COVID-19 Poised to Upend the Cath Lab, ACC and SCAI Say

Amid a dynamic situation with few data to guide practice, the American College of Cardiology (ACC) and the Society for Cardiovascular Angiography and Interventions (SCAI) have teamed up to produce a primer on how catheterization labs should prepare for COVID-19.

The joint statement, published online yesterday in the Journal of the American College of Cardiology, touches on everything from patient selection to resource allocation, protection of healthcare workers, and the need for accurate information.

Frederick Welt, MD (University of Utah School of Medicine, Salt Lake City), chair of the ACC’s Interventional Council, said the document emerged naturally. “We had our regular scheduled monthly conference call on Thursday. And of course, every call you get on [these days] regardless of whether it’s the topic or not turns to COVID-19. What was evident in that conversation was that we were all struggling with what this meant for the cath lab,” he told TCTMD.

The group enlisted the help of SCAI participants, writing over the weekend and bouncing drafts back and forth. “We definitely wanted this to be a cooperative venture and speak with one voice,” Welt said, with the goal of “trying to anticipate what might occur if things really accelerate, all the derivative impacts on resources.”

Across the board, cath labs need to carefully weigh the balance between staff exposure and patient benefit, the ACC/SCAI experts say in their report.

What’s also needed, they advise, is transparency: “Already, social media has provided a venue for some excellent discussions and insight from practitioners at institutions experiencing the effects of the pandemic. As the pandemic progresses, we will need to create avenues for reporting and collation of data, and then methods for rapidly dispersing that information in order to better care for our patients and to protect healthcare workers.”

For Lloyd Klein, MD (UCSF Medical Center, San Francisco, CA), “the main thing that comes out of this article is at least people are thinking about [how to prepare], but I don’t think anyone really understands yet the magnitude of this.”

Healthcare systems around the world have handled COVID-19 differently, with starkly disparate success, he observed. “Although everybody is scared tremendously by the potential, I don’t know if that will happen or won’t happen. If it does happen, then there’s no way you can plan for it, honestly, because it would be overwhelming. You can’t plan for a catastrophe like that.”

Avoid Elective Cases

Ahead of ramped-up demand, elective procedures are widely being discouraged, since these cases use up potentially needed resources and put patients in a hospital environment where the risk of contracting SARS-CoV-2 (which causes COVID-19) might be higher. However, “the definition of truly elective requires clinical judgement, because in some cases deferral of patients may have independent deleterious effects,” the ACC/SCAI report points out, adding, “Case decisions should be individualized, taking into account the risk of COVID-19 exposure versus the risk of delay in diagnosis or therapy.”

Examples of procedures that might reasonably wait include PCI for stable ischemic heart disease, endovascular intervention for ilio-femoral disease in patients with claudication, and patent foramen ovale closure.

Taking a pause is wise, Klein agreed, but what’s elective and not is open to interpretation. “When we’re talking about the heart, that’s not such a simple judgement,” he commented.

MI in the COVID-19 Era

STEMI care, with its inherent urgency, has particular challenges.

In the United States, where rapid testing for COVID-19 isn’t widely available, it may be impossible to know whether a STEMI patient has the disease when making the choice to perform primary PCI. This is in contrast to China, where nucleic acid tests can quickly diagnose a SARS-CoV-2 infection. With this in mind, physicians based at the Sichuan Provincial People’s Hospital have developed an algorithm, published in Intensive Care Medicine, that emphasizes rapid testing and immediate fibrinolysis with PCI as needed.

For relatively stable STEMI patients with active COVID-19, fibrinolysis may be an option, Welt and colleagues suggest.

Welt told TCTMD that this was one of the more controversial topics in developing the joint statement. In many parts of the United States, lytics aren’t used, so practitioners there may be unfamiliar with them. “Where I am in Utah, we actually see a fair amount of it because we get transfers from fairly distant places where we could never meet the recommended door-to-balloon time. It would never be our first choice, but in patients who are transferred, it’s entirely reasonable,” he explained, adding that all agreed primary PCI is the best option when possible.

Another report, this one from Hong Kong, was published online this week in Circulation: Cardiovascular Quality and Outcomes. With the arrival of COVID-19, researchers at Queen Mary Hospital observed sharp increases in the average time between symptom onset and first medical contact as well as door-to-balloon time. They conjecture that fear of infection may have made some patients reluctant to seek care and that COVID-related precautions at the hospital could have delayed diagnosis and treatment.

