key: cord-0782224-ro20ibaq authors: Briedis, Kasparas; Aldujeli, Ali; Aldujeili, Montazar; Briede, Kamilija; Zaliunas, Remigijus; Hamadeh, Anas; Stoler, Robert C; McCullough, Peter A title: Considerations for Management of Acute Coronary Syndromes During the SARS-CoV-2 (COVID-19) Pandemic date: 2020-06-30 journal: Am J Cardiol DOI: 10.1016/j.amjcard.2020.06.039 sha: 4d57bea35a54d27af075bfcc59a530edb94642f8 doc_id: 782224 cord_uid: ro20ibaq Accumulating evidence suggests that influenza and influenza-like illnesses can act as a trigger for acute myocardial infarction (AMI). 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. In this document, we suggest recommendations as to how to triage patients diagnosed with acute coronary syndromes (ACS) and provide with algorithms of how to manage the patients and decide the appropriate treatment options in the era of COVID-19 pandemic. We also address the inpatient logistics and discharge to follow-up considerations for the function of already established ACS network during the pandemic. Accumulating evidence suggests that influenza and influenza-like illnesses can act as a trigger for acute myocardial infarction (AMI) (1) (2) (3) (4) . In this document, we suggest recommendations as to how to triage patients diagnosed with acute coronary syndromes (ACS) and provide with algorithms of how to manage the patients and decide the appropriate treatment options in the era of COVID-19 pandemic. We also address the inpatient logistics and discharge to follow-up considerations for the function of already established ACS network during the pandemic. To minimize the misunderstanding in COVID-19 case definitions between healthcare workers we recommend adopting the World Health Organization (WHO) guidelines on case definitions as following: -Confirmed case (COVID-19 +) -a patient with laboratory confirmation of COVID-19 infection, irrespective of clinical signs and symptoms. -Suspected case (COVID-19 +/-) -a patient with acute respiratory illness (fever and at least one sign/symptom of respiratory disease, e.g., cough, shortness of breath), OR a patient with acute respiratory illness (fever and at least one sign/symptom of respiratory disease, e.g., cough, shortness of breath), AND for whom first testing for the COVID-19 virus is inconclusive or negative -being the result of the test reported by the laboratory, AND in the absence of an alternative diagnosis that fully explains the clinical presentation AND/OR a patient belongs to the risk group (Table 1) . -Contact case (COVID-19 C) -a patient with no clinical signs and symptoms AND having been in face-to-face/direct contact or direct care for the patient without proper PPE with a confirmed COVID-19 case AND being in self-isolation. -Non-suspected case (COVID-19 NS) -a patient is not suspected for COVID-19 disease. The triage of patients is recommended on the basis of COVID-19 probability, being described as confirmed, suspected, contact or non-suspected cases for COVID-19 disease. All the patients must be fitted with disposable face masks once they enter the hospital. Confirmed COVID-19 cases according to the severity of patients' condition and the need for services should be admitted to either a COVID ward or COVID CCU / ICU. All confirmed COVID-19 cases can be treated with no isolation in the same rooms. COVID ward or COVID CCU / ICU are considered infectious zones. Suspected COVID-19 cases according to the severity of patients' condition and the need for services should be admitted to either a COVID ward or COVID CCU / ICU. Suspected cases ideally must be treated in single rooms (isolated) and have a separate restroom. Contact COVID-19 cases according to the severity of patients' condition and the need for services should be admitted to either a Cardiology ward or CCU / ICU. Contact cases must be treated in single rooms (isolated) and have a separate restroom. Cardiology ward or CCU / ICU are considered as non-infectious zones. Non-contact COVID-19 cases are managed as per standard institutional policies and protocols. Some of the porter services can be transformed to dedicated COVID transfer teams who have everyday experience and skills on proper donning and doffing sequences for personal protective equipment. When performing cardiac procedures on confirmed and suspected COVID-19 cases, procedures should be performed in a dedicated COVID catheterization laboratory (6) . It should contain COVID dedicated lead aprons, conventional equipment with the most commonly used balloon and stent sizes, wires, catheters and other equipment (7) . Ventilation systems in dedicated COVID laboratories should ideally be converted to negative pressure systems. This conversion would offer optimal protection to personnel working in adjacent areas. However, if temporary conversion to negative pressure room is performed, cross contamination of other rooms may occur (7) . Cleaning procedures before and after the cases must be strictly followed according to the institutional policies (8) . Intense cleaning of lead aprons should be added to the protocols (9) . Cardiac procedures for all other cases should be performed per usual protocols with standard equipment in non-COVID dedicated catheterization laboratory (10) . The vital aspect in stopping the virus spread among healthcare workers is the appropriate usage of personal protective equipment and proper donning and doffing sequences ( Table 2 ). All staff members providing healthcare for patients with confirmed or suspected COVID-19 cases must be equipped with FFP2/FFP3 (N95) respirators, goggles and/or face shields, long sleeved gowns, tall disposable shoe covers, extra gloves (7). Personnel who provide care for the contact COVID-19 cases should at least wear disposable face masks, disposable gowns, head covers and gloves. It is also recommended during the pandemic that even non-contact patients who are hospitalized be fitted with disposable face masks given a potential rapid change in the epidemiologic situation. All patients with COVID-19 confirmed or suspected disease, presenting with acute coronary syndrome can be divided into 3 main categories as described below in order to achieve a simplified workflow. 