May 2020 Issue
ISSN 2689-291X
ISSN 2689-291X
COVID-19 and Interventional Cardiology:
To Cath or Not to Cath! That May Not Be The Only Question!
Introduction:
The COVID-19 pandemic has not only altered daily life for most people around the world, it has also created turmoil in the medical field. This pandemic has forced physicians to adopt alternative standards of care practices in many ways in order to reduce infection exposure to health care workers and the healthcare system as a whole [1]. The ramifications continue to be far reaching at multiple clinical and financial levels, including the impact of canceling or deferring elective procedures and surgeries to reduce the spread of the infection [2]. The rapid scholarly dissemination and expedited reviews and publications on the topic [3], together with employing data registries [4] has resulted in better understanding of the behavior of COVID-19 and its effect on multiple organ systems, especially the heart [5], and elucidating some of the molecular mechanisms of cardiovascular injury [6]. The heart has been recognized early on as a primary target of the COVD-19 infection [7], and the cardiovascular system has emerged as the culprit of catastrophic outcomes and demise of many patients secondary to arrhythmia [8], acute coronary syndrome and myocarditis [9], and the cardiovascular syndrome of extreme cardiovascular stress even in the absence of obstructive coronary disease [10]. COVID-19 infection tends to predominantly impact patients with underlying cardiovascular disease [11] or risk factors such as hypertension [12], and diabetes [13], imposing added cardio-respiratory burden on these patients [14].
COVD-19 & Cardiovascular Procedures:
The COVID-19 pandemic has created new logistical consideration in the triage and treatment of cardiovascular patients [15], necessitating the prompt dissemination of multiple new guidelines on how to approach the need for cardiovascular procedures in the setting of heightened infection risk. Such guidelines, calling for vigilance and extreme precautions, using personal protective equipment (PPE), were published addressing cardiopulmonary resuscitation, CPR [16], electrophysiology studies [17], and interventional/structural heart disease procedures [18] by multiple cardiovascular societies.
The extent of preparedness required to perform a coronary intervention in the COVID-19 or suspect patient is enormous and should involve a team-based structured approach with well delineated priorities and responsibilities [19]. This may not be feasible in many low volume, less prepared centers. The length of time required for preparedness may exceed the recommended door to balloon time of 90 minutes, which calls into question the necessity or feasibility of transferring such patients to facilities capable of performing prompt percutaneous coronary intervention (PCI), at a time when many hospitals are inundated and may decline transfers, as opposed to the administration of thrombolysis. The thrombolytic option may allow the cath lab staff extra time to get prepared for a rescue PCI according to preparedness guidelines [20] or transfer the patient if needed, if thrombolysis is not successful in reestablishing coronary flow. High risk PCI with the support of Impella device in a COVID-19 patient has been reported [21], however, such cases and outcomes would likely depend on a particular center’s preparedness, resources and patient presentation.
The American College of Cardiology (ACC) and Society for Cardiovascular Angiography and Interventions (SCAI) released a joint consensus statement addressing the concern for COVID-19 infection exposure in the catheterization lab [22] by calling for more conservative noninvasive treatment for Non-ST-segment Elevation Myocardial Infarction (NSTEMI) in COVID-19 patients. The same statement urged consideration of thrombolysis in eligible ST-segment Elevation Myocardial Infarction (STEMI) patients who are COVID-19 positive or suspect rather than primary PCI. The statement further called for postponing all elective cardiac catheterization procedures to minimize potential exposure to patients and staff and to preserve the much needed PPE.
