EAPCI Position Statement on Invasive Management of Acute Coronary Syndromes during the COVID-19 pandemic

Abstract

The coronavirus disease 2019 (COVID-19) pandemic poses an unprecedented challenge to healthcare worldwide. The infection can be life threatening and require intensive care treatment. The transmission of the disease poses a risk to both patients and healthcare workers. The number of patients requiring hospital admission and intensive care may overwhelm health systems and negatively affect standard care for patients presenting with conditions needing emergency interventions. This position statements aims to assist cardiologists in the invasive management of acute coronary syndrome (ACS) patients in the context of the COVID-19 pandemic. To that end, we assembled a panel of interventional cardiologists and acute cardiac care specialists appointed by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) and from the Acute Cardiovascular Care Association (ACVC) and included the experience from the first and worst affected areas in Europe. Modified diagnostic and treatment algorithms are proposed to adapt evidence-based protocols for this unprecedented challenge. Various clinical scenarios, as well as management algorithms for patients with a diagnosed or suspected COVID-19 infection, presenting with ST-and non-ST-segment elevation ACS are described. In addition, we address the need for re-organization of ACS networks, with redistribution of hub and spoke hospitals, as well as for in-hospital reorganization of emergency rooms and cardiac units, with examples coming from multiple European countries. Furthermore, we provide a guidance to reorganization of catheterization laboratories and, importantly, measures for protection of healthcare providers involved with invasive procedures. Abbreviations ACS= acute coronary syndrome ED = emergency department HCWs = healthcare workers NSTEMI = non-ST-elevation myocardial infarction PCI = percutaneous coronary intervention PPE = personal protective equipment STEMI = ST-elevation myocardial infarction Myocardial injury: the role of cardiac biomarkersAcute myocardial injury is defined as a rise and fall in cardiac troponin (cTn) with at least one value above the 99 th percentile 1840 A. Chieffo et al.

A Review of Coronary Artery Thrombosis: A New Challenging Finding in COVID-19 Patients and ST-elevation Myocardial Infarction

“…The vast majority of ACS patients are candidates for medical treatment based on clinical risk, and only very high-risk Non-STEMI cases and STEMI patients require taking an interventional approach. 6 Our statistics related to incidence of STEMI are mostly in the form of case reports, and therefore, the epidemiology cannot be stated precisely. During a 40-day study in Lombardy, Italy, from February 20 to March 30, 28 cases of STEMI were reported, 24 of which (85.7%) reported STEMI as the first manifestation of COVID-19 before polymerase chain reaction (PCR) testing.…”

“…Additionally, echocardiography can also be helpful in assessing regional wall motion abnormality in suspected cases. 6 Recent reports have shown an increase in cardiac biomarkers such as troponin from 5% to 25% in patients with COVID-19 who are in intensive care unit. 2 , 14 In fact, this increase is due to acute myocardial injury and is associated with a worse prognosis in patients.…”

“…With regard to suspicious cases, as mentioned, echocardiography and ECG are very helpful. 6 CAG is recommended as the final and main diagnostic test, limited to patients with suspected STEMI type 1. In fact, CAG is performed in order to carry out interventional revascularization.…”

“…ST-elevation myocardial infarction (STEMI) is the most important component of ACS during COVID-19 pandemic, and more recently, it has been reported in reports as the first manifestation of patients with COVID-19 or in the course of treatment of this viral infection. 6 Apart from the challenge of choosing the right treatment strategy for these patients (primary percutaneous coronary intervention (PCI) versus fibrinolytic therapy), the angiographic pattern of these patients which is based on the presence of significant coronary artery thrombosis is a matter of contention for us as well as cardiologists.…”

The Coronavirus Disease 2019 Outbreak Highlights the Importance of Sex-sensitive Medicine

“…A recent European position statement on invasive management of ACS during the COVID-19 pandemic emphasised that the use of coronary angiography for COVID-19-positive patients with elevation in troponin-c should be restricted to those in whom type I ACS is suspected. 30 This occurs more often in men than women and its diagnosis may be delayed in people needing longterm ventilation. 31 In the Lombardy region, a striking increase in out-of-hospital cardiac arrests of 58% was seen compared to a year earlier, of which more than 77% were related to COVID19 infections.…”