COMMENTARY

COVID-19: Reconfiguration of Cardiac Services and Delivery of Cardiovascular Care

Prof Mamas Mamas

Disclosures

March 28, 2020

This transcript has been edited for clarity.

Hi, welcome to Medscape UK. My name is Mamas Mamas. I'm professor of cardiology based at Keele University. Today we're going to talk around something that's rapidly evolving: how we're going to change delivery of care to patients with cardiac diseases during the global pandemic of COVID-19.

As you're all aware, since Monday, the Prime Minister Boris Johnson announced a lockdown, which will impact our delivery of care, particularly from the outpatient perspective.

Managing patients with cardiovascular disease in these times of crisis is important, particularly given that patients with cardiovascular disease are amongst the highest risk patients.

A number of studies both from China and Italy have suggested that mortality rates of patients infected with COVID, if they have underlying cardiovascular disease, is around 10%, and around 7% in patients with diabetes.

Therefore, the management and reconfiguration of services that serve these patients is crucial.

This can be taken from a number of different perspectives. First and foremost, we have to reconsider how we deliver elective care. It's a balance between managing patients' chronic cardiovascular conditions in the way that's safe to patients, and to staff, to minimise their risk of getting infections from COVID.

From the second perspective, cardiology is an acute speciality. We have patients presenting with acute heart failure, decompensations, acute coronary syndrome, arrhythmias, and so forth.

And very much the focus of treatment and importance here is discharging patients safely with the lowest risk of potential adverse outcomes from their acute admission, but also maintaining their time in hospital to a minimum to reduce the risk of infection. And finally delivering acute services in a safe manner that will minimise the risk of infection to staff.

The video will be split into three sections with experiences from colleagues from all over the United Kingdom.

We will talk about how we have reconfigured heart failure services in certain areas and trusts.

Secondly, we will talk about acute coronary syndromes and delivery of care, and how we've had to change the way we deliver these services.

And finally, we're going to talk around protection of staff and how changes in PPE [personal protective equipment] have become more and more important in the care of patients with cardiovascular disease.

For the first video, I will be joined by Dr Fozia Ahmed, consultant in cardiology at Manchester NHS Foundation Trust, who has a special interest in heart failure and devices. Dr Ahmed will focus around how in central Manchester they have reconfigured heart failure services to optimise the care of these patients both in the elective setting, but also in acute situations.

Dr Fozia Ahmed

Like yours, our service has been significantly affected by COVID-19. And so in the next couple of minutes, I'm going to very briefly take you through our preparedness strategy and operational strategy, for managing heart failure patients during what is very much unprecedented times.

Until a few days ago, we were in phase 1 of our escalation strategy for heart failure, in that we had replaced all face-to-face appointments with telephone clinic appointments. And that was to try and maintain this social distancing that had been introduced by the Government.

We're now in phase 2 of our escalation strategy for heart failure. From an inpatient perspective, this means reviewing and prioritising discharge of any medically fit patients who can be safely discharged after their admission with decompensated heart failure. And that's in anticipation of there being a requirement for increased numbers of beds to deal with COVID-19 admissions.

And at the same time, we have also scaled up our existing admission avoidance strategies, in that patients who are decompensated, and who require IV diuretics but have no contraindications and are otherwise stable, are assessed to see whether they would be suitable for IV diuretics in the home environment, administered by our IV At Home Team.

Patients who are moderately decompensated, whose diuretics can be titrated in their own home, we're stratifying to be managed in this way, with point-of-care blood testing available for any face-to-face clinic appointments that are required, facilitated by our community teams as well to ensure that bloods are taken in a timely manner.

In the UK patients with implanted devices, pacemakers and ICDs [implantable cardioverter-defibrillator], have been stratified to remote-only monitoring for the duration of COVID-19.

Patients with heart failure often have an implanted device, and the information that's collected by these devices, specifically the health-related data, heart rate, arrhythmias, activity levels, fluid levels, can help to paint a picture about the patient's overall stability or relative instability. And during these challenging times when we need to use all of the information that's available to us, I think we may find this a valuable tool in our armamentarium.

Conflicts: None declared.

Acute Coronary Syndrome

My next guest, Professor Nick Curzen, professor of cardiology at Southampton University, as well as the current president of the British Cardiovascular Interventional Society, will providing a framework for the management of patients with acute coronary syndrome during this COVID pandemic. There are a number of issues that we need to consider, first and foremost, should we be continuing to offer a primary PCI [percutaneous coronary intervention] service in these patients or should we be thrombolysing?

Secondly, in patients with non-ST elevation myocardial infarction, is it business as normal? Or will we take a higher threshold for transfer of these patients to the cath[eter] lab, and if so, which are the patients that we should still be managing invasively?

In patients with multi vessel disease should we be trying to achieve full revascularisation, or just treating culprits and then discharging them?

Prof Nick Curzen

With regard to the treatment of acute coronary syndrome patients presenting to us during the COVID-19 pandemic, I think we may all need to exercise very careful clinical assessment and judgement with regard to the suitability of patients to go to the cath lab, particularly if they're very elderly or comorbid.

With regard to the type of patients that we try and perform angiography on, there is a lot of speculation about whether we should be using thrombolysis in STEMI [ST-elevation myocardial infarction] and deferring NSTEMI patients instead of taking them to the lab.

In the UK, our current guidelines, devised by the Department of Health with British Cardiovascular Intervention Society and the BCS (British Cardiovascular Society) is that we should try as much as possible to maintain primary angioplasty for STEMI and offer angiography with a view to revascularisation to NSTEMI patients, except perhaps to one in the lowest risk category.

