|Year : 2020 | Volume
| Issue : 2 | Page : 132-139
How to run the cardiology service in COVID times? A practical guide
Anish Kapil, Sivasubramanian Ramakrishnan
Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
|Date of Submission||09-May-2020|
|Date of Decision||17-Jun-2020|
|Date of Acceptance||25-Jul-2020|
|Date of Web Publication||27-Aug-2020|
Dr. Sivasubramanian Ramakrishnan
Department of Cardiology, All India Institute of Medical Sciences, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
Coronavirus disease 2019 (COVID-19) has placed an enormous strain on the health-care systems. In this systematic review, we briefly review the cardiovascular manifestation of COVID and how a cardiology service can be geared to tackle the COVID pandemic. These guidelines are based on how our hospital is being run based on guidelines which have come out from time to time from the Indian Council of Medical Research, WHO, Centers for Disease Control and Prevention, and other health authorities. COVID-19 is more severe in patients with cardiovascular disease and hypertension and may be associated with myocarditis like illness and shock. Patients with preexisting comorbidities have to be handled with extra care, and the manifestation of COVID-19 has to be distinguished from cardiovascular problems. Running a cardiology service requires ensuring preventing cross infection between patients, preventing patients from infecting health-care personal, and this requires precautions at all levels including the outpatient, ward, echocardiography, angiography, and during surgery. All these aspects are discussed. Different wards and different procedures carry a different level of risk requiring different levels of protection which are outlined. There have to be triage areas to screen patients while the COVID reports are coming in, keeping in mind that the patients can be COVID positive even if the reports are negative. Each hospital has to have guidelines in place to handle different cardiac emergencies.
Keywords: AIIMS, cardiology practice, coronavirus, COVID
|How to cite this article:|
Kapil A, Ramakrishnan S. How to run the cardiology service in COVID times? A practical guide. J Pract Cardiovasc Sci 2020;6:132-9
|How to cite this URL:|
Kapil A, Ramakrishnan S. How to run the cardiology service in COVID times? A practical guide. J Pract Cardiovasc Sci [serial online] 2020 [cited 2020 Sep 30];6:132-9. Available from: http://www.j-pcs.org/text.asp?2020/6/2/132/293589
| Introduction|| |
We are in the midst of a pandemic. The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) that results in coronavirus disease 2019 (COVID-19) has been declared a pandemic on March 11, 2020, and is affecting the provision of health-care services in countries affected by it world over. As of May 30, 2020, more than 5.95 million cases of COVID-19 have been reported in more than 188 countries and territories, resulting in more than 365,000 deaths. In India, as of May 30, 2020, 173,763 cases of COVID-19 have been reported with 4971 deaths. Health-care workers are at a high risk of contracting this virus as most services require close interaction with the patients. The virus carries a relatively high mortality and morbidity risk, particularly for certain populations like patients with multiple comorbidities.
COVID-19 has placed an enormous strain on the health-care systems of nations where it has spread widely. Implications of COVID-19 for a cardiologist include how to modify standard practice for elective cardiac patients, those who are suspected COVID-19 patients, and those patients with COVID-19 who have either unrelated cardiac conditions or cardiac manifestations of the disease. It merits emphasis that this is a dynamic situation and one for which there are limited data and there are enormous variations in local conditions.
In this systematic review, we briefly review the cardiovascular manifestation of COVID and how a cardiology service can be geared to tackle the COVID pandemic. These guidelines are based on how our hospital is being run based on guidelines which have come out from time to time from the Indian Council of Medical Research (ICMR), WHO, Centers for Disease Control and Prevention (CDC), and other health authorities. Available publications were also sourced.
| Methodology|| |
A literature search was done in PubMed/Medline and Google Scholar/Google using the keywords: Corona, COVID-19, Cardiac, Cardiology, Hospital, India, ICMR, CDC, WHO, angiography, surgery, STEMI, acute myocardial infarction, emergency medical system, fibrinolysis, percutaneous coronary intervention, echocardiography, infection control, pneumonia, and safety. Articles which provided new information were reviewed and used for this review and also for developing guidelines for running our cardiology services.
