to be 5 to 6 days for COVID-19, with a range from 1 to 14 days. 5 Moreover, prolonged viral RNA shedding has been reported from nasopharyngeal swabs (up to 37 days after onset of symptoms). Immunocompromised patients may shed SARS-CoV-2 virus for prolonged periods and as cardiac surgery with cardiopulmonary bypass induces postoperative immunosuppression and impaired pulmonary function, there is an argument for PCI or a delay to surgery for at least 6 weeks.

worse in-hospital outcomes and should be protected from infected subjects and those whose COVID-19-related status is still unknown. 6 Wang et al 7 Patients with CAD appear to share the same co-morbidities as those with COVID-19. A large Chinese study analyzing data of 44 672 confirmed COVID-19 cases revealed 12.8% had hypertension, 5.3% diabetes, and 4.2% cardiovascular disease (CVD). 8 A further study of 5700 patients from the USA reported a similar message that hypertension (56.6%), obesity (41.7%), diabetes (33.8%), CAD (11.1%) and congestive heart failure (6.9%) were common comorbidities in patients with COVID-19. 9 Although the clinical manifestations of COVID-19 are dominated by respiratory symptoms, some patients develop severe cardiovascular damage. 10 Cardiac involvement is common in COVID-19 and adversely affects prognosis. Myocarditis appears in COVID-19 patients several days after initiation of fever, indicating myocardial damage caused by the SARS-CoV-2. Furthermore, myocardial injury secondary to COVID-19 infections is associated with increased cardiac biomarker levels, which may be a consequence of both myocarditis and ischemia, complicating decision making, and management.

COVID-19 patients appear to be at higher risk for thrombotic disease states including acute coronary syndrome (ACS), venous thromboembolism (VTE) and stroke. COVID-19 may predispose to VTE in several ways including through endothelial dysfunction, systemic inflammation, and release of high plasma levels of proinflammatory cytokines and platelet activation. 11 ACS and acute myocardial infarction can occur in patients with COVID-19 due to heightened thrombotic activity. Given the elevated risks in affected patients, consideration is now being given to thrombolytic therapy. 11 In addition, there are increasing concerns about a possible increase in platelet aggregability associated with COVID-19 leading to stent thrombosis. Thus, patients undergoing coronary stenting may be at increased risk and the ideal antiplatelet therapy in these patients needs further investigation.

A study examining the clinical characteristics and outcomes of patients with SARS-CoV-2 infection undergoing surgery, suggests that surgery accelerates and exaggerates disease progression of COVID-19. 12 Patients developed COVID-19 symptoms within a few days of the surgery suggesting that these patients were in their incubation period before undergoing surgery. In addition, the mortality rate appears higher than the reported overall mortality rate of 2% to In patients with COVID-19, unless requiring emergency surgery, we advocate a delay of surgery until recovered or PCI, if surgery cannot be delayed. In those with unknown COVID-19 status, preoperative testing is mandatory and patients should only be offered surgery if the results are negative. If results are not available and the patient needs urgent surgery, the patient should be nursed in a side room until shown to be negative. When considering these recommendations, it is important to also consider the test sensitivity/ specificity.

Multiple protocols have been mandated to provide a safety net for cardiac patients attending hospitals for interventions. It appears that these stringent protocols have minimized the number of COVID patients entering tertiary centers, but it remains undetermined whether they are effective in optimizing outcomes in patients with cardiac disease in general and amongst infected patients.

With increasing fatalities worldwide and governments poised between lockdown and easing measures, the future is uncertain. Patients with CAD will continue to die with and without treatment, waiting lists will get longer and patients will present at a more advanced stage of their disease. Given the fluidity of the situation, there is a need for new clinical decisionmaking processes and frameworks that help guide patients to the appropriate revascularisation strategy of coronary artery bypass grafting or PCI amid COVID is needed.

And it may be appropriate that these recommendations appear to contradict legacy guidelines derived from studies undertaken in a pre-COVID era. 

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