The American College of Cardiology (ACC) together with other North American cardiovascular societies issued a framework for ethically and safely reintroducing invasive cardiovascular procedures and diagnostic tests after the initial peak of the COVID-19 (SARS-CoV-2) pandemic. The document was published in early May in the Journal of the American College of Cardiology (JACC).
The COVID-19 pandemic has forced appropriate, but significant, restrictions on routine medical care, including postponing invasive procedures to treat heart disease and diagnostic tests to diagnose heart disease. As the pandemic unfolded, many non-urgent cardiac tests and imaging studies were deferred in an attempt to reduce coronavirus transmission among patients and healthcare workers, conserve personal protective equipment (PPE) and prepare for the expected surge of COVID-19 patients. Although COVID-19 disease prevalence and new case trends continue to differ substantially by region, many facilities are now planning resumption of non-urgent and elective medical services.
Many hospitals and practices have attempted to defer and replace these critical procedures with intensified triage and management of patients on waiting lists. However, many patients with untreated cardiovascular disease are at an increased risk of adverse outcomes, and delays in the treatment of patients with confirmed cardiovascular disease can be detrimental. Also, reduced access to diagnostic testing can lead to a high burden of undiagnosed cardiovascular disease that will further delay time to treatment.
Cardiovascular disease is the leading cause of death in women and men worldwide and these patients need prioritization as healthcare systems return to normal capacity. In this document, North American cardiovascular societies outline how to reintroduce regular cardiovascular care in a progressive manner with appropriate safeguards.
“Unprecedented times call for unprecedented collaboration, and a collaborative approach will be essential to mitigate the ongoing morbidity and mortality associated with untreated cardiovascular disease,” said Athena Poppas, M.D., FACC, ACC president and one of the authors on the document. “It is essential that we work together to ensure cardiovascular disease patients are safely cared for during this pandemic and that we don’t allow for a new crisis of undiagnosed, untreated or worsening cardiovascular disease to occur in the aftermath of this pandemic.”
The authors have outlined three areas that must be considered when reintroducing services. These including:
• Ethical considerations that include maximizing benefits by prioritizing procedures that will ensure the most lives or life years are saved over those that benefit fewer people to a lesser degree, ensuring fairness in how cases are treated, ensuing proportionality so that the risk of further postponing treatment is weighed again exacerbating the spread, and maintaining consistency in reintroduction across populations regardless of ability to pay and assuring health equity.
• Collaboration between regional public health officials, health authorities and cardiovascular care providers to manage the dynamic balance between provision of essential cardiovascular care and responding to future fluctuations in COVID-19 infections and hospital admissions.
• Protection of patients and health care workers through regions having the necessary critical care capacity, personal protective equipment (PPE), and trained staff available, and a transparent plan for testing and re-testing potential patients and health care workers for COVID-19. Strategies for social distancing between patients and health care workers should also be considered, including virtual pre-procedural clinics, virtual consenting for procedures and diagnostic tests, and minimizing the number of health care workers in physical contact with any given patient.
The document outlines a 3 level system of when it will be safe to reintroduce various cardiovascular procedures and diagnostic tests during the COVID-19 pandemic. It includes:
• Level 0, which is normal operations;
• Level 1, when most cardiovascular services can be introduced; and
• Level 2, which is when some cardiovascular services can be reintroduced.
The list of services included on this list includes:
• Treatment of STEMI
• Treatment on Non-STEMI/ACS
• Cardiovascular surgery (coronary bypass and valve surgery)
• Elective Cath lab cases
• Transcatheter aortic valve replacement (TAVR)
• MitraClip Procedures
• ASD and PFO closures
• Left atrial appendage (LAA) occlusions
• Electrophysiology (EP) ablations and device implants
• Echocardiography (transthoraciic, TEE and exercise stress)
• Cardiac computed tomography (CTA)
• Cardiac MRI
• Cardiac nuclear imaging
• Heart failure testing, biopsy, catheterization or transplants
• Critical limb ischemia (CLI)
• Thoracic endovascular aortic repair (TEVAR)
• Endovascular treatment of abdominal aortic aneurysms (EVAR)
• Deep vein thrombosis
North American Cardiovascular Societies represented on the document are:
• American Heart Association (AHA)
• Canadian Cardiovascular Society
• Canadian Association of Interventional Cardiology
• Society for Cardiovascular Angiography and Interventions (SCAI)
• Heart Valve Society
• American Society of Echocardiography (ASE)
• Society of Thoracic Surgeons (STS)
• Heart Rhythm Society (HRS)
• Society of Cardiovascular Computed Tomography (SCCT)
• American Society of Nuclear Cardiology (ASNC)
• Society of Nuclear Medicine and Molecular Imaging (SNMMI)
• Society for Cardiovascular Magnetic Resonance (SCMR)
• Society of Nuclear Medicine
• Canadian Heart Failure Society
• Canadian Society of Cardiac Surgeons
Reopening Cardiac Ultrasound Services
The American Society of Echocardiography (ASE) issued its own statement on how centers may consider to reopen cardiac ultrasound services as hospitals begin resuming elective procedures and tests amid the pandemic.
The authors of the ASE expert census statement said the safe and efficient reintroduction of outpatient echocardiography services will require consideration of appropriate timing of reopening. This is based on:
• Projected COVID-19 case trends;
• Prioritizing procedure scheduling based on current or change in disease acuity;
• Applying exam protocols to address the clinical question while enhancing lab throughput;
• Implementing appropriate PPE and sanitization protocols; and
• performing pre-procedural COVID-19 testing in certain patient cohorts.
The timing of reintroduction of non-urgent and elective echo procedures should be aligned with institutional policies and follow recommendations of regional public health authorities, ASE stated. Important considerations include local COVID-19 disease prevalence and new case trends, as well as available institutional resources including facilities, staffing and equipment (including adequate supply of appropriate PPE).
It is suggested that gradual introduction of echo services should be part of a phased reopening plan, which will vary by institution and region.
Read the full article - When and How to Reopen Echocardiography Services During the COVID-19 Pandemic.
Related Content on Reopening Cardiology Services Anid COVID-19:
1. David A. Wood, Ehtisham Mahmud, Vinod H. Thourani, et al. Safe Reintroduction of Cardiovascular Services during the COVID-19 Pandemic: Guidance from North American Society Leadership. JACC. May 2020. DOI: 10.1016/j.jacc.2020.04.063.
3. Judy Hung, Theodore P. Abraham, Meryl S. Cohen, et al. ASE Statement on the Reintroduction of Echocardiography Services During the COVID-19 Pandemic. American Society of Echocardiography. Issued May 2020.