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 principles of this document are to maintain essential interventional cardiovascular care while minimizing risks of COVID-19 to patients/staff and maintaining the overall healthcare resources. As the COVID-19 pandemic evolves, procedures will be increased or reduced based on the current level of restriction to health care services.
While 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.
The world is currently in the midst of the global COVID-19 pandemic, which has rapidly resulted in significant morbidity and mortality 1,2 . 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. While some consistency across the country is desirable, provincial and regional considerations will influence how these recommendations are implemented. In collaboration with all 11 Affiliates, CCS 3 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 manuscript, 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 Table 1 Given the unavoidable interaction of these individual recommendations, the order doesn't necessarily reflect priority ranking. Relative prioritization will vary over time and in different regions as the crisis evolves.
The principles above 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 small, or evidence uncertain, alternate 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 Table 1 . 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 in order to mitigate the risk of transmission to both Health Care Workers (HCW) 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. positivity, and if available in the future, rapid COVID-19 testing should be strongly encouraged so that patients can receive appropriate care and by-pass the emergency department; 6) The goal of rapid but safe discharge with teleconference or telephone follow-up should be promoted to facilitate maximizing the use of bed capacity and avoid hospital exposure.
In summary, we believe the above framework and the recommendations in Table 1 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. Complete inability to provide PPCI. All patients will be treated with Thrombolysis as per regional protocols.
• Patients with low probability of COVID-19 -Continue as per usual regional practice.
• Patients with moderate/High probability or COVID-19 +ve -Consider an invasive approach with Aerosol Level PPE and N95 mask if age OR comorbidities do not preclude a reasonable likelihood of meaningful survival.
• Most patients now considered Moderate/High probability or COVID-19 +ve -Consider an invasive approach with Aerosol Level PPE and N95 mask if age OR comorbidities do not preclude a reasonable likelihood of meaningful survival.
Medical management of all cardiogenic shock cases.
Out of Hospital Cardiac Arrest (OHCA)
• Patients with low probability of COVID-19 -Continue as per usual regional practice.
• Patients with moderate/High probability or 