Impact of Cardiovascular Care of COVID-19: Lessons Learned, Current Challenges, and Future Opportunities

Abstract

Summary COVID-19 has disrupted traditional cardiovascular care pathways leading to significant challenges. With these challenges have also come opportunities to iterate our testing strategies to ensure they are patient centered and also that they are most appropriate and best align with infection protection protocols. Introduction SARS-CoV-2, the causative agent of COVID19, is a singled strand, positive-sense, enveloped RNA virus. It has spike proteins on outside of membrane which help it attach to human cells. Corona virus has been identified in avian hosts and mammals which include camels, bats, mice, dogs, and cats. The initial disease outbreak as an unidentified pneumonia was started in Wuhan, China in the December of 2019. The first fatality from this viral infection was reported in China on January 11, 2020. The 1st US case was reported in Washington State on January 21, 2020. WHO declared COVID19 a pandemic on March 11, 2020. To date, US is leading the world with the total confirmed cases at 760,245 and New York City has the highest fatality rate in the country with 14,451 deaths (1-3). The COVID-19 pandemic has rapidly and profoundly impacted the global economy and nearly all aspects of our personal lives. These sweeping societal effects have not spared healthcare. Procedure-based care has been largely suspended for all but the most acute circumstances, owing to the need to create capacity in the healthcare system and the intent to avoid unnecessary risks of infection for our patients and members of our healthcare teams. Similarly, diagnostic evaluations and follow-up care have been either postponed or rethought in approach. Relative to other disciplines, the time domain for making care decisions is often more acute within the cardiovascular medicine. Moreover, results stemming from any delays in care are often more consequential. Thus, practicing cardiovascular medicine amidst the COVID-19 pandemic has presented particular clinical challenges. We present perspectives herein as to how those practicing in the midst of the COVD-19 pandemic are approaching these issues. Lessons from NYC The epicenter of this global pandemic migrated from its origin in Hubei province through Italy and on to NYC. The reasons for this are beyond the scope of this document, but the impact on healthcare provision in NYC was sudden and severe. The first response to COVID was to create acute care capacity by halting all elective procedures and diagnostic testing. Within the Division of Cardiology at Lennox Hill Hospital, this involved the stopping of all elective diagnostic angiography, percutaneous intervention, and non-invasive imaging procedures. While this was effective to create needed bed capacity and to preserve vital personal protection equipment (PPE), it created challenges in providing care for patients with chest pain who had presented either to the emergency department or in the outpatient setting and who have intermediate pretest likelihood of coronary artery disease. With these outpatients, screening tools using clinical history and ECG often can allow for safely deferring diagnostic evaluation, but for how long? What if patient has undiagnosed left main disease, as was seen in over 5% of those in the ISCHEMIA trial (4)? And in the emergency department, the issue isn’t about whether to test but more so about how to test these patients. Our system has moved toward using coronary CTA (CCTA) as the primary means for evaluating chest pain symptoms in such patients. CCTA is a well-established clinical modality, with Class 1 recommendation for chest pain in the emergency department and in the ambulatory setting. While other testing modalities are also indicated, in the COVID clinical environment we believe that CCTA offers superior clinical advantages. It is highly accurate, with a very high negative predictive value, and most importantly, it can be performed more rapidly and with far less personal contact with care providers than traditional stress testing. Given these benefits, we are aware that many other institutions have shifted to CCTA their first-line testing strategy in evaluating patients with chest pain. The Western Region of Northwell Health Includes a tertiary hospitals (449 beds), two community hospitals--Phelps Memorial Hospital and Northern Westchester Community Hospital (with 220 and 195 beds, respectively), and an outpatient health annex, which provides both ED and outpatient imaging services to the Southern Manhattan district of New York City. Our region has been relying completely on CCTA to triage inpatient and ED acute chest pain, in order to minimize the number of tests required to get the most and accurate information possible during this crisis situation (Table 1). TABLE 1: Summary data of first 2 months of using CCTA first during COVID-19 in New York City Historically, CCTA has been used for triple rule out (TRO) of acute chest pain for the assessment of acute pulmonary embolism, acute coronary syndrome, and acute thoracic aortic dissection. During this COVID-19 crisis, we have added two more critical diagnoses which include COVID lung infection and acute viral peri-myocarditis. Our