Both Welt and Klein said this experience may not be generalizable to the United States. If delays do start to occur, said Welt, it’s important to figure out which among them can be avoided.

NSTEMI, on the other hand, offers the relative luxury of more time for diagnosis and planning, the ACC/SCAI report notes. “Rapid discharge of patients with primary NSTEMI following revascularization will likely be important in terms of maximizing bed availability and reducing patient exposure within the hospital. Follow-up through telehealth venues could be satisfactory in most cases.”

Just yesterday, the Centers for Medicare & Medicaid Services announced expanded telehealth coverage for Medicare beneficiaries.

One wrinkle to COVID-19 in the cardiovascular setting, Welt said, is that there have been reports of patients who present with what seems to be an MI but turn out to have normal coronaries and then later on develop symptoms and signs of infection. “There’s at least some anecdotal evidence that the myocarditis that has been pretty well established can present with EKG changes that would mimic MI. Twitter has had a lot of these examples. I think that that’s on everybody’s mind,” observed Welt.

As explored in a recent TCTMD feature article, the potential link between COVID-19 and myocardial injury is a hot topic of discussion, with little published evidence, as yet, to clarify just how the virus is directly affecting the heart.

Safety Requires Equipment, Planning

The ACC/SCAI statement highlights the reality that everyday processes and safety protocols require a rethink in the shadow of COVID-19.

Cath labs in general aren’t designed to isolate infection, with most having either normal or positive ventilation systems. “Therefore, catheterization labs will require a terminal clean following the procedure leading to delays for subsequent procedures,” the report’s authors advise.

When PCI is performed, the cath lab team must wear personal protective equipment (PPE; eg, gown, gloves, goggles/shields, and N95 masks) and may need to use powered air-purifying respirators.

Especially risky are patients who need intubation, suction, or active CPR, as these “likely result in aerosolization of respiratory secretions increasing likelihood of exposure to personnel,” Welt et al note, offering specific suggestions for timing and equipment. “Close coordination with critical care, [infectious disease], and anesthesia teams in airway management will be critical to avoid spread of infection.” Patients expected to need intubation, they say, should be intubated prior to arrival in the cath lab.

Worries about potential nosocomial infections appear valid: Singapore-based researchers reported in JAMA earlier this month that a single patient with mild upper respiratory tract involvement had, before routine cleaning, been able to contaminate things as diverse as air outlet fans, toilet bowls, sinks, and door handles.

Anticipate Disruption

Already some safety equipment is scarce, and supply chains may soon be affected, Welt noted to TCTMD. Lack of access to PPE, he said, is an “anxiety-producing” area.

“Right now, at least in my institution, [PPE amounts to] standard droplet precautions, that would be a regular surgical mask, hair net, some sort of eye protection (whether that’s plastic shields or goggles or both), gown, and gloves,” Welt said.

Klein pointed out that, in the United States, COVID-19 is currently being handled in intensive care units that are cordoned off and by personnel wearing full equipment. “So far that’s not really reached into the world of cardiology. It will. It may well within a week or two. Obviously, the people who are the ones who are going to be the most intensely ill [from COVID-19] are going to be people with heart disease and lung disease. So undoubtedly we’re going to get called into that but exactly how that’s going to work, I don’t know.”

Obviously, the people who are the ones who are going to be the most intensely ill [from COVID-19] are going to be people with heart disease and lung disease. Lloyd Klein

Welt said there are hints of trouble ahead. “Things like our standard cath packs—which come with all of the accoutrement that you need for a case: bowls, syringes, gowns, etc—we are being told that there may disruptions in supply chain and so we need to make sure that we’re conserving those resources,” he commented. That includes being more selective about who scrubs in for cases.

Additionally, there may be obstacles to staffing due to workers being exposed or infective and thus requiring quarantine. School closings, too, “will put a strain on home, dependent, and child-care resources,” the report says, proposing that it may help to develop teams that separate clinicians with overlapping skill sets.

In a big-picture sense, Klein expressed doubts that the US healthcare system will be able to handle the demands of COVID-19.

“For 15 or 20 years we’ve been cutting back capability and capacity to save money. The hospital administrations pat themselves on the back and give each other big bonuses for all the money they’ve saved, and the doctors are beaten over the head to do more with less and to keep working [until] productivity increases,” he said, adding, “You can’t just start it up again. You can’t just flip a switch and suddenly [everything] will appear.”