Commentary

COVID-19: An Unintended Force for Medical Revolution?

Xiaowen Wang, MD and Deepak L. Bhatt, MD, MPH

Xiaowen Wang, MD and Deepak L. Bhatt, MD, MPH

J INVASIVE CARDIOL 2020;32(4):E81-E82. Epub 2020 March 25.

KEY WORDS: COVID, practice management


Since the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in December 2019, coronavirus disease 2019 (COVID-19) has ravaged the world and caused a global pandemic. Our healthcare systems are facing unprecedented pressure to come up with innovative solutions (Figure 1). Healthcare communities have been scrambling to come up with guidelines to ensure appropriate patient care while protecting healthcare workers. While much has been learned from the 2003 Severe Acute Respiratory Syndrome (SARS) pandemic,1 COVID-19 has affected more countries and a larger population, and therefore a concerted effort is required to curtail its further spread. 

The Society for Cardiovascular Angiography and Interventions (SCAI) should be applauded for their prompt effort in providing guidance to frontline clinicians. In their article on cardiac catheterization lab (CCL) procedures during the COVID-19 pandemic,2 the authors outlined several important considerations in regard to the activation of the CCL, in particular in ST-segment elevation myocardial infarction (STEMI) patients who are confirmed or suspected to have COVID-19. While early experiences in China emphasized using fibrinolytic therapy in STEMI patients, the authors took into account regional differences in healthcare resources and COVID-19 case burden and gave recommendations based on levels of treatment of STEMI and of COVID-19. For example, level 1 refers to situations when the hospital infrastructure is overwhelmed with COVID-19 patients and fibrinolytic therapy is preferred, whereas percutaneous coronary intervention (PCI) is still preferred in level 3 situations when the system has a low level of COVID-19 patients. It is essential to continue to monitor local resources and the strain on healthcare systems to determine feasibility of performing primary PCI. Many ancillary studies can also help with the judicious use of CCL, such as point-of-care echocardiography. 

It is worth noting that there are already case reports of patients presenting with electrocardiograms concerning for STEMI but found to have fulminant myocarditis.3 In addition, there are several reports on Twitter (#CardioTwitter) of presumed STEMI patients who have subsequent angiograms showing no significant epicardial coronary artery disease. In these patients, especially in those in whom there is a high suspicion of COVID-19 and low suspicion for an acute coronary syndrome, coronary computed tomography angiography may play an important role. Randomized trials with clinical endpoints will be important to sort out the best therapies for patients with COVID-19; we must as a medical community resist the temptation to forego this pivotal step in evaluating new drugs, especially ones with the potential for serious toxicity.

The SCAI document also addressed important considerations in personnel management, personal protective equipment, and environmental control measures. The safety of staff should be paramount. Staff attrition will not only decrease morale, but also impair the effectiveness of the healthcare system. The authors addressed this important issue by providing a multifaceted approach, such as environmental control measures that would decrease spread of infection to other areas of the hospital and rotation of personnel to decrease exposure between teams of staff. These recommendations provide an important framework for CCLs across the country to develop the strategies that fit their own resources and COVID-19 caseload. Their suggestions may also be of utility in potential future pandemics.

Several other considerations are worth pondering as the medical community continues to cope with the new reality of providing healthcare in the COVID-19 era. First, as we gain more understanding of SARS-CoV-2, we must swiftly adapt our clinical practices and safety measures to ensure the best patient care and safety. For example, activation of the CCL is often an emergent, time-sensitive issue, especially in patients with STEMI and cardiogenic shock. Patients may be unable to provide enough clinical history, or there may not be time to conduct an adequate screening for COVID-19. Based on prevalence of disease in local communities, hospitals should consider adopting COVID-19 precautions for all patients going to the CCL to ensure staff safety. Consideration should be given to foregoing the public reporting of door-to-balloon times, and indeed, this may be an opportunity to reassess whether this metric should be retired altogether.

Second, as the Centers for Medicare and Medicaid Services (CMS) works to remove administrative barriers during this pandemic, we are becoming more aware of regulations and quality measures that may create barriers for effective patient care.4,5 For example, in response to an increased demand for telehealth, CMS waived penalties for HIPAA violations when healthcare providers use technology such as FaceTime or Skype, which ordinarily would not have been HIPAA compliant, to reach patients. CMS also offered reimbursement for telehealth services, further incentivizing healthcare providers to offer these services to minimize the need for patients to visit healthcare facilities. While these measures are only temporary during this public health crisis, they should, in fact, provide an opportunity to permanently expand telemedicine to reach a wider patient population. 

