Abstract
Background:
The Japanese Circulation Society proposes recommendations for all healthcare professionals involved in cardiovascular medicine to protect them from infection and ensure that seriously ill patients requiring urgent care receive proper treatment.
Methods and Results:
Patients are divided into “Positive or suspected coronavirus disease 2019 (COVID-19)” and “All others”. Furthermore, tests and treatments are divided into emergency or standby. For each category, we propose recommendations.
Conclusions:
To maintain the cardiovascular care system, The Japanese Circulation Society recommends completely preventing nosocomial COVID-19 infections, ensuring adequate PPE necessary for healthcare personnel, and learning and implementing standard precautions.
The Japanese Circulation Society is deeply concerned that the cardiovascular medicine system could be overwhelmed because of rapid spread of the coronavirus disease 2019 (COVID-19).1
At many locations vast amounts of medical resources, including healthcare workers, medical equipment, and personal protective equipment (PPE) (Table 1), have already been allocated to treat COVID-19 patients. Consequently, medical resources are being depleted, and maintaining the cardiovascular medicine system has become increasingly challenging. More specifically, in addition to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive or suspected patients, we must presume COVID-19 infection when treating emergency patients in COVID-19 hotspots. Moreover, we must pay careful attention to the physical and mental burden placed on physicians and medical staff who provide COVID-19-related care.
Table 1.
Personal Protection Equipment for Each Procedure
| • Pre-examination triage, outpatient department (not suspected/not probable SARS-CoV-2 patient) |
| • SARS-CoV-2 negative in-patient |
| Disposable surgical cap, Disposable surgical mask, Work uniform, and Latex gloves |
| • All suspected/probable or confirmed SARS-CoV-2 patients should wear a disposable surgical mask |
| • Outpatient department (suspected/probable or confirmed SARS-CoV-2 patients) |
| • Isolation ward and intensive care unit areas |
| • Nasopharyngeal swab |
| • Non-respiratory specimen examination of suspected/probable or confirmed SARS-CoV-2 patients |
• Percutaneous invasive procedures (coronary angiography, percutaneous coronary intervention, electrophysiology procedures) in
suspected/probable or confirmed SARS-CoV-2 patients |
• Cleaning of surgical or diagnosis instruments (TTE/TEE transducers, stethoscopes) used in suspected/probable or confirmed SARS-CoV-2
patients |
| Disposable surgical cap, Medical protection mask (N95/FFP2), Work uniform, Gown, Disposable surgical gloves, and Goggles |
| • TEE in suspected/probable of confirmed SARS-CoV-2 patients |
• Aerosol-generating procedures: nasopharyngeal swab, endotracheal intubation or other procedures during which the suspected/probable or
confirmed SARS-CoV-2 patients may spray or splash respiratory secretions, body fluids or blood |
Disposable surgical cap, Medical protection mask (FFP3), Work uniform, Gown, Disposable surgical gloves, and Full-face
respiratory protection devices or powered air-purifying respirator, if available |
SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; TEE, transesophageal echocardiography; TTE, transthoracic echocardiography.
Under such circumstances, we face an unprecedented situation in which some cardiovascular disease patients, who would be saved under normal circumstances, might lose their lives.2
Therefore, the Japanese Circulation Society proposes the following recommendations for all healthcare professionals involved in cardiovascular medicine to protect them from infection and ensure that seriously ill patients requiring urgent care will receive proper treatment (Figure).
These recommendations should be considered general principles in view of the circumstances in each region.
Methods
Positive or Suspected COVID-19
This category includes both cases of a patient with a SARS-CoV-2 positive polymerase chain reaction (PCR) test and cases of suspected COVID-19 in patients presenting with clinical findings (Table 2) or who have a history of exposure despite a negative PCR test.
Table 2.