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 in order to reduce possible staff contamination and to provide further discussion of the risks and benefits for all personnel involved in these cases. Patients diagnosed with non-ST elevation acute coronary syndromes (unstable angina or NSTEMI) without high-risk features for ongoing myocardial ischemia (Table 3) . If these patients present to the emergency department, they should be admitted to the ward and zone described above based on COVID-19 disease probability. Medical treatment for ACS needs to be initiated without any delay. In stable patients with confirmed or suspected COVID-19 disease presenting within 12 hours of symptom onset, PCI as first line therapy may be deferred in order to reduce the possible exposure risks to the staff given higher CPR and intubation rates compared with other ACS presentations. Fibrinolytic therapy should be considered a first line option in the absence of contraindications (Table 5 ). Fibrinolytic therapy is considered effective if pain is relieved with resolution of ST segments by more than fifty percent within 60 to 90 minutes after the last dose has been administered (13) . In this case further medical treatment should be continued and elective coronary angiography may be scheduled after full recovery from COVID-19 disease. If fibrinolytic therapy is ineffective, prompt decision making meeting with a senior colleague should be undertaken to discuss the benefits and risks of PCI relative to the possible high exposure risk to the staff. Rescue PCI should be attempted as soon as a COVID dedicated catheterization laboratory is available. If medical treatment is selected, patient should be initiated on Aspirin, P2Y12 receptor blocker, intravenous unfractionated heparin for at least 48 hours, ACE inhibitors and beta blockers. In confirmed COVID-19 cases with severe pneumonia with or without SARI, conservative medical treatment versus fibrinolytic therapy without rescue PCI should be considered given the unfavorable prognosis of COVID-19 disease at that stage (12) . In non COVID-19 patients, there is evidence suggesting that systematic and early invasive revascularization is superior to a delayed or ischemic-guided revascularization approach (14) . However, this may not hold true in severe COVID-19 cases as they are commonly complicated by coagulopathy (15, 16) , which may pose a higher risk for in-stent thrombosis if PCI is performed emergently in those patients. Patients treated for acute coronary syndromes during pandemic who have tested negative for COVID-19 disease should be discharged as early as the condition of the patient allows (9). There is a higher risk of patient exposure and contamination in the hospital even if in non-infectious zones (8) . We recommend aiming for very early discharge for NSTEMI cases within less than 24 hours and less than 48 hours for STEMI patients. Patients diagnosed with ACS and have tested positive for COVID-19 disease with mild illness can be discharged within the same timeframes (Table 6) . After discharge, patients should self-isolate for at least 14 days or until full recovery from COVID-19, whichever is longer (17) . Patients with positive COVID-19 and ACS who have a moderate to severe presentation such as pneumonia, severe pneumonia, ARDS or even sepsis with or without septic shock should be managed primarily for the viral illness as inpatients for as long as the condition requires (9) . All face to face follow-up appointments in outpatient clinics after the discharge during the pandemic should be postponed (17) . Teleconsultation services with online drug prescription options for follow-up should be established and encouraged in order to avoid unnecessary patient contamination (10) . The proposed strategies and algorithms are based on limited available data and might change as the epidemiologic conditions and transmission routes change. This document provides recommendations that may not be applicable to all institutions, and each center may need to modify these recommendations to survive with the resources that they may or may not have. Appropriate treatment strategies for acute coronary syndromes in patients diagnosed with COVID-19 disease during pandemic is not well understood due to lack of clinical trials or large studies to date. In addition, testing turnaround times are long for most centers and availability is not present in all institutions for in-house services. The ☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. A patient with one or more of the following: - Patients with uncomplicated upper respiratory tract viral infection may have non-specific symptoms such as fever, fatigue, cough (with or without sputum production), anorexia, malaise, muscle pain, sore throat, dyspnea, nasal congestion, or headache. Rarely, patients may also present with diarrhoea, nausea, and vomiting. The elderly and immunosuppressed may have atypical presentations. Symptoms due to physiologic adaptations of pregnancy or adverse pregnancy events, such as dyspnea, fever, GI-symptoms or fatigue, may overlap with COVID-19 symptoms. 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Very High-Risk features ☐The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: