Expert Consensus on Operating Procedures at Chest Pain Centers in China during the Coronavirus Infectious Disease-19 Epidemic

Abstract

In December 2019, an outbreak of novel coronavirus infectious disease (COVID-19)[1] occurred in the city of Wuhan, Hubei Province, China, sparking a grim epidemic. On January 20, 2020, the National Health Commission (NHC) of the People's Republic of China issued a decree (2020 Decree No. 1) that the disease be categorized as Class B infectious diseases as specified in the Law of the People's Republic of China on Prevention and Treatment of Infectious Diseases and be managed as for Class A infectious diseases. Consequently, many regions in China have activated Level I major public health emergency response, and some areas have implemented local traffic control. More than 4000 Chest Pain Centers across China, with regional collaborative rescue as its core mission, are facing new challenges and confusion in actual work. To further standardize and enhance the effectiveness of treatment for patients with acute chest pain and minimize the risk of spread of the COVID-19 epidemic, and fully protect medical staff and patients and their family members, the Chest Pain Committee of the Chinese Medical Doctor Association, Chinese College of Cardiovascular Physicians, China Chest Pain Centers Alliance, Executive Committee of China Chest Pain Centers, China Cardiovascular Health Alliance, and Headquarter of Chest Pain Centers have enlisted the help of Chest Pain Center construction experts across China to timely develop the current consensus. The aim is to provide working guidance during the COVID-19 epidemic for frontline healthcare professionals at Chest Pain Centers across China. The recommendations in the current consensus are only applicable to the unique period of COVID-19 epidemic and are mainly aimed at the patients with both of acute chest pain and suspected/confirmed COVID-19, including patients who do not meet the NHC diagnostic criteria for suspected COVID-19[2,3] but in whom COVID-19 currently cannot be completely ruled out. Acute chest pain patients in whom COVID-19 has been explicitly excluded are managed according to the Chest Pain Center routine protocols. Once the COVID-19 epidemic has come to an end, Chest Pain Centers shall return to their routine protocols.[4,5] The current consensus puts forward the general operating principles of Chest Pain Centers in accordance with the country's COVID-19 prevention and control requirements. Due to regional variations in the severity of the COVID-19 epidemic and control measures and regional disparities in medical resources, the adjustment should be made by each region or hospital on the basis of the current consensus according to local conditions so that region and hospital-compatible workflow procedures and exquisite rules for the implementation may be developed. Algorithm for Diagnosis and Treatment of Patients Triage Each hospital should rearrange its prescreening triage station and fever clinic during the COVID-19 epidemic, according to the NHC requirements for COVID-19 prevention and control.[2,3] The prescreening triage station should be separate from the Chest Pain Center triage station. The former should be set up at the entrance of the emergency department (ED), and persons who have not undergone prescreening triage are prohibited from entering the outpatient department and ED. All ED patients and outpatients are required to undergo temperature check and complete an epidemiological survey. The prescreening triage personnel should take Level II or above infectious disease protection measures. An epidemiological survey can be waived in severely infected areas.[2] Chest pain patients with suspected COVID-19 should be first seen at the fever clinic. The fever clinic should be equipped with an electrocardiogram (ECG) machine, particular for the suspected COVID-19 patients if capable. In hospitals without such capabilities, ECG should be conducted by relevant personnel using Level II or above infectious disease protection measures. Chest pain patients in whom COVID-19 has been ruled out by prescreening transfer to the Chest Pain Center triage station to undergo routine procedures. Suspected cases of COVID-19 should be managed according to the Diagnostic and Therapeutic Protocols for Novel Coronavirus Pneumonia (NCP) (Trial Version 5) issued by the NHC of the People’ Republic of China.[2] Chest pain patients with suspected coronavirus infectious disease-19 Patients should be first evaluated for the stability of vital signs. When the vital signs are unstable, the cause of instability should be investigated whether it may be mainly caused by NCP or by chest pain diseases. If the unstable vital signs are due to NCP, the patients are immediately triaged to an isolation ward in the fever clinic for treatment and reported to the public health authorities. When the unstable vital signs are caused by chest pain diseases, the patients should receive immediate rescues in the isolation zone in ED to maintain the stability of vital signs. Hospital staff should take Level II or above infectious disease protection measures and should use Level III infectious disease protection measures during invasive procedures [Figure 1].Figure 1:: The triage algorithm during the coronavirus infectious disease-19 epidemicThe mean latency period of COVID-19 is 3 days (range: 0-24 days). The general population is susceptible to the disease. Some patients show atypical manifestations, and a sizable proportion of patients may present without fever. Moreover, infected persons may remain asymptomatic and become a source of transmission. Therefore, Level II or above infectious disease protection standards [Appendix 1][6] should be applied for physicians and nurses delivering medical care at ED.