‘New era of close collaboration’ key when reintroducing elective CV procedures during COVID-19 pandemic
Once the COVID-19 pandemic starts to subside, gradual reintroduction and collaborative approaches are important to continue the care of patients with untreated CVD, according to guidance from 15 North American cardiology societies.
The guidance document, from 15 societies including the American College of Cardiology, the American Heart Association, the Canadian Cardiovascular Society, the Society for Cardiovascular Angiography and Interventions, the Canadian Association of Interventional Cardiology, the Society of Thoracic Surgeons and the Heart Rhythm Society, was published the Journal of the American College of Cardiology, the Canadian Journal of Cardiology and The Annals of Thoracic Surgery.
“The key part here is this has never been done before,” David A. Wood, MD, professor and director of the Centre for Cardiovascular Innovation at the University of British Columbia, Vancouver, Canada and the president of the Canadian Association of Interventional Cardiology, told Healio. “In our lifetime, we’ve never had a pandemic. No one really knows how to create a roadmap to start doing procedures and tests again and start treating patients on our waiting lists. We know we need to do the sicker patients, and we know we need to treat people at high risk for a bad outcome in the short term first. As far as how to gradually treat patients on our waiting lists — which are getting longer and longer — no one has ever done that before.”
Elective procedures during pandemic
Near the beginning of the pandemic, public health officials and North American CV societies asked cardiologists and health care professionals to defer most invasive CV procedures and diagnostic tests. For example, on March 17, the ACC’s Interventional Council and SCAI issued a statement in the Journal of the American College of Cardiology with initial recommendations including the deferment of elective procedures during the COVID-19 pandemic. Societies recommended intensified management and triage of patients who were on waiting lists for procedures.
“Unfortunately, patients with untreated cardiovascular disease are at increased risk of adverse outcomes,” Wood and colleagues wrote. “Delays in treatment of patients with confirmed cardiovascular disease will be detrimental. Similarly, reduced access to diagnostic testing will lead to a high burden of undiagnosed cardiovascular disease that will further delay time to treatment.”
Given these risks, cardiologists should prioritize CV patients when health care systems start to return to normal capacity after the pandemic, according to the document. Several ethical considerations should be focused on during this process, including the following:
- maximizing benefits for these patients;
- fairness so that patients are treated alike;
- proportionality of the risk for further postponement and the risk for spreading COVID-19;
- consistently reintroducing procedures across patient populations regardless of ethically irrelevant factors; and
- procedural justice through ethical framework to make the decisions based on best available evidence.
Collaboration with health authorities, regional public health officials and CV care providers is also critical when reintroducing these procedures, according to the document.
“Before the pandemic, I don’t believe there was much communication between cardiovascular medicine and our public health leaders,” Wood said in an interview. “I think there needs to be a new era of close collaboration so that we understand what’s happening from a public health perspective and they understand what’s happening with excess morbidity and mortality on our cardiovascular waiting lists. This is dynamic as we need to restrict procedures and tests again if a second wave occurs.”
A sustained reduction in new admissions for COVID-19 and deaths within a specific geographic area should occur during a prespecified time interval before changes for interventional procedures can begin, according to the document. If rates of admissions and deaths decrease then increase again, transparent and immediate cessation of most elective invasive procedures and tests is warranted.
Before any introduction of CV tests and procedures occur, a discussion must occur regarding the protection of health care workers and patients.
“Regions must have the necessary critical care capacity, personal protective equipment and trained staff available before the recommendations ... can be implemented,” Wood and colleagues wrote. “Importantly, a transparent plan for testing and retesting potential patients and health care workers for COVID-19 must be operationalized before elective procedures and tests are resumed.”
Other considerations regarding the protection for health care workers and patients include physical distancing, screening for COVID-19 and personal protective equipment, according to the document.
Leaders from the societies included in this document recognize that these recommendations are based mainly on expert opinion, according to the document. “This reflects the global challenge of managing a new and rapidly evolving pandemic where evidence is limited,” Wood and colleagues wrote.
Wood told Healio that the COVID-19 pandemic may lead to positive changes in the field. “There are multiple silver linings from the pandemic: No. 1, a new spirit of collaboration amongst all 15 societies; No. 2, a new spirit of collaboration between cardiovascular medicine and public health as we safely reintroduce these procedures and treat patients on our growing waiting list, and No. 3, we are going to streamline all aspects of cardiovascular medicine,” he said. “I do believe that telehealth and virtual visits will become routine not just during the pandemic but in the future because they’re better for patients, we can streamline patient visits as well as diagnostic tests and get people the most appropriate care faster.”
Prevention of a ‘new crisis’
“Unprecedented times call for unprecedented collaboration, and a collaborative approach will be essential to mitigate the ongoing morbidity and mortality associated with untreated cardiovascular disease,” Athena Poppas, MD, FACC, president of the ACC and one of the authors of the paper, said in a press release. “It is essential that we work together to ensure cardiovascular disease patients are safety cared for during this pandemic and that we don’t allow for a new crisis of undiagnosed, untreated or worsening cardiovascular disease to occur in the aftermath of this pandemic.”
“We must continue to strike the delicate balance of ensuring optimal and timely cardiovascular care that can reduce morbidity and mortality, weighed against the risk of COVID-19 exposure,” Robert Harrington, MD, FAHA, president of the AHA, said in the release. “A tailored and collaborative approach that adapts based on the number of COVID cases and the mortality rate within each community, in tandem with local health and government leaders, is ideal. The safety of our patients and their families from both cardiovascular disease and COVID-19 is our priority.”
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For more information:
David A. Wood, MD, can be reached at firstname.lastname@example.org.
Disclosures: Wood reports he receives unrestricted grant support from Abbott Vascular and Edwards Lifesciences and consults for Abbott Vascular, Boston Scientific, Edwards Lifesciences and Medtronic. Poppas and Harrington report no relevant financial disclosures. Please see the paper for all other authors’ relevant financial disclosures.