Part one: Cardiovascular manifestations of COVID-19
COVID-19 infections are associated with significant cardiovascular manifestations. Autopsies have shown infiltration of the myocardium with mononuclear inflammatory cells. Similar to Middle East respiratory syndrome and SARS viruses, common cardiac complications associated with COVID-19 are myocarditis, arrhythmias, sudden cardiac death, left ventricular dysfunction, and troponin elevation., The myocardial injury and increased troponin values are likely due to infection-associated myocarditis and ischemia. Some studies have shown that elevated biomarker levels are associated with a significant increase in mortality. Apart from acute complications, COVID-19 is also associated with an increase in hypercoagulability and systemic inflammation, which can persist for a long period after infection.,
The prevalence of preexisting hypertension seems to be higher in COVID-19 patients who develop severe disease versus those who do not., The mechanisms underlying this relationship are most likely due to age and associated comorbidities as the confounding factors. Previous speculation suggested that treatment with renin–angiotensin system (RAS) inhibitors may influence the binding of the virus to the angiotensin-converting enzyme 2 (ACE2) receptor, promoting the disease. This is based on some experimental findings, but it is important to state that there is no clear evidence that using RAS inhibitors leads to upregulation of ACE2 receptor in humans., One observational study from Asia, Europe, and North America did not show any harmful association of RAS inhibitors with mortality, and a Chinese study showed that RAS inhibitors were associated with a lower risk of COVID-19 infection and risk of death or complications.,,,,,, Guidelines from multiple cardiovascular societies have stated that patients on RAS inhibitors should not stop their treatment.,
Myocarditis appears in COVID-19 patients several days after initiation of fever which indicates myocardial damage caused by viral infection. The mechanisms may be related to the upregulation of ACE2 in heart and coronaries., Respiratory failure and hypoxia may also cause damage to the myocardium, and immune mechanisms of inflammation may contribute.,, In severe COVID-19, increases of numerous cytokines including interleukin (IL)-6, IL-2, IL-7, granulocyte colony-stimulating factor, C-X-C motif chemokine 10, chemokine (C-C motif) ligand 2, and tumor necrosis factor-α have all been observed, which correspond to the characteristics of a cytokine release syndrome (CRS). Altered vascular permeability can result in noncardiogenic pulmonary edema and promotes respiratory failure as well as multi-organ dysfunction. High serum IL-6 levels are commonly seen in CRS, which have been associated with mortality.
The symptom of chest pain or tightness is common in patients with COVID-19. It is poorly localized and may be due to underlying pneumonia. Associated profound hypoxemia and tachycardia may result in chest pain and electrocardiographic changes suggestive of myocardial ischemia. Where biomarkers are altered, Type 2 myocardial infarction (MI) may be suggested. Patients with acute coronary syndrome, however, experience the more typical symptoms of ischemia.
In critically ill COVID-19 patients at risk for cardiogenic shock (CS) (such as those with large anterior MI and acute decompensated heart failure) and sepsis, a mixed etiology of CS and septic shock should be considered in addition to the sole cardiogenic component. Parameters allowing for a differential diagnosis between CS and septic shock, such as the presence of vasodilatation and central venous oxygen saturation values, may be assessed. Important diagnostic testing in patients with suspected CS, including electrocardiogram (ECG), bedside echocardiography, and urgent/emergent coronary angiography should be performed with personal protective equipment (PPE) to ensure best care.
