1.Cardiac Catheterization Laboratory Volume Changes During COVID-19—Findings from a Cardiovascular Fellows Consortium

https://www.ajconline.org/article/S0002-9149(20)30565-8/fulltext

Kadavath S, Mohan J, Ashraf S, Kassier A, Hawwass D, Madan N, Salehi N, Bernardo M, Mawri S, Rehman KA, Ya'qoub L, Strobel A, Dixon SR, Siraj A, Messenger J, Spears JR, Lopez-Candales A, Madder R, Bailey SR, Alaswad K, Kim MC, Safian RD, Alraies MC.2020 Sep 1;130:168-169

2.How The COVID-19 Pandemic Has Affected Cardiology Fellow Training

https://www.ajconline.org/article/S0002-9149(21)00322-2/fulltext

Kadavath S MD , Hawwas D MD , Strobel A MD , Mohan J DO , Bernardo M MD , Kassier A MD ,Ya’qoub L MD , Madan N MD MPH , Ashraf S MD , Salehi N MD , Mawri S MD MS , Abdur Rehman K MD , Siraj A MD , Alraies C MD MPH , Saad M MD PhD , Aronow H MD

doi: https://doi.org/10.1016/j.amjcard.2021.03.052

Section Co-Leads: 

• Sabeeda Kadavath, MD (@sabeedak1)
• Jay Mohan, DO (@DrJayMohan)

Section Contributors:

• Said Ashraf, MD (@SaidAshrafMD)
• Chadi Alraies, MD (@chadialraies)
• Marie Bernardo, MD
• Tanush Gupta, MD (@DrTGupta)
• Atif Hassan, MD
• Dalia Hawwass, MD
• Adnan Kassier, MD (@AKassier)
• Nidhi Madan, MD MPH(@Nidhi_Madan9)
• Sagger Mawri, MD (@SaggerMawri)
• Karim Abdur Rehman MD
• Negar Salehi, MD (@NegarSalehiMD)
• Aisha Siraj, MD (@DrAishaSiraj)
• Aaron Strobel, MD(@StrobelAaron)
• Lina Ya'qoub, MD (@yaqoub_lina)

Cardiac Catheterization Laboratory (Welt et al,JACC, 2020)

1. The overall consensus for catheterization laboratory case scheduling is to restrict cases to only ones that require urgent or emergent care. This is to be done at the providers discretion. 
2. Strategies to reduce exposure to staff and the conservation of personal protective equipment should be maximized 
3. For COVID positive cases that enter the catheterization laboratory a terminal clean must be completed with each case.
4. Staffing is variable. Should reserve at least one to two 24-hour teams to maintain care of cardiac emergencies. Given unique skills, catheterization lab staff should preferably be diverted to non-COVID-19 patients only.

How to balance acute myocardial infarction and COVID-19: the protocols from Sichuan Provincial People’s Hospital (Zeng et al, Intensive Care Medicine, 2020)

·      Perform rapid nucleic acid test for SARS-CoV-2 if available.

·      If positive or time for results significantly delays time to reperfusion, follow protocol below

Protocol for STEMI:

1. Stable patients:

·      Onset of symptoms <12 hrs: Perform thrombolytic therapy if no contraindication. If contraindication present, consider infection risk vs. benefits of PCI. After treated and recovered (test negative twice for COVID-19), elective PCI should be considered for those who received thrombolysis.

·       Onset of symptoms >12 hrs: Consider infection risk vs. benefits of PCI if there is continuing evidence of ischemia.

2. Unstable patients:

·      Severe pneumonia: Conservative management.

·      Mild to moderate pneumonia: Assess time of onset and follow STEMI protocol for stable patient

Protocol for NSTEMI:

·      Exclude SARS-CoV-2 infection first.

·      Conservative medical management until recovery from COVID-19 pneumonia, then reassess the benefit of PCI.

·      If unstable or malignant arrhythmia, perform PCI in isolated catheter room

Catheterization Laboratory Considerations During the Coronavirus (COVID-19) Pandemic: From ACC’s Interventional Council and SCAI (Welt et al, JACC, 2020)

Key Points as summarized by Ajay Kirtane MD ( @ajaykirtane)

Considerations for Cardiac Catheterization Laboratory Procedures During the COVID-19 Pandemic (Szerlip et al, CCI, 2020)

• Appropriate triage and management of patients that are COVID+ or PUI presenting with acute coronary syndrome.
• Patients presenting with COVID+ or high risk findings of a possible COVID infection should be managed noninvasively if possible.
• Thrombolytic should be considered for therapy in low risk (non anterior wall MI)
• Bedside procedures should be utilized if possible to avoid contamination of the cath lab.
• If a patient is brought to the lab appropriate PPE should be utilized by all staff members. Post procedure a terminal clean is required. 
• Overall, patient selection is critical during this pandemic. When possible conservative measures should be taken in order to protect the staff as well as to preserve PPE.

Management of Acute Myocardial Infarction During the COVID-19 Pandemic: A Consensus Statement from the Society for Cardiovascular Angiography and Interventions (SCAI), American College of Cardiology (ACC), and the American College of Emergency Physicians (ACEP) (Mahmud et al, CCI, 2020)

• Addresses care of patients focusing on:

• The varied clinical presentations
• Appropriate PPE for health care workers
• Role of the ER, EMS and Catheterization Laboratory
• Regional STEMI systems of care.



• Primary PCI remains the standard of care for STEMI patients at PCI capable hospitals.
• Fibrinolysis‐based strategy may be entertained at non‐PCI capable referral hospitals or in specific situations where primary PCI cannot be executed or is not deemed the best option.

European Society of Cardiology (ESC) COVID-19 Guidance

Key Points:

1. Use of non invasive imaging for intermediate risk ACS
2. Immediate complete revascularization when possible
3. Discretion with devices & dialysis in shock/AKI & ECMO preferred 
4. Resource conservation/allocation

Reproduced from the original work here . Permission obtained from © The European Society of Cardiology 2020. All rights reserved.

