Cardiologists from across Europe have shared their experience of having treated COVID-19 patients, in a series of videos produced by the European Society of Cardiology (ESC), part of a suite of resources provided by the society to aid physicians in coping during the pandemic.
Topics covered in the video series include cardiac complications in COVID-19, diagnostic imaging, acute coronary syndromes, clinical presentation of respiratory failure and cardiac care in the COVID-19 pandemic. Additionally, the Society has also sought to underline messaging around treating non-COVID-19 patients with cardiovascular disease during this time.
Introducing the series Barbara Casadei (John Radcliffe Hospital, Oxford, UK) recorded a video address in which she also sought to reinforce two important messages on the outbreak. She said: “We at the ESC have tried to put together some short practical podcasts for you, coming directly from the regions with the greatest experience in this disease.”
And, turning to her two key messages, she added: “Do not forget the needs of patients with cardiovascular disease. Even now, there will be more people dying of cardiovascular disease than COVID-19. In fact, patients with cardiovascular disease will be more likely to die of COVID-19.”
Casadei said that it needs to be clear that the message not to attend hospitals “does not apply to patients with STEMI [ST-elevation myocardial infarction] or other acute syndromes”.
The second message conveyed by Casadei was to “think outside the hospital”, and support the enforcement of strict lockdown measures to prevent the spread of the disease. “We must engage both inside, and outside our workplace,” she said. “We must alert our patients and the public that they need to come into the hospital if they have chest pain—we have to be able to offer a rapid and safe triage for these patients.”
Maddalena Lettino, (San Gerardo Hospital, Monza, Italy), offered some learnings on cardiac care in the COVID-19 outbreak from Italy, which has been the among the worst affected nations worldwide.
Echoing Casadei’s point about cardiovascular patients avoiding hospital treatment during the pandemic, she noted that there had seemed to be a drop in the number of cardiologic patients being treated once COVID-19 infections began to steadily increase, or cardiovascular patients were presenting much later, and potentially with more acute complications.
“Most patients arriving at hospitals are those with infectious disease. Probably cardiologic patients remain at home, waiting at home until they have much more severe symptoms to go to the hospital. The number of beds dedicated to COVID-19 patients are definitely many more than the number of beds dedicated to cardiologic patients.”
Lettino highlighted that the worst complication of COVID-19 is pneumonia with acute respiratory failure. She added that, so far, there have not been a large number of cardiovascular complications, and that these are usually the “last effect of the initial infections.”
She said: “Still, we are seeing that patients with pre-existing cardiovascular disease, or sometimes patients having some of the main risk factors for cardiovascular disease have the highest mortality.”
Presenting on the topic of diagnostic imaging, covering chest X-ray and computed tomography (CT) scanning, Stephan Achenbach (University of Erlangen, Erlangen, Germany) and Antoine Khalil (Hôpitaux de Paris, Paris, France) discussed the typical changes in chest X-rays in COVID-19 pneumonia, the extent of imaging changes and whether they correlate to the clinical course and the potential for early diagnosis of COVID-19 through CT scans.
Offering some comments on when it is appropriate to carry out a chest X-ray or a CT scan in assessing a COVID-19 patient, Khalil offered his view that a CT scan is a favourable option for assessing COVID-19 patients, but said that this cannot be used in every case. Khalil noted that this can depend on the availability of a CT scanner, and the risk to the patient posed by transfer to the CT scanner.
“Chest CT-scan is better than chest X-ray,” he commented. “In an outbreak situation, especially with an infectious disease, my preference goes to preserving the technicians and our personnel. We do what is better for one shot. Not a chest X-ray, find that it is not good, and then a CT scan.” This strategy is necessary, he posited, for reducing the risk of infection to key staff.
Achenbach also chaired a discussion with Jose Luis Zamorano Gomez (University Complutense, Madrid, Spain) looking at the presentation of respiratory failure in COVID-19. During the discussion, Achenbach question Zamorano Gomez on the parameters that may predict rapid deterioration in patients. Gomez highlighted oxygen saturation as a useful predictor of patient condition.
“There is nothing really reliable,” Zamorano Gomez said. “But there is no doubt that older people, people with comorbidities are at extremely high risk. We should consider that X-ray does not really correlate well with the symptoms and with the status of the patient.”
He added: “Those patients may deteriorate rapidly, but really you need to closely monitor the oxygen saturation level. This is something that you can immediately see, a drop off in the saturation and then you need to transfer those patients to the ICU.”
In a further video in the series, Susanna Price (Royal Brompton Hospital, London, UK) offered tips on preparing a cath lab for handling acute coronary syndromes in COVID-19. Price highlighted the importance of ensuring staff are adequately supplied with protective personal equipment (PPE) and training in correct application and removal of PPE to limit the risk of infection, as well as the need for strong cross-departmental working to ensure adequate resources are available.
Price commented: “Consider where you are as a structure and a network, that is critical care networks, cardiology networks, PCI networks, ambulance networks. You may need to form new alliances, and you may need to redistribute work. You will need friends, right across the network.”