Coronavirus disease 2019 (COVID-19) has caused significant reallocation of resources focusing on public awareness, social distancing, and the burden of the disease and health care costs. During the peak of the COVID-19 pandemic in the United States—specifically, March through June of 2020 and again in late 2020—the number of COVID-19 cases has increased tremendously. Due to the severity of the illness, health care systems were forced to focus on critical care management. Besides the decrease in the number of patients presenting to the hospital with heart disease, cardiology fellows were dispatched to cover critical care units and COVID-19 units to relieve their colleagues. Similarly, the number of patients presenting to the catheterization laboratory for elective procedures has decreased tremendously.

In an attempt to study the decrease of catheterization laboratory procedures, we surveyed multiple catheterization laboratories in the United States. There was a 46% decrease in the number of patients presenting to the catheterization laboratory for elective procedures.¹ The same reduction in number has been noted at the national and international levels due to the concern of patients coming to the hospital for elective procedures and possibly getting infected.² Furthermore, the number of patients presenting with acute coronary syndrome (ACS) was decreased for a variety of reasons. Multiple hypotheses were suggested to explain the decrease in catheterization laboratory volume, including patients being afraid of coming to the hospital and getting infected and local stay-at-home orders leading to lack of activity and triggering cardiac symptoms or decreased awareness of heart symptoms. Indeed, patients might have been sedentary to the level of not doing any physical activity, which could potentially trigger cardiac symptoms. Furthermore, media and public awareness campaigns focused mainly on interventions to stop the spread of the virus in public aside from the stay-at-home orders, including social distancing and mask wearing. This led to less attention to heart disease symptom awareness, which could have caused patients to ignore serious symptoms.^2,3 There are multiple reports of patients presenting late with ACS because they did not recognize their symptoms as cardiac symptoms or how serious these were. In addition, many patients have been afraid of getting COVID-19 by coming to the hospital.^3,4 These factors led to a decrease in "typical" ACS cases; at the same time, ACS cases complicated with mechanical complications rose to levels that have not been seen for many decades.⁴

During the previous academic year, interventional cardiology fellows were concerned that they would not get their Accreditation Council for Graduate Medical Education requirements in percutaneous coronary interventions due to the decrease in the elective and emergent cases in the catheterization laboratory. Luckily, many of the programs in the United States were able to graduate their fellows with their requirements because the decrease was mainly in the last quarter of the year. However, fellows' education was not the same because the journal club, didactic lectures, and film reviews were minimized or canceled. Similarly, the majority of the cardiology meetings in 2020, such as those from the American College of Cardiology, American Heart Association, Society of Cardiovascular Angiography and Interventions, Transcatheter Cardiovascular Therapeutics, and the European Society of Cardiology, were offered only as  virtual experiences. Furthermore, courses that focus on interventional cardiology fellows were canceled, which means that fellows were deprived of great educational activities.

To fill the gap in these educational activities and exercises, there was a tremendous investment from the American College of Cardiology to offer more online educational materials, webinars, and online courses to keep the interventional fellows engaged and their education uninterrupted. In an effort to illustrate different ways for trainees to continue their education, we put together an article published in Cardiology magazine that focuses on different ways to stay up to date and continue didactic education using online resources such as webinars, YouTube channels, social media, and medical podcasts.

Aside from medical and clinical education, interventional cardiology fellows had difficulty searching for and finding jobs that fit their clinical interests. The majority of fellows were interviewed virtually, which allowed them to meet with their future practice or hospital partners but not visit or tour the practice, hospital, and the catheterization laboratory.

The COVID-19 pandemic also created challenges for early career cardiologists who started practice in 2020. Launching a career in cardiology was challenged with a lack of patients showing up to the clinic, limited face-to-face visits to referring physicians, obstacles to getting grants accepted, and cancellation of opportunities to present at national and international meetings. To overcome these challenges, early career interventionalists should focus on utilizing digital platforms to promote the practice, collaborate with other centers on registries and databases, and learn new techniques from providers at different institutions. Indeed, there was increased utilization of webinars and video conferences to share best practices, have case-based discussions, and showcase recently published articles hosted by experts in the field of cardiology.

In recent months, the number of both coronary and structural heart interventions has been slowly coming back to what it was before the COVID-19 pandemic. This could be explained by the creation of a more structured way of screening patients coming to the hospital for elective procedures and those coming from the emergency department for cardiac procedures. Furthermore, catheterization laboratory staff are more familiar with the personal protective equipment for patients who are suspected of or positive for COVID-19 infection.

Going forward, the impact of COVID-19 on catheterization laboratory procedures will be lessened by greater attempts to avoid deferring cases based on urgency, which should help maintain appropriate patient care and training volume. However, there is no doubt that at least over the next year, utilizing all the resources noted above will remain necessary to maximize trainee education. Likely there will be an enhanced need for practice and career mentoring to cover existing training deficiencies.

References

1. Kadavath S, Mohan J, Ashraf S, et al. Cardiac Catheterization Laboratory Volume Changes During COVID-19-Findings from a Cardiovascular Fellows Consortium. Am J Cardiol 2020;130:168-9.
2. Ashraf S, Ilyas S, Alraies MC. Acute coronary syndrome in the time of the COVID-19 pandemic. Eur Heart J 2020;41:2089-91.
3. Ullah W, Sattar Y, Saeed R, et al. As the COVID-19 pandemic drags on, where have all the STEMIs gone? Int J Cardiol Heart Vasc 2020;29:100550.
4. Pilato E, Pinna GB, Parisi V, Manzo R, Comentale G. Mechanical complications of myocardial infarction during COVID-19 pandemic: An Italian single-centre experience. Heart Lung 2020;49:779-82.

Clinical Topics: Acute Coronary Syndromes, COVID-19 Hub, Diabetes and Cardiometabolic Disease, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging, Exercise

Keywords: COVID-19, Laboratories, American Heart Association, Coronavirus, severe acute respiratory syndrome coronavirus 2, Acute Coronary Syndrome, Personal Protective Equipment, Exercise, Registries, Accreditation, Health Care Costs, Percutaneous Coronary Intervention, Percutaneous Coronary Intervention, Critical Care, Catheterization, Hospitals, Delivery of Health Care, Emergency Service, Hospital, Coronary Angiography, Angiography

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