Chronic Coronary Syndrome (ESC Guidance 3/2020)

• Key Points

• Follow up via Tele-Health
• Postpone revascularization in low-intermediate risk patients
• Revascularization in presence of high risk symptoms +/-large area of ischemia +/- high risk coronary anatomy
• Postpone non invasive testing
• CT Angiography preferred
• Screen for Covid worth nasopharyngeal swab and CT before cardiac surgery
• PCI over CABG in select patients
• Defer invasive management in Covid positive, whenever possible.

• Antithrombotic therapy in patients with acute coronary syndrome complicated by cardiogenic shock or out-of-hospital cardiac arrest (Gorog et al, EHJ, 2020)

• Patients with CS or OHCA of presumed ischemic cause are a very high-risk group.
• Impaired drug absorption, metabolism, altered distribution and/or excretion, and associated multiorgan failure, and co-administered treatments such as opiates, TTM, RRT, and ECMO, have a major impact on the effectiveness and safety of antithrombotic drugs.
• Careful attention to the choice of agent, route of administration, minimization of drug-drug interactions, therapeutic drug monitoring, and factors that affect drug efficacy and safety.

• EAPCI Position Statement on Invasive Management of Acute Coronary Syndromes during the COVID-19 pandemic (Chieffo et, EHJ, 2020)

Key messages:

• Recommended to dedicate at least one cathlab for invasive treatment of suspected or confirmed COVID-19 patients
• Establish clear pathways for COVID-19 patients in the cathlab at each intervention centre
• Only HCWs involved in the procedure should remain inside the cathlab; cathlab doors should be kept closed at all times.
• A surgical mask for the patients, and complete PPE for HCWs involved in the cathlab intervention
• All HCWs have to be routinely trained in the correct use of PPE .

Incidence:

• Not well known although evidence of elevated high-sensitivity troponin levels is commonly observed in severe cases (Majdid M et al,JAMA Cardiology, 2020 ; Driggin et al,JACC, 2020)

• Summary of interventional cases : The Variety of Cardiovascular Presentations of COVID-19 (Fried JA et al, Circulation, 2020)

• Case 1 STEMI

 64-yo F, PMH HTN, HLD, came with chest pain and was found to have anterolateral STEMI V2-6, I, AVL, ST depression in AVR, troponin 7.9 ng/ml on admission, LHC showed non-obstructive CAD. RHC showed RAP 10 mmHg, pulmonary artery pressure of 30/20 mmHg, PCWP 21 mmHg and a Fick cardiac index of 1.0 L/min/m2. IABP and Dobutamine was started. Echo EF 30% with small LV associated with thick LV walls and dilated hypokinetic RV. Lactate of 5. She was started on oral hydroxychloroquine 600 mg every 12 hours for 1 day followed by 400 mg daily for 4 additional days. Lactate normalized, troponin peaked at 18.6 then normalized. IABP and inotropes weaned off after 7 days. Hospital day 10, repeat echo EF 50% and reduced LV thickness.

Thoughts 1- For hemodynamics: To reduce the potential contamination associated with patient transport to the catheterization suite, bedside placement of a pulmonary artery catheter and IABP may be considered? Other potential indicators of the hemodynamic status may include sampling the central venous saturation or hemodynamic assessment via echocardiography.

 2- Does the increased wall thickness present in this patient suggest a characteristic finding of myocarditis-like presentations with COVID-19? 

3- A low threshold to assess for shock in acute systolic HF associated with COVID. Similarly, there should be a low threshold for SARS-CoV-2 testing in patients presenting with signs of myopericarditis even in the absence of fever and respiratory symptoms. 

• Case 2 MCS 

38-yo F, DM II, presented with cough, dyspnea and pleuritic chest pain. TTE normal LVEF. CXR pulmonary infiltrates, COVID positive. Respiratory status deteriorated requiring intubation, then paralytic and prone position without significant improvement, PO2 56, pH 7.26, pCO2 40 mmHg. VV ECMO was initiated, L femoral and L IJ. She became hypotensive requiring inotropic support, decrease urine output and lactate of 5. Repeat TTE showed LVEDD of 4.5 cm, LVEF 20-25%, with akinesis of the mid LV segments, and normal RV. High sensitivity troponin T was 1341 ng/L. After a multidisciplinary discussion, a 15F arterial limb was added via the right femoral artery to convert the circuit to veno-arterial-venous (VAV) ECMO, achieving 2L of arterial flow. Over 24 hours, lactate normalized and she was off pressors. ECMO decannulated after 7 days, she remains intubated.

 Thoughts 1- The cardiac involvement became evident after the initiation of VV ECMO. 

2- Direct cardiac injury may occur as the result of viral invasion, or cytokine storm induced by COVID-19

 3- Reports of ECMO use in COVID-19 patients are limited. Utility is likely limited due to the extensive resources required to provide the therapy and limited availability.

 4- Are such relatively low levels of hemodynamic support sufficient in other cases with COVID-19 related cardiogenic shock? decreased likelihood of LV distention with its associated consequences?

• Case 3 Decompensated HF

 64 yo F, NICM (recovered EF), PAF, HTN, DM, presented with a non-productive cough and shortness of breath for two days. ECG PAC, PVC, prolonged QTc 528 ms. No hydroxychloroquine, given antibiotics for pneumonia, respiratory deterioration requiring intubation, Echo severely reduced EF, RHC with PAP 40/20, Fick’s CI 1.7, hypotension requiring dobutamine (caused NSVT so was discontinued), IABP considered but BP and lactate improved, troponin stable peak 214 ng/ml, remains intubated on day 9, multiple extubation attempts.

Thoughts 1- Neither myocarditis nor cytokine storm were probable mediators of the recurrence of her depressed cardiac function, given the relatively low biomarker levels. 

2- Early intubation and reversal of her respiratory failure led to improvements in hemodynamics in the absence of direct cardiac support.

