The following are key points to remember from the European Association of Percutaneous Cardiovascular Interventions (EAPCI) Position Statement on Invasive Management of Acute Coronary Syndromes (ACS) during the coronavirus disease 2019 (COVID-19) pandemic:

1. This position statement aims to assist cardiologists in the invasive management of ACS patients in the context of the COVID-19 pandemic.
2. Myocardial injury, as quantified by cardiac troponin T/I concentrations, may occur in COVID-19 infections as in other pneumonias. The level of cardiac troponins correlates with disease severity and also seems to have a prognostic value.
3. Mild elevations in cardiac troponin T/I (e.g., <2–3 times the upper limit of normal [ULN]), particularly in an older patient with pre-existing cardiac disease, do not require workup for type 1 myocardial infarction (MI), unless strongly suggestive clinically by angina chest pain and/or electrocardiographic (ECG) changes. Such mild elevations are in general well explained by pre-existing cardiac disease and/or the acute injury/stress related to COVID-19 infection.
4. Marked elevations in cardiac troponin T/I concentrations (e.g., >5 times the ULN) may indicate the presence of severe respiratory failure, tachycardia, systemic hypoxemia, shock as part of COVID-19, myocarditis, Takotsubo syndrome, or type 1 MI triggered by COVID-19. If no symptoms or ECG changes are suggestive of type 1 MI, echocardiography should be considered to help diagnose the underlying cause. It is essential to differentiate type 1 MI from other causes of troponin elevation and/or ST changes without a coronary etiology.
5. ST-segment elevation MI (STEMI) and high-risk non-STEMI (NSTEMI) have to be managed as COVID-19 positive, and dedicated entry points in the emergency department as well as in the hospital pathway need to be organized. In addition, hospital pathways should be redesigned in order to allocate patients according to their admission symptoms and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test result in COVID-19 and non-COVID wards and intensive care unit according to their clinical presentation and stability.
6. Primary PCI is first-line therapy for STEMI if it can be performed in a timely fashion—120 minutes from symptom onset. Fibrinolysis if not contraindicated can be considered when the delay is longer.
7. Very high-risk NSTE-ACS should be managed similarly to STEMI. High-risk NSTE-ACS should be tested before coronary angiography. Intermediate-risk NSTE-ACS could be evaluated noninvasively, if feasible, with coronary computed tomography angiography (CCTA). Consider adding CCTA protocol to thorax CT scan performed in COVID-19 patients.
8. Clinical outcome in cardiogenic shock (CS) is even worse in COVID-19 patients (30–40% vs. 45–50% survival). STEMI patients in CS should be transferred and further managed in expert centers, which may offer different choices of mechanical circulatory support (MCS). Intra-aortic balloon pump (IABP) may be an option in hemodynamically depressed COVID-19 patients presenting with STEMI and mechanical complications if other MCS not available. Veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) support is considered the device of choice in COVID-19 patients with hemodynamic and respiratory failure. Impella (or IABP) may be used to manage left ventricular overdistension in patients receiving VA ECMO.
9. In regions with moderate and heavy involvement in the pandemic, the STEMI network has to be reorganized. ACS should be directed to COVID-19 hospitals with 24/7 cath lab facilities.
10. It is recommended to dedicate at least one cath lab for the invasive treatment of suspected or confirmed COVID-19 patients. Furthermore, it is crucial to establish clear pathways for COVID-19 patients in the cath lab at each intervention center. Only health care workers (HCWs) involved in the procedure should remain inside the cath lab; cath lab doors should be kept closed at all times. A surgical mask for the patients, and complete personal protective equipment (PPE) for HCWs involved in the cath lab intervention is indicated. Finally, all HCWs have to be routinely trained in the correct use of PPE (donning and doffing).

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, COVID-19 Hub, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Stable Ischemic Heart Disease, Vascular Medicine, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and SIHD, Acute Heart Failure, Mechanical Circulatory Support, Interventions and ACS, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Echocardiography/Ultrasound, Nuclear Imaging, Chronic Angina

Keywords: Acute Coronary Syndrome, Cardiac Catheterization, Cardiology Interventions, Coronary Angiography, Coronavirus, COVID-19, Echocardiography, Electrocardiography, Extracorporeal Membrane Oxygenation, Fibrinolysis, Intra-Aortic Balloon Pumping, Myocardial Infarction, Myocarditis, Percutaneous Coronary Intervention, Personal Protective Equipment, SARS Virus, Secondary Prevention, Shock, Cardiogenic, ST Elevation Myocardial Infarction, Takotsubo Cardiomyopathy, Troponin

< Back to Listings