Societies advise on COVID-19 concerns for electrophysiologists, stroke centers
In light of the COVID-19 pandemic, cardiology societies have issued new guidance on concerns related to the virus relevant to electrophysiologists and stroke centers.
Early reports show that among patients with COVID-19, nearly one-fifth of patients in the hospital and nearly one-half of those in the ICU had arrhythmias, and arrhythmia disorders during the recovery phase also appear to be common. This means that electrophysiologists and their staff may be in frequent contact with patients with COVID-19, putting them at risk, according to guidance issued by the Electrophysiology Section of the American College of Cardiology, the Electrocardiography and Arrhythmias Committee of the American Heart Association, and the Heart Rhythm Society.
Moreover, early data suggest that more than one-third of patients with COVID-19 have neurological symptoms, and stroke is a complication of COVID-19. The Stroke Council Leadership of the AHA and American Stroke Association issued interim guidance for stroke centers on how to protect staff and patients during the pandemic.
Guidance for electrophysiologists
Electrophysiologists and other staff members may be in frequent contact with patients with COVID-19, putting them at risk, according to the guidance for electrophysiologists authored by Dhanunjaya R. Lakkireddy, MD, FACC, FHRS, executive medical director of the Kansas City Heart Rhythm Institute & Research Foundation and professor of medicine at the University of Missouri-Columbia, and colleagues.
“In the hospital, the number of individuals rounding should be minimized and social distancing should be practiced,” the authors wrote. “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. Nonurgent or nonemergent procedures should be postponed to a later date.”
For patients with arrhythmias who are not hospitalized, use of telehealth and remote checks of implantable cardiac devices should be increased, according to the authors.
While “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,” the authors wrote. “Improved understanding of this is critical.”
Screening of all patients for COVID-19 is paramount, according to the guidance.
“It is important that all electrophysiologists have a high degree of suspicion for COVID-19 in any patient they interact with in the EP laboratory, hospital or outpatient setting,” Lakkireddy and colleagues wrote. “A thorough travel history and assessment of contact with individuals/family members who were sick or received hospitalization is mandatory. Patients with fever, cough and upper respiratory symptoms deserve special attention and should be immediately isolated. Testing for SARS-CoV-2, along with other respiratory viruses (eg, influenza, respiratory syncytial virus), should be pursued.”
All clinicians and health care providers should don personal protective equipment when treating any patients with suspected COVID-19, the authors wrote. If an N95 mask is not available, “substitution with a surgical mask with a face shield combination or other protective eyewear during routine nonprocedural care has been recommended by the CDC.”
Urgent or emergent procedures may be performed if the patient is screened for COVID-19 and proper precautions are taken, the authors wrote. These include, among other conditions, ventricular tachycardia ablations to treat electrical storm that cannot be controlled by medication; catheter ablation of incessant, hemodynamically significant, severely symptomatic supraventricular tachycardia, atrial fibrillation or atrial flutter that cannot be controlled by medication; lead revision for malfunction in a patient with a pacemaker or implantable cardioverter defibrillator receiving inappropriate shocks; generator change in pacemaker-dependent patients; lead or device extractions for infections not responding to medication; and pacemaker implantations for complete heart block, Mobitz type II atrioventricular block or high-grade atrioventricular block with symptoms or severe symptomatic sinus node dysfunction with long pauses.
Semi-urgent procedures may be performed with the proper screening and precautions taken at the discretion of the operator, the patient and the care team, the authors wrote. These include ablation for recurrent ventricular tachycardia not responding to medication, ablation for supraventricular tachycardia not responding to medication and resulting in ED visits, nonurgent/nonemergent battery replacement for implantable cardiac device generators and implantation of an ICD for primary prevention in patients at high risk for a life-threatening ventricular arrhythmia.
It is reasonable to delay any other procedures “for several weeks or months until the pandemic subsides and restrictions on elective procedures are lifted,” Lakkireddy and colleagues wrote.
Procedure times should be minimized, same-day discharges should be considered when possible, procedures on patients with known or suspected COVID-19 should be done at the end of the day and ventilation systems of EP labs should be reviewed to determine whether there is sharing of air return that could require disinfection of other rooms.
“To protect patients (many of whom are high risk due to coexisting comorbidities) and health care teams from COVID-19 exposure, preserve resources and maintain access to necessary cardiovascular care, it is important that nonessential encounters, tests and procedures be postponed,” Lakkireddy and colleagues wrote. “While electrophysiology is uniquely suited to leverage virtual care and remote monitoring, it is important to assure patients that they have our full support, and we are ready and able to provide care as necessary.”
Guidance for stroke centers
In the interim guidance for stroke centers, Patrick Lyden, MD, professor of neurology and Carmen and Louis Warschaw Chair in Neurology at Cedars-Sinai, and colleagues described the presence of neurological symptoms in patients with COVID-19, with early reports showing that stroke was a complication of COVID-19 in approximately 6% of patients.
Stroke teams may encounter difficulties in obtaining the proper personal protective equipment, which presents challenges because patients with stroke may not be able to provide adequate answers during COVID-19 screening, Lyden and colleagues wrote. Therefore, each patient should be treated as if they are infected with COVID-19, the authors wrote. To minimize personal protective equipment use, as few personnel as possible should see the patients, according to the guidance.
Although some stroke centers have had personnel diverted during the pandemic, “all stroke teams should endeavor to adhere to all published guidelines regarding patient selection for therapy; treatment times (eg, door-to-needle and door-to-groin puncture); and post-recanalization monitoring,” the authors wrote. “However, we wish to inform regulatory authorities — and we wish to reassure stroke teams — that in the setting of the pandemic full compliance has become a goal, not an expectation.”
Although many ICU beds will be dedicated to patients with COVID-19, “we want to encourage appropriate resource allocation for critically ill stroke patients,” the authors wrote, noting that once patients with stroke are stabilized, they can be moved out of the ICU if their bed is needed. Patients with hemorrhagic stroke are more likely to need intensive care than those with ischemic stroke, according to the authors.
Obtaining the NIH Stroke Scale score can be done via telemedicine, and “televideo is superior to telephone, yet telephonic consultation is superior to no consult,” the authors wrote.
“Collaboration, collegiality and compassion for one another are crucial to making it through this challenge,” Lyden and colleagues wrote. “A true sense of a unified Stroke System of Care is needed now more than ever.” – by Erik Swain
Disclosures: The authors of both documents report no relevant financial disclosures.
Editor’s note: Developments in the COVID-19 pandemic are quickly evolving. Information in this article was up to date at the time of publication. To access the latest updates for practicing clinicians, visit Healio’s COVID-19 Resource Center at www.healio.com/coronavirus.
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Lakkireddy DR, et al. Heart Rhythm. 2020;doi:10.1016/j.hrthm.03.028.
Lyden P, et al. Stroke. 2020;doi:10.1161/STROKEAHA.120.030023.
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