The reason that we have made these guidelines is the impression that primary angioplasty is such an effective treatment for STEMI; that it's associated with a lower complication rate, a more rapid discharge, and therefore less exposure of the patient to staff and other patients.

Wit NSTEMI, making a diagnosis with regard to coronary disease, and then treating a culprit lesion, is also associated with a very rapid discharge, and a much lower rate of re-presentation due to further infarction.

So at the moment, we're recommending that we try and maintain the same practice for large groups of patients presenting with STEMI and NSTEMI in order to treat them effectively and get them out of hospital as quickly as possible.

It is highly likely that given the restrictions there are going to be on access to operating theatres and intensive care, we will all be using our judgement in order to decide that there are patients who we might normally refer, particularly for bypass surgery, who we will perform PCI [percutaneous coronary intervention] on instead.

Previous experience with unprotected left main disease and multi-vessel disease has generally increased, so we are quite well equipped at the current time to take on those cases, once they've been considered in a judicious manner.

So that sums up I think the approaches that we may take to key coronary syndromes during this pandemic. But of course, the best-laid plans may well be ruined by problems with staffing cath labs, etc. In which case clinical judgement and working in networks may well offer a solution.

I wish everyone the best of luck. Thank you.

Conflicts: None declared.

PPE

My final guest is Dr Sukh Nijjer, who is a consultant interventional cardiologist based at Imperial College London.

In this COVID pandemic, there are risks; risks to both to the patients, but importantly risks to the staff, and Dr Nijjer will talk around PPE protection and what we know are the optimal methods of PPE and how much PPE we require in different settings both in general cardiology wards, but also in the cath lab.

Dr Sukh Nijjer

I'm an interventional cardiologist. I work at Imperial College, and Chelsea and Westminster. These are two very busy trusts here in London. Both have had very similar and comprehensive responses to the COVID-19 crisis. Imperial moved very quickly in the first instance, and has been rapidly copied in most of the other trusts in the local area. But there is a great deal of geographic variation in how patients are being managed, and how staff are being protected. And this continues to be a source of concern and anxiety amongst colleagues. I can tell you that there's no universal agreement in how we should be managing this, and therefore I can tell you about our local experience.

We worked in a multi-pronged way by cancelling all elective work and moving to a situation where all emergency work was done as a high priority. And those patients identified at highest cardiovascular risk, risk of mortality in the next few months, were dealt with early and were cleared from the waiting lists.

We stopped all face-to-face clinics and everything has moved to a telephone-only service, and those clinicians who are unable to be on the front line due to health reasons have been redeployed to be able to answer and perform these duties to take the weight off the others.

We've made sure that our cath labs are divided into a number of territories with dirty and clean cath labs, with clearly demarcated approaches into the cath lab. We have an environment where the ambulances park outside of the heart attack assessment centre; we are assessing the patients in the ambulance and then bringing the patients up according to our findings.

The challenge really is that we don't know who is truly COVID-19 positive or not, but what we've been finding over the last week or 2 is that the vast majority of admissions coming into hospital are either having symptoms or features of COVID-19 or are demonstrating as COVID-19 positive shortly after admission, and therefore we've taken the approach to have full PPE cover for cath lab operators. Certainly the first operator and any second operator should be fully protected, and that should be performed by wearing a surgical hood, double gloves, a visor, protection for the eyes, as well as a double gown and boots.

This should be really carefully put on but most importantly carefully removed. And the doffing is a key component to this, as it's very easy to infect yourself from the contaminated surfaces of these gowns. Once patients have been moved, we then have clearly demarcated areas for dirty and clean wards. And, as we are finding new data that this virus may well be aerosolised, we may need to increase the amount of PPE protection we provide for our staff on these wards too.

This is highly controversial. Clearly, our trusts are following the national guidance, but many feel that this isn't strong enough. And we're asking to see what data supports this national guidance, and we're waiting for clear evidence on this. Certainly new data to suggest that this virus is aerosolised and therefore could explain its rapidity of spread, and why so many patients are declaring COVID-positive shortly after being on the wards. And so I suggest we will end up moving to greater protective masks. The issue is the availability, we are finding that there are many suppliers around the world who can make them available to us. But the issue is whether we are allowed to place the orders and make them available.

I would say that we're moving very quickly. We're working together as a team. I would say that that is super-important for all cardiac services around the world.

Conflicts: None declared.

Evolution

So thank you for joining me on Medscape UK. And thank you to my guests for giving their time and valuable insights as to how we're going to reconfigure our services within cardiology.

I think we should look at this as a period of opportunity. I think we really will have to change the way we deliver services, particularly in the United Kingdom, even when the COVID pandemic is over. We know that services are stretched, particularly inpatient where we run at between 97% and 99%, bed capacity occupancy.

I think, now, out of necessity, we're going to start developing new ways of seeing patients, utilising telephone follow ups, utilising telemonitoring of patients, and perhaps moving a lot of our inpatient care that we currently deliver, particularly around heart failure, to more outpatient care. Certainly in terms of management of elective patients in the United Kingdom, we very much have seen a move towards inpatient invasive investigations of patients, for example, with cardiac catheterisation, to the outpatients with cardiac CT and CT-FFR, and so forth.

So whilst I think that we are facing challenging times, I think that these challenging times are promoting evolution of our services and I think these are necessary evolutions, and welcome evolutions.

I thank you for joining me and I would like to hear your opinions below. Thank you.

You can follow Mamas Mamas on Twitter

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