 3- RHC to assess hemodynamics 

4- Prolonged cQT Case 

• Case 4 Heart transplant recipient 

51 yo M, heart transplantation 2007, renal transplantation 2010, presented with intermittent fever, dry cough, and shortness of breath for 9 days, on immunosuppression: tacrolimus 5 mg BID, mycophenolate mofetil 250 mg BID, and prednisone 5 mg daily. Mx: Mycophenolate mofetil was discontinued, started on hydroxychloroquine and azithromycin as well as ceftriaxone for empiric treatment of pneumonia. Discharged on day 7. 

Thoughts 1- stopped the mycophenolate mofetil during the infection, with a plan to resume it following full recovery.

 2- Programs must balance the risks of new transplant recipients contracting COVID-19 during their hospitalization with the risks of waitlist mortality if transplantation is postponed.

 3- COVID-19 may also impact the donor pool due to diversion of crucial resources and fear of disease transmission from donors

• A Refresher on Fibrinolytics: Dr Nadeen Faza MD (@Nadeen Faza MD)

(pre COVID19 Guidelines)

• Indications

• Contraindications

• Fibrinolytic Agents

• Why Fibrinolytic Therapy (FT) for STEMI in The COVID-19 Pandemic is Not Your New Best Friend ( Kirtane et al, Circulation: Cardiovascular Quality and Outcomes,2020)
• FT is an inferior reperfusion alternative to PPCI in patients with STEMI, achieving lower rates of TIMI-3 flow compared with PPCI
• Due to the high rate of reinfarction, modern implementations of a FT-based approach involve secondary cardiac catheterization, either rescue (in the case of failed reperfusion) or routine (in order to definitively treat the underlying lesion after successful fibrinolysis)
• The syndrome of COVID-19 myopericarditis is not an uncommon cause of ST-elevation on the electrocardiogram.6 Administration of potent FT to a patient with myopericarditis is not only likely to be ineffective, but incurs substantial bleeding risk.
• The role of the cardiac catheterization laboratory in STEMI is not solely limited to PPCI. Diagnostic catheterization with coronary angiography accompanied by the judicious use of hemodynamic assessments can be instrumental.
• Two most compelling reasons to advocate for a strategy of FT for STEMI in the COVID-19 era relate to reducing staff exposure/resources as well as in overcoming delays to reperfusion.

• Reduced Rate of Hospital Admissions for ACS during Covid-19 Outbreak in Northern Italy (De Fillipo et al, NEJM 2020)
• Total 547 patients w ACS Italy
• (76.8%) males/age 68yr
• (45.3%) STEMI
• ACS Admission 13/day compared to 18/day previous yr
• After lockdown March 8, further decrease in ACS admissions

• ST-Elevation Myocardial Infarction in Patients with COVID-19: Clinical and Angiographic Outcomes(Stefanini et al, Circulation, 2020)
• STEMI can be 1st clinical manifestation of COVID 19 (so full PPE justified)
• Of 28 patients, culprit stenosis absent in 40%, 13d mortality 39%

Highlights from the Webinar by C3 Academy on The North American Experience in managing patients with ACS/STEMI

• Practical Considerations
• MeNTS Score as a tool to determine urgency of procedures

 Population Trends of interventions for ACS worldwide: In the third most populous region of Italy, a decline of 32% in the number of PCI for ACS was observed (Piccolo et al, Circulation, 2020)

• Post STEMI Complications:

Ventricular septal defect observed in three cases (Moroni et al, JACC CR, 2020)

Video Link

• STEMI and COVID-19: Angiographic Outcomes (Ahmed B, ACC.org, 2020)
• Citation: Stefanini et al, JACC, 2020
•  Total of 28 patients with COVID-19 and STEMI were included.
•  Symptoms of STEMI were the main reason for presentation, and abnormal wall motion was seen on echo in the majority of patients.
•  Culprit lesion was identified in 60% of the STEMI patients, while the rest had type 2 acute MI.
•  The impact of primary PCI on time to reperfusion and outcomes during the pandemic remains to be determined.

COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-up. (Bikdeli et al )

COVID-19 and antithrombotic therapy for acute coronary syndrome (ACS)

In presentations consistent with ACS due to plaque rupture (i.e. Type I MI), dual antiplatelet therapy (DAPT) and full dose anticoagulation per American College of Cardiology (ACC)/American Heart Association (AHA) and the European Society of Cardiology (ESC) guidelines should be administered unless there are contraindications. In patients with perceived elevated bleeding risk, regimens with less potent antiplatelet agents, such as with clopidogrel, should be considered.

COVID-19 and interventional therapies for ACS.

The ACC and Society for Cardiovascular Angiography and Interventions (SCAI) recommendations note that it is reasonable to continue optimal medical therapy and defer non-urgent cardiac procedures, in order to preserve personal protective equipment (PPE), hospital resources, and minimize exposure for patients and healthcare workers.

Prior to intervention, efforts should be made to distinguish non-specific myocardial injury, myocarditis, and true plaque rupture presentations. Even in case of STEMI, in which primary percutaneous coronary intervention (PCI) reduces mortality and reinfarction, risk of COVID-19 transmission from patients to healthcare workers must be considered.

Disseminated intravascular coagulopathy (DIC) and Considerations for Antithrombotic Therapy

Long-acting antiplatelet agents should be discontinued in most patients with DIC, unless required (e.g. recent ACS or stent implantation). In general, it is reasonable to continue dual antiplatelet therapy if platelet count ≥50,000, reduce to single antiplatelet therapy if 25,000≤platelet count. However, these guidelines may be revised upward or downward depending on the individualized relative risk of stent related thrombotic complications vs. bleeding

Covid-19 investigational therapies and their interaction with anti-platelet agents

Bevacizumab

This is a monoclonal antibody that binds to vascular endothelial growth factor (VEGF), and is under investigational use for COVID-19, is associated with increased risk for adverse cardiovascular events, including MI, cerebrovascular accidents, and VTE.