protocol includes a gated non contrast scan of the chest for the evaluation of COVID-19 lung disease and calcium score, followed by an ECG synchronized CTA of the heart (5), heart and aorta, or heart, pulmonary arteries, and aorta (TRO). The clinical role of TRO remains modest but has been used in patients that have positive d-dimer or high clinical suspicion of having acute pulmonary embolism. There have been some reports suggesting that a delayed enhancement CT protocol may be helpful in aiding in the diagnosis of COVID myocarditis (6) as has been described previously for other causes of myocarditis. Although CMRI is the preferred noninvasive technique for the detection of acute myocarditis and scarring, the clinical access to CMR during the acute crisis has been very limited in addition the lack of direct visualization of the coronary arteries limits the utility. During this COVID crisis, we found 2 positive acute perimyocarditis using our protocol in 10 known COVID positive patients. During this crisis, our standard CT protocol has included wide reconstructed field of view for the evaluation of the pulmonary parenchyma for the evaluation COVID lung disease in patients with cardiac symptoms and elucidating the etiology of atypical chest pain and dysrhythmia. The pulmonary findings have been interpreted in a standardized fashion as laid out in recent guidance documents (7) Instead of TEE, CCTA has also become the non-invasive imaging of choice for the evaluation of the left atrial appendage thrombus during this crisis. The challenges with performing CCTA on critically ill COVID-19 patients with fever, shortness of breath, and coughing include tachycardia, unable to breath hold, and risk of exposing frontline workers to the risk of contracting the virus. Some modifications of the routine patient preparation and scanning procedures are often required. Prior to COVID-19, many centers have been providing oral heart rate control and beta blockade in triage or holding areas but with a desire to keep time in the department to a minimum we and others have expanded our use of outpatient pre-beta blockade. Owing to a desire to optimize social distancing, every effort is made to lower the heart rate using a combination of oral (Table 2) one day or two prior to the testing and intravenous beta blocker on the CT couch to achieve the best images with the least amount radiation exposure possible in accordance with SCCT acquisition guidance (5,8). However, high heart rate as a result of fever and systemic infection may render heart rate control with either beta blocker or calcium blocker difficult. Due to the urgency of the scan, we may rely on wide acquisition windows covering the entirety of the cardiac cycle to help increase the likelihood of an interpretable scan. During the COVID-19 crisis, we also received approval from our administration to send CCTA cases from both the EDs and inpatient cases to Heart Flow for Fractional Flow Reserve analysis if needed to improve our positive predictive value. Table 2. Beta blockade for outpatient Table 3. Lessons learned from COVID-19 and Future Opportunities for CCTA We have also found utility in extending the use of CCTA in the evaluation of select higher risk patients, such as those presenting with chest pain and biomarkers indicating myocardial injury. The safety and efficacy of this approach was recently demonstrated in the VERDICT CT study (9), which evaluated the diagnostic performance and the potential clinical utility of CCTA in patients with NSTEMI. The timing of the reporting of these findings is opportune, given the overlap between COVID cardiac disease and acute coronary syndrome (ACS). The experience in Northern Italy has been an unexpectedly high rate (∼3-fold) of finding nonobstructive coronary artery disease in COVID (+) patients presenting with ACS (10-11). This highlights the opportunity to integrate CCTA into care pathways prior to proceeding directly to the catheterization laboratory. This approach mitigates PPE use and potentially avoids exposing invasive catheterization laboratory staff unnecessarily to COVID (+) patients. In the setting of known or highly probable COVID-19, there is also a potential role for pre-catheterization evaluation of patients presenting with ST-segment elevation MI (STEMI) (11-12). The experience in Northern Italy has raised awareness of fulminant COVID-associated myocarditis presenting as STEMI. In all, it is estimated that in the setting of widespread community COVID infection that as many as 60% of STEMI presentation may be related to COVID rather than an acute plaque rupture amenable to PCI. Many have suggested that point of care ultrasound examination may help to define those patients more likely to have myocarditis by virtue of lack of regional wall motion abnormality. While some have proposed the use of CCTA in advance of ICA for those with suspected COVID infection who present with STEMI, it is important that logistical issues should not delay appropriate care in the patients with true epicardial obstruction. Of particular note, in patients with atypical presentations, CCTA may be particularly helpful where the findings of ST elevation and transthoracic echocardiography are divergent. Further the European Society of