BACK

RESOURCES

In The News

In The News

Impact of the COVID-19 Pandemic on Emergency Department Visits — United States, January 1, 2019–May 30, 2020

Centers For Disease Control and Prevention

Morbidity and Mortality Weekly Report

Impact of the COVID-19 Pandemic on Emergency Department Visits — United States, January 1, 2019–May 30, 2020

Hartnett KP, Kite-Powell A, DeVies J, Coletta MA, Boehmer TK, Adjemian J, Gundlapalli AV, National Syndromic Surveillance Program Community of Practice Morbidity and Mortality Weekly Report Early Release / Vol. 69 June 3, 2020.

Key Points:

  • Early in the COVID – 19 Pandemic, California in the USA along with Hong Kong, Autria and Italy noted significant drops in Emergency Department (ED) visits.
  • To assess the impact of COVID – 19 on US ED visits the CDC compared ED visits in the early Pandemic period in the USA for 4 weeks (March 29-April 25, 2020) to the comparable time period in 2019 (March 31-April 27).
  • ED visits were 42% less for the 2020-time frame compared to 2019 (Figure 1).
  • The largest decreases were for children under age 14, females and geographically in the Northeast (Figure 2).
  • It is difficult to directly assess the impact on cardiac events but the weekly mean visits for non-specific chest pain declined nationally by 24,258 visits, while weekly ED visits for cardiac arrest and ventricular fibrillation increased by 472, the most extreme ED visit adverse consequence that could be defined.
  • The CDC emphasizes that telemedicine screening is ideal for many lower risk conditions but emphasizes the importance of continually educating patients on the importance of seeking immediate ED evaluation for potentially cardiac events.
  • Health Care Providers and Hospitals are important sources of such information as has been reported here previously via the SCAI Every Second Still Counts information site and a joint Op Ed piece by the ACC and SCAI emphasizing this point.
VIEW

In The News

Mechanical Circulatory Support in COVID-19: When to Consider, What to Expect?

Soltesz E, Surgical Director of Cleveland of the Kaufman Center for Heart Failure and Recovery, from a recent Tall Rounds online CME activity from Cleveland Clinic covering COVID-19 and the heart published online In Consult QD.

Link

 

 

Key Points:

This summary describes the uses and potential limitations of Extracorporeal membrane oxygenation (ECMO) as well as other mechanical Circulatory (MCS) Devices.

  • Circulatory support in COVID – 19 patients is likely most effective for single organ system disease such as acute respiratory distress syndrome (ARDS) and/or cardiogenic shock.
  • Limitations involve patients with cytokine-mediated myocardial dysfunction plus severe respiratory failure, who despite support have a limited prognosis.
  • VV-ECMO and ARDS. (Extracorporeal Life Support Organization – ELSO).
    • Notes:
  • Contraindications include: older age, mechanical ventilations >7days; multiorgan failure.
  • VV-ECMO Oxygen indications focus on the ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2:FiO2)
  • VV ECMO indicated if PaO2:FiO2 ≥ 150 mmHg and
    • pH < 7.25 with PaCO2 ≥ 60 mmHg for > 6 hours.
  • For those with PaO2:FiO2 < 150 mmHg and
    • PaO2:FiO2 < 80 mmHg for > 6 hours  
    • PaO2:FiO2 < 50 mmHg for > 3 hours
    • pH < 7.25 with PaCO2 >60 mmHg for > 6 hours.
  • Challenges to VV-ECMO include:
    • Prolonged ECMO support requires – up to 3 weeks due to slow lung healing.
    • Systemic inflammation producing a prothrombotic state requiring large heparin and/or bivalirudin dosages.
    • Potential ECMO induced advancement of of COVID – 19 to other organ systems.
  • Hemodynamic Support for the Management of Cardiogenic Shock
    • Optimal for left ventricular failure from a viral myocarditis – as an isolated organ problem.
  • Goals of Support
    • To provide adequate tissue perfusion (To break the shock spiral)
    • Unload the injured ventricle serving as a bridge to recovery, transplant or a permanent device.
  • Potential Devices:
    • Veno-arterial ECMO (VA-ECMO)
  • Advantages – can be implanted at bedside and provides full, biventricular support
  • Disadvantages – Lack of ventricular unloading adversely effecting left ventricular recovery (LV) while increasing risk of lung injury, risk of aortic/LV thrombosis as well as hemolysis. Lastly, it is unable to uncouple the left and right ventricles challenging the ability to predict next requirements. Ambulation generally not possible.
    • Impella
  • Advantages – Completely unloads the LV, protecting the lungs. Long term support is possible beyond one month with the larger devices. In addition, it has a low rate of hemolysis Ambulation is feasible with axillary cannulation (often surgical).
  • Disadvantages – Surgical implantation requires surgery and transesophageal echocardiogram for placement which possibly increases increased risk to personnel.
    • Temporary right-ventricular assist devices (RVADs)
  • Device types – ProtekDuo/TandemHeart, CentriMag and Impella RP
  • An oxygenator can be spliced in to provide an oxy-RVAD configuration.
  • Specific management:
    • Combined devices – Frequently beneficial – VA ECMO with combined Impella for unloading.
    • Heart Team Decisions critical
  • Summary
    • In appropriately selected patients, particularly with COVID – 19, these devices can be lifesaving.