Fingolimod

It is an immunomodulating agent being tried for COVID-19, may reduce reperfusion injury and improve outcomes in patients suffering from acute ischemic stroke.

Hydroxychloroquine

It may potentially exert antithrombotic properties, especially against anti-phospholipid antibodies.

Lopinavir/ritonavir

It is a protease inhibitor and inhibits CYP3A4 metabolism. Although the active metabolite for clopidogrel is mostly formed by CYP2C19, inhibition of CYP3A4 may also lead to reduction in effective dosage of clopidogrel. This inhibition of CYP3A4 may increase effects of ticagrelor.

Remdesivir

This is a nucleotide-analog inhibitor of RNA-dependent RNA polymerase, reportedly an inducer of CYP3A4; however, dose adjustments for oral antiplatelet agents are currently not recommended

Of note, there are no major drug-drug interactions between investigational COVID-19 therapies and parenteral antiplatelet agents such as cangrelor and glycoprotein IIb/IIIa inhibitors.

Covid-19 investigational therapies and their interaction with anti-coagulation agents

Lopinavir/ritonavir

It has the potential to also affect choice and dosage of a number of anticoagulants. For example, vitamin K antagonists, apixaban, and betrixaban may all require dose adjustment, while edoxaban and rivaroxaban should not be 13 co-administered with lopinavir/ritonavir.

Tocilizumab

It is an IL-6 inhibitor. It increases expression of CYP3A4; however, no anticoagulant dose adjustments are currently recommended with concomitant use of tocilizumab at this time.

There are no major drug-drug interactions between investigational COVID-19 therapies and parenteral anticoagulants.

Considerations for venous thromboembolic (VTE) prophylaxis

The World Health Organization interim guidance statement recommends prophylactic daily low-molecular weight heparins (LMWHs), or twice daily subcutaneous unfractionated heparin (UFH). If pharmacological prophylaxis is contraindicated, mechanical VTE prophylaxis (intermittent pneumatic compression) should be considered in immobilized patients.

Every effort should be made to ensure that patients receive all scheduled doses of pharmacologic VTE prophylaxis because missed doses are associated with worse outcomes. In addition, once daily dosing regimen of LMWHs may be advantageous over UFH to reduce personal protective equipment (PPE) use and exposure of healthcare workers.

Extended (post-discharge) VTE prophylaxis. After hospital discharge from acute medical illness, extended prophylaxis with LMWH or direct oral anticoagulants (DOACs) can reduce the risk of VTE, at the cost of increase in bleeding events. The consideration of extended prophylaxis (for up to 45 days) should be reasonable for patients with elevated risk of VTE (e.g., reduced mobility, co-morbidities such as active cancer, elevated D-dimer >2 times the upper normal limit) who have low risk of bleeding

COVID-19 and interventional therapies for VTE

Pulmonary embolism response teams (PERTs) allow for multidisciplinary care for patients intermediate and high-risk with VTE. During the COVID-19 pandemic, PERTs should transition from in-person inpatient evaluation to e-consults using phone calls or telemedicine systems whenever feasible. It is important to note that, there are minimal available data demonstrating lower mortality from routine use of advanced VTE therapies. Therefore, the use of catheter-directed therapies should be limited to the most critical situations. Recurrent PE despite optimal anticoagulation, or clinically-significant VTE in the setting of absolute contraindications to anticoagulation are among the few scenarios in which placement of an inferior vena cava filter may be considered.

Intermediate-risk hemodynamically stable patients (intermediate-low risk, or intermediate-high risk PE according to ESC classification, sub-massive PE according to prior classifications) should be managed initially with anticoagulation and close monitoring. In case of deterioration, rescue systemic fibrinolysis should be considered, with catheter-directed options as an alternative. For patients with overt hemodynamic instability (high-risk PE according to the ESC classification, massive PE according to prior classifications) systemic fibrinolysis is indicated, with catheter-based therapies reserved for scenarios that are not suitable for systemic fibrinolysis.

In cases of shock, if infection control settings are equal, bedside initiation of extracorporeal membrane oxygenation (ECMO) is preferred in cases with known COVID-19 positivity or uncertain status, rather than support strategies requiring the use of a catheterization laboratory or an operating room in order to limit unnecessary exposure.

The vast majority of patients with symptomatic acute deep venous thrombosis (DVT), should be managed with anticoagulation, with home treatment whenever possible. The few that may require acute endovascular techniques (either local fibrinolysis or embolectomy) include those with phlegmasia, or truly refractory symptoms.

• STEMI Management

• Impact of COVID-19 on STEMI care: Circulation: CV quality and outcomes. (Tam CF et al, Circ Cardiovasc Qual Outcomes.,2020)

• Inclusion Criteria:

Patients with STEMI admitted via the Accident and Emergency

Department and in whom PPCI was performed

• Exclusion Criteria:

Inpatient STEMI (n=1), STEMI with unknown symptom onset time

(n=3), and cardiac arrest patients (n=2)

• Period of Study: January 25, 2020, to February 10, 2020

Comparison Group: 108 patients with STEMI treated with PPCI in the prior year from February 1, 2018, to January 31, 2019 (N=108)

• Study Findings:
• This single hospital experience showed delays in all aspects of STEMI care since the beginning of the COVID-19 pandemic. That included:
• Delay in seeking medical contact likely due to patient fear,
• Delay in door to device time due to implementation of infection control strategies and PPEs
• Delay in cath lab arrival to device time as well

• Reduction in STEMI Cath lab activation in the USA during COVD-19. (Garcia S et al,JACC, 2020)

• Inclusion Criteria:

March 1 st was identified as the beginning of the “After COVID period (AC)”. In this paper they compared cath lab activation In 9 high volume centers (>100 PPCI/year) for STEMI before and after March 1 st.

Study duration: Between Jan 1 st 2019 and March 31 st 2020.

• Study Findings:

•38% decrease in STEMI activation (95% CI: 26,49; p&lt;0.001)

•All sites combined reported >180 STEMI activation every month (mean of 23.6 act/mo) in BC period.

