key: cord-0936871-le76u2ua authors: Wood, David A.; Mahmud, Ehtisham; Thourani, Vinod H.; Sathananthan, Janarthanan; Virani, Alice; Poppas, Athena; Harrington, Robert; Dearani, Joseph A.; Swaminathan, Madhav; Russo, Andrea M.; Blankstein, Ron; Dorbala, Sharmila; Carr, James; Virani, Sean; Gin, Kenneth; Packard, Alan; Dilsizian, Vasken; Légaré, Jean-François; Leipsic, Jonathon; Webb, John G.; Krahn, Andrew D. title: Safe Reintroduction of Cardiovascular Services during the COVID-19 Pandemic: Guidance from North American Societies date: 2020-05-04 journal: Can J Cardiol DOI: 10.1016/j.cjca.2020.04.031 sha: 14245ceafcc7c0f5ffc40578d5709a0957d21394 doc_id: 936871 cord_uid: le76u2ua nan The COVID-19 pandemic has led to marked global morbidity and mortality [1] [2] [3] . There have been appropriate but significant restrictions on routine medical care to comply with public health guidance on physical distancing, and to help preserve or redirect limited resources. Most invasive cardiovascular (CV) procedures and diagnostic tests have been deferred with North American cardiovascular societies advocating for intensified triage and management of patients on waiting lists 4 . Unfortunately, patients with untreated cardiovascular disease are at increased risk of adverse outcomes 5 . Delays in the treatment of patients with confirmed cardiovascular disease will be detrimental. Similarly, reduced access to diagnostic testing will lead to a high burden of undiagnosed cardiovascular disease that will further delay time to treatment. Although there will be a myriad of competing demands from multiple disciplines, this risk warrants the prioritization of cardiovascular patients as healthcare systems return to normal capacity 4 . While COVID-19 has had a global impact, there are regional differences in the burden of the pandemic. Some regions have not experienced a significant surge of cases variably related to social and health care adaptation measures, or the surge has passed and was less substantial than predicted. In these areas, there are available health sector resources that can be redeployed quickly. As regions move along the journey of managing the COVID-19 pandemic, there is an opportunity to reintroduce regular cardiovascular care in a progressive manner with appropriate safeguards. Cardiovascular societies have released a number of position or guidance statements which predominantly focus on the provision of cardiovascular care during the peak of the pandemic 6-12 . These documents highlight the central theme of balancing essential cardiovascular care services while reducing exposure and preserving health care resources to address the pandemic. As the COVID-19 pandemic abates, developing appropriate strategies to reintroduce routine cardiovascular care will be crucial. Unprecedented times require unprecedented collaboration. In this consensus report, we harmonize recommendations from North American cardiovascular societies and provide guidance on the safe reintroduction of invasive cardiovascular procedures and diagnostic tests after the initial peak of the COVID-19 pandemic. Similar to rationing decisions made in preparation for the initial surge of COVID-19 cases, progressive and thoughtful reintroduction of cardiovascular services must be based on robust ethical analysis 13 . Relevant values to be operationalized include 14 : 1) Maximizing benefits such that the most lives, or life years are saved so that procedures or tests that are likely to benefit more people and to a greater degree are prioritized over procedures that will benefit fewer people to a lesser degree; 2) Fairness such that like cases are treated alike, taking into consideration baseline health inequities; 3) Proportionality such that the risk of further postponement is balanced against the risk of exacerbating COVID-19 spread; and 4) Consistency such that reintroduction is managed across populations and among individuals regardless of ethically irrelevant factors such as ethnicity, perceived social worth or ability to pay. Finally the promotion of procedural justice, with the use of an ethical framework 15 , is essential to ensure all decisions reflect best available evidence with transparent communication. Collaboration between regional public health officials, health authorities and cardiovascular care providers Some regions have seen an escalation in COVID-19 cases when social restrictions and physical distancing have been eased. Hospital based CV teams must establish active partnerships with regional public health policy makers to exchange up-to-date information on both the local status of the pandemic and the growing morbidity and mortality on cardiovascular waiting lists. This is essential for the safe reintroduction of regular CV services. There should be a sustained reduction in the rate of new COVID-19 admissions and deaths in the relevant geographic area for a prespecified time interval as determined by local public health officials before changes can be implemented. Importantly, if COVID-19 admissions and deaths start to increase, there must be immediate and transparent cessation of most elective invasive procedures and tests. Resumption of these services would occur in collaboration with regional public health policy makers. As discussed below, COVID-19 testing of potential patients and health care workers (HCW), as well as personal protective equipment (PPE), must also be carefully monitored to minimize the risk of shortages as the pandemic escalates and abates. A cohesive partnership with regional public health officials will facilitate management of the dynamic balance between provision of essential cardiovascular care and responding to ongoing fluctuations in COVID-19 admissions and deaths. The protection of patients and HCWs must be addressed before any reintroduction of cardiovascular procedures and tests. Regions must have the necessary critical care capacity, PPE, and trained staff available before the recommendations summarized in Table 1 can be implemented. Importantly, a transparent plan for testing and re-testing potential patients and HCWs for COVID-19 must be operationalized before elective procedures and tests are resumed. Additional considerations include: 1) Physical distancing: Consider strategies to minimize patient contact with HCWs performing invasive cardiovascular procedures and diagnostic tests. These may include virtual pre-procedural clinics, virtual consenting for procedures and diagnostic tests, and minimizing the number of HCWs in physical contact with any given patient. Restrictions should be implemented on the number of people that can accompany a patient or visit a patient after a procedure or test. Whenever possible, multiple tests or procedures should be consolidated into a single comprehensive visit. 2) COVID-19 Screening: Encourage routine screening of all patients prior to any cardiovascular procedure or test to ensure the safety of HCWs. This testing may include nasopharyngeal swabs and saliva or rapid antibody tests and should be guided by local institutional infectious disease experts and closely coordinated with regional public health officials. Key considerations include the availability and accuracy of the above tests as well as the frequency and timing of COVID-19 testing and re-testing. Appropriate PPE is required to protect HCWs even if patients are asymptomatic, as the sensitivity of available tests are low in this setting. A significant benefit of testing is the opportunity of defer COVID-19 positive patients if they remain clinically stable. 3) PPE: The use of PPE for HCWs during routine cardiovascular procedures and diagnostic tests will be an important consideration. The need to ensure staff safety must be balanced against the need to conserve PPE supplies in the event the pandemic escalates. Emergent cases, such as ST segment elevation myocardial infarction (STEMI) patients and urgent surgeries, or aerosol-generating medical procedures (AGMP) will likely continue to require the highest level of PPE for the foreseeable future and thus available supplies must be carefully monitored. Leaders from the North American cardiovascular societies acknowledge that the recommendations in this guidance document are based predominantly on expert opinion. This reflects the global challenge of managing a new and rapidly evolving pandemic where evidence is limited. 1) Decisions regarding transitioning between Response Levels requires close collaboration with public health officials and health systems. It is expected this process will be dynamic and continue to evolve as new information becomes available. 2) A transparent collaborative plan for COVID-19 testing and PPE use must be in place before a safe reintroduction of procedures and tests can occur. 3) It is expected that different regions will be at different Response Levels as the pandemic escalates and abates. 7) The language in Table 1 was chosen to give clinicians, health systems and policy makers the maximum flexibility when moving between Response Levels in their region. COVID-19 prevalence, admission and death rates as well as appropriate time intervals for safe reintroduction will change and thus, we utilized "selective" cases and "some" or "most" cardiovascular procedures in Table 1 . This consensus report provides harmonized guidance from North American cardiovascular societies. It provides an ethical framework with appropriate safeguards for the gradual reintroduction of invasive cardiovascular procedures and diagnostics tests after the initial peak of the COVID-19 pandemic. A collaborative approach will be essential to mitigate the ongoing morbidity and mortality associated with untreated cardiovascular disease. • COVID-19 status may be unavailable at time of STEMI. Use of PPE will be dictated by regional health authority and COVID-19 penetrance. • PPCI for most patients. Selective pharmacoinvasive therapy as per regional practice. • If moderate/high probability or COVID-19 +ve consider alternative investigations (TTE and/or CCT) prior to cath lab activation or pharmacoinvasive therapy • COVID-19 status may be unavailable at time of STEMI. Use of PPE will be dictated by regional health authority and COVID-19 penetrance. • PPCI for most patients. Selective pharmacoinvasive therapy as per regional practice. • If moderate/high probability or COVID-19 +ve consider alternative investigations (TTE and/or CCT) prior to cath lab activation or pharmacoinvasive therapy • COVID-19 status may be unavailable at time of STEMI. Use of PPE will be dictated by regional health authority and COVID-19 penetrance. • PPCI for most patients. Selective pharmacoinvasive therapy as per regional practice. • If moderate/high probability or COVID-19 +ve consider alternative investigations (TTE and/or CCT) prior to cath lab activation or pharmacoinvasive therapy • NSTEMI (High Risk) -Invasive strategy (Refractory symptoms, hemodynamic instability, significant LV dysfunction, suspected LM or significant proximal epicardial disease, GRACE risk score >140) • A Novel Coronavirus from Patients with Pneumonia in China First Case of 2019 Novel Coronavirus in the United States Covid-19 in Critically Ill Patients in the Seattle Region -Case Series Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the Coronavirus Disease 2019 (COVID-19) Pandemic Reduction in ST-Segment Elevation Cardiac Catheterization Laboratory Activations in the United States during COVID-19 Pandemic Precautions and Procedures for Coronary and Structural Cardiac Interventions during the COVID-19 Pandemic: Guidance from Canadian Association of Interventional Cardiology Triage Considerations for Patients Referred for Structural Heart Disease Intervention During the Coronavirus Disease 2019 (COVID-19) Pandemic: An ACC /SCAI Consensus Statement ASE Statement on Protection of Patients and Echocardiography Service Providers During the 2019 Novel Coronavirus Outbreak Society of Cardiovascular Computed Tomography Guidance for Use of Cardiac Computed Tomography Amidst the COVID-19 Pandemic Adult cardiac surgery during the COVID-19 Pandemic: A Tiered Patient Triage Guidance Statement Cardiac surgery in Canada during the COVID-19 Pandemic: A Guidance Statement from the Canadian Society of Cardiac Surgeons Infarction During the COVID-19 Pandemic Fair Allocation of Scarce Medical Resources in the Time of Covid-19 Principles for allocation of scarce medical interventions A Framework for Rationing Ventilators and Critical Care Beds During the COVID-19 Pandemic. JAMA. 2020. cases: • Congenital heart disease • Cardiac masses • Vascular: thoracic aortic disease and pulmonary vein mapping