Symptoms Compatible With SARS-CoV-2 Infection
| Fever (>37.2℃, may be intermittent or not be present in some patients) |
| Cough |
| Shortness of breath |
| Sore throat |
| Anosmia and/or ageusia (loss of smell and/or taste) |
| Muscle aches |
| Nausea and/or vomiting |
| Diarrhea |
| Abdominal pain |
| Headache |
| Runny nose |
| Fatigue |
“All others” are cases that do not fit the criteria for positive or suspected SARS-CoV-2. This includes all cases of patients who have no clinical findings related to SARS-CoV-2 or a negative PCR test, or the PCR test results have not been reported. Even with a negative PCR test, patients can later test positive for SARS-CoV-2, and if emergency treatment is required, these patients are not defined as SARS-CoV-2 negative because SARS-CoV-2 negativity is impossible to prove.
Emergency Invasive Cardiac Procedures and Treatments
Medically obvious invasive cardiac procedures and treatments for which the prognosis will clearly change if not performed as quickly as possible.
Standby Invasive Cardiac Procedures and Treatments
Invasive cardiac procedures and treatments that do not fit the definition of emergency.
Results
Emergency Invasive Cardiac Procedures and Treatments
For both patients with “Positive or suspected COVID-19” and “All other cases”, given that standard precautions to fully protect physicians and medical staff from infection have been learned and implemented, emergency invasive cardiac procedures and treatments will be performed only in cases of medically necessary urgent procedures based on a total assessment of the medical necessity at the time of the emergency, the medical risks to the patient, the physicians, and medical staff if a nosocomial outbreak of COVID-19 occurs, the medical risks of postponing the invasive cardiac procedures and treatments, and the treatment conditions and medical resources that can be allocated, and after considering the maximum number of options for postponement.
For patients with positive or suspected COVID-19, institute the following.
1. Use dedicated private rooms, catheter rooms, etc., for COVID-19 positive patients whenever possible. Furthermore, use negative pressure rooms whenever possible.
2. Restrict the number of physicians and medical staff who enter the room to the minimum needed for each type of procedure.
3. All physicians and medical staff attending invasive cardiac procedures and treatments must learn and implement standard precautions, and must wear N95 masks if aerosol countermeasures are required.
4. Surgical masks must be worn by patients.
5. If there is a chance of aerosol release, all attending staff must wear N95 masks. N95 masks must be tested for fit and checked for seal in advance.
6. Whenever possible, aerosol-releasing procedures will be performed in a dedicated private room or negative pressure room.
7. If tracheal intubation is performed, the tube will be connected immediately to a closed-circuit ventilator with a high efficacy particulate air (HEPA) filter whenever possible. It should be verified in advance whether a closed-circuit ventilator is available or not.
8. In principle, non-invasive positive pressure ventilation (NPPV) and high-flow nasal cannula oxygen therapy (HFNC) will not be used.
9. In emergency circulatory testing and treatments, emergency tracheal intubation and/or cardiopulmonary resuscitation due to a sudden event may be needed, so consider performing a tracheal intubation in advance more proactively than usual.
For all other cases.
1. Emergency invasive cardiac procedures and treatments will be performed after standard precautions have been learnt and implemented to fully protect physicians and medical staff from infection.
2. N95 masks must be used whenever possible to counter aerosol infection.
Standard Precautions
This term refers to both contact infection and airborne/droplet infection precautions. More specifically, this refers to use of PPE such as a surgical mask with an eye shield, or a combination of surgical mask and goggles/eye shield/face guard, and wearing caps, gowns, and gloves.
Aerosol Infection Precautions
Because of concerns about possible infection from aerosols, measures to prevent aerosol infection are required if there is a chance that a large volume of aerosol will be released. Situations that can produce aerosols include: tracheal intubation/extubation, NPPV, HFNC, tracheostomy, cardiopulmonary resuscitation, manual ventilation, transesophageal echocardiography, bronchoscopy, nebulizer therapy, sputum induction, and esophageal thermometer insertion.
Standby Invasive Cardiac Procedures and Treatments
In principle, invasive cardiac procedures and treatments will be put on standby for both “Positive or suspected COVID-19” and “All other” cases.
1. For positive or suspected COVID-19 cases, standby invasive cardiac procedures and treatments that have been postponed will be performed when improvement has been confirmed by clinical findings/blood tests and imaging findings, or when the patient has had 2 consecutive negative PCR tests 48 h after improvement of symptoms, and it has been confirmed by telephone, etc. that there have been no clinical symptoms of COVID-19 for at least 2 weeks after discharge.