There is very limited literature available on the occurrence of arrhythmia in COVID-19. In a study of 138 hospitalized patients with COVID-19 in Wuhan, arrhythmia was reported in 16.7% of total patients and in 16 of 36 patients admitted to the intensive care unit (ICU) (44%). In a subsequent publication by the same institute, ventricular tachycardia (VT) and fibrillation was reported as a complication of COVID-19 in 11 of 187 patients with a significantly higher incidence in patients with elevated troponin values. Hypoxia and systemic inflammation may cause new-onset atrial fibrillation, and consideration should be given to rhythm control and anticoagulation.
Definite evidence is still lacking, but numerous case reports suggest that the incidence of pulmonary embolism (PE) in COVID-19 infection may be high.,, Along with COVID-19-associated systemic inflammation, coagulation activation, hypoxia, and immobilization, anticoagulation at standard prophylactic doses should be considered for all patients admitted to the hospital with COVID-19 infection. Patients with COVID-19 present with respiratory distress, chest pain, and hemoptysis, and these symptoms overlap with presentation of acute PE, which may lead to underdiagnosis., It is recommended to only order tests when PE is clinically suspected, but the threshold for suspicion must be kept low. Treatment for PE remains guided by risk stratification, as per previous guidelines for PE. Some investigational drugs may have interactions with novel oral anticoagulants (NOACs), and in such cases, NOACs may be avoided.
Part two: Strategies to run the cardiology department
A surgical mask should be provided to every patient and health-care provider. Checking of temperature and saturation (optional) and administering a simple screening form for symptoms of COVID is desirable before the patient entry to outpatient department areas. A triage should be performed to assess patient status to risk stratify into suspected cases and not suspected or negative cases. The suspected cases should be sent to a dedicated COVID screening facility for testing and further management, and the other group may be managed with level I protection for health-care workers [Table 1]. [Table 2] outlines the PPE recommendations in the outpatient department.
|Table 2: Personal protective equipment recommendations in outpatient department setting|
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Telemedicine and home drug delivery
The use of telemedicine should be encouraged to minimize the risk of SARS-CoV-2 transmission in both patients and health-care workers. Whenever possible, this technology should be utilized to provide medical advice and follow-up of stable patients and to reserve direct contact for emergency situations. It is advisable that health-care workers make telephonic contact with patients with chronic conditions, such as heart failure, valvular heart disease (VHD), and stable angina, to verify the need for the hospital visit but also to provide psychological support. If feasible, home delivery and mailing of drugs to the patients is a viable option as many patients are visiting the hospital for refilling of medications.
Inpatient cardiac care
Given the nature of cardiovascular diseases, patients will be presenting to the erectile dysfunction (ED) with conditions requiring admission. Newly admitted patients in a cardiology ward should be regarded as possibly infected. All patients and their caregivers should be provided with a surgical mask.,, If there are adequate resources, there is a benefit in testing all patients, even without COVID symptoms, particularly in areas where there is community transmission. All admitted patients should be managed in the meantime with adequate personal protection while awaiting reverse transcription–polymerase chain reaction results. These patients need to be managed in a dedicated area of the ward. The use of dedicated medical equipment (e.g., blood pressure cuffs, stethoscopes, and thermometers) for confirmed/probable/suspected cases is strongly recommended. If not possible, equipment must undergo disinfection according to local policies. Not suspected or negative cases should be managed in a different area of the ward or a different ward where only COVID-19-negative cases are admitted. PPE recommendations in the inpatient setting is mentioned in [Table 3].
|Table 3: Personal protective equipment recommendation in inpatient setting|
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COVID-19 triage should be performed, and dedicated areas should be identified to separate not suspected from suspected/probable cases. Before performing cardiology consultations, it is advised to carry out a quick telephonic interview to ascertain if the patient has suspected COVID-19 symptoms or risk factors for COVID-19 or suspicious chest X-ray/computed tomography (CT) scan. If any suspicion is present and cardiology advice is urgent, the patient should be considered positive for SARS-CoV-2 infection, and maximum protection measures must be taken level II or level III in case of aerosol-generating procedures. Other ED cases should be managed with level I protection.
