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Protecting High-Risk Cardiac Patients During the COVID-19 Outbreak

2020; Elsevier BV; Volume: 34; Issue: 6 Linguagem: Inglês

10.1053/j.jvca.2020.03.043

1532-8422

Antonio Pisano, Giovanni Landoni, Alberto Zangrillo,

COVID-19 epidemiological studies

In the effort to face the ongoing Coronavirus Disease 2019 (COVID-19) epidemic, which caused severe pneumonia requiring intensive care unit (ICU) admission in up to 15% of confirmed cases so far, many hospitals in Italy are setting up new ICUs, stopping nonurgent admissions, limiting the access to emergency rooms and wards, and providing separate pathways for suspected COVID-19 and other diseases. In parallel, it is mandatory to continue ensuring the provision of non-postponable treatments (eg, primary percutaneous coronary interventions or urgent/emergency cardiac surgical procedures). The particularly high mortality rates recorded in Italy among COVID-19 patients (apparently more than 9% at the time of writing)1Protezione Civile. Coronavirus emergency. Available at: www.protezionecivile.gov.it. Accessed March 23, 2020.Google Scholar suggest that the actual number of people infected with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) may be much higher than that of confirmed cases, with a substantial number of asymptomatic or minimally/mildly symptomatic infections.2Fauci A.S. Lane H.C. Redfield R.R. Covid-19 - navigating the uncharted.N Engl J Med. 2020; 328: 1268-1269Crossref Scopus (1208) Google Scholar Indeed, a high percentage of asymptomatic infections (likely contributing to rapid dissemination of the contagion) recently was confirmed in a retrospective investigation in China3Li R. Pei S. Chen B. et al.Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (SARS-CoV2).Science. 2020 Mar 16; ([E-pub ahead of print], Accessed March 22, 2020)https://doi.org/10.1126/science.abb3221Crossref Scopus (2242) Google Scholar and among the population of one of the first outbreak villages in Italy (data not yet published). Moreover, it has been suggested that person-to-person transmission can occur from individuals with an asymptomatic course and in the prodromal phase of disease,4Chang D. Xu H. Rebaza A. et al.Protecting health-care workers from subclinical coronavirus infection.Lancet Respir Med. 2020; 8: e13Abstract Full Text Full Text PDF PubMed Scopus (451) Google Scholar,5Chan J.F.-W. Yuan S. Kok K.-H. et al.A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: A study of a family cluster.Lancet. 2020; 395: 514-523Abstract Full Text Full Text PDF PubMed Scopus (6145) Google Scholar or even after recovery.6Lan L. Xu D. Ye G. et al.Positive RT-PCR test results in patients recovered from COVID-19.JAMA. 2020 Feb 27; ([E-pub ahead of print], Accessed March 22, 2020)https://doi.org/10.1001/jama.2020.2783Crossref PubMed Scopus (886) Google Scholar Accordingly, every patient admitted to the hospital with urgency/emergency criteria (eg, acute myocardial infarction, cardiogenic shock, aortic dissection) potentially might be infected and, once transferred to either a coronary unit or ICU, may disseminate the contagion among patients already admitted to these units and among health care personnel working therein, who in turn may become (or already be) subclinically infected, and further contribute to the spread of infection among patients with a very high risk of a fatal outcome from SARS-CoV-2 (eg, cardiac transplantation recipients, patients with mechanical circulatory support, patients with major complications after cardiovascular surgery). If, as suggested, health care providers should be protected from subclinical SARS-CoV-2 infection,4Chang D. Xu H. Rebaza A. et al.Protecting health-care workers from subclinical coronavirus infection.Lancet Respir Med. 2020; 8: e13Abstract Full Text Full Text PDF PubMed Scopus (451) Google Scholar high-risk patients also should be protected from new patients admitted to ICUs (who may have become infected during their previous social contacts or during admission to emergency departments in the same or other hospitals) and from asymptomatic or minimally/mildly symptomatic health care providers. During the ongoing health emergency, all new patients admitted to hospital units hosting immunocompromised; complex; critical; and, more generally, acutely ill patients probably should be isolated initially and screened for SARS-CoV-2 infection, and separate pathways should be provided until the virological test results are obtained. Moreover, because routine use of high-level personal protective equipment outside the management of suspected cases in the emergency departments and of confirmed cases within COVID-19–dedicated units probably is not feasible, health care providers working in other (acute care) units should be turned away and screened immediately in the presence of minimal symptoms of respiratory infection, if not routinely screened regardless of the presence of symptoms.