Despite this joint consensus statement, there remains debate on whether the use of thrombolytic agents in STEMI and medical management in NSTEMI is the appropriate course of action [23, 24]. A recent poll published by the ACC addressed this divide [25]. Out of 1800 votes, 44% of respondents chose to use thrombolytic agents to manage STEMI in the absence of cardiogenic shock or failed thrombolytic therapy, while 33% chose to continue with primary PCI as usual. For NSTEMIs, 63% of respondents chose the more conservative approach with medical management, while 21% chose an invasive strategy. A small percentage of physicians also stated that treatment plans should consider availability of resources and experience of each healthcare system. The lack of readily available testing and the shortage of PPE may have led more physicians to favor the conservative approach. The balance of COVID-19 exposure and patient benefit must be considered. Additionally, resources must be taken into account as the COVID-19 pandemic evolves. For healthcare systems that are lacking timely preparedness, it would be appropriate to consider thrombolysis in patients who do not have cardiogenic shock. Currently, thrombolytic agents are primarily considered in STEMI patients who arrive at PCI-incapable facilities, when the anticipated first medical contact to balloon time exceeds 120 minutes, as an alternative means of early reperfusion. In the 1960s – 1970s, thrombolytic agents were considered the gold standard treatment for STEMI before the advent of PCI [26]. The GUSTO-I trial published in NEJM in 1993 showed a mortality benefit with the use of accelerated tissue plasminogen activator (TPA) and heparin together [27]. Although it may not be common practice, the use of thrombolysis in STEMI patients does afford mortality benefit and successful reperfusion, as evidenced by improvement in clinical symptoms and normalization of EKG changes. Overall, a decrease in cath lab activations for STEMI were observed during the COVID-19 pandemic [28].
Discussion:
The interventional cardiologist is often the first to call on ACS patients. Perhaps the term “interventional” conveys the expectation and obligation to perform PCI. However, the interventional cardiologist is first and foremost a cardiology consultant [29] who provides a comprehensive cardiovascular evaluation, with the extra qualifications to perform interventional procedures if deemed necessary, feasible and justifiable by a risk/benefit analysis. Beyond the duty of providing the optimal care for their patients, interventional cardiologists have to guarantee a safe environment for themselves and the cath lab personnel. While the interventional field has perfected protection against the deadly radiation with accurate exposure-measuring devices, there is no such tool for the deadly COVID-19 virus infection exposure, leaving personnel with a sense of unease and uncertainty about the adequacy of any level of preparedness. These are unprecedented considerations which call for swift decision making with regards to the optimal approach to treat ACS, taking into consideration a multitude of factors to assure the best outcome. Therefore, the approach to ACS in the COVID-19 or suspect patient cannot be narrowed down to a simplistic “to cath or not to cath”, as this under represents the complex decision making the interventional cardiologist has to take in approaching ACS in the current pandemic. Among the many considerations is whether an intervention would be expected to provide the anticipated therapeutic benefit seen in non-COVID-19 patients, given the non-traditional pathophysiology seen. Further factors include the risk of arrhythmia and need for CPR with even further risk of exposure and potential breach of protective precautions, the feasibility of performing PCI in such an environment, utilizing minimum staff, with the potential need for circulatory support devices such as intra-aortic balloon bump (IABP), Impella peripheral ventricular assist device (PVAD) or extracorporeal membrane oxygenation (ECMO) to support an intervention, in addition to many other unknowns.
Current medical practices have become diverse and dynamic amidst the battle against COVID-19, which has led to controversy and uncertainty about the appropriate management of patients in different clinical settings. As the outside world continues to look up to us and greet us as heroes, we remain plagued with new realities, with little proven treatments to guide our practices; we have to strive to live up to this title ! [30]
References:
Authors:
Sarina Sachdev, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Hassan Tahir, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Landai Nguyen, D.O.
Cardiology Fellow
University of South Alabama
Mobile, AL
Muhammad Rafique, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Siva Chiranjeevi, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Nilarun Chowdhuri, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Amod Amritphale, M.D.
Assistant Professor of Cardiology
University of South Alabama
Mobile, AL
G. Mustafa Awan, M.D.
Associate Professor of Cardiology
University of South Alabama
Mobile, AL
Bassam Omar, M.D., Ph.D.
