Cath and Coronavirus: ACC, SCAI Weigh in on MI, Elective Cases

March 16, 2020

New challenges can lead to new rules, or at least new protocols based on the best available data.

The president of the Society for Cardiovascular Angiography and Interventions (SCAI) recently announced a set of informal recommendations on how to manage patients with confirmed or possible COVID-19 infection who, in ordinary times, would be sent to the cardiac catheterization laboratory without hesitation.

The next day, a fuller and more nuanced version of the recommendations was published in the Journal of the American College of Cardiology under the sponsorship of SCAI itself and the American College of Cardiology (ACC).

Although good data for guiding the process are in short supply, "We can leverage the lessons from China and determine how we might want to apply them to our healthcare systems," writes SCAI president Ehtisham Mahmud, MD, University of California, San Diego, on the society's website.

Seven COVID-19 patients had been admitted to his center over the previous 72 hours, writes Mahmud, who is a coauthor on the ACC/SCAI document.

The recommendations cover patients with ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and elective or emergent cath procedures, including percutaneous coronary intervention (PCI).

In particular, Mahmud argues against a "thrombolysis first" approach to treating STEMI, one that has been followed in China. He says he doubts that strategy would be generally appropriate for the United States given its current burden of COVID-19 disease.

On the other hand, the ACC/SCAI statement proposes that "fibrinolysis can be considered an option for the relatively stable STEMI patient with active COVID-19," after careful consideration of possible patient benefit vs the risks of cath-lab personnel exposure to the virus.

Patients with STEMI or with NSTEMI and symptoms or compromised hemodynamics "should be taken to the cath lab for angiography/primary PCI," Mahmud recommends. "Post-transfer patients who have received fibrinolysis should still be taken for rescue PCI if clinically appropriate."

The following approach "seems prudent," Mahmud writes. In summary, patients with:

  • Confirmed COVID-19 infections: For STEMI or NSTEMI, send patients to the cath lab for angiography and, as appropriate, PCI; in stable NSTEMI, "medical management with coronary angiography for recalcitrant symptoms only may be the most logical approach."

  • Possible COVID-19 infection: In STEMI, treat with primary PCI. In NSTEMI, "await coronary angiography until a negative COVID-19 test has been obtained."

  • Elective cath procedures: "This group of patients requires an approach that is evolving," Mahmud says. As most of them will have structural heart or peripheral vascular disease, for now "these patients should probably not undergo elective procedures until we have better assessment of the situation over the next few weeks."

The ACC/SCAI document notes that many centers have already suspended elective cath procedures. "This certainly seems prudent in locales where the disease is highly prevalent," it states.

"Under any circumstance, to preserve hospital bed capacity, it would seem reasonable to avoid elective procedures on patients with significant comorbidities or in whom the expected length of stay is >1 to 2 days (or anticipated to require the intensive care unit)."

The recommendations may change rapidly "depending on the overall critical care and inpatient service burden, especially as we continue to follow the growth trajectory of COVID-19 infections," Mahmud writes.

"You will have to work with your local institutions and administration to determine the best way to approach these decisions in concert with [Centers for Disease Control and Prevention] guidelines, and both infectious disease experts and critical care intensivists."

Mahmud discloses receiving consulting fees from Abiomed, Medtronic, and Boston Scientific; holding equity interest in Abiomed; and being a national or site principal investigator for studies sponsored by Corindus, CSI, and Abbott Vascular. Disclosures for the other authors are in the document.

Society for Cardiovascular Angiography and Interventions.
Posted March 16, 2020. Letter

Journal of the American College of Cardiology. Published online March 17, 2020. Report.

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