key: cord-1024720-rw0y1e9b authors: Li, Yi-Heng; Wang, Mei-Tzu; Huang, Wei-Chun; Hwang, Juey-Jen title: Management of Acute Coronary Syndrome in Patients with Suspected or Confirmed Coronavirus Disease 2019: Consensus from Taiwan Society of Cardiology date: 2020-07-13 journal: J Formos Med Assoc DOI: 10.1016/j.jfma.2020.07.017 sha: f24134a5a9a0ac871e830c41dda384c281eb5133 doc_id: 1024720 cord_uid: rw0y1e9b Abstract Coronavirus disease 2019 (COVID-19) is a highly contagious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Infection with SARS-CoV may cause coronary plaque instability and lead to acute coronary syndrome (ACS). Management of ACS in patients with COVID-19 needs more consideration of the balance between clinical benefit and transmission risk of virus. This review provides recommendations of management strategies for ACS in patients with suspected or confirmed COVID-19 in Taiwan. On 12 March, 2020, the World Health Organization (WHO) declared the infection caused by coronavirus disease 2019 (COVID-19) a pandemic due to rapidly spreading outbreaks around the world. The pathogen causes pneumonia and is officially named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by the WHO. COVID-19 resulted in a lower case-fatality rate but a stronger transmission capacity compared with the severe acute respiratory syndrome coronavirus (SARS-CoV) that caused an outbreak in 2003. 1 In addition to respiratory symptoms and pneumonia, cardiac complications, including acute cardiac injury, heart failure and arrhythmia, could occur in patients with COVID-19. 2 4 Previous study reported that SARS-CoV may trigger coronary plaque instability and lead to ACS. 5 In patients with COVID-19, increased interleukin-6 and D-dimer indicated enhanced systemic inflammation and augmented coagulation response, 3 both of which have linked to plaque instability and occurrence of ACS. Based on previous SARS experiences, several actions were taken immediately by Taiwan Government and effectively prevents large-scale community outbreaks of COVID-19 in Taiwan so far. 6 Strict infection control measures were implemented early in hospitals in Taiwan to protect first-line health care workers and avoid in-hospital transmission. 7 Recent study indicated that, in addition to droplet, fomite could be an important nosocomial transmission pathway of SARS-CoV-2 because the virus can remain viable on surfaces up to days. 8 Timely percutaneous coronary intervention (PCI) 3 and adequate antithrombotic therapy are the major treatment modalities for ACS. Primary PCI is the major reperfusion strategy for ST-segment elevation myocardial infarction (STEMI) in Taiwan. 9,10 Fibrinolytic therapy could be considered first when primary PCI cannot be performed rapidly for any reason after STEMI diagnosis. 11 According to database of ACS registries established by the Taiwan Society of Cardiology, primary PCI was performed in 98.2% of STEMI cases, whereas fibrinolysis therapy was used in only 1.8%. 10, 12 Preliminary study showed strict infection control measures in COVID-19 outbreak delayed door to device time and catheterization laboratory arrival to device time of primary PCI for STEMI. 13 When STEMI is encountered in patients with suspected or confirmed COVID-19 in Taiwan, the suggested revascularization strategy is shown in the Figure 1 . Considering the time needed for patient transportation to catheterization laboratory and preparation of personnel protection, it is not easy to achieve optimal door to device time. Fibrinolysis is suggested as the first-line therapy if there is no contraindication, which was also recommended in recent publication. [14] [15] [16] [17] In Taiwan The recommendations for strategies when treating patients with suspected or confirmed COVID-19 were summarized in the Table 1 . Furthermore, personal protective equipment in cardiac catheterization lab was suggested in Figure 2 , which showed more detailed steps to wear personal protective equipment with compared to previous publication. 21 The outbreak of COVID-19 causes great impact on the health care system and practicing behaviors of medical profession. For management of ACS in patients with suspected or confirmed COVID-19, fibrinolysis could be administered first and reserve PCI for those with failed fibrinolysis in STEMI. For NSTE-ACS, coronary angiography and PCI are considered only for very high risk patients that symptoms cannot be stabilized after adequate medical treatment. Personnel protection to avoid in-hospital viral transmission is crucial in catheterization laboratory. Since the pandemic is still ongoing and scientific data are limited, the protocols recommended in this review only reflect the viewpoints at current stage. More information is needed to determine which way could provide optimal care for these patients and protect healthcare workers at the same time. 9. Prohibit other staffs entry catheterization laboratory area during the