Professor of Cardiology
University of South Alabama
Mobile, AL
The COVID-19 pandemic has not only altered daily life for most people around the world, it has also created turmoil in the medical field. This pandemic has forced physicians to adopt alternative standards of care practices in many ways in order to reduce infection exposure to health care workers and the healthcare system as a whole [1]. The ramifications continue to be far reaching at multiple clinical and financial levels, including the impact of canceling or deferring elective procedures and surgeries to reduce the spread of the infection [2]. The rapid scholarly dissemination and expedited reviews and publications on the topic [3], together with employing data registries [4] has resulted in better understanding of the behavior of COVID-19 and its effect on multiple organ systems, especially the heart [5], and elucidating some of the molecular mechanisms of cardiovascular injury [6]. The heart has been recognized early on as a primary target of the COVD-19 infection [7], and the cardiovascular system has emerged as the culprit of catastrophic outcomes and demise of many patients secondary to arrhythmia [8], acute coronary syndrome and myocarditis [9], and the cardiovascular syndrome of extreme cardiovascular stress even in the absence of obstructive coronary disease [10]. COVID-19 infection tends to predominantly impact patients with underlying cardiovascular disease [11] or risk factors such as hypertension [12], and diabetes [13], imposing added cardio-respiratory burden on these patients [14].
COVD-19 & Cardiovascular Procedures:
The COVID-19 pandemic has created new logistical consideration in the triage and treatment of cardiovascular patients [15], necessitating the prompt dissemination of multiple new guidelines on how to approach the need for cardiovascular procedures in the setting of heightened infection risk. Such guidelines, calling for vigilance and extreme precautions, using personal protective equipment (PPE), were published addressing cardiopulmonary resuscitation, CPR [16], electrophysiology studies [17], and interventional/structural heart disease procedures [18] by multiple cardiovascular societies.
The extent of preparedness required to perform a coronary intervention in the COVID-19 or suspect patient is enormous and should involve a team-based structured approach with well delineated priorities and responsibilities [19]. This may not be feasible in many low volume, less prepared centers. The length of time required for preparedness may exceed the recommended door to balloon time of 90 minutes, which calls into question the necessity or feasibility of transferring such patients to facilities capable of performing prompt percutaneous coronary intervention (PCI), at a time when many hospitals are inundated and may decline transfers, as opposed to the administration of thrombolysis. The thrombolytic option may allow the cath lab staff extra time to get prepared for a rescue PCI according to preparedness guidelines [20] or transfer the patient if needed, if thrombolysis is not successful in reestablishing coronary flow. High risk PCI with the support of Impella device in a COVID-19 patient has been reported [21], however, such cases and outcomes would likely depend on a particular center’s preparedness, resources and patient presentation.
The American College of Cardiology (ACC) and Society for Cardiovascular Angiography and Interventions (SCAI) released a joint consensus statement addressing the concern for COVID-19 infection exposure in the catheterization lab [22] by calling for more conservative noninvasive treatment for Non-ST-segment Elevation Myocardial Infarction (NSTEMI) in COVID-19 patients. The same statement urged consideration of thrombolysis in eligible ST-segment Elevation Myocardial Infarction (STEMI) patients who are COVID-19 positive or suspect rather than primary PCI. The statement further called for postponing all elective cardiac catheterization procedures to minimize potential exposure to patients and staff and to preserve the much needed PPE.
Despite this joint consensus statement, there remains debate on whether the use of thrombolytic agents in STEMI and medical management in NSTEMI is the appropriate course of action [23, 24]. A recent poll published by the ACC addressed this divide [25]. Out of 1800 votes, 44% of respondents chose to use thrombolytic agents to manage STEMI in the absence of cardiogenic shock or failed thrombolytic therapy, while 33% chose to continue with primary PCI as usual. For NSTEMIs, 63% of respondents chose the more conservative approach with medical management, while 21% chose an invasive strategy. A small percentage of physicians also stated that treatment plans should consider availability of resources and experience of each healthcare system. The lack of readily available testing and the shortage of PPE may have led more physicians to favor the conservative approach. The balance of COVID-19 exposure and patient benefit must be considered. Additionally, resources must be taken into account as the COVID-19 pandemic evolves. For healthcare systems that are lacking timely preparedness, it would be appropriate to consider thrombolysis in patients who do not have cardiogenic shock. Currently, thrombolytic agents are primarily considered in STEMI patients who arrive at PCI-incapable facilities, when the anticipated first medical contact to balloon time exceeds 120 minutes, as an alternative means of early reperfusion. In the 1960s – 1970s, thrombolytic agents were considered the gold standard treatment for STEMI before the advent of PCI [26]. The GUSTO-I trial published in NEJM in 1993 showed a mortality benefit with the use of accelerated tissue plasminogen activator (TPA) and heparin together [27]. Although it may not be common practice, the use of thrombolysis in STEMI patients does afford mortality benefit and successful reperfusion, as evidenced by improvement in clinical symptoms and normalization of EKG changes. Overall, a decrease in cath lab activations for STEMI were observed during the COVID-19 pandemic [28].