2. Based on the number of COVID-19 patients and future estimates for the region, in addition to resources at each facility (number of acute case beds, infectious disease beds, and ICU beds; medical staff; medical equipment such as ventilators; PPE, etc.), management will ensure the safety and health of physicians, medical staff, and the community, and decide when and how to implement the standby invasive cardiac procedures and treatments that have been postponed.
3. In principle, postponing tests and procedures (cardiopulmonary exercise test, transesophageal echocardiography, insertion of esophageal thermometer, etc.) that may cause COVID-19 aerosol infection from droplet formation is preferred, but if it is determined from a specialist standpoint that there is great medical necessity, precautions against infection must be taken before performing tests and procedures.
4. For patients undergoing arrhythmia treatment that can be monitored remotely (such as a pacemaker), routine outpatient examinations (for pacemaker outpatients, etc.) will be postponed as long as the patient’s condition remains stable.
5. Telephone or online consultations should be considered for patients with stable conditions.
Discussion
To maintain the cardiovascular care system, The Japanese Circulation Society recommends completely preventing nosocomial COVID-19 infections, ensuring adequate PPE necessary for healthcare personnel, and learning and implementing standard precautions.
The Japanese Circulation Society strongly urges cardiologists who are not accustomed to treating infectious diseases to first diligently learn the basics about infectious diseases, and then take positive action to avoid contributing to the spread of a nosocomial COVID-19 infection.
The American College of Cardiology (ACC) Interventional Council and the Society for Cardiovascular Angiography and Interventions (SCAI) have published a joint statement for issues facing catheterization laboratory personnel during COVID-19 pandemic.3
They suggest that case decisions should be individualized, taking into account the risk of COVID-19 exposure vs. the risk of delay in diagnosis or therapy. Moreover, they also recommend, where it seems reasonable, to avoid elective procedures on patients with significant comorbidities or in whom the expected length of stay is >1–2 days (or anticipated to require admission to the ICU). Percutaneous coronary intervention (PCI) for stable ischemic heart disease, endovascular intervention for iliofemoral disease in patients with claudication, and patent foramen ovale closure are recommended to defer. In contrast, in a patient with known COVID-19 and ST-elevated myocardial infarction, the ACC and SCAI suggest that the balance of staff exposure and patient benefit will need to be weighed carefully. In patients with active COVID-19 in whom primary PCI is to be performed, the ACC and SCAI recommend that appropriate PPE should be worn, including gown, gloves, goggles (or shields), and an N95 mask. In addition, it is recommended that patients with COVID-19 or suspected COVID-19 requiring intubation, including out-of-hospital cardiac arrest cases, be intubated prior to arrival at the catheterization laboratory. These recommendations are compatible with our statement.
The highest risk of COVID-19 infection in the field of cardiovascular emergency is endotracheal intubation. Not only full PPE, but also first-attempt success and avoidance of closely intubating are necessary. The use of neuromuscular blocking agent and video laryngoscopy is recommended.4,5
These recommendations are provisional and will be revised periodically. Furthermore, this content will be reviewed as appropriate, depending on the extent of the spread of COVID-19 in Japan, progress in the understanding of its pathology, test methods, and therapeutic agents, and the development of preventive vaccines in the future. In addition, these recommendations cannot be applied uniformly to all medical institutions throughout the nation, and differences may arise depending on the supply and stockpiling of medical resources, and on the local medical situation.
These recommendations were prepared by the COVID-19 Task Force Mission Team of the Japanese Circulation Society, and approved by the Emergency Council of the Directors of the Japanese Circulation Society.
Acknowledgments
We appreciate the special assistance from Taro Inaba and Tomohiro Ogura, as well as the office staff of the Japanese Circulation Society, in support of the COVID-19 Task Force Mission Team of the Japanese Circulation Society.
Disclosures
I.K., K.N. are members of
Circulation Journal
’ Editorial Team. The other authors report no potential conflicts of interest.
Supplementary Files
Please find supplementary file(s);
http://dx.doi.org/10.1253/circj.CJ-20-0518
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