[3] Currently, given the lengthy wait for and a relatively high false-negative rate of COVID-19 nucleic acid test results, it is recommended to perform routine chest computed tomography (CT) scans and routine blood tests for patients with chest pain accompanied with fever and/or respiratory symptoms. If time and conditions permit, patients may undergo tests for high-sensitivity C-reactive protein, erythrocyte sedimentation rate, procalcitonin, and respiratory viruses detection.[2,3] In areas where COVID-19 infection remains prevalent, all hemodynamically stable chest pain patients should undergo a chest CT scan to investigate NCP. Patients in Hubei province should receive a clinical diagnosis of NCP if abnormalities, especially imaging features suggestive of COVID-19 infectious, are demonstrated on a chest CT scan.[2] Such patients in other areas should be placed under the isolation ward for the observation or be transferred to a local COVID-19-designated hospital and undergo nucleic acid testing as soon as possible. Currently, our understanding of COVID-19 is somewhat limited. A proportion of critically ill patients may have concurrent viral pneumonia and fulminant myocarditis with clinical manifestations mimicking acute coronary syndrome (ACS). Such patients, once the diagnosis is established, should be treated according to “the 2017 Chinese Society of Cardiology Expert Consensus Statement on the diagnosis and treatment of adult fulminant myocarditis.”[7] Therefore, great attention should be paid to suspected cases of COVID-19 with chest pain. To provide essential support for the diagnosis and treatment of these patients, each Chest Pain Center should establish a diagnosis and treatment coordination and collaboration system involving ED, fever clinic, and departments of infection control, cardiovascular department, respiratory medicine, the office of medical administration, and other related departments. Algorithm for ST-segment elevation acute myocardial infarction therapy If COVID-19 is explicitly excluded, patients with confirmed ST-segment elevation acute myocardial infarction (STEMI) should be treated routinely according to the Chest Pain Center protocol;[4,5] however, if patients are initially seen at a non-percutaneous coronary intervention (PCI)-capable hospital, intravenous thrombolytic therapy (third-generation fibrinolytic agents as the first choice) should be the therapeutic choice,[8] and patient transfer should be avoided. Regardless whether at standard or grassroots Chest Pain Centers, once STEMI is diagnosed in suspected/confirmed COVID-19 cases, in principle, the patients should receive thrombolytic therapy, if the onset of chest pain is within 12 h. Thrombolytic therapy can be undertaken either in ED or in fever clinic depending on the condition of the hospital but should be in the isolated ward with Level II and preferably Level III infectious disease protection. Patients with successful thrombolysis continue to be observed in the isolation ward and are transferred to the cardiovascular department for elective coronary angiography if COVID-19 is subsequently ruled out and to a COVID-19-designated hospital for further therapy if COVID-19 is confirmed. Patients who have failed to or are contraindicated for thrombolytic therapy should undergo further evaluation for the balance of urgent PCI benefit to the risk shared by both medical staff and patients (risk of infection for physicians and nurses and interventional procedure risk for patients). If the risk outweighs the benefit, or the patient or his family does not agree with the surgery, although the benefit of the PCI results is significant, or the patient's onset time exceeds 12 hours, and the hemodynamic stability is stable, the patient should be transferred to an isolation ward for conservative treatment and investigation of COVID-19. If the benefit is significantly higher than the risk and the patient and family agree to the procedure, then emergency PCI is performed [Figure 2]. For patients who have more than 12 hours of onset but still have symptoms of chest pain or hemodynamic instability, emergency PCI may also be considered after balancing the benefits and risks.Figure 2:: Reperfusion strategy for ST-segment elevation acute myocardial infarction patients with confirmed/suspected coronavirus infectious disease-19Algorithm for therapy of confirmed/suspected coronavirus infectious disease patients with non-ST-segment elevation acute coronary syndrome In principle, during the epidemic of COVID-19, all confirmed non-ST-segment elevation ACS (NSTE-ACS) patients are recommended to receive mainly pharmacotherapy at hospitals they are initially seen and undergo investigation for COVID-19. Patients who have failed pharmacotherapy should be transferred to a local urgent PCI-capable and COVID-19-designated hospital for the treatment. Patients receiving adequate pharmacotherapy are stratified for ischemia and bleeding risks, according to the NSTE-ACS diagnosis and treatment guidelines.