key: cord-0760809-hj77rg85 authors: Lakkireddy, Dhanunjaya R.; Chung, Mina K.; Gopinathannair, Rakesh; Patton, Kristen K.; Gluckman, Ty J.; Turagam, Mohit; Cheung, Jim; Patel, Parin; Sotomonte, Juan; Lampert, Rachel; Han, Janet K.; Rajagopalan, Bharath; Eckhardt, Lee; Joglar, Jose; Sandau, Kristin; Olshansky, Brian; Wan, Elaine; Noseworthy, Peter A.; Leal, Miguel; Kaufman, Elizabeth; Gutierrez, Alejandra; Marine, Joseph M.; Wang, Paul J.; Russo, Andrea M. title: Guidance for Cardiac Electrophysiology During the Coronavirus (COVID-19) Pandemic from the Heart Rhythm Society COVID-19 Task Force; Electrophysiology Section of the American College of Cardiology; and the Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology, American Heart Association date: 2020-04-01 journal: Heart Rhythm DOI: 10.1016/j.hrthm.2020.03.028 sha: 0014b643b47d9b881e401ad5c4995622e0a39433 doc_id: 760809 cord_uid: hj77rg85 Covid-19 is a global pandemic that is wreaking havoc with the health and economy of much of human civilization. Electrophysiologists have been impacted personally and professionally by this global catastrophe. In this joint document from representatives of the HRS, ACC and AHA we identify the potential risks of exposure to patients, allied health care staff, industry representatives and hospital administrators. We describe the impact of COVID-19 on cardiac arrhythmias and methods of triage based on acuity and patient comorbidities. We provide guidance for managing invasive and non-invasive electrophysiology procedures, clinic visits and cardiac device interrogations. We discuss resource conservation and the role of tele-medicine in remote patient care along with management strategies for affected patients. China, in late 2019 and has quickly become a pandemic, significantly impacting the health and economy of the United States and the rest of the world.(1,2) There are several hundred thousands of cases and thousands of deaths related to COVID-19 (the disease caused by SARS-CoV-2) worldwide, with an estimated mortality rate ranging from 1-5%. ( 2) The United States has been impacted by this pandemic significantly with hundreds of deaths reported; these numbers will continue to worsen.(1) This healthcare crisis has imposed an unprecedented strain on society and has challenged the ability of health care organizations to provide adequate care. Electrophysiologists play an important role in cardiovascular health, with more than 40% of cardiology encounters being arrhythmia-related. In a recent report from Wuhan, China, 16 bronchoscopy, open tracheal suctioning, intubation, extubation, non-invasive positive pressure ventilation, endoscopy, or transesophageal echocardiography. (6) As the prevalence of COVID-19 increases exponentially, patients presenting with seemingly non-related medical problems may expose health care providers to increased risk of contracting the disease if not properly protected. Such exposure puts electrophysiology (EP) staff, physicians, and other clinical personnel at increased risk of contracting COVID-19. Reducing contact between health care personnel and COVID-19 patients is an integral step in limiting its spread and resource utilization, including use of personal protective equipment (PPE). In the hospital, the number of individuals rounding should be minimized and social distancing should be practiced. For patients with suspected or confirmed COVID-19 infection, time and personnel spent in the room should also be limited. Many EP consults may be completed without a face-to-face visit, by reviewing the chart and monitoring data. Non-urgent or non-emergent procedures should be postponed to a later date. Clinic visits and in person cardiac implantable electronic device (CIED) checks should be converted to tele-health and remote checks whenever feasible. Minimizing fellow trainee contact with patients may include rotation of days involved in direct patient service, managing remote checks and conducting patient tele-health visits. Attempts should be similarly made to limit exposure of EP allied professionals, including nurses, device clinic personnel, hospital administrators, and medical device company representatives. Additional steps may need to be taken to minimize exposure for higher risk individuals (e.g., age >60 years, pregnant, immunocompromised and other co-morbid conditions). exhibit a wide range of clinical manifestations, ranging from an asymptomatic state to severe disease with hypoxia and acute respiratory distress syndrome (ARDS) type lung injury. (7, 8) In the setting of hypoxemic respiratory failure, ground glass opacification on chest imaging is found in more than 50%.(7) Because the majority of patients will experience only mild symptoms, including fever, cough, headache, anorexia, diarrhea, and/or malaise, it can be difficult to distinguish COVID-19 from the common cold. COVID-19 has the potential to cause myocardial injury with at least 17% found to have an elevated troponin and 23% noted to have heart failure in a study of 191 inpatients from Wuhan, China.