•All sites combined reported 138 activations/ month (mean 15.3 act/mo) in AC period.

•These findings are similar to 40% reduction noticed in Spain.

•The Spanish Society of Cardiology has reported a drop of 40%. (Rodriguez-Leor et al,Rec: Interventional Cardiology, 2020)

• ST-Segment Elevation in Patients with Covid-19 — A Case Series. (Bangalore et al ,NEJM, 2020)

•Patients with confirmed Covid-19 who had ST-segment elevation on electrocardiography were included in the study from six New York hospitals. 

•They identified 18 patients with Covid-19 who had ST-segment elevation

•Median age of the patients was 63 years, 83% were men, and 33% had chest pain.total of 10 patients (56%) had ST-segment elevation at the time of presentation, and the other 8 patients had development of ST-segment elevation during hospitalization.

•9 patients (50%) underwent coronary angiography; 6 of these patients (67%) had obstructive disease, and 5 (56%) underwent percutaneous coronary intervention (1 after the administration of fibrinolytic agents).

•Total of 13 patients (72%) died in the hospital (4 patients with myocardial infarction and 9 with noncoronary myocardial injury).

•Management of Acute Myocardial Infarction During the COVID-19 Pandemic (Mahmud et Al, JACC, 2020)

• Ultrarapid testing
• Not bypass ED
• Screen with Chest XRay, pulse oximetry
• Consider the clinical presentation, setting
• Point of Care Ultrasound
• Dedicated Labs
• PPE
• Negative pressure procedure room
• May be delays in Door To Balloon times
• STEMI patients with cardiogenic shock and/or resuscitated cardiac arrest : prioritized for a primary PCI
• Non PCI capable: Fibrinolysis within 30 minutes of STEMI diagnosis, and transfer for rescue PCI when necessary

•A reasonable algorithm and timely discussion on STEMI management (Daniels et al, Circulation, 2020)

•Institutional Protocols on ACS Management:

Henry Ford STEMI Protocol



Beth Israel Deaconess Cath Lab Protocol

• Definition:
• High-sensitivity cardiac troponin above the 99th percentile upper limit, or new electrocardiographic and echocardiographic abnormalities( Zhou at al, Lancet, 2020)

• Patients with known history of coronary artery disease and those with risk factors for cardiovascular disease are at risk (Bonow, et al, JAMA Cardiology, 2020)

• Incidence of ACI:
• 19.7% ( 416 patients studied) (Shi, et al, JAMA Cardiology, 2020)
• 27.8% (n = 52) (Guo, et al, JAMA Cardiology, 2020)
• 12% overall, 31% ICU, 4% non-ICU (n =41 patients) (Huang, et al, Lancet, 2020)
• 17% overall (n=191) (Zhou, et al, Lancet, 2020)

• Spontaneous coronary artery dissection (SCAD) reported in France (Courand, JACC Interventions, 2020)

• Diagnosis:
• ECG 
• Limited echo cardiogram
• Inflammatory markers to evaluate hyperinflammation
• IL-6, Ferritin, D- dimer

• Differentials:

• Myocarditis/Pericarditis: 

 Presents with a broad spectrum and severity of symptoms 

• Case reports/case series :
• Ruan et al, Intensive Care Med, 2020
• Zeng et al, Preprints, 2020
• Hu et al, Eur Heart J, 2020



• Evidence of myocarditis on MRI (Inciardi et al, JAMA Cardiology ,2020)

• Coronavirus Myocarditis MRI : Video (JAMA Network JN Learning™ 2020)

• Autopsy series :
• 4 patients from New Orleans (Fox, et al, medRxiv, 2020)
• Most significant gross findings were cardiomegaly, and right ventricular dilatation.
• The coronary arteries showed no significant stenosis or acute thrombus formation.

• No clear evidence of myocarditis on limited cardiac biopsy (Xu, et al, Lancet Respir Med, 2020)

1.Cardiogenic Shock and Mechanical Support (Henry, Lancet , 2020) 

·      Immunological status of patients should be considered when selecting candidates for ECMO

·      Elevated IL-6 concentrations in lung noted to induced by initiation of ECMO

·      Clinicians should consider tracking both lymphocyte count and IL-6 during ECMO to onitor patient status and prognosis

·      Patients who died from COVID-19 are reported to have had significantly lower lymphocyte counts than survivors

2. Cardiac Arrest:

Cause of Death: (Arentz et al, JAMA 2020)

Heart failure with respiratory failure (33%)

Myocardial damage (7%)

Outcome:

Outcomes for in-hospital cardiac arrest with attempted resuscitation from China (Shao et al, Resuscitation, 2020)

• n=136; 113 in general ward, 23 in ICU 
• Did not achieve ROSC: 118
• Achieved any ROSC: 18
• Factors associated with ROSC and 30-day survival were initial rhythm and location of arrest
• Of those who achieved ROSC, 14 died in hospital, 4 survived at 30-days
• Initial rhythm of patients with cardiac arrest
• Asystole 89%
• PEA 4.4%
• VF/VT 5.8

Lombardia Cardiac Arrest Registry ( Baldi et al, NEJM, 2O2O)

·     Out of Hospital Card Arrest During Covid-19 in Italy

·     Increase of 58% relative to comparable period in 2019

·     77% of Outside Hospital Cardiac Arrests +

·     Highlights the importance of using all-cause mortality as an indicator of COVID-19 burden

• Impella use in a patient with COVID-19: Case as described by D'Alessandro MD, Massachusetts General Hospital

Role of ECMO as described in the webinar by C3 Academy on the North American Covid Experience



• An Increased Severity Of Peripheral Arterial Disease In The COVID-19 Era (Sena G et al, Journal of Vascular Surgery 2020)

• The department of vascular surgery at “Pugliese-Ciaccio” Hospital, Catanzaro, Italy has observed an increase of almost 50% in the number of amputations performed between March 9 and April 20 in 2020 compared to the same period last year.
•  Like most of cardiac care, COVID-19 pandemic has led to important changes in the management of patients with vascular diseases as well.
• Vascular diseases including peripheral arterial disease (PAD) require rapid treatment in certain cases depending on severity
•  The most severe grades of PAD classification including critical limb ischemia (CLI) often require rapid revascularization to avoid tissue loss and amputation.
• The introduction of the lockdown as well as the fear of contagion likely led to the underestimation of the symptoms and also delayed access to treatment through the emergency room. For this reason, patients with severe CLI with important septic ulcers and gangrene are not seeking early medical care.
• Due to the late presentation, more patients are undergoing amputation surgery which has much higher morbidity and mortality.
• The Covid-19 pandemic has led to a poor management of patients with PAD and it is necessary to adopt more suitable measures to avoid serious consequences to patients.
•  Consequently, it would be necessary to identify paths that allow these patients to have rapid access to treatment with a marked outcome improvement.

