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Practice Guideline
. 2020 May 14;41(19):1839-1851.
doi: 10.1093/eurheartj/ehaa381.

EAPCI Position Statement on Invasive Management of Acute Coronary Syndromes During the COVID-19 Pandemic

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Free PMC article
Practice Guideline

EAPCI Position Statement on Invasive Management of Acute Coronary Syndromes During the COVID-19 Pandemic

Alaide Chieffo et al. Eur Heart J. .
Free PMC article

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.

Keywords: ACS; COVID-19; NSTEMI; PCI; STEMI.

Figures

Figure 1
Figure 1
Management of patients with STEMI during the COVID-19 pandemic. The figure considers the following potential scenarios: (i) STEMI patients accessing care through the STEMI network (i.e. by ambulance) should be directly transported to COVID-19 hospitals with 24/7 catheterization laboratory facilities (cathlabs). If at the time of hospital arrival the dedicated COVID-19 cathlab room is not available, fibrinolysis should be considered. (ii) STEMI patients self-presenting at the emergency department of hospitals with cathlabs should undergo reperfusion in COVID-19 hospitals with 24/7 primary percutaneous coronary intervention (PCI) facilities. Otherwise, patients should be transferred. If a timely primary PCI cannot be achieved taking into account an estimated 60 min extra delay due to the COVID-19 outbreak, fibrinolysis should be considered. (iii) Patients with STEMI self-presenting at the emergency department of hospitals without cathlabs should be transferred to COVID-19 hospitals with 24/7 primary PCI facilities. If a timely primary PCI cannot be achieved taking account of the extra delay due to the COVID-19 outbreak, fibrinolysis should be considered. (iv) Hospitalized COVID patients suffering from STEMI should be treated with primary PCI if the COVID-19 hospital has 24/7 cathlab facilities. Otherwise, transfer the patient to a COVID-19 hospital with 24/7 cathlab facilities. If a timely primary PCI cannot be achieved, patients should be treated with fibrinolysis. Timely primary PCI as described in the text is a primary PCI performed within 120 min from symptom onset. It is suggested to perform left ventriculography during catheterization.
Figure 2
Figure 2
Recommendations for management of patients with NSTE-ACS in the context of ther COVID-19 outbreak. LVEF = left ventricular ejection fraction; MI = myocardial infarction; NSTEMI = non-ST-segment elevation MI; *estimated glomerular filtration rate <60 mL/min/1.73 m2. **Coronary computed tomography angiography (CCTA) should be favoured, if equipment and expertise are available. In low risk patients, other non-invasive testing might be favoured in order to shorten hospital stay. It is suggested to perform left ventriculography during catheterization.
Figure 3
Figure 3
Reorganization of emergency department and hospital paths during COVID-19 pandemic in hub centres for an STEMI/NSTEMI network. In a hub centre for an STEMI/NSTEMI network in the emergency department, dedicated different entry points and triage as well as hospital pathways and wards are advocated for patients with diagnosed or suspected of having COVID-19 because of symptoms (blue), cardiovascular emergencies without diagnosed or suspected COVID-19 (red), and other emergencies without diagnosed or suspected COVID-19 (yellow). All patients admitted to the cardiovascular emergency triage for ACS should receive SARS-CoV-2 testing. Patients with STEMI or very high risk NSTEMI should be immediately referred to the cathlab, while those in the other NSTEMI risk categories should be referred to a dedicated chest pain unit before SARS-CoV-2 testing results are available. Patients should be further managed according to SARS-CoV-2 testing. The red dotted lines highlight the dedicated units for the management of ACS patients.
Figure 4
Figure 4
Individual protection equipment for cardiac health workers of cardiac invasive facilities in suspected or diagnosed COVID 19 patients.

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