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\begin{document}

\title{Considerations on Cardiac Patients During Covid-19 Outbreak}



\author[1]{Fabiola Sozzi}%
\author[1]{Marta Belmonte}%
\author[1]{Marco Schiavone}%
\author[1]{Francesco Blasi}%
\affil[1]{La Fondazione IRCCS Ospedale Maggiore Policlinico}%


\vspace{-1em}



  
  \date{May 08, 2024}


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\begin{abstract}
SARS-CoV-2 not only causes viral pneumonia but has major implications
for the cardiovascular system. Nevertheless, we assisted to a drastic
reduction in the number of ACS during this period. Telemedicine and
telecardiology, intended as integration to the traditional management
appear precious tools especially in Covid-19 era. Given the decrease in
new Covid-19 cases worldwide20, now we are approaching the so-called
``Phase 2'' challenge of a gradual return to pre-Covid-19 life. The
epidemiological and clinical situation is rapidly evolving and practice
patterns with policies depend on institutions and local availability.%
\end{abstract}%



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\textbf{}

The ongoing coronavirus disease (Covid-19) pandemic have challenged
globalized societies to cope with the adoption of revolutionary health
care measures for the world survival. The severe acute respiratory
syndrome coronavirus-2 (SARS-CoV-2), not only causes viral pneumonia but
also acute myocardial injury and chronic damage to the cardiovascular
system\textsuperscript{1}. In this time, the healthcare of patients with
cardiovascular disease (CVD) needs to be guaranteed, albeit with changes
in the modalities. A network of ``\emph{hub} '' and ``\emph{spoke} ''
centers based on a system of specialized Covid-19 referral hospitals has
been rearranged in order to guarantee optimal medical care to patients
with cardiac emergencies. In Lombardy, Italy (the epicenter of the
European outbreak), the regional network for ST-elevation myocardial
infarction (STEMI) management has been reorganized, reducing by more
than 75\% the number of previous referral centers with 24 hours/7 days a
week capacity to perform a primary percutaneous coronary intervention,
according to local medical and logistic resources, with 13 hospitals
acting as ``hubs'' and other 42 acting as ``spokes''\textsuperscript{2}.
Generally, we have witnessed a drastic reduction of patients referring
non-Covid-19 related symptoms to the Emergency Department. The fear of
contagion has caused a significant drop of improper access to the
hospital facilities. In particular, national and international
registries have reported a significant decrease in the number of
admissions for acute coronary syndromes (ACS). In Northern Italy a
significant decrease in ACS-related hospitalization rates was reported.
Realistically, more and more people with ACS have not sought for medical
attention and have been left untreated, as it is confirmed by the
increase in delayed presentation of the ACS treated in hospital and
their higher mortality. Therefore, an alarming increase in worse
outcomes are expected in the near future.

The problem is furtherly amplified by the uncertain trend of this
pandemic and the not clearly predictable duration of the isolation.
Hence, the limited mobility measures and the weak integration between
hospitals and territorial medicine, especially in high-risk areas,
constitutes an additional issue. The most vulnerable cardiac
Covid-19-free subjects, such as patients with chronic cardiac disorders
(i.e. heart failure), are set away from the hospital facilities. A rapid
reorganization of cardiac services and practical guidance on how to
manage chronic patients are needed in the shortest time. Telemedicine
and telecardiology, integrated to the traditional management, appear to
be precious tools for this emergent medical model, focused on the
interplay of social, economic, environmental and clinical factors. The
flexible use of telematic devices, now available for teleconsultation
and/or remote monitoring, allows the creation of integrated and
personalized management programs, that are effective and efficient for
patients. Indeed, in order to minimize risks of in-hospital SARS-CoV-2
spreading, telemedicine should be adopted whenever possible, especially
for frail and older patients. Telemedicine is crucial in handling this
viral outbreak containment, preventing patient health from deteriorating
because of mistreated CVD while coping with the high infectious
risks\textsuperscript{3}. Also, telerehabilitation should be considered
as an option for patients discharged from hospitals after an ischemic
event and healthcare providers should be aware of the potential for
innovative program delivery models.

