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We read with interest the article by Cosentino et al., who described a triage pathway for patients with acute coronary syndrome (ACS) during a COVID-19 outbreak.
Boukhris M, Hillani A, Moroni F, et al. Cardiovascular implications of the COVID-19 pandemic: a global perspective [e-pub ahead of print]. Can J Cardiol https://doi.org/10.1016/j.cjca.2020.05.018. Accessed July 3, 2020.
Wood DA, Mahmud E, Thourani VH, et al. Safe reintroduction of cardiovascular services during the COVID-19 pandemic: guidance from North American societies [e-pub ahead of print]. Can J Cardiol https://doi.org/10.1016/j.cjca.2020.04.031. Accessed July 3, 2020.
In Singapore, the first case of COVID-19 was reported toward the end of January 2020. The National Heart Centre Singapore is the largest cardiac centre locally, with more than 10,500 admissions per annum. During the COVID-19 outbreak, all cardiac inpatients were screened using a risk-stratified approach. If patients had suspicious travel/epidemiology history, respiratory symptoms, or pulmonary infiltrates on imaging, they were placed in a dedicated ward where SARS-CoV-2 was tested for and health care workers (HCWs) used N95 masks, disposable gowns, gloves, and goggles, until COVID-19 was excluded. Patients who tested positive were transferred to isolation wards and patients who tested negative were decanted to the general ward. If percutaneous coronary intervention (PCI) was necessary before COVID-19 could be excluded, patients were managed as if they were positive.
Over a 12-week period (February 5 to May 1, 2020), 336 cardiac inpatients, representing 20% of all admissions (336/1589), were tested for COVID-19. Most had pulmonary infiltrates on baseline imaging (88.9%; 299/336); 31.8% (107/336) had concomitant respiratory symptoms; and 3.6% (12/336) had epidemiological risk-factors for COVID-19. A total of 9 cardiac patients (2.7%; 9/336) tested positive for respiratory viruses (3 SARS-CoV-2, 6 other respiratory viruses), compared with 18.9% (352/1945) of noncardiac medical inpatients in our co-located general hospital who tested positive over the same period (103 SARS-CoV-2, 249 other respiratory viruses). Details of the 6 cardiac patients with COVID-19 are shown in Figure 1. Two were asymptomatic and tested on the basis of epidemiology alone; 1 had respiratory symptoms and pulmonary infiltrates. One presented with congestive cardiac failure likely precipitated by COVID-19, another was asymptomatic but presented with hypertensive urgency; and the last case was admitted for ACS requiring PCI. Of the 40 emergency PCIs carried out, 17.5% (7/40) of the patients were tested for COVID-19; only 1 tested positive. To date, no health care-associated transmission of COVID-19 has been detected at our institution. Vigilance should be maintained for viral causes of common cardiac complications, as well as epidemiologic risk factors for COVID-19, given the possibility of presymptomatic transmission.
Figure 1Clinical details, imaging findings, and epidemiology investigations for cardiac patients positive for SARS-CoV-2 (n = 3) at a specialist cardiac centre in Singapore, during a COVID-19 outbreak. HCW, health care worker; hrs, hours; PPE, personal protective equipment; yo, year old.
Boukhris M, Hillani A, Moroni F, et al. Cardiovascular implications of the COVID-19 pandemic: a global perspective [e-pub ahead of print]. Can J Cardiol https://doi.org/10.1016/j.cjca.2020.05.018. Accessed July 3, 2020.
Wood DA, Mahmud E, Thourani VH, et al. Safe reintroduction of cardiovascular services during the COVID-19 pandemic: guidance from North American societies [e-pub ahead of print]. Can J Cardiol https://doi.org/10.1016/j.cjca.2020.04.031. Accessed July 3, 2020.
Owing to the COVID-19 outbreak in Lombardy, Italy) there is an urgent need to manage cardiovascular emergencies, including acute coronary syndrome (ACS), with appropriate standards of care and dedicated preventive measures and pathways against the risk of SARS-CoV-2 infection. For this reason, the Government of Lombardy decided to centralize the treatment of ACS patients in a limited number of centers, including our university cardiology institute, which in the past 4 weeks became a cardiovascular emergency referral center in a regional hub-and-spoke system.
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