It is prudent to avoid elective procedures in an effort to preserve resources and avoid exposure of patients to the hospital environment where COVID-19 may be more prevalent. It also preserves hospital bed capacity, which may be facing a shortage depending on the prevalence of COVID-19 in the area. The classification of a procedure as elective requires clinical judgment, and procedures such as percutaneous coronary intervention (PCI) for stable angina, patent foramen ovale closure, or peripheral vascular intervention for claudication may be deferred.
ST-Segment elevation myocardial infarction patients
The Chinese protocol relied on a rapid testing method and reliance on fibrinolytic therapy. This can be problematic in areas where the rapid test is not available and in institutions where primary PCI is routine for ST-segment elevation MI (STEMI) patients. There is no time to wait for nasopharyngeal swab result, so the procedure should be performed in a dedicated COVID-19 catheterization laboratory (where only COVID-19-positive cases are done), and all STEMI patients should be considered as COVID-19 positive. As per the European Society of Cardiology guidelines, primary PCI remains the reperfusion therapy of choice if feasible within the usual time frame and performed in hospitals approved for the treatment of COVID-19 patients in a safe manner for both health-care providers and other patients. Immediate complete revascularization should be considered if clinically indicated to avoid repeat procedures and reduce hospital stay. Left ventriculography should be done during the procedure to avoid echocardiography. As per the American College of Cardiology/Society for Cardiovascular Angiography and Interventions recommendations, in the patient with known COVID-19 and STEMI, the balance of staff exposure and patient benefit will need to be weighed carefully, and fibrinolysis can be considered an option for the relatively stable STEMI patient with active COVID-19. In patients with active COVID-19 in whom primary PCI is to be performed, appropriate PPE should be worn, especially given the limited ability to take a history from the patient as well as the potential for clinical deterioration in STEMI cases. The use of Powered Air-Purifying Respirator systems may also be considered, especially for patients who may be vomiting or those who may require cardiopulmonary resuscitation (CPR) and/or intubation. The vast number of catheterization laboratories has either normal or positive ventilation systems and is not designed for infection isolation. Therefore, laboratories will have to be sterilized and cleaned after every procedure.
Non-ST-segment elevation myocardial infarction patients
For most patients with non-STEMI (NSTEMI) and suspected COVID-19, time should allow for diagnostic testing for COVID-19 before cardiac catheterization. In appropriately selected cases of patients with known COVID-19 and NSTEMI, conservative therapy may be sufficient based on the patient's risk. Noninvasive imaging using CT may help risk stratify patients and avoid an invasive approach allowing early discharge. Unstable NSTEMI patients whose instability is due to the acute coronary syndrome (rather than other factors) may be considered under the STEMI protocol.
Patients requiring intubation and/or cardiopulmonary resuscitation
Intubation, suction, and active CPR result in aerosolization of respiratory secretions increasing likelihood of exposure to health-care workers. Patients who are already intubated pose less of a transmission risk as the ventilation is through a closed circuit. Patients with COVID-19 or suspected COVID-19 requiring intubation should be intubated before arrival to the catheterization laboratory. Further, the threshold to consider intubation in a patient with borderline respiratory status may need to be lowered in order to avoid emergent intubation in the catheterization laboratory.
Other laboratory procedures
Staff shortages should be anticipated based on both the possibility of infected/exposed/quarantined staff. Given the infectious risk of transporting patients from wards to the catheterization laboratory, some procedures routinely done in the catheterization laboratory should be considered for bedside performance, for example, pericardiocentesis, insertion of intra-aortic balloon pump, or temporary pacemaker. For known COVID-19-positive patients, restriction of cases to a dedicated laboratory may be considered.