• Live Discussion with Q&A on “Management of PAD Patients During the COVID-19 Pandemic”From Mount Sinai Hospital NY (Webinar Link)

• Inpatient vs. Telehealth Triage
• Acceptable to follow PAD patients with telehealth if symptoms are stable vs. patients with sudden change in symptoms need to be seen in person.
• Acute change in symptoms need further evaluation and/or anticoagulation.
• Diagnostic tests for arterial and venous disease: Vascular staff needs to be protected with proper PPE and preferably use a dedicated room for presumed and Covid positive patients
• Urgent tests needed for Pseudoaneurysm’s, DVT’s, symptomatic carotid disease and ALI (acute limb ischemia).
• Treadmill ABI’s should be avoided to reduce the risk of respiratory droplet transmission.

• ALI/CLI
• Thrombotic complications of COVID-19 need to be considered in patients who present with ALI (acute limb ischemia).

• Management:
• Endovascular approach should be preferred vs. surgery to avoid increased risk of exposure from anesthesia needs. In some acute limb ischemia patients open surgical thrombectomy might be possible with regional anesthesia.  
• Percutaneous intervention with mechanical thrombectomy vs. therapeutic AC needs to be decided on case by case basis.

Triage Considerations for Patients Referred for Structural Heart Disease Intervention During the Coronavirus Disease 2019 (COVID‐19) Pandemic: An ACC/SCAI Consensus Statement (April 6). (Shah et al, CCI, 2020)

• Symptomatic Severe Aortic Stenosis (AS)
• For inpatients with severe symptomatic AS associated with a reduction in EF thought secondary to AS, presence of class III-IV congestive heart failure (CHF), or syncope secondary to AS, TAVR should be considered .
• Ok to schedule TAVR for outpatients with severe to critical aortic stenosis and class III-IV CHF symptoms.  
• Minimally Symptomatic Severe To Critical AS 
• For patients with class I-II NYHA CHF symptoms and quantitative measures of valve severity that indicate a critically tight valve, it is reasonable to consider either urgent TAVR or close outpatient virtual monitoring by the valve coordinator. 
• Features that warrant consideration of TAVR include particularly high peak or mean gradient, very small calculated aortic valve area, or very low dimensionless index.
• Asymptomatic Severe To Critical AS
• For truly asymptomatic patients, it is reasonable to postpone consideration of transcatheter aortic valve replacement (TAVR) for three months or until after hospital operations resume elective procedures. Close outpatient monitoring, possibly via telehealth, should continue for all patients with severe AS.

• Percutaneous Mitral valve repair:
• Inpatients with Functional MR (FMR) severity 3+/4+ who cannot be safely discharged despite optimized GDMT.
• Outpatients with severe FMR (3+/4+) with hospitalization for CHF within thirty days despite optimized GDMT.
• Inpatients with CHF and severe degenerative MR (DMR) (3+/4+) due to acute valvular dysfunction high risk for surgical mitral valve repair/replacement.
• Outpatients with severe DMR (3+/4+) with hospitalization within thirty days despite optimized medical therapy who are high risk for surgical mitral valve repair/replacement. 
• Patients with either severe DMR or FMR who are in low-output, decompensated heart failure requiring ICU-level care where edge-to-edge device implantation might improve hemodynamics for extubation and/or transfer out of ICU setting.
• Valve in Valve (ViV) TMVR during the COVID-19 pandemic should be considered for patients with severe bioprosthetic mitral stenosis/regurgitation who are inpatients with CHF or outpatients who have had a hospitalization for CHF within 30 days despite optimized GDMT.
• Paravalvular leak (PVL) closure during the COVID-19 pandemic in inpatients with CHF and/or hemolysis.

 Intraprocedural Imaging Considerations:

 •Full PPE for the structural imager

•Major aerosolization risk to the structural imager and cardiac anesthesia team during the initial intubation and any TEE probe manipulation thereafter in a non-intubated patient.  

•In already ventilated patient, HEPA filter be placed with the ET tube to maximize safety .

Outpatient Clinic:

•STS/ACC TVT registry allowed for substitution of in-person visits with telephone or virtual visits for the 30-day and 1-year follow-up visits.

• Suggestions for procedural considerations for structural interventions by the JACC Twitter Club (05/07/20)

• RECORDED WEBINAR: TAVR and COVID-19: Latest Society Guidance and Experiences From the US and Canada (April 2)

• Urgent MitraClip (recorded) Procedure in Cardiogenic Shock in Covid-19: Video Link ( CCCLive Cases, 2020 )

• Thromboembolic Disease/Coagulopathy

• Thrombocytopenia (platelets 100-150) in 20% (Fan, et al., American Journal of Hematology, 2020)
• Coagulopathy noted
• 34.1% (Guo, et al., JAMA Cardiology, 2020)
• 19% (n = 37) (Zhou, et al., Lancet, 2020)
• Thromboembolic events common.
• 31% -most commonly pulmonary embolism (Klok, et al, Thrombosis Research, 2020)