Discussion:
The interventional cardiologist is often the first to call on ACS patients. Perhaps the term “interventional” conveys the expectation and obligation to perform PCI. However, the interventional cardiologist is first and foremost a cardiology consultant [29] who provides a comprehensive cardiovascular evaluation, with the extra qualifications to perform interventional procedures if deemed necessary, feasible and justifiable by a risk/benefit analysis. Beyond the duty of providing the optimal care for their patients, interventional cardiologists have to guarantee a safe environment for themselves and the cath lab personnel. While the interventional field has perfected protection against the deadly radiation with accurate exposure-measuring devices, there is no such tool for the deadly COVID-19 virus infection exposure, leaving personnel with a sense of unease and uncertainty about the adequacy of any level of preparedness. These are unprecedented considerations which call for swift decision making with regards to the optimal approach to treat ACS, taking into consideration a multitude of factors to assure the best outcome. Therefore, the approach to ACS in the COVID-19 or suspect patient cannot be narrowed down to a simplistic “to cath or not to cath”, as this under represents the complex decision making the interventional cardiologist has to take in approaching ACS in the current pandemic. Among the many considerations is whether an intervention would be expected to provide the anticipated therapeutic benefit seen in non-COVID-19 patients, given the non-traditional pathophysiology seen. Further factors include the risk of arrhythmia and need for CPR with even further risk of exposure and potential breach of protective precautions, the feasibility of performing PCI in such an environment, utilizing minimum staff, with the potential need for circulatory support devices such as intra-aortic balloon bump (IABP), Impella peripheral ventricular assist device (PVAD) or extracorporeal membrane oxygenation (ECMO) to support an intervention, in addition to many other unknowns.
Current medical practices have become diverse and dynamic amidst the battle against COVID-19, which has led to controversy and uncertainty about the appropriate management of patients in different clinical settings. As the outside world continues to look up to us and greet us as heroes, we remain plagued with new realities, with little proven treatments to guide our practices; we have to strive to live up to this title ! [30]
References:
- Driggin E, Madhavan MV, Bikdeli B, et al. Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the Coronavirus Disease 2019 (COVID-19) Pandemic. J Am Coll Cardiol. 2020 Mar 18. pii: S0735-1097(20)34637-4.
- Zarrintan S. Surgical operations during the COVID-19 outbreak: Should elective surgeries be suspended? Int J Surg. 2020 Apr 14;78:5-6.
- Vervoort D, Ma X, Luc JGY, et al. Rapid Scholarly Dissemination and Cardiovascular Community Engagement to Combat the Infodemic of the COVID-19 Pandemic. Can J Cardiol. 2020 Apr 4.
- Alger HM, Williams Iv JH, Walchok JG, Bolles MM, et al. The Role of Data Registries in the Time of COVID-19. Circ Cardiovasc Qual Outcomes. 2020 Apr 16.
- Liu PP, Blet A, Smyth D, et al. The Science Underlying COVID-19: Implications for the Cardiovascular System. Circulation. 2020 Apr 15.
- Foo R, Wang Y, Zimmermann WH, et al. Cardiovascular molecular mechanisms of disease with COVID-19. J Mol Cell Cardiol. 2020 Apr 11.
- Libby P. The Heart in COVID19: Primary Target or Secondary Bystander? JACC Basic Transl Sci. 2020 Apr 10.
- Kochi AN, Tagliari AP, Forleo GB, et al. Cardiac and arrhythmic complications in patients with COVID-19. J Cardiovasc Electrophysiol. 2020 Apr 9.
- Chapman AR, Bularga A, Mills N. High-Sensitivity Cardiac Troponin Can Be An Ally in the Fight Against COVID-19. Circulation. 2020 Apr 6.