Most of the electrophysiology (EP) laboratory activities are being markedly reduced or suspended in areas that have been severely affected by COVID-19 outbreak. All patients with clinical indication for an EP procedure should undergo a nasopharyngeal swab immediately after admission. In critical conditions such as syncope and complete heart block, patients should immediately be transferred to the EP laboratory and undergo pacemaker implantation under level II protection measures [Table 1]. After the procedure, these patients should be transferred to a dedicated ward area where COVID screening may be performed. In COVID-positive patients, ablation procedures should be deferred, and anti-arrhythmic drugs should be used. If procedure is necessary, the number of operators should be limited to the essential. Implantable devices that have remote control technology are desired. Cleaning and sanitation of laboratory should be performed after every procedure.
Given the risk of cardiovascular complications in the setting of COVID-19, including preexisting cardiac disease, acute cardiac injury, and drug-related myocardial damage, echocardiographic services will likely be required in the care of patients with suspected or confirmed COVID-19. Consequently, echo providers will be exposed to SARS-CoV-2.
When to use?
The appropriate use criteria (AUC) should be utilized to guide echocardiographic imaging. If the examination is unlikely to yield clinically important information in the short term, even if indicated as per the AUC, it may be deferred. In cases where echocardiography is deemed required, knowing the status of a patient allows for the appropriate application of PPE and its conservation when not needed, in addition to reducing the exposure risk to echocardiography personnel. Transesophageal echoes (TEEs) carry a heightened risk of spread since they may provoke aerosolization of a large amount of virus due to coughing or gagging that may result during the examination. The use of contrast-enhanced CT and magnetic resonance imaging (MRI) has emerged as an alternative to TEE for exclusion of left atrial appendage thrombus before cardioversion. The use of these tests to avoid an aerosolizing procedure should be balanced against the risk of transporting a patient through the hospital to the CT or MRI scanner, the need to disinfect the CT or MRI room, and iodinated contrast and radiation for CT and long scan times for MRI.
Where to perform?
The portability of echocardiography affords a clear advantage in imaging patients without having to move them and risk virus transmission in the clinic or hospital. All forms of echocardiography (including chemical stress tests) can be performed in emergency departments, hospital wards, ICUs, operating theaters, recovery areas, and structural heart and EP procedure laboratories, in addition to echocardiography laboratories. Bedside performance is encouraged if an adequate study can be performed.
Equipment care is critical in the prevention of transmission. Measures such as covering probes and machine consoles with disposable plastic and foregoing the use of electrocardiography (ECG) stickers may be done. It must be balanced against the potential of suboptimal images and prolongation of scan time. Certain machines or probes may be set aside for use on patients with suspected or confirmed infection. Echocardiogram machines and probes should be thoroughly cleaned, ideally in the patient's room and again in the hallway. The risk of transmission also occurs in scan reading rooms. Keyboards, monitors, mice, chairs, phones, desktops, and doorknobs should be frequently cleaned, and ventilation provided wherever possible.
Part three: Management of specific conditions
Valvular heart disease
VHD has not been specifically linked to increased morbidity or mortality in COVID-19. The symptoms of disease progression may mimic those of lung infection. VHD may aggravate the course of COVID-19 and complicate hemodynamic management of cytokine storm, ARDS, or sepsis. Elective surgical or transcatheter interventions require significant resources and should be inappropriate during the pandemic. However, patients with severe disease may require close monitoring and be asked to report in case of progress of symptoms. In a scenario where a patient requires early intervention, the use of less invasive procedures (such as transcatheter aortic valve implantation) may help in reducing ICU stay and hospital admission. Clinical decision-making using the Heart Team approach remains critical for best care.
Chronic heart failure
The risk of COVID-19 in this group may be higher because of advanced age and multiple comorbidities. Routine clinical assessment including temperature measurement, ECG (arrhythmias, MI, and myocarditis), chest X-ray (pneumonia and cardiomegaly), and laboratory measurements (erythrocyte sedimentation rate, C-reactive protein, and lymphocytopenia) can provide a diagnostic clue. Echocardiography and chest CT may add additional diagnostic information. Patients with chronic heart failure should strictly follow protective measures to prevent infection. Stable heart failure patients should refrain from visiting the hospital. Optimal medical therapy should be continued. Telemedicine should be considered whenever feasible to follow up stable patients. As mentioned in the section on hypertension, RAS inhibitors should be continued in these patients as well, irrespective of COVID-19 status. COVID-19 patients may have hypotension due to dehydration and hemodynamic deterioration, and adjustment of medication doses should be considered in such a scenario.