Both European and American Societies have shown to be up to the
challenge, providing statements and recommendations on how to manage
cardiac patients in this critical period\textsuperscript{4,5}, and, more
importantly, encouraging the rapid sharing of clinical experience and
knowledge through any available sources (e.g. webinars, free on-line
access to mostly all medical resources). One of the most burning issues
has been the appropriate use of cardiovascular imaging in diagnosis and
management of both Covid-19 and non-Covid-19 patients. It has become
widely accepted that traditional cardiovascular risk factors,
particularly older age, previous CVD, diabetes, and hypertension
increase significantly the risk of mortality in Covid-19
patients\textsuperscript{1}. Therefore, indications and recommended
procedures to assess cardiovascular function in suspected or confirmed
Covid-19 cases needed to be standardized. The shared principles at the
base of cardiovascular imaging has been the appropriateness of
indication and the selection of the exam that is most likely to
substantially change patient management, with the shortest duration and
the safest for healthcare providers. Transthoracic echocardiography
could be very useful in this setting, since it allows a bedside cardiac
and respiratory assessment and remote interpretive assistance if needed,
but unfortunately requires close contact to the patient. Therefore,
Focused Cardiac Ultrasound Study (FoCUS), Ultrasound Assisted Physical
Examination (UAPE) and Point Of Care Cardiac Ultrasound (POCUS) are
recommending, according to American Society of Echocardiography, to
reduce the duration of exposure and to limit the use of additional
resources. Special attention has been dedicated to personal protective
equipment, which should be adequate to the risk level of the patient
with regard to Covid-19 (low/minimal: not suspected; moderate:
suspected; high: confirmed), evaluated before the exam. Therefore,
careful planning and review of medical history of the patient are
crucial to obtain diagnostic views but should also be comprehensive
enough to avoid the need to return for additional images. Because of the
high risk of aerosolization, transesophageal echocardiography should be
replaced by alternative imaging modalities whenever possible. Computed
tomography (CT) has gained attention, not only for its crucial role in
confirming Covid-19 pneumonia, but also for the possible synergies and
opportunities in evaluating cardiac morphology. Coronary CT has been
shown to be accurate in the evaluation of both chronic and ACS, and thus
can non-invasively provide information to solve doubtful situations,
e.g. unexplained elevation of cardiac troponins, that is frequently
encountered in Covid-19 patients. Cardiac magnetic resonance (CMR)
should be provided for urgent care to patients who have no known active
Covid-19. When necessary, performing CMR on patients with confirmed or
suspected SARS-CoV-2 infections should focus on the specific clinical
question with an emphasis on myocardial function and tissue
characterization while optimizing patients and staff safety. At this
time CMR have had marginal role so far, due to long duration of exams
and the limited availability. Nevertheless, in patients with confirmed
SARS-CoV-2 infections and underlying CVD or developing ischemic or
inflammatory injury, indications for CMR may arise. Being the gold
standard for evaluation of cardiac function and tissue characterization,
CMR may offer an effective choice to obtain critical information for
clinical decision-making. If cardiovascular imaging in Covid-19 patients
could be challenging, the management of non-Covid patients may be even
more complicated. Both American and European Societies of Cardiology
recommend the deferral or even the cancellation of elective non-urgent
and routine follow-up visits, encouraging the use of telemedicine, in
order to avoid SARS-CoV-2 spreading and to protect healthcare workers.
However, the triage of patients with CVD is seldom black or white: many
patients could overlook signs and symptoms of clinical worsening when
reporting to physicians. Moreover, SARS-CoV-2 infections share symptoms,
like shortness of breath, fatigue, weakness and sometimes chest pain,
which are in common with ACS, pulmonary embolism and acute heart
failure.

\textbf{CONCLUSIONS}

SARS-CoV-2 has major implications for the cardiovascular system. Given
the decrease in new Covid-19 cases worldwide, now we are approaching the
so-called ``Phase 2'' challenge of a gradual return to pre-Covid-19
life. The epidemiological and clinical situation is rapidly evolving and
practice patterns with policies depend on institutions and local
availability. We expect a continue and progressive update of the
recommendations, which serve as general framework in cardiac patients.

\textbf{REFERENCES}

1. Guo T, Fan Y, Chen M, et al. Cardiovascular implications of fatal
outcomes of patients with coronavirus disease 2019 (COVID-19).\emph{JAMA
Cardiol} . 2020. doi:10.1001/jamacardio.2020.1017

2. Stefanini GG, Azzolini E, Condorelli G. Critical organizational
issues for cardiologists in the COVID-19 outbreak: A frontline
experience from Milan, Italy. \emph{Circulation} . 2020.
doi:10.1161/circulationaha.120.047070

3. Hollander JE, Carr BG. Virtually perfect? Telemedicine for
Covid-19.\emph{N Engl J Med} . 2020. doi:10.1056/NEJMp2003539

4. ESC guidance for the diagnosis and management of CV disease during
the COVID-19 pandemic.
https://www.escardio.org/Education/COVID-19-and-Cardiology/ESC-COVID-19-Guidance

5. ASE Statement on COVID-19.
https://www.asecho.org/ase-statement-covid-19/

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