Critical Organizational Issues for Cardiologists in the COVID-19 Outbreak
2020; Lippincott Williams & Wilkins; Volume: 141; Issue: 20 Linguagem: Inglês
10.1161/circulationaha.120.047070
ISSN1524-4539
AutoresGiulio G. Stefanini, Elena Azzolini, Gianluigi Condorelli,
Tópico(s)COVID-19 Clinical Research Studies
ResumoHomeCirculationVol. 141, No. 20Critical Organizational Issues for Cardiologists in the COVID-19 Outbreak Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessArticle CommentaryPDF/EPUBCritical Organizational Issues for Cardiologists in the COVID-19 OutbreakA Frontline Experience From Milan, Italy Giulio G. Stefanini, Elena Azzolini and Gianluigi Condorelli Giulio G. StefaniniGiulio G. Stefanini Giulio G. Stefanini, MD, PhD, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele-Milan, Italy. Email E-mail Address: [email protected] Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy (G.G.S., E.A., G.C.). Humanitas Clinical and Research Hospital IRCCS, Rozzano, Milan, Italy (G.G.S., E.A., G.C.). , Elena AzzoliniElena Azzolini Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy (G.G.S., E.A., G.C.). Humanitas Clinical and Research Hospital IRCCS, Rozzano, Milan, Italy (G.G.S., E.A., G.C.). and Gianluigi CondorelliGianluigi Condorelli Gianluigi Condorelli, MD, PhD, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele-Milan, Italy; Email E-mail Address: [email protected] Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy (G.G.S., E.A., G.C.). Humanitas Clinical and Research Hospital IRCCS, Rozzano, Milan, Italy (G.G.S., E.A., G.C.). Originally published24 Mar 2020https://doi.org/10.1161/CIRCULATIONAHA.120.047070Circulation. 2020;141:1597–1599Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: March 24, 2020: Ahead of Print Lombardy, in northern Italy, is one of the regions most affected by coronavirus disease 2019 (COVID-19) secondary to severe acute respiratory syndrome coronavirus 2 infection.1,2 Since the first case diagnosed on February 20, 2020, in Codogno Hospital (Lodi, Lombardy, Italy), the infection has rapidly spread throughout Lombardy, reaching 28,761 confirmed cases, with 3776 deaths as of March 23, 2020.As cardiologists working in this situation, we are facing many critical issues about organizational aspects of management and treatment of cardiovascular disease because of reorganization of the Regional Health Service in response to this epidemic.3Prioritization of unstable patients with cardiovascular disordersThe Italian tax-funded National Health Service, established in 1978, is administered through regional authorities (ie, the Regional Health Service). In late February, one of the first measures adopted by the Lombardy Regional Health Service was to reduce the number of elective hospitalizations by approximately 80%, with the aim of increasing capacity for patients with COVID-19. Under normal conditions, our waiting list allows patients with chronic coronary syndromes and clinical indications to undergo coronary angiography within approximately 3 weeks. After the decision to reduce the number of elective hospitalizations was implemented, maintaining the same waiting times was no longer possible. Already during the first week of restrictive measures (ie, February 24–29), we had to postpone 80% of planned procedures. Therefore, we needed a strategy to select patients in whom clinical status would not allow postponement of their planned cardiac procedure. Prioritization was based on risk stratification, taking into account symptoms, evidence of a large area of ischemia, and the presence of known critical disease of the left main stem or of the proximal left anterior descending coronary artery at previous coronary angiogram or at coronary computed tomography angiography. In addition, we prioritized patients with decompensated, symptomatic, severe aortic stenosis scheduled for transcatheter aortic valve replacement. This has led to the postponement of a large number of elective hospitalizations. The impact on patient prognosis of this inevitable decision is unknown.Reorganization of clinical activities for cardiologistsBecause of the reorganization of the Regional Health Service, available resources for cardiology (eg, ward beds, intensive care unit beds, outpatient clinics) have been drastically reduced. In our setting, outpatient clinics have been closed, and beds available for cardiology (both in wards and intensive care units) are limited to those required to manage patients with cardiovascular emergencies.However, it is noteworthy that patients with COVID-19 tend to be elderly and have several comorbidities.4,5 Among these comorbidities, a history of ischemic heart disease and other cardiovascular risk factors is prevalent and is associated with worse outcomes. Along the same lines, myocardial involvement has been described in patients with COVID-19; those with the most severe clinical presentation have elevated cardiac biomarkers coupled with impairment of left ventricular ejection fraction.4,5In this context, the clinical activities of cardiologists have been reorganized into 2 teams: those taking care of cardiovascular emergencies and those focusing on the management of cardiovascular comorbidities and myocardial involvement in critical patients with COVID-19. The latter task requires close and