Arrhythmogenic and QTc prolongation of coronavirus disease 2019 therapies
Treatment strategies for COVID-19 use a combination of several drugs which are being used “off-label.” Drugs include chloroquine/hydroxychloroquine, lopinavir–ritonavir, remdesivir, and azithromycin.,,, Glucocorticoids, interferons, and tocilizumab are also being used.
Hydroxychloroquine is being used as a drug for prophylaxis as well as treatment against COVID-19 in India. One major concern with these drugs is the very rare risk of QTc prolongation and torsades de pointes (TdP)/sudden death. A recent meta-analysis on arrhythmogenic potential of quinolones and structurally similar antimalarials suggested that this risk is minimal. However, during COVID-19 infection, the QT-related risk may be increased by concomitant use of other QTc-prolonging drugs and electrolyte imbalances (hypokalemia, hypomagnesemia, and/or hypocalcemia). A second concern with hydroxychloroquine is the potential for conduction disturbances, although these are rare and appear to be linked mostly to long-term treatment.
Azithromycin is another common drug being used in India for COVID-19 treatment. It has been associated with QTc prolongation and TdP, mainly in individuals with additional risk factors., Two studies from Africa have looked at safety profile of using this combination for the treatment of malaria and showed acceptable safety profile.,
QTc prolongation with such drugs may rarely lead to polymorphic VT/TdP. [Figure 1] provides a practical flowchart for the management of patients to prevent TdP and for timing and repetition of ECG and QTc measurements. All modifiable (hypocalcemia, hypokalemia, hypomagnesemia, concomitant use of QTc-prolonging medications, and bradycardia) and nonmodifiable (congenital long QT syndrome, known QT prolongation on QT-prolonging drugs, females, age more than 65, structural heart disease, hypertrophic cardiomyopathy, decompensated heart failure, and renal or liver impairment) risk factors for QTc prolongation should be checked in every patient. Serum potassium should be kept at higher end >4.5 mEq/L. Baseline ECG should be performed, and baseline QTc >500 ms is at higher risk for TdP. In patients with recent ECG showing normal QTc and no evidence of cardiovascular alteration due to COVID-19, it may be appropriate to not do baseline ECG, as every ECG exposes health-care workers and equipment. ECG should be performed once on treatment. If the patient has a QTc ≥500 ms or shows a △ QTc ≥60 ms, consideration should be given to either switching to a drug with a lower risk of QTc prolongation or reducing the dose administered. Close surveillance of the QTc (preferably including telemetry for arrhythmia monitoring) and electrolyte balance are mandatory.
|Figure 1: Practical flowchart for the management of patients to prevent torsades de pointes, for guidance on the timing and repetition of ECG recording, and on QTc measurements that may alter therapy.|
Click here to view
| Conclusion|| |
Running the cardiology service during a pandemic presents to us unique challenges. Controlling the pandemic while providing optimal care to the cardiology patients has a fine balance which has to be maintained as much as possible. The COVID-19 pandemic also brings with it new cardiovascular problems which have to be identified and dealt with. This practical guide provides some information which may be helpful in this new scenario. As more and more information becomes available, therapies and guidelines will need to be updated to provide the best care for all patients.
The health-care personal have to be aware of the cardiovascular manifestations of COVID-19 and the up-to-date management of both COVID and cardiology emergencies in the setting of COVID. They also need to be aware of what levels of PPE they need to wear in a different setting. They also have to be constantly retrained in the latest guidelines because the guidelines keep changing based on the latest information.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]