When the extent of the coronavirus threat became clear, it was an obvious imperative to close down elective catheter lab work for all cases except for patients at the highest level of clinical urgency. The effect of this action is illustrated by the national survey reported by Adlan and colleagues.1
Above and beyond the immediate, unarguable imperative to limit elective work, a range of other equally immediate challenges relating to patient care were apparent, and generated strong but divergent opinion within the interventional cardiology community. Firstly, the optimal treatment plan for patients presenting with ST-elevation myocardial infarction (STEMI)… should primary percutaneous coronary intervention (PCI) remain the default strategy, or should it now be to adopt thrombolysis as a default, as recommended by hastily constructed care pathways in other countries which were affected by COVID-19 earlier than the UK? Secondly, what level of personal protective equipment (PPE) should cardiologists and cath lab staff wear for the cases who did make it to the lab? Finally, how should patients admitted to hospital with severe symptomatic aortic stenosis be treated?
In response to the need for guidance and clarity, national consensus statements have been published as a consensus between the British Cardiovascular Society, the British Cardiovascular Intervention Society (BCIS), NHS England/Public Heath England and the Heart Rhythm Society (in the case of the PPE document). The rationale and considerations behind these statements is discussed more fully elsewhere.2 In brief, the guidance for the three contentious areas listed above is summarised as follows.
Firstly, the recommendation was that the default treatment for STEMI in the UK should remain primary PCI, unless circumstances dictated in individual cases that this was not possible to deliver in a timely fashion. I am pleased that this has proved to be a successful choice, given the clear evidence upon which primary PCI has always been based, of better outcome, lower complication rate and shorter hospital stay when compared with thrombolysis.
Secondly, detailed guidance in relation to appropriate PPE has been well received, affording a balance between genuine protection for all catheter lab staff and a degree of choice on an individual case basis.
Finally, the common sense recommendation that the default strategy for aortic stenosis patients who require inpatient treatment should be transcatheter aortic valve implantation (TAVI) rather than surgery, can probably be justified by current randomised trial data in any case (shameless personal interpretation of the data aside!). It is undoubtedly a popular option with those patients and their families. It has facilitated much more rapid treatment and discharge for suitable patients whilst relieving the NHS machine of a demand for access to theatres and intensive care beds.
Adlan and colleagues have reported the degree of the reduction in catheter lab activity.1 They also speculate upon the reduction in patients presenting with myocardial infarction and PCI overall. A detailed national audit of these clinical issues is currently underway thanks to a novel expedited pathway for accessing national database and NHS Digital data engineered by a collaboration between the National Institute for Cardiovascular Outcomes Research (NICOR), NHS England, NHS Digital and several other agencies and societies. The results will be presented in due course, hopefully via expedited ‘COVID’ pathways for publication!
The next imminent, and meaty, question is how the system can safely restart elective cath lab activity. The pressure to care for patients with worsening angina and deteriorating aortic stenosis grows daily… in an environment in which the virus lurks still, engineering the optimal method for treating those patients is the next big challenge. One thing seems likely: that some of the modifications we have made to our previous care pathways have worked so well that they may well threaten our previously ‘established’ thinking and behaviour.
Finally, if there is an up side to what we have witnessed and experienced over the last few weeks, it is the team spirit, the unthinking courage, the willingness to solve problems and compromise, and above all, the unity of purpose to put patient care above everything else, including money. We should never forget that?
The article by Adlan AM et al. can be found here.
Conflicts of interest
1. Adlan AM, Lim VG, Dhillon G et al. Impact of COVID-19 on primary percutaneous coronary intervention centres in the UK. Br J Cardiol 2020;27:49–52 (published online ahead of print). https://doi.org/10.5837/bjc.2020.016
2. Curzen N. An extended statement by the British Cardiovascular Intervention Society President regarding the COVID-19 pandemic. Interv Cardiol 2020;15:e01 (published online 15th April 2020). https://doi.org/10.15420/icr.2020.10