procedure. Characteristics of and public health responses to the coronavirus disease 2019 outbreak in China Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China Critical care response to a hospital outbreak of the 2019-nCoV infection in Shenzhen COVID-19 and the cardiovascular system Coronary plaque instability in severe acute respiratory syndrome Response to COVID-19 in Taiwan: big data analytics, new technology, and proactive testing Protecting health care workers during the COVID-19 coronavirus outbreak -lessons from Taiwan's SARS response Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1 Changing practice pattern of acute coronary syndromes in Taiwan from The Taiwan Heart Registries: its influence on cardiovascular patient care TSOC) for the management of ST-segment elevation myocardial infarction Women were noninferior to men in cardiovascular outcomes among patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention from Taiwan acute coronary syndrome full-spectrum registry Impact of coronavirus disease 2019 (COVID-19) outbreak on ST-segment-elevation myocardial infarction care in Hong Kong, China. Circ Cardiovasc Qual Outcomes A Treatment Strategy for Acute Myocardial Infarction and Personal Protection for Medical Staff During the COVID-19 Epidemic: The Chinese Experience Recommendations From the Peking Union Medical College Hospital for the Management of Acute Myocardial Infarction During the COVID-19 Outbreak Catheterization Laboratory Considerations During the Coronavirus (COVID-19) Pandemic: From the ACC's Interventional Council and SCAI Considerations for cardiac catheterization laboratory procedures during the COVID-19 pandemic perspectives from the Society for Cardiovascular Angiography and Interventions Emerging Leader Mentorship (SCAI ELM) Members and Graduates Guidelines of the Taiwan Society of Cardiology, Taiwan Society of Emergency Medicine and Taiwan Society of Cardiovascular Interventions for the management of non ST-segment elevation acute coronary syndrome ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC) Coronavirus fulminant myocarditis saved with glucocorticoid and human immunoglobulin EAPCI Position Statement on Invasive Management of Acute Coronary Syndromes during the COVID-19 pandemic Strict personal protective equipment, including gloves, eye and face protection, N95 mask, and isolation gown Disposable gowns and medical supplies are suggested during PCI After the procedure, the catheterization laboratory and lead coats should be disinfected according to the suggestions from infection control team. Ultraviolet light disinfection and 500 ppm diluted bleach or other disinfectants can be Use of a high-flow nasal cannula or non-invasive ventilation during PCI is not suggested to prevent aerosol spreading Negative pressure isolation room for intensive care is recommended in all AMI patients suspected COVID-19 infection During transport before or after hospitals, emergent medical services should be equipped with adequate protective gear Transfer for urgent PCI among hospitals is suggested only in patients with unstable hemodynamics, acute pulmonary edema, severe tachy-or bradyarrhythmias or contraindication to fibrinolysis All medical staffs involved in PCI should be closely monitor for 14 days. ST-segment elevation myocardial infarction (STEMI) Patients Fibrinolysis before feasible intervention in all patients except contraindications Fibrinolytic therapy is suggested within 12 hours of symptom onset if primary PCI is not feasible and there are no contraindications, and fibrin-specific agent (i.e. tenecteplase, alteplase, or reteplase) is preferred compared to nonfibrin-specific agent Primary PCI is suggested in patients contraindicated fibrinolysis Urgent rescue PCI is considered in patients who fail fibrinolysis with unstable hemodynamics, acute pulmonary edema and severe tachy-or bradyarrhythmias Delay angiography could only be considered after COVID-19 virus screen negative for twice Non ST-segment elevation acute coronary syndrome Patients Repeated sampling and testing from lower respiratory specimen are strongly recommended before intervention except very-high-risk patients For very-high-risk NSTE-ACS patients with unstable hemodynamics, acute pulmonary edema and severe tachy-or bradyarrhythmias, intervention is suggested within 2 hours from hospital admission Early coronary angiography is suggested within 24 hours for high risk patients, until COVID-19 virus screen tests show negative for once or twice Selective intervention can be considered for low risk patients until COVID-19 virus screen tests show negative for twice, if there is evidence of inducible ischemia in a non-invasive stress test Acute myocardial infarction; COVID-19: coronavirus disease Non ST-segment elevation acute coronary syndrome; PCI: percutaneous coronary intervention; SARS-CoV-2: severe acute respiratory syndrome coronavirus 2; STEMI: ST-elevation myocardial infarction