- Hendren NS, Drazner MH, Bozkurt B, et al. Description and Proposed Management of the Acute COVID-19 Cardiovascular Syndrome. Circulation. 2020 Apr 16.
- Aghagoli G, Gallo Marin B, Soliman LB, et al. Cardiac involvement in COVID-19 patients: Risk factors, predictors, and complications: A review. J Card Surg. 2020 Apr 19.
- Zuin M, Rigatelli G, Zuliani G, et al. Arterial hypertension and risk of death in patients with COVID-19 infection: systematic review and meta-analysis. J Infect. 2020 Apr 10.
- Roncon L, Zuin M, Rigatelli G, et al.Diabetic patients with COVID-19 infection are at higher risk of ICU admission and poor short-term outcome. J Clin Virol. 2020 Apr 9;127:104354.
- Gonzalez-Jaramillo N, Low N, Franco OH. The double burden of disease of COVID-19 in cardiovascular patients: overlapping conditions could lead to overlapping treatments. Eur J Epidemiol. 2020 Apr 15.
- Robert Denniss A, Chow CK, Kritharides L. Cardiovascular and Logistic Issues Associated With COVID-19 Pandemic. Heart Lung Circ. 2020 Apr 10.
- Edelson DP, Sasson C, Chan PS, et al. Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With the Guidelines®-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in Collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists: Supporting Organizations: American Association of Critical Care Nurses and National EMS Physicians. Circulation. 2020 Apr 9.
- Lakkireddy DR, Chung MK, Gopinathannair R, et al. Guidance for Cardiac Electrophysiology During the Coronavirus (COVID-19) Pandemic from the Heart Rhythm Society COVID-19 Task Force; Electrophysiology Section of the American College of Cardiology; and the Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology, American Heart Association. Heart Rhythm. 2020 Apr 1.
- Wood DA, Sathananthan J, Gin K, at al. Precautions and Procedures for Coronary and Structural Cardiac Interventions During the COVID-19 Pandemic: Guidance from Canadian Association of Interventional Cardiology. Can J Cardiol. 2020 Mar 24.
- Campo G, Rapezzi C, Tavazzi L, et al. Priorities for Cath Labs in the COVID-19 Tsunami. Eur Heart J. 2020 May 14;41(19):1784-1785.
- Szerlip M, Anwaruddin S, Aronow HD, et al. 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. Catheter Cardiovasc Interv. 2020 Mar 25.
- Bettari L, Pero G, Maiandi C, et al. Exploring Personal Protection During High-Risk PCI in a COVID-19 Patient: Impella CP Mechanical Support During ULMCA Bifurcation Stenting. JACC Case Rep. 2020 Apr 10.
- Welt FGP, Shah PB, Aronow HD, et al. Catheterization Laboratory Considerations During the Coronavirus (COVID-19) Pandemic: From ACC's Interventional Council and SCAI. J Am Coll Cardiol. 2020 Mar 16.
- Daniels MJ, Cohen MG, Bavry A, et al. Reperfusion of STEMI in the COVID-19 Era - Business as Usual? Circulation. 2020 Apr 13.
- Mahmud E. The Evolving Pandemic of COVID-19 and Interventional Cardiology. Catheter Cardiovasc Interv. 2020 Apr 12.
- https://www.acc.org/latest-in-cardiology/articles/2020/03/18/15/07/poll-covid-19-and-interventional-cardiology.
- White HD, Van de Werf FJ (1998). "Thrombolysis for acute myocardial infarction". Circulation. 97 (16): 1632–46.
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Authors:
Sarina Sachdev, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Hassan Tahir, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Landai Nguyen, D.O.
Cardiology Fellow
University of South Alabama
Mobile, AL
Muhammad Rafique, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Siva Chiranjeevi, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Nilarun Chowdhuri, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Amod Amritphale, M.D.
Assistant Professor of Cardiology
University of South Alabama
Mobile, AL
G. Mustafa Awan, M.D.
Associate Professor of Cardiology
University of South Alabama
Mobile, AL
Bassam Omar, M.D., Ph.D.
Professor of Cardiology
University of South Alabama
Mobile, AL