The COVID-19 outbreak has greatly affected life and business in the last few weeks, and the cardiac catheterization laboratory is no exception.
The cath lab at MedStar Washington Hospital Center has seen fewer patients because elective cases have been canceled because of the outbreak, said Hayder Hashim, MD.
Personal-protective equipment (PPE) procedures are basically the same for patients not suspected of having COVID-19: head cover, googles or other eye protection, gloves, gown and shoe cover. However, for patients under investigation (PUI) for COVID-19, Hashim said, “we have been using a specific designated lab and we do increase PPE to add a second pair of gloves and wear a specific mask known as N95.”
“After finishing the case, the physical lab undergoes specific cleaning and sterilization procedures in preparation for any future cases,” he said.
One area of intense discussion is whether cath labs will be stricter about accepting COVID-19 patients.
Jie Zeng, MD, and colleagues of Sichuan Provincial People’s Hospital, China, wrote a research letter that appeared in Intensive Care Medicine outlining that hospital’s protocols for treating patients with acute myocardial infarction during the COVID-19 outbreak. In general, the protocol emphasizes more conservative treatment wherever feasible.
For example, patients within the reperfusion time window and with no contraindication for thrombolysis should be given thrombolytic therapy in an isolation ward, the letter says. Those who do have contraindications for thrombolysis, or for whom thrombolysis fails, would be evaluated for risks of percutaneous coronary intervention (PCI) and infection control.
Another research letter by Chor-Cheung Frankie Tam, MBBS, and colleagues of Queen Mary Hospital, Hong Kong, recently published in Circulation: Cardiovascular Quality and Outcomes reported on time components of seven consecutive patients who underwent primary PCI from Jan. 25 through Feb. 10, 2020. None of these patients had COVID-19, and six presented to the hospital during normal work hours (8 a.m. to 8 p.m.). The largest difference the authors noted was time from symptom onset to first medical contact, which increased from a median 82.5 minutes during office hours and 91.5 minutes during non-office hours in 2018-2019 to 318 minutes among these seven patients.
The authors noted that most of that time increase appeared to be caused by patients delaying seeing treatment amid the COVID-19 outbreak. Even more concerning than delays, the authors said, is patients suffering ST-elevation myocardial infarction (STEMI) not seeking care at all, but they were not able to evaluate whether this is happening.
On the institution side, delays can be caused because clinicians will are performing more detailed COVID-19 screening, including travel and contact history, symptomatology and chest X-ray. This is because “catheterization laboratories generally have positive pressure ventilation so COVID-19 infection inside these rooms can theoretically cause widespread contamination of the surrounding environment,” Tam and colleagues wrote.
Hashim said that MedStar Washington Hospital Center has designated one of its cath labs to host patients suspected of having, or having, COVID-19.
He added that in addition to the recent publications concerning COVID-19’s effect on cath labs, some reports have emerged of cardiovascular involvement or manifestations of COVID-19, including severe fulminant myocarditis, cardiogenic shock, and electrocardiogram changes mimicking STEMIs.
These, Hashim said, “are adding a layer of confusion whether percutaneous interventions or even diagnostic coronary angiograms are indicated vs. medical supportive management.”
“In modern society, infectious agents like the COVID-19 outbreak can spread quickly and evolve into a pandemic,” Tam and colleagues wrote in their letter. “Hospitals not only need to consider methods for containing and treating these infections but how infection outbreaks may affect systems of care beyond the immediate infection.”
Zeng J, HuangJ, Pan L. How to balance acute myocardial infarction and COVID-19: the protocols from Sichuan Provincial People’s Hospital. Intensive Care Med 2020 Mar 11. doi: 10.1007/s00134-020-05993-9.
Tam CF, Cheung KS, Lam S, et al. Impact of Coronavirus Disease 2019 (COVID-19) Outbreak on ST-Segment-Elevation Myocardial Infarction Care in Hong Kong, China. Circ Cardiovasc Qual Outcomes. 2020;13:e006631.