[9] Patients who are not at very high risk for ischemia or who are at very high risk for both ischemia and bleeding are recommended to undergo conservative therapy in the isolation ward, with the treatment advice by a cardiologist. If the benefit of urgent PCI is expected to outweigh the overall risk for medical staff and patients who are at very high risk for ischemia but not at high risk for bleeding, urgent PCI is recommended and should be conducted in isolation-capable cardiac catheterization laboratory that meets infection control requirements. Patients, if confirmed with COVID-19 post-PCI, receive further treatment in the isolation ward in a COVID-19-designated hospital or are transferred to the coronary care unit (CCU) if COVID-19 is ruled out [Figure 3].Figure 3:: Algorithm for diagnosis and treatment of confirmed/suspected coronavirus infectious disease-19 patients with non-ST-segment elevation acute coronary syndromeAlgorithm for urgent percutaneous coronary intervention of acute coronary syndrome patients suspected of coronavirus infectious disease-19 It is rather challenging to prevent and control COVID-19 due to its high infectivity and our current lack of complete understanding of its intermediate host (s) and modes of transmission. Therefore, great caution should be exercised when deciding to proceed with urgent PCI for ACS patients suspected of COVID-19, with full consideration of the benefit of urgent PCI and risk for medical staff and patients. Once a decision to proceed with urgent PCI is made, the key is, apart from adherence to a routine of urgent PCI protocols, effective implementation of infection control measures [Figure 4].Figure 4:: The flowchart for urgent percutaneous coronary intervention for suspected coronavirus infectious disease-19 casesPreoperative preparations Preparations at emergency department/fever clinic Staff at ED/fever clinic should make sure that patients and family members wear face masks and cap (in principle, only one family member is allowed as a caregiver). Patients with mild hypoxemia should wear a face mask based on nasal cannula oxygen therapy. The faces of intubated mechanically ventilated patients should be covered with disposable impermeable sterile drapes to prevent contamination by nasal or oral secretions. To avoid nonessential on-site consultation, cardiologists are invited for teleconsultation, and on-site consultation, if necessary, should be conducted with Level II infectious disease protection measures. The cardiac catheterization laboratory is activated upon the receipt of informed consent, and preoperative instructions are provided. The physician overseeing the initial visit by a patient is responsible for reporting the case to the appropriate authorities according to infection control requirements,[3] and the Infection Control Department is asked to provide guidance on infection control. Staff at the ED/fever clinic assist the execution of preoperative instructions and preparation of patient transfer. Physicians at ED/fever clinic complete blood chemistries related to the diagnosis of COVID-19 and ACS (blood routine test, liver and kidney function, rapid C-reactive protein, and myocardial biomarkers). All suspected COVID-19 patients should undergo an emergency chest CT scan, and medical staff should take Level II or above infectious disease protection measures. A nasopharyngeal swab is performed if the condition of the patient allows, and the staff performing the task should take Level III infectious disease protection measures. The patient is transferred to the cardiac catheterization laboratory upon of a chest CT Preparations at cardiac catheterization laboratory PCI for COVID-19 patients should be conducted at a cardiac catheterization laboratory to avoid On receiving the staff at the cardiac catheterization the cardiac catheterization laboratory and all and on both of the for patients and in the cardiac catheterization laboratory and on the if and the sterile are to the and control on the angiography and other in the operating is with the disposable sterile Medical come with sterile are and of to be for the interventional procedures are are not and of the The of staff in the procedure should be and the operating staff one interventional one one and one in the control The should Level III infectious disease protection and in principle, the interventional and should also Level III infectious disease protection measures. Level III infectious disease protection measures may are recommended to measures based on their conditions that take consideration infection control, and the for For the infection control may be with the full use of the to relatively the patient from the or by the isolation of the or the In an may be to minimize the of measures on the of the The or is in the perform and then wear a face and isolation on and wear or face mask and perform wear a disposable the if is not and wear transfer The should be during the patient transfer from the ED/fever clinic to the cardiac catheterization the patient should wear a face mask and a during transfