key: cord-0972885-m7wpt05x
authors: Gambaro, Alessia; Ho, Hee Hwa; Kaier, Thomas E.; Pires-Morais, Gustavo; Patel, Jignesh A.; Ansari Ramandi, Mohammad Mostafa
title: ACUTE CORONARY SYNDROME MANAGEMENT IN THE COVID-19 ERA: Voices from the Global Cardiology Community
date: 2020-06-09
journal: JACC Case Rep
DOI: 10.1016/j.jaccas.2020.05.074
sha: 1ee0f6ff0ad7184fa1fd2328e35cb658ce68c738
doc_id: 972885
cord_uid: m7wpt05x

nan

The coronavirus disease 2019 (COVID-19) pandemic due to severe acute respratory syndrome coronavirus 2 (SARS-CoV-2) infection has greatly disrupted our professional and personal lives.

Six early career cardiologists briefly comment on their personal experiences.

Everyone in the hospital has to wear surgical masks and no relatives are allowed to visit the patients; they are updated by telephone calls. The hospital and the emergency department (ED) have been reorganised into COVID-19 and non-COVID-19 units. COVID-19 patients needing urgent treatment are admitted to the cardiac catheterization laboratory (CCL) directly and subsequently transferred to COVID-19 units according to their needs. Patients with suspected COVID-19 infection are admitted to the ED where the SARS-CoV-2 test is performed immediately, and then transferred to the CCL. They are then admitted to the Cardiology unit, but isolated in a single monitored room and considered as "infected" until SARS-CoV-2 test results are available. If the first test is negative, a second test is repeated after 72 hours. Patients who are infected are transferred to COVID-19 units, while those negative remain on the Cardiology Unit.

If an urgent interventional procedure is not needed, suspected COVID-19 patients are cared for by the on-call cardiologist and the ED doctors using personal protective equipment (PPE) in the ED until the SARS-CoV-2 test results are available (4-8 hours).

If possible, cardiology consultations are performed remotely. Otherwise, the cardiologist with PPE assesses the patients at the bedside. Dedicated echocardiography machines are used in COVID-19 wards. All the necessary cardiology procedures are performed in COVID-19 patients with adequate PPE and sanitation of the machines and rooms. Elective procedures have been temporarily halted to reduce the contagion risk. Patient follow-up is done remotely (Skype, telephone calls) when possible; those needing direct assessment and treatment (diuretic infusion, ICD re-programming, etc.) are seen in the clinic.

Chinese physicians facing the first wave of patients with COVID-19 advocated for fibrinolysis as first-line therapy for STEMI instead of primary percutaneous coronary intervention (PPCI). In Singapore, PPCI is the first-line reperfusion therapy. We are also treating patients with NSTE-ACS with invasive coronary angiography and PCI. All cath lab staff must use maximal PPE during the procedure and re-establish a sanitary environment when the case is over. We strongly advocate a prophylactic early intubation strategy if the patient demonstrates significant signs and symptoms suggestive of acute respiratory distress or has a high likelihood of respiratory deterioration. An airway team with full PPE and powered air-purifying respirators should ideally be on stand-by for stable patients who were not intubated prophylactically.

PPCI remains the preferred option for patients with STEMI. While fibrinolysis is an option, most patients will require coronary angiography within 24 hours and therefore the risks outweigh the benefits of reduced or delayed operator-exposure. In patients with NSTE-ACS, the goal is riskstratification: we transfer high-risk cases to the CCL for coronary intervention and consider medical therapy with an expedited outpatient test in low-risk cases. This facilitates the rapid discharge of patients to reduce the risk of contracting COVID-19. It is concerning that acute cardiovascular presentations have dropped by 50%.

Routine outpatient visits have been replaced by telephone triage. Those identified as requiring face-to-face assessment are reviewed in a dedicated outpatient clinic. Whilst surgical services have been centralized in a non-COVID-19 hospital, there is a clear preference for transcatheter valve implants over surgical replacement, and PCI over coronary artery bypass grafting, when the patient cannot wait for the 'flattening' of the pandemic curve.

Pre-hospital care remains as usual. We have not changed patient care for ACS, as we believe it results in fewer complications and a shorter hospital stay. Patients with STEMI proceed emergently to the CCL and patients with NSTE-ACS go within 24 hours. The weekend activity does not differ from weekdays. Samples for SARS-CoV-2 are collected, but results are only available after 8 hours. Patients with confirmed/suspected infection are admitted to COVID-19 units.

The initial department plan divided the cardiology staff into three teams, each working for seven days while providing full service (inpatient care, interventional cardiology, pacing/EP and cardiac imaging), while others stayed home. Following a 40% reallocation of staff to COVID-19 units, a second plan was set in motion dividing the remaining staff into two teams performing seven-day rotations. All routine outpatient cardiology activity was cancelled. Secure, remote access to hospital software was created, allowing for at-home phone appointments, electronic prescription of medication, and review of medical imaging or data.

The CCL nursing staff was reinforced to speed-up procedures. All non-critical equipment or supplies were removed from the CCL to facilitate cleaning/disinfection procedures. Availability of PPE is a concern, so we created two sets of PPE to best manage available resources: a midlevel kit and a full-protection kit for suspected/confirmed cases. 

There has been a significant drop in the number of outpatient and ED visits by cardiovascular patients. I have seen more STEMI patients compared with the same period last year, which may be because unstable angina patients are presenting late in fear of being infected at the hospital.

Having no PPCI facilities in smaller cities has made it difficult to manage these patients who are afraid of being referred to a tertiary care hospital during the pandemic. I identified my high-risk patients through the hospital data system and contacted them by phone to raise awareness about important cardiovascular signs and symptoms and to answer their concerns. This was highly appreciated.

I am a young cardiologist working in a COVID-19 intensive care unit. My social life is limited to phone and skype calls. To avoid the risk of reciprocal contagion with my partner (a physician as well) we decided to live in different flats (we are lucky that we have this possibility). I commute from home to hospital with a car I have rented. There are still too many people using public transportation, and we are experiencing a shortage of masks. The last time I met my parents was 6 weeks ago. I could not meet my father when he was in the hospital. We are living a very stressful situation in solitude, with fear of falling sick, and experience the loss of patients every day. That said, more than 30% of registrars and young specialists have volunteered to work in COVID-19 units. People and newspapers say that we are heroes. It is not true. We simply do our job.

My hospital is co-located with the National Centre for Infectious Disease ( 

Some of the long-term gains that often informed the outcome in a heart team discussion are not only being re-evaluated, but pale in comparison with the perceived short-term risk from potential exposure to a viral pathogen. Cardiology trainee work now focuses on providing acute cardiovascular on-call care with back-up in the case of sickness. Training opportunities had to be put on hold. The worry amongst colleagues and their households is palpable. With my wife a fellow healthcare worker, we felt that exposure was a question of when rather than if -a daunting prospect (and ultimately true). We are all more stressed than ever, and the social separation makes this harder still. What keeps us awake at night is the worry for our families, who live in different European countries; never have they felt so far away to us. When the lockdown is over, that basic human connection will be held in even higher regard.

I am an interventional cardiologist currently working in one of three intensive care units dedicated to COVID-19 patients, and I have not been with my parents or siblings for nearly two months. In a unique occasion, my family met for Easter lunch using an internet video platform. I am in close contact with a group of friends, though physically apart. All this 'distant proximity' is invaluable.

A relevant number of colleagues at work have dramatically changed their lifestyle. Family care is a major concern and some are living in hotels to prevent contact with families at home. Some who have tested positive for COVID-19 in a number of consecutive tests are anxious to test negative and receive permission to go back to work. Many young residents in cardiology had been studying for months when they saw the much-awaited date of the final residency examination postponed, and yet they joined the frontline at the hospital.

Despite the concern of the medical community, we believe society has largely adhered to the social isolation recommendations as we are looking at a constant drop in intensive care unit admissions and an increase in patients successfully discharged. The availability of masks for everyone is still not a reality as we are conceiving the first draft of a plan to reduce restriction measures.

Many cardiovascular team members with young children and/or elderly parents at home decided to either send their families away or stay in a hotel/garage in an attempt to avoid transmitting the virus to their loved ones. Those who live with their families remain under the constant stress of accidentally infecting their loved ones and yet they show up to work to fulfill their moral and professional obligations. The emotional toll of COVID-19 deaths, especially those who were young or previously healthy, is indescribable. Yet, there is joy in reuniting patients with their family after treating them successfully, as well as with the few successful extubations, to lift our human spirit.

Many doctors and nurses are working away from home to care for patients around the country.

Most of them had been away from families for months before the pandemic and were planning family reunions during the Iranian Nowruz Ceremony (Persian New Year Holiday). However, most were so busy that they never got the chance. Some even prohibited their parents from visiting them in fear of this infection. Considering the work burden, loneliness, separation from families, and losing family members, the 1399 th Nowruz was like a premature cold autumn rather than a mature warm spring for many Iranians.

For some Iranian doctors, future career planning and training have also been touched. I was recently awarded a training grant from the European Society of Cardiology to study heart failure in Scotland. I may face difficulty in moving to Scotland because of the cancellation of international exams and the closure of administrative offices. The anxiety about this issue has cast a shadow over the excitement I had for being awarded the grant.

Fellows in training and early career colleagues who are sacrificed at a daily basis for COVID-19

Different healthcare systems, 6 voices but one theme: professionalism, as embodied in commitment, responsibility, sacrifice, courage, and personal and professional growth