• Abnormal coagulation is common in severe disease (Zhou, et al., Lancet, 2020)
• D-Dimer >1ug/dL is an independent risk factor for inhospital death
• Extensive intravascular microthrombosis seen at autopsy
• Treat with anticoagulation if possible

• Treatment Dose Anticoagulation and In-Hospital Survival (Paranjpe et al,JACC, 2020):
• Systemic AC may be associated with improved outcomes among hospitalized patients. The potential benefits of systemic AC, however, need to be weighed against the risk of bleeding.
• Among 2,773 hospitalized patients, 786 (28%) received systemic AC.
• In-hospital mortality for patients treated with AC was 22.5%, median survival of 21 days, compared to 22.8% and median survival of 14 days in patients who did not receive AC.
• Patients who received AC were more likely to require invasive mechanical ventilation (29.8% vs 8.1%, p<0.001).
• In patients who required mechanical ventilation (N=395), in-hospital mortality was 29.1% with a median survival of 21 days for those treated with AC as compared to 62.7% with a median survival of 9 days in patients who did not receive AC.

• Autopsy findings and Venous Thromboembolism in Patients With COVID-19: (Wichmann et al, Ann Int Med, 2020)
• Autopsy findings of first 12 consecutive COVID-19–positive deaths in Germany
• Deep venous thrombosis in 7 of 12 patients (58%) in whom venous thromboembolism was not suspected before death
• Pulmonary embolism was the direct cause of death in 4 patients

Articles & Webinars discussing prevalence of coagulopathy and thromboembolic disease in COVID-19 patients:

•Feature | Thrombosis and COVID-19: FAQs For Current Practice (Barnes et al,ACC Apr 22, 2020)

•JACC Paper Outlines Implications, Considerations For Thrombotic Disease Patients During COVID-19 Pandemic (Bikdeli et al, JACC, 2020)

• COVID-19 and Hemostasis Parameters:
• The most consistent hemostatic abnormalities with COVID-19 include mild thrombocytopenia and increased D-dimer levels which are associated with a higher risk of requiring mechanical ventilation, intensive care unit [ICU] admission, or death.
•  Disease severity is variably associated with prolongation of the prothrombin time (PT) and international normalized ratio (INR) , and thrombin time (TT) , and variably by a trend toward shortened activated partial thromboplastin time (aPTT).
• Tang et al. assessed 183 patients with COVID-19, 21 of whom (11.5%) died (Tang et al, J Thromb Haemost, 2020) . Among the notable differences between patients who died and those who survived were increased levels of D-dimer and fibrin degradation products ([FDPs], ~3.5- and ~1.9-fold increase, respectively) and PT prolongation (by 14%, P<0.001). Further, 71% of COVID-19 patients who died fulfilled the International Society on Thrombosis and Haemostasis (ISTH) criteria (29) for DIC, compared with only 0.6% among survivors. Collectively, these hemostatic changes indicate some forms of coagulopathy that may predispose to thrombotic events, although the cause is uncertain. A recent study reported 3 cases with severe COVID-19 and cerebral infarction ( Zhang et al, NEJM, 2020), one associated with bilateral limb ischemia, in the setting of elevated antiphospholipid antibodies. Whether antiphospholipid antibodies play a major role in pathophysiology of thrombosis associated with COVID-19 requires further investigation.

• COVID-19 Investigational Therapies and Considerations for Thrombotic Disease
• Several investigational agents are being tested in the management of COVID-19, especially for patients who develop severe disease. Some of these drugs have clinically important interactions with antiplatelet or anticoagulant agents . Further, a few of these investigational agents have been associated with excess risk (or, in other cases, reduced risk) for thrombotic events, or for thrombocytopenia in prior studies.
• Examples: bevacizumab, a monoclonal antibody that binds to vascular endothelial growth factor (VEGF), and is under investigational use for COVID-19, is associated with increased risk for adverse cardiovascular events, including MI, cerebrovascular accidents, and VTE .
• Alternatively, fingolimod, an immunomodulating agent being tried for COVID-19, may reduce reperfusion injury and improve outcomes in patients suffering from acute ischemic stroke.
• Hydroxychorloquine, may potentially exert antithrombotic properties, especially against anti-phospholipid antibodies.

• COVID-19 investigational therapies and antiplatelet agents:
•  Lopinavir/ritonavir may lead to reduction in effective dosage of clopidogrel and may increase effects of ticagrelor. Therefore, the concomitant use of these agents along with lopinavir/ritonavir should be cautioned. use of P2Y12 platelet function testing to guide the use of clopidogrel or ticagrelor in this setting might be considered. An alternative, in the absence of contraindications, is to use prasugrel, which is not prone to these interactions.
• There are NO major drug-drug interactions between investigational COVID-19 therapies and parenteral antiplatelet agents such as cangrelor and glycoprotein IIb/IIIa inhibitors.

• COVID-19 investigational therapies and anticoagulants:
• Lopinavir/Ritonavir: vitamin K antagonists, apixaban, and betrixaban may all require dose adjustment, while edoxaban and rivaroxaban should NOT be co-administered with lopinavir/ritonavir.
• There are no major drug-drug interactions between investigational COVID-19 therapies and parenteral anticoagulants.

• COVID-19 and VTE :Risk stratification and in-hospital prophylaxis:
•   A recent study from China (Wang et al,.Lancet Haematol, 2020), using the Padua model, reported that 40% of hospitalized patients with COVID-19 were at high risk of VTE.
•  The World Health Organization interim guidance statement recommends prophylactic daily low-molecular weight heparins (LMWHs), or twice daily subcutaneous unfractionated heparin (UFH). (LMWH preferred to preserve PPE). 
• If pharmacological prophylaxis is contraindicated, mechanical VTE prophylaxis (intermittent pneumatic compression) should be considered in immobilized patients.
• The risk of VTE is increased during pregnancy and the postpartum period. It is reasonable to consider pharmacological thromboprophylaxis, especially if they have other VTE risk factors.

