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Canadian Journal of Cardiology

Surveillance for COVID-19 in Cardiac Inpatients: Containing COVID-19 in a Specialized Cardiac Centre

      To the Editor:
      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.
      • Cosentino N.
      • Assanelli E.
      • Merlino L.
      • et al.
      An in-hospital pathway for acute coronary syndrome patients during the COVID-19 outbreak: initial experience under real-world suboptimal conditions.
      However, although COVID-19 might manifest as ACS, other cardiac complications can also be associated with SARS-CoV-2 infection

      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.

      ; for instance, respiratory viruses can cause heart failure or myocarditis. Because a small percentage might be presymptomatic,
      • Wei W.E.
      • Li Z.
      • Chiew C.J.
      • et al.
      Presymptomatic Transmission of SARS-CoV-2 - Singapore, January 23-March 16, 2020.
      this makes detection even more challenging. Some form of risk stratification is necessary to prioritize patients for COVID-19 testing.

      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 thumbnail gr1
      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.

      Funding Sources

      The authors have no funding sources to declare.

      Disclosures

      The authors have no conflicts of interest to disclose.

      References

        • Cosentino N.
        • Assanelli E.
        • Merlino L.
        • et al.
        An in-hospital pathway for acute coronary syndrome patients during the COVID-19 outbreak: initial experience under real-world suboptimal conditions.
        Can J Cardiol. 2020; 36: 961-964
      1. 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.

        • Wei W.E.
        • Li Z.
        • Chiew C.J.
        • et al.
        Presymptomatic Transmission of SARS-CoV-2 - Singapore, January 23-March 16, 2020.
        MMWR Morb Mortal Wkly Rep. 2020; 69: 411-415
      2. 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.

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