Guidelines for ACS Management During the COVID-19 Pandemic

An international group of frontline physicians formulated guidelines regarding the triage and management of patients with acute coronary syndrome (ACS) during the coronavirus disease 2019 (COVID-19) pandemic, including workflow algorithms and appropriate therapeutic options. These guidelines were published in The American Journal of Cardiology.

Influenza-like illnesses — including that caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) — may trigger acute myocardial infarction (AMI) in some patients. The guideline authors sought to outline strategies for dealing with AMI and other ACS presentations in the midst of the COVID-19 global pandemic.

In order to avoid confusion, the group suggested the World Health Organization (WHO) case definitions be adopted universally for communication among healthcare providers. The WHO divides COVID-19 cases into 4 categories, based on clinical history, presentation, and laboratory findings: confirmed (COVID-19 +), suspected (COVID-19 +/-), contact (COVID-19 C), or non-suspected (COVID-19 NS). Patients should be triaged according to COVID-19 probability, and should all wear disposable face masks upon hospital entry.

All COVID-19 + cases in need of hospitalization should be admitted to either a dedicated COVID-19 ward/floor/unit or a COVID-19 intensive/critical care unit (ICU or CCU, respectively), with these areas considered infectious zones. Patients who are COVID-19 +/- should also be admitted to dedicated COVID-19 units, preferably in isolation rooms with individual bathrooms, pending lab results. Those who are categorized as COVID-19 C should be admitted to standard cardiology wards or conventional ICUs/CCUs (noninfectious zones), or in isolated rooms with separate bathrooms. Individuals categorized as COVID-19 NS can be admitted following standard protocols.

A dedicated COVID-19 cardiac catheterization laboratory, ideally outfitted with a negative pressure ventilation system, should be used for all cardiac procedures performed on patients with confirmed or suspected COVID-19 outfitted with equipment dedicated to COVID-19 laboratory, with special attention paid to pre- and post-procedure cleaning routines, particularly regarding lead aprons. Patients without COVID-19 should be treated in a separate dedicated non-COVID laboratory.

The adequate use of personal protective equipment (PPE) remains of paramount importance in stemming the spread of COVID-19. All healthcare providers treating patients with confirmed or suspected COVID-19 should wear N95 respirators, face shields and/or goggles, gowns with long sleeves, and tall shoe covers, and be double-gloved. When treating patients with COVID-19, providers should wear disposable surgical masks, gowns, gloves, and head covers. It is recommended that all patients, regardless of COVID-19 status, wear disposable masks while hospitalized for the duration of the pandemic.

Patients categorized as COVID-19 + or COVID-19 +/- who present with probable ACS should be divided into 3 categories: non-ST elevation MI ACS diagnosis (NSTEMI) or unstable angina with no features indicating high risk for continued myocardial ischemia; NSTEMI ACS diagnosis with ≥1 feature indicative of very high risk for ongoing myocardial ischemia; or ST elevation MI (STEMI) diagnosis.

For patients with an NSTEMI ACS diagnosis, prompt initiation of medical therapy is crucial. Rapid polymerase chain reaction (PCR) testing for SARS-CoV-2, if available, should be performed in the emergency department (ED) in all suspected and contact cases; when rapid PCR is not an option, stable patients should have invasive procedures delayed until standard PCR results are in. Patients with COVID-19 + should be transferred to infectious zone units, and patients with suspected COVID-19 who are in stable condition who test negative can be admitted or transferred to a cardiology department for routine care. Patients at higher risk or with uncertain diagnoses who initially test negative for COVID-19 should be retested by PCR and admitted to an infectious zone for ACS treatment pending laboratory results of the second test.

Patients with ACS and confirmed negative COVID-19 PCR results should receive standard therapy and early discharge when feasible. In patients who are COVID-19 +, medical therapy for ACS should continue until full recovery from COVID-19, at which point coronary angiography should be performed.

While PCR testing for SARS-CoV-2 should be performed in all appropriate patients, those in the second diagnostic category with an NSTEMI ACS diagnosis and ≥1 feature indicative of very high risk for ongoing myocardial ischemia require an immediate decision regarding the need for percutaneous coronary intervention (PCI), which ideally should be performed within 2 hours of ED presentation, based on senior staff collaboratively weighing the risk for provider SARS-CoV-2 exposure with the potential benefit to the patient. For patients with confirmed COVID-19 + who have severe pneumonia, with or without severe acute respiratory infection (SARI), conservative ACS medical management is recommended.

For stable patients who presented within 12 hours of symptom onset diagnosed with STEMI, clinicians should consider fibrinolytic therapy instead of PCI as a first-line treatment in all COVID-19 + and COVID-19 +/- cases, to minimize SARS-CoV-2 exposure risk. Effective fibrinolysis should be followed by continued medical treatment until the patient has fully recovered from COVID-19, at which time coronary angiography should be conducted. For patients for whom fibrinolytic therapy is ineffective, senior staff should immediately weigh the risk and benefits of PCI to the staff and patient, respectively. If PCI is chosen, a rescue procedure should be undertaken once a dedicated COVID-19 catheterization laboratory is available. Alternatively, medical therapy should comprise beta-blockers, angiotensin converting enzyme inhibitors, aspirin, P2Y12 blockers, and ≥48 hours of intravenous unfractionated heparin. When severe pneumonia is observed with or without SARI, clinicians should decide between conservative medical management and fibrinolytic therapy, but not rescue PCI, given the poor COVID-19 prognosis.

Inpatients treated for ACS who have tested negative for COVID-19 should be discharged as soon as possible, based on diagnosis and overall condition. Patients with NSTEMI and STEMI should ideally be discharged within <24 hours and <48 hours, respectively. These same discharge timeframes can be followed for patients with COVID-19 + with mild disease presentation and an ACS diagnosis, with instructions to isolate at home for 14 days or until full recovery from COVID-19. Patients with ACS with moderate to severe COVID-19 manifestations should receive primarily COVID-19 therapy.

Post-discharge in-person follow-ups should be postponed in favor of telemedicine appointments and online prescription services throughout the duration of the pandemic.

Limitations of these guidelines include the use of limited data to inform strategies, potential inapplicability to all institutions, and insufficient testing capacity in some centers as well as extended turnaround times for results.

There are 5 key components to successful execution of these recommendations: early risk stratification of all ACS patients based on SARS-CoV-2 infection probability; staff familiarity with ACS management protocols during the pandemic; workflow simplification using effective algorithms developed based on established patient selection criteria; rescheduling of all nonurgent elective procedures; and provider training in and execution of proper PPE donning and doffing sequences to reduce viral spread among healthcare workers.

“Despite these unprecedented times, providers should not overlook ACS guidelines, but may choose to modify the recommended approach in situations with confirmed or suspected COVID-19 disease,” noted the guideline authors.

Reference

Briedis K, Aldujeli A, Aldujeili M, et al. Considerations for management of acute coronary syndromes during the SARS-CoV-2 (COVID-19) pandemic [published online ahead of print, 2020 Jun 30]. Am J Cardiol. 2020. doi:10.1016/j.amjcard.2020.06.039