constant collaboration between the cardiologists and infectious disease experts, pulmonologists, and intensive care specialists managing these patients.Providing safe and timely access to care for acute myocardial infarctionAnother critical issue for cardiologists working in our current situation is to provide timely access to care for patients with acute myocardial infarction (AMI). The major goal is not to compromise the standard-of-care for the management of patients with AMI. To continue to treat patients with AMI in line with current guidelines while preventing their exposure to severe acute respiratory syndrome coronavirus 2, the Lombardy Regional Health Service restructured the AMI network. Under normal conditions, Lombardy has 129 accredited hospitals, 55 of which are equipped with cardiac catheterization laboratories offering 24/7 service for AMI to approximately 10 million inhabitants. On March 8, 2020, the regional government passed a deliberation to reduce to 13 the hospitals with catheterization laboratories, which now act as Hubs, with the remaining hospitals acting as Spokes. Patients are now referred to a Hub on the basis of geographic proximity. The same model has been applied to other cardiovascular emergencies (eg, stroke). The result of this measure has been to concentrate a large majority of patients with AMI in a limited number of hospitals. Whether this will have an impact on timely reperfusion strategies is currently unknown.Safety of healthcare professionalsLast but not least, a key issue is how to manage patients with COVID-19 with cardiovascular emergencies. In recent weeks, a small number of patients with COVID-19 have required coronary angiography because of suspected acute coronary syndromes. In addition, some patients underwent urgent coronary angiography, only to test positive for COVID-19 afterward. This exposed healthcare professionals to risk of infection as a result of their involvement in the provision of acute care for these patient. The safety of healthcare professionals in this setting is a major challenge and requires detailed and dedicated training on the appropriate use of personal protective equipment. Moreover, to mitigate the risk of infection among healthcare professionals in the setting of acute AMI, we implemented a protocol to manage all patients undergoing urgent coronary angiography as potentially COVID-19–positive in the absence of an available negative test.Final considerationsItaly is facing its most dramatic emergency of its National Health Service. This crisis has many implications for the organization of clinical activities related to cardiology. All resources and efforts implemented to limit the diffusion of severe acute respiratory syndrome coronavirus 2 infection and to treat COVID-19 should not compromise contemporary standard-of-care for the treatment of cardiovascular diseases.Thus, key actions for cardiologists should include efforts toward the following:Foster a close collaboration with other specialists involved in the management of patients with COVID-19Define pathways to appropriately manage cardiovascular diseases in both COVID-19–positive and uninfected patients, while guaranteeing safety of healthcare professionalsEnhance cooperation between hospitals to centralize services to treat cardiovascular diseases.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.https://www.ahajournals.org/journal/circGianluigi Condorelli, MD, PhD, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele-Milan, Italy; Email gianluigi.condorelli@hunimed.euGiulio G. 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Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetailsCited By Xu X, Luo L, Xu H and Fang Y (2023) The emergency hierarchical medical system in China: Improving patient waiting times and operation management, International Journal of Healthcare Management, 10.1080/20479700.2023.2229525, (1-11) McGuinness S, Josphin J, Eades O, Clifford S, Fisher J, Kirkman M, Russell G, Hodgson C, Kelsall H, Lane R, Skouteris H, Smith K and Leder K (2022) Organizational responses to the COVID-19 pandemic in Victoria, Australia: A qualitative study across four healthcare settings, Frontiers in Public Health, 10.3389/fpubh.2022.965664, 10 Baigent C, Windecker S, Andreini D, Arbelo E, Barbato E, Bartorelli A, Baumbach A, Behr E, Berti S, Bueno H, Capodanno D, Cappato R, Chieffo A, Collet J, Cuisset T, de Simone G, Delgado V, Dendale P, Dudek D, Edvardsen T, Elvan A, González-Juanatey J, Gori M, Grobbee D, Guzik T, Halvorsen S, Haude M, Heidbuchel H, Hindricks G, Ibanez B, Karam N, Katus H, Klok F, Konstantinides S, Landmesser U, Leclercq C, Leonardi S, Lettino M, Marenzi G, Mauri J, Metra M, Morici N, Mueller C, Petronio A, Polovina M, Potpara T, Praz F, Prendergast B, Prescott E, Price S, Pruszczyk P, Rodríguez-Leor O, Roffi M, Romaguera R, Rosenkranz S, Sarkozy A, Scherrenberg M, Seferovic P, Senni M, Spera F, Stefanini G, Thiele H, Tomasoni D, Torracca L, Touyz R, Wilde A and Williams B (2021) ESC guidance for the diagnosis and management of cardiovascular disease during the COVID-19 pandemic: part 2—care pathways, treatment, and follow-up, Cardiovascular Research, 10.1093/cvr/cvab343, 118:7, (1618-1666), Online publication date: 22-Jun-2022. 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