 

VIEW

In The News

The New Pandemic Threat: People May Die Because They’re Not Calling 911 There has been a dramatic decrease in Myocardial Infarction presentations worldwide during the current COVID – 19 Pandemic.

Key Points:

  • There has been a dramatic decrease in Myocardial Infarction presentations worldwide during the current COVID – 19 Pandemic.
  • Multiple reasons for the reduction in infarctions have been postulated but a worrisome and likely significant one is that patients don’t seek care promptly, if at all for symptoms of a heart attack.
  • This “New Pandemic Treat” Statement is signed by multiple organizations and is directed to patients – emphasizing the importance of immediately seeking treatment for important heart attack and stroke symptoms.
  • Perhaps as physicians are communicating with patients remotely, healthcare professionals might consider downloading and distributing this statement to their patients to combat an important, “indirect” COVID – 19 risk!
  • Pass this statement on – its an inexpensive but important “Vaccine” – A 911 Call.
VIEW

In The News

CMS Recommendations Re-opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare: Phase I

On April 17, CMS announced a plan to begin allowing the elective procedures resume. Below is a brief summary of the requirements.

  • States or Regions must meet “Gating Criteria”
    • A lowering trend in flu-like illnesses, COVID – 19 Cases/or positive test numbers percentages during a 14 day period.
    • An effective COVID – 19 testing program for potentially exposed healthcare workers.
  • Reopening Facilities will require.
    • Testing equipment.
    • Appropriate numbers of workforce for the care of patients.
    • Sufficient PPE.
    • Being prepared for a potential surge in COVID – 19 Cases.
  • Optimal strategy is to have hospitals establish COVID Free Units (“non-COVID Care (NCC) zones”)
    • Staff only work in these areas (No cross rounding between COVID – 19 Patients or units and NCC area.
    • Such units will require strict screening for patients before entry and for staff.
    • Screening emphasizes clinical assessment for recent symptoms and fever.
VIEW

In The News

Coagulopathy Associated with COVID-19

An international panel provides guidance on prognostic variables and management strategies for COVID-19–associated coagulopathy

VIEW

In The News

An Interview With an Italian Intensivist on the COVID Experience in Italy – American College of Cardiology

Key Points:

 

 

  • Reaffirms primary presentation is respiratory
  • Cardiovascular Involvement is definite; often myocarditis, but concerns of excluding traditional infarction induced by high inflammatory markers.
  • Use of Hemodynamic support is used selectively, often with V-V ECMO for oxygenation but other considerations include conversion to V-A ECMO with considerations for Impella unloading (ECPella)
  • Challenges in managing cardiogenic shock include limitation of Right Heart Catheterization and the challenges of potentially placing an Impella in the ICU. (See Posted article on A-Cure sight Pappalardo description of ICU Impella Insertion.)
  • Deciding on Resource utilization generally targets patients based on blood pressure levels, pressors required and Left Ventricular Ejection Fraction.
VIEW

In The News

A Heart Attack? No, It Was the Coronavirus.

New York Times 3/29/2020

Cardiologists are seeing infected patients whose worst symptoms are not respiratory, but cardiac.

VIEW