In addition, “all patients should undergo lung CT examination to evaluate for imaging features typical of COVID-19…. Chest X-ray is not recommended because of a high rate of false negative diagnosis,” the authors write.
Intervene With Caution
Medical therapy should be optimized in patients with emergent cardiovascular issues, with invasive strategies for diagnosis and therapy used “with caution,” according to the Chinese experts.
Conditions for which conservative medical treatment is recommended during COVID-19 pandemic include ST-segment elevation myocardial infarction (STEMI) where thrombolytic therapy is indicated, STEMI when the optimal window for revascularization has passed, high risk non-STEMI (NSTEMI), patients with uncomplicated Stanford type B aortic dissection, acute pulmonary embolism, acute exacerbation of heart failure, and hypertensive emergency.
“Vigilance should be paid to avoid misdiagnosing patients with pulmonary infarction as COVID-19 pneumonia,” they note.
Diagnoses warranting invasive intervention are limited to STEMI with hemodynamic instability, life-threatening NSTEMI, Stanford type A or complex type B acute aortic dissection, bradyarrhythmia complicated by syncope or unstable hemodynamics mandating implantation of a device, and pulmonary embolism with hemodynamic instability for whom IV thrombolytics are too risky.
Interventions should be done in a cath lab or operating room with negative-pressure ventilation, with strict periprocedural disinfection. PPE should also be of the strictest level.
In patients for whom COVID-19 cannot be ruled out presenting in a region with low incidence of COVID-19, interventions should only be considered for more severe cases and undertaken in a cath lab, EP lab, or operating room “with more than standard disinfection procedures that fulfill regulatory mandates for infection control.”
If negative-pressure ventilation is not available, air conditioning (e.g., laminar flow and ventilation) should be stopped.
Establish Plans Now
“We operationalized all of these strategies at Beth Israel Deaconess Medical Center several weeks ago, since Boston had that early outbreak with the Biogen conference, but I suspect many institutions nationally are still formulating plans,” said Dhruv Kazi, MD, MSc, in an email exchange with theheart.org | Medscape Cardiology.
Although COVID-19 is “primarily a single-organ disease — it destroys the lungs” — transmission of infection to cardiology providers was an early problem that needed to be addressed, said Kazi.