Cardiology provided guidance regard testing in the COVID environment CT Angiography should be preferred to non-invasive functional testing during COVID-19 pandemic highlights include that CT Angiography should be preferred to non-invasive functional testing. In case CCTA is not possible or available, non-invasive testing should be postponed owing to the close contact between patients and personnel (stress echocardiography) (13). Considerations for CCTA in cardiovascular care delivery While CCTA requires less patient contact than ICA, it is not without its own risks and constraints. It is therefore essential that the care be provided in a safe and thoughtful fashion. Where at all possible, beta blockade should be initiated prior to arrival in the hospital for outpatients; for stable inpatients it should be initiated prior to patient transfer to the CT department. Ideally, one CT scanner in the department should be designated for use for patients with probable or confirmed COVID. Proper PPE in line with infection protection guidance and exposure is needed, as is limiting the number of staff exposed to these patients. CCTA protocols should be aligned with current acquisition guidance to ensure optimal image quality and accurate diagnosis. Along with beta-blockade, nitroglycerin administration should be administered whenever possible. Widened acquisition windows to acquire multiple phases of the cardiac cycle is generally recommended to help ensure that studies are fully diagnostic given the added complexity of repeat scanning in such patients. Acquiring such views may afford detection of COVID-related lung disease in these patients. Potential long-term implications of CCTA in cardiovascular care delivery Parallel to the uptake of CCTA, we have also seen use of telemedicine as a means to provide patient care yet limit the patient’s physical contact with the health care environment. While imaging clearly cannot be done remotely, the COVID crisis nevertheless highlights the need for implementing the most efficient and direct approaches to diagnostic testing. During COVID, testing modalities that involve patients spending as little time in a hospital or outpatient department seeing should be considered. Arguably, this objection should be maintained after the pandemic wanes. CCTA meets this bar. For patients who arrive rate controlled, CCTA will typically only require <1 hour at the testing site (6). The comprehensiveness of the evaluation is as important as its applicability. In instances when CCTA identifies anatomical lesions of uncertain clinical relevance, post-test physiological assessment by FFRCT can be applied to guide downstream management. While other testing strategies for evaluating patient with chest pain will undoubtedly resume in clinical practice when the pandemic passes, we believe that a “CCTA first” pathway should remain as the strongly favored approach. To do so, access to testing in outpatient facilities rather than only in hospital will be essential. In rationed healthcare systems, such as Canada and the UK, this is particularly challenging, as essentially all CT scanners are housed within hospital departments. In the US, many states have certificate of need laws that limit acquisition of CT scanners, and reimbursement mechanisms greatly favor inpatient imaging centers. New CT platforms in lower cost care environments will need to be installed to meet clinical demand. Such obstacles will need to be addressed as we emerge from the acute crisis with a renewed focus on safe and effective care delivery. Concluding Thoughts The ongoing COVID pandemic has had significant impact on cardiovascular care delivery, with a marked reduction in elective diagnostic testing and face-to-face patient care. But it has also resulted an acute and necessary re-examination of how we deliver cardiac care. Too often our approaches to cardiac care delivery have been so deeply marbled into our clinical practice that we have not appropriately considered alternative approaches, those new ways to provide care that have been afforded by technical advances. In many ways, the COVID crisis has been like a crucible: anything that is extraneous or unnecessary, anything that has gone on “just because” gets melted away, leaving left only that which is inherently of value and worth keeping (14). Just as uptake of telemedicine is showing us that indeed not every patient needs to present in person to us in order to have meaningful interactions that advance or safeguard care, our experience with an expanded clinical role of CCTA in ambulatory and acute care settings has been equally beneficial. Neither approach, however, will be sustainable in the future unless the regulatory and reimbursement systems that undergird care delivery prove receptive and adaptable to such innovative approaches. To what extent these COVID-related shifts in approach to cardiac care will be maintained as we begin to transition into the “recovery” phase of the pandemic is as yet uncertain. But it would seem that those pathways that provide the most efficient answers to clinical questions in a manner that is the most patient-centric—those care pathways that create the greatest clinical value—will endure in the long run. And our patients deserve nothing less.