Ischaemic heart disease

4 changes you should make in cardiology services: lessons from Italian cardiologists

Cardiologists in Italy hit hardest by the COVID-19 pandemic have offered four key lessons on how to reorganise services to cope with the disruption to clinical care and the risks of infection with coronavirus.

Based on their experience of 28,761 confirmed cases of COVID-19 and 3,776 deaths, cardiologists in the Lombardy Regional Health Service are urging clinicians in other areas to think about issues such as the prioritisation of highest urgency patients and redeployment of cardiologists into new teams.

Writing in Circulation, Dr Giulio Stefanini and colleagues from Humanitas University, Milan, say cardiologists must foster close collaboration with other specialists involved in the management of COVID-19 patients and also develop cooperative arrangements with other  hospitals to centralise services such as catheter labs to treat cardiovascular diseases.

At the same time, cardiologists must adapt to a situation where elective surgery is cancelled and patients are triaged for access to the limited services that can be provided during the pandemic crisis.

Their four main lessons are:

1. Prioritise unstable patients with cardiovascular disorders

With most elective procedures postponed, the cardiologists had to prioritise which patients with chronic coronary syndromes should undergo coronary angiography. They used risk stratification based on symptoms, evidence of a large area of ischaemia, and the presence of known critical disease of the left main stem or of the proximal left anterior descending coronary artery at prior coronary angiogram. They also prioritised patients with decompensated, symptomatic, severe aortic stenosis scheduled for TAVR.

2. Reorganise clinical teams for cardiologists

Outpatient clinics were closed and cardiology ward/ICU beds were drastically reduced and limited to cardiovascular emergency cases. Cardiologists were reorganised into two teams; one taking care of cardiovascular emergencies and another focusing on the management of cardiovascular comorbidities and myocardial involvement (elevated cardiac biomarkers and impairment of LVEF) in critical COVID-19 patients. The latter team needed close and constant collaboration with infectious disease experts, pulmonologists, and intensive care specialists.

3. Centralise services to maintain timely access for acute MI/stroke patients

To maintain timely access for patients with acute MI or stroke while minimising infection risk, reperfusion services were reorganised in a hub and spoke model. For example, the region’s 55 catheter labs serving 129 hospitals were reorganised to concentrate most patients in 13 labs providing 24/7 services on a geographical access basis.

4. Ensure safety of healthcare professionals

Cardiologists found that some patients undergoing procedures such as coronary angiography subsequently tested positive for COVID-19. They therefore stress the importance of thorough training of staff in appropriate use of PPE. They also implemented protocols that assumed all patients with acute MI as potentially COVID-19-positive.

The cardiologists conclude that reorganisation of cardiology clinical activities can help limit the diffusion of SARS-CoV-2 infection while maintaining standard-of-care for the treatment of cardiovascular diseases.

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