key: cord-0923449-nznav0q0 authors: Zhang, Lin; Fan, Yongzhen; Lu, Zhibing title: Experiences and lesson strategies for cardiology from the COVID-19 outbreak in Wuhan, China, by ‘on the scene’ cardiologists date: 2020-04-03 journal: Eur Heart J DOI: 10.1093/eurheartj/ehaa266 sha: 3395a7267f678a2cdd76d30f4106c44e943a96ee doc_id: 923449 cord_uid: nznav0q0 nan Between 1 and 31 January 2020, of 417 inpatients and 116 health workers in our department, 4 patients (1 male, 3 female) and 1 nurse (female) were diagnosed with COVID-19. The 77-year-old male patient, who was initially admitted for acute myocardial infarction (AMI), was confirmed as COVID-19 (presumed to be hospital acquired) and died of respiratory and circulation failure 2 weeks later. In the other three patients, the outbreak occurred shortly after hospitalization but they showed no COVID-19-related symptoms, and were presumed to be already in the incubation period before admission. They eventually recovered and were discharged. The nurse probably became infected due to close contact with confirmed patients when providing nursing care under insufficient personal protection, since she had no other known exposure history. Details of these cases are given in Supplementary material online. To contain possible transmissions in the cardiology ward, we have elaborated a detailed protection plan defining personal protection in different clinical settings on the basis of general control and prevention principles. Our major control and prevention measures are summarized in Table 1 . Regarding the use of personal protection equipment (PPE), facial and eye protection, gown, and gloves are considered crucial since the main transmission routes of COVID-19 are respiratory droplets and contact. The PPE is classified into three levels according to exposure risk. For instance, a level-1 PPE is used for general medical contact with non-infected inpatients in cardiology, while a level-3 PPE is proposed when aerosolgenerating procedures (i.e. cardiopulmonary resuscitation) or emergent cardiovascular interventions are performed for confirmed or highly suspected cases. AMI is one of the most life-threatening cardiovascular emergencies. In response to the epidemic, a modified workflow for managing AMI patients was developed in our centre ( Figure 1 ), which had undergone repeated discussions among local cardiologists before its implementation, by fully weighing the risk-benefit ratio from both the patients' and health workers' perspective. Although primary percutaneous coronary intervention (PCI) or emergent PCI is an effective reperfusion strategy, especially for STsegment elevation myocardial infarction (STEMI) cases, its role had to be relatively secondary in the context of the sudden COVID-19 outbreak. Increased exposure risks due to lack of negative pressure catheterization rooms and shortage of PPE and the significant increased difficulty in fine manipulation of guidewires under level-3 protection may all contribute to clinical decision-making. We recommend that fibrinolysis be preferred when both PCI and fibrinolysis can be selected. Once PCI is required, all staff engaged should be under level-3 protection, and thorough environmental disinfection must be given after each PCI. Similarly, for patients with non-STEMI, PCI can be performed in the high-risk population group: ongoing ischaemic symptoms, haemodynamic instability, and malignant arrhythmias. An in-hospital multidisciplinary consultation (involving experts from cardiology, ICU, department of infectious disease, and emergency department) should be organized in cases of AMI or other cardiovascular emergencies complicated with COVID-19. However, we have to acknowledge that our changed treatment for AMI is not evidence based but is a compromise in the context of the COVID-19 pandemic. Further validations may be warranted to observe its potential impact on patient outcome. Great care should also be taken by cardiologists since they may also confront COVID-19 cases. Prompt identification could be challenging when the patients are asymptomatic or still in an incubation period at admission, highlighting the importance of early proper protection measures in advance. Our practical strategies could be useful for cardiology departments worldwide in response to the COVID-19 outbreak. Figure 1 Workflow for the management of STEMI patients in the context of a COVID-19 outbreak. STEMI, ST-segment elevation myocardial infarction PCI, percutaneous coronary intervention Supplementary material is available at European Heart Journal online.