Third, this global pandemic also offers an opportunity for us to re-examine our practice models and habits. Many physicians are being forced to re-evaluate the utility of certain procedures in this unprecedented time. Physicians are thinking twice before ordering tests to make sure they will really change management, or seeing whether there is an alternative test that could provide similar information while minimizing staff exposure. The pandemic has created an excellent opportunity for us to study our healthcare system, examine its strengths and flaws, and propel evolution in providing better, more efficient care. 

As a global pandemic, COVID-19 will undoubtedly change our behaviors, shift our ways of living, and challenge different healthcare systems all over the world. While each healthcare system faces challenges in its own socioeconomic and political environments, it is important to remember and take solace in the fact that we are all fighting this invisible war together as a global community. Collaboration and communication across countries, including through social media, are more important than ever. Sharing our knowledge and perspectives in a timely manner will be an invaluable weapon in fighting this global pandemic.  

References

1. Tsui KL, Li SK, Li MC, et al. Preparedness of the cardiac catheterization laboratory for severe acute respiratory syndrome (SARS) and other epidemics. J Invasive Cardiol. 2005;17:149-152.

2. Szerlip M, Anwaruddin S, Aronow HD, et al. Considerations for cardiac catheterization laboratory procedures during the COVID-19 pandemic: SCAI ELM perspectives. Catheter Cardiovasc Interv. Epub 2020 Mar 24. Accessed at  http://www.scai.org/covid-19-resources. Accessed 2020 Mar 25.

3. Hu H, Ma F, Fang Y. Coronavirus fulminant myocarditis saved with glucocorticoid and human immunoglobulin. Eur Heart J. Epub 2020 Mar 16. 

4. Gupta A, Allen LA, Bhatt DL, et al. Association of the hospital readmissions reduction program implementation with readmission and mortality outcomes in heart failure. JAMA Cardiol. 2018;3:44-53.

5. Wadhera RK, Bhatt DL. Toward precision policy — the case of cardiovascular care. N Engl J Med. 2018;379:2193-2195.


From Brigham and Women’s Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Bhatt reports the following relationships:  Advisory Board for Cardax, Cereno Scientific, Elsevier Practice Update Cardiology, Medscape Cardiology, PhaseBio, PLx Pharma, Regado Biosciences; Board of Directors for Boston VA Research Institute, Society of Cardiovascular Patient Care, TobeSoft; Chair of the American Heart Association Quality Oversight Committee; Data Monitoring Committees for Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute, for the PORTICO trial, funded by St. Jude Medical, now Abbott), Cleveland Clinic (including for the ExCEED trial, funded by Edwards), Duke Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine (for the ENVISAGE trial, funded by Daiichi Sankyo), Population Health Research Institute; honoraria from the American College of Cardiology (Senior Associate Editor, Clinical Trials and News, ACC.org; Vice-Chair, ACC Accreditation Committee), Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute; RE-DUAL PCI clinical trial steering committee funded by Boehringer Ingelheim; AEGIS-II executive committee funded by CSL Behring), Belvoir Publications (Editor in Chief, Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees, including for the PRONOUNCE trial, funded by Ferring Pharmaceuticals), HMP Global (Editor in Chief, Journal of Invasive Cardiology); Journal of the American College of Cardiology (Guest Editor; Associate Editor), Medtelligence/ReachMD (CME steering committees), MJH Life Sciences, Population Health Research Institute (for the COMPASS operations committee, publications committee, steering committee, and USA national co-leader, funded by Bayer), Slack Publications (Chief Medical Editor, Cardiology Today’s Intervention), Society of Cardiovascular Patient Care (Secretary/Treasurer), WebMD (CME steering committees); Clinical Cardiology (Deputy Editor), NCDR-ACTION Registry Steering Committee (Chair), VA CART Research and Publications Committee (Chair); Research Funding: Abbott, Afimmune, Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Cardax, Chiesi, CSL Behring, Eisai, Ethicon, Ferring Pharmaceuticals, Forest Laboratories, Fractyl, Idorsia, Ironwood, Ischemix, Lexicon, Lilly, Medtronic, Pfizer, PhaseBio, PLx Pharma, Regeneron, Roche, Sanofi Aventis, Synaptic, The Medicines Company; Royalties: Elsevier (Editor, Cardiovascular Intervention: A Companion to Braunwald’s Heart Disease); Site Co-Investigator: Biotronik, Boston Scientific, CSI, St. Jude Medical (now Abbott), Svelte; Trustee of the American College of Cardiology; unfunded research for FlowCo, Merck, Novo Nordisk, and Takeda. Dr Wang reports no conflicts of interest regarding the content herein. 

Manuscript submitted March 24, 2020 and accepted March 24, 2020.

Address for correspondence: Deepak L. Bhatt, MD, MPH, Brigham and Women’s Hospital Heart & Vascular Center, Harvard Medical School, 75 Francis Street, Boston, MA 02115. Email: DLBhattMD@post.Harvard.edu; Twitter: @DLBhattMD

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