• Extended (post-discharge) VTE prophylaxis:
•   While no data specific to COVID- 19 exist, it is reasonable to employ individualized risk stratification for thrombotic and hemorrhagic risk, followed by consideration of extended prophylaxis (for up to 45 days) for patients with elevated risk of VTE (e.g., reduced mobility, co-morbidities such as active cancer, and [according to some authors in the writing group], elevated D-dimer >2 times the upper normal limit) who have low risk of bleeding.
•  The role of thromboprophylaxis for quarantined patients with mild COVID-19 but significant co-morbidities, or for patients without COVID-19 who are less active because of quarantine is uncertain. These patients should be advised to stay active at home.

• Diagnosis of VTE in patients with COVID-19.
• Elevated D-dimer levels is a common finding in patients with COVID-19 , and does not currently warrant routine investigation for acute VTE in absence of clinical manifestations or other supporting information. However, the index of suspicion for VTE should be high in the case typical DVT symptoms, hypoxemia disproportionate to known respiratory pathologies, or acute unexplained right ventricular dysfunction.
• A diagnostic challenge arises among patients with COVID-19, as imaging studies used to diagnose DVT or PE may not be pursued given risk of transmitting infection to other patients or healthcare workers and potentially due to patient instability or positioning like (prone position in ARDS).
• A potential option may be to consider echocardiography to assess for signs of potentially worsening right ventricular dysfunction and in rare circumstances, clot in transit

• Role for empiric therapeutic anticoagulation without a diagnosis of VTE:
•   At this moment, while practitioners use a variety of prophylactic, intermediate, or therapeutic doses of anticoagulants in patients, the optimal dosing in patients with severe COVID-19 remains unknown and warrants further prospective investigation. The majority of panel members consider prophylactic anticoagulation, although a minority consider intermediate-dose or therapeutic dose to be reasonable.
• Medical therapy for VTE:
•  In many ill inpatients with VTE, parenteral anticoagulation (e.g. UFH) is preferred as it may be temporary, however, LMWHs may be preferred in patients unlikely to need procedure (to preserve PPE and minimize interruptions).
• DOACs or LMWH would be preferred in patients ready for discharge to limit contact of patients with healthcare services required for INR monitoring for VKAs.

• COVID-19 and interventional therapies for VTE.
• The use of catheter-directed therapies during the current outbreak should be limited to the most critical situations. Indiscriminate use of inferior vena cava filters should be avoided.
• Recurrent PE despite optimal anticoagulation, or clinically significant VTE in the setting of absolute contraindications to anticoagulation would be among the few scenarios in which placement of an inferior vena cava filter may be considered.
•  Intermediate-risk hemodynamically stable patients (intermediate-low risk, or intermediate-high risk PE , sub-massive PE ) should be managed initially with anticoagulation and close monitoring. In case of further deterioration, rescue systemic fibrinolysis should be considered, with catheter-directed options as an alternative.
• For patients with overt hemodynamic instability (high-risk PE according to the ESC classification, massive PE) systemic fibrinolysis is indicated, with catheter-based therapies reserved for scenarios that are not suitable for systemic fibrinolysis.
•   If infection control settings are equal, bedside initiation of extracorporeal membrane oxygenation (ECMO) is preferred in cases with known COVID-19 positivity or uncertain status, rather than support strategies requiring the use of a catheterization laboratory or an operating room. 
•  The vast majority of patients with symptomatic acute deep venous thrombosis (DVT), should be managed with anticoagulation, with home treatment whenever possible. The few that may require acute endovascular techniques (either local fibrinolysis or embolectomy) include those with phlegmasia, or truly refractory symptoms.

•Case of Venous Thromboembolism by Dr Rebecca Hahn MD (@hahn_rt )

•Thrombosis, Thromboprophylaxis & Coagulopathy in COVID- 19 Infections ISTH Webinar Link

•ACC Webinar-the China Experience describing abnormal coagulation in COVID-19 (ACC Webinar, March 18, 2020)

•C3 Academy Webinar Slide describing the inflammatory response:

CDC guidelines 

Recommend N95 respirator, face shield, gown and gloves used by all code responders during code events (CDC Guidelines, 2020) 

Donning and Doffing Sequence:

SCAI Recommendations

 ·      Wear appropriate PPE during all procedures including N95 mask or powered air-purifying respirator (PAPR) before patient arrival.

·      Avoid compacting contaminated clothing in the waste container to prevent aerosolization.

·      Final mask removal takes place in the anteroom to avoid air droplet exposure.

Equipment 

·      Designate single procedure room

·      Use HEPA filters as an additional strategy for safe containment and elimination 

·      Dedicated COVID-19 equipment cart

·      Minimize number of personnel 

Patient Transportation and Cleaning

·     Frequent wipe downs

·     Terminal clean 

·     Entry into the room should be delayed after procedure

SCAI : Video link

Another Link :courtesy Dr Bangalore MD

C3 Academy Webinar explaining facility modification for PCI :

Cathlab recommendations: reverse airflow, biplane suite, pre-packed equipment for dirty lab

Webinar slide on post COVID-19 guidance from Northshore Hospital

Safe Reintroduction of Cardiovascular Procedures and Diagnostic Tests during the COVID-19 Pandemic: Guidance from North American Societies (Wood et al, JACC, 2020)

As regions move along the journey of managing the COVID-19 pandemic, there is an opportunity to reintroduce regular cardiovascular care in a progressive manner with appropriate safeguards.

• ACC: COVID-19 Hub

• SCAI : COVID-19 Resource Center

• PCR online: Link for case examples

• CMS Recommendations for non emergent elective procedures (CMS 4/7/2020)

• Social Media:
• ACC Interventional Cardiology Tweetorial describing a case of STEMI in a presumed COVID-19. (4/20/2020)

• ACCIC Tweetorial describing Thromboembolic Manifestations of COVID-19 (4/27/2020)

• ACCIC Tweetorial providing the Summary of ACC/SCAI Recommendations for Structural Heart Disease Interventions during COVID Pandemic (05/04/2020)

• MedShr: Cardiology Fellows COVID-19 Group