(9) Cases of fulminant myocarditis with cardiogenic shock have also been reported, with associated atrial and ventricular arrhythmias. (10, 11) Given that hypoxia and electrolyte abnormalities that are common in the acute phase of severe illness can potentiate cardiac arrhythmias, the exact arrhythmic risk related to COVID-19 in patients with less severe illness or those who recover from the acute phase of the severe illness is currently unknown. Improved understanding of this is critical, primarily in guiding the need for additional arrhythmia monitoring (e.g., mobile cardiac telemetry) post discharge and whether an implantable cardioverter defibrillator (ICD) or wearable cardioverter defibrillator will be needed in those with impaired left ventricular function thought secondary to COVID-19. In patients with suspected COVID-19 infection, it is recommended that PPE be donned by all clinicians and health care providers. This includes a face mask, protective eyewear, gown and gloves. Initial PPE recommendations in these patients included the use of fitted N95 or powered air purifying respirator (PAPR) masks, protective eyewear, gloves, and gowns. However, due to a shortage of N95 masks and increased understanding of droplet and airborne transmissibility during routine care of suspected and positive COVID-19 patients, substitution with a surgical mask with a face shield combination or other protective eyewear during routine non-procedural care has been recommended by the Centers for Disease Recommendations related to PPE may continue to change based on supply chain, contingency and/or crisis capacity status. Consultation with the hospital infection control team is strongly recommended. Appropriate donning and doffing procedures should be followed as outlined by the CDC (see useful links below). It is also important to be know how to report potential COVID-19 cases or exposure to public health authorities; local or hospital COVID-19 hotlines can be useful in this regard. Other urgent or semi-urgent clinical indications can be evaluated in-person on an individualized basis. Select patients with worsening heart failure or arrhythmia symptoms or for whom there is a need for device reprogramming may warrant office evaluation. These include but are not limited to AF patients with worsening heart failure, ICD patients with recent shocks or syncope, CIED patients with recent symptoms suggesting possible device malfunction (e.g., syncope or heart failure exacerbation), or suspected device infection. A limited physical examination may well be appropriate based on their clinical presentation. When possible, in-person visits and procedures should be coordinated on the same day to minimize multiple exposures for the patient. In patients coming for outpatient visits, measures should be taken to screen patients for concerning symptoms (e.g., fever, cough) before they present to clinic. If suggestive symptoms or a fever are present, patients should be re-directed to an appropriate screening clinic or facility, with appropriate measures taken. ( Figure 2 ) In order to minimize exposure of EP staff and device manufacturer representatives to patients with suspected or confirmed COVID-19 infection, it is prudent to only perform in-person CIED interrogations as follows. Importantly, device interrogation programmers, cables, and wands should be disinfected between all patients. COVID-19): Cases in the U.S. Updated World Health Organization. Coronavirus Disease (COVID-19) Situation Reports Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China Presumed Asymptomatic Carrier Transmission of COVID-19 SARS-CoV-2 Viral Load in Upper Respiratory Specimens of Infected Patients Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1 Clinical Characteristics of Coronavirus Disease 2019 in China First Case of 2019 Novel Coronavirus in the United States Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study Coronavirus fulminant myocarditis saved with glucocorticoid and human immunoglobulin Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the Coronavirus Disease 2019 (COVID-19) Pandemic Anesthetic Management of Patients With Suspected or Confirmed 2019 Novel Coronavirus Infection During Emergency Procedures HRS Expert Consensus Statement on remote interrogation and monitoring for cardiovascular implantable electronic devices Department of Health & Human Services. HHS.gov. Notification of Enforcement for Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency Inhibition of hERG K+ currents by antimalarial drugs in stably transfected HEK293 cells The hazards of chloroquine self prescription in west Africa Cardiac toxicity secondary to long term treatment with chloroquine The arrhythmogenic cardiotoxicity of the quinoline and structurally related antimalarial drugs: a systematic review Urgent Guidance for Navigating and Circumventing the QTc Prolonging and Torsadogenic Potential of Possible Pharmacotherapies for COVID-19 We acknowledge several members of the HRS, ACC EP Council and AHA ECG and Arrhythmia Committee of the Council on Clinical Cardiology and the who have provided significant input into these recommendations. None related to the topic None