Precautions and Procedures for Coronary and Structural Cardiac Interventions During the COVID-19 Pandemic: Guidance from Canadian Association of Interventional Cardiology

The globe is currently in the midst of a COVID-19 pandemic, resulting in significant morbidity and mortality. This pandemic has placed considerable stress on health care resources and providers. This document from the Canadian Association of Interventional Cardiology-Association Canadienne de Cardiologie d'intervention, specifically addresses the implications for the care of patients in the cardiac catheterization laboratory (CCL) in Canada during the COVID-19 pandemic. The key Canadian Journal of Cardiology 36 (2020) 780e783
The world is currently in the midst of the global COVID-19 pandemic, which has rapidly resulted in significant morbidity and mortality. [bib_ref] A novel coronavirus emerging in China: key questions for impact assessment, Munster [/bib_ref] [bib_ref] A novel coronavirus from patients with pneumonia in China, Zhu [/bib_ref] This pandemic has placed considerable stress on health care resources and providers.
Acknowledging the strain on the entire health care system, this document specifically addresses the implications for the care of patients in the cardiac catheterization laboratory (CCL). Cardiovascular disease encompasses a spectrum of clinical conditions associated with significant morbidity and mortality. As long as the capacity of the Canadian health care system allows, clinicians and policy makers must attempt to maintain essential coronary and structural interventional procedures while minimizing additional burdens on hospital and system resources during the COVID-19 pandemic. The operational challenges are evolving rapidly; therefore, this guidance must be interpreted with flexibility and pragmatism. Although some consistency across the country is desirable, provincial and regional considerations will influence how these recommendations are implemented. In collaboration with all 11 affiliates, Canadian Cardiovascular Society (CCS),and Canadian Association of Interventional Cardiology-Association Canadienne de Cardiologie d'intervention (CAIC-ACCI: https:// caic-acci.org) have already issued guidance for inpatient and ambulatory cardiovascular care in Canada. In this paper, we provide guidance on the management of coronary and structural procedures in the CCL as the COVID-19 pandemic escalates and eventually abates.
The executive, in collaboration with key subspecialty and general cardiologists from across Canada, embraced the following objectives when creating the [fig_ref] Table 1: CAIC-ACCI guidance for the management of coronary and structural procedures as COVID-19... [/fig_ref]. The objectives reflect the core ethical principles of public health ethics: respect, the harm principle, fairness, consistency, least coercive and restrictive means, working together, reciprocity, proportionality, preservation of resources, flexibility, and procedural justice (as indicated in parentheses):
Limit cardiac use of overall system capacity, especially with inpatient/intensive care unit beds (working together, proportionality). Minimize risk to health care workers (reciprocity, care provider safety, and sustainability). Maximize preservation of personal protective equipment (preservation of resources). Maximize compliance with social and health care distancing (the harm principle). Minimize the incremental risk of patients acquiring COVID-19 related to cardiac investigations or procedures (the harm principle, proportionality). Maintain essential interventional cardiology service to patients at high risk of cardiovascular events in the short term (preservation of resources). Minimize adverse outcomes for cardiovascular patients during the COVID-19 pandemic (the harm principle). Ensure decisions are made in a consistent manner (procedural justice, accountability, reasonableness). Ensure that decisions are communicated in a transparent and sensitive manner (respect and transparency).
Given the unavoidable interaction of these individual recommendations, the order does not necessarily reflect priority ranking. Relative prioritization will vary over time and in different regions, as the crisis evolves.
These principles are predicated on balancing anticipated benefits and risks for individual patients while also considering societal needs during this crisis. A reduction in CCL activity is inevitable, at least over the short term and possibly longer; criteria are therefore based on identifying groups of patients most likely to benefit from a specific intervention or, conversely, most likely to suffer harm without such an intervention. In situations for which the treatment effect is smalldor evidence uncertaindalternate approaches that place less burden on hospital resources may be used, even if these deviate from the usual pattern of care.
The recommendations are outlined in the [fig_ref] Table 1: CAIC-ACCI guidance for the management of coronary and structural procedures as COVID-19... [/fig_ref]. As the COVID-19 pandemic evolves, procedures will be increased or reduced, based on the current level of restriction to health care services. Recommendations also vary based on the likelihood of COVID-19 in the population to mitigate the risk of transmission to both health care workers and patients. CAIC-ACCI acknowledges that this document is predominantly based on consensus agreement. This approach reflects the considerable challenge of making practice recommendations in the face of a rapidly evolving global pandemic, with limited scientific evidence to guide clinical practice. The unknown duration of the crisis mandates timely review of these recommendations. Postponement, rather than cancellation, may be appropriate for many procedures; however, lengthy delays (several months) could have a significant negative impact on morbidity and mortality, even for patients facing relatively low short-term risk.
A few important additional considerations: (1) We encourage all Canadian research teams to track cardiovascular outcomes carefully in the coming months and focus on key research gaps recently identified. [bib_ref] COVID-19: towards controlling of a pandemic, Bedford [/bib_ref] If we document a large increase in potentially avoidable cardiac deaths from unavailable procedures, difficult but necessary discussions about allocation of resources to infection vs emergent cardiovascular procedures will be crucial. (2) Certain cardiac catheterization staff with comorbidities associated with adverse events in the setting of contracting COVID-19 (age > 60 years; patients with diabetes, hypertension, or pre-existing cardiovascular disease) may wish to refrain from procedures with an increased principles of this document are to maintain essential interventional cardiovascular care while minimizing risks of COVID-19 to patients and staff and maintaining the overall health care resources. As the COVID-19 pandemic evolves, procedures will be increased or reduced based on the current level of restriction to health care services. Although some consistency across the country is desirable, provincial and regional considerations will influence how these recommendations are implemented. We believe the framework and recommendations in this document will provide crucial guidance for clinicians and policy makers on the management of coronary and structural procedures in the CCL as the COVID-19 pandemic escalates and eventually abates.
Canada pendant la pand emie de COVID-19. Les recommandations principales de ce document sont de maintenir les soins d'intervention cardiovasculaires essentiels tout en minimisant les risques de COVID-19 pour les patients et le personnel et en maintenant les ressources globales de soins de sant e. A mesure que la pand emie de COVID-19 evolue, les proc edures seront accrues ou r eduites en fonction du niveau r eactualis e de restriction des services de soins de sant e. Bien qu'une certaine coh erence soit souhaitable dans l'ensemble du pays, des consid erations provinciales et r egionales influenceront la maniere dont ces recommandations seront mises en oeuvre. Nous pensons que le cadre et les recommandations de ce document fourniront des orientations cruciales aux cliniciens et aux d ecideurs politiques sur la gestion des proc edures coronaires et structurelles dans le LCC a mesure que la pand emie de COVID-19 s'aggrave et finit par s'att enuer. Complete inability to provide PPCI. All patients will be treated with thrombolysis as per regional protocols.
Cardiogenic shock Patients with low probability of COVID-19: Continue as per usual regional practice. Patients with moderate/high probability or COVID- In summary, we believe this framework, and the recommendations in the [fig_ref] Table 1: CAIC-ACCI guidance for the management of coronary and structural procedures as COVID-19... [/fig_ref] , will provide crucial guidance for clinicians and policy makers on the management of coronary and structural procedures in the CCL as the COVID-19 pandemic escalates and eventually abates.

# Funding sources
Limited inpatient cases that would facilitate hospital discharge
[table] Table 1: CAIC-ACCI guidance for the management of coronary and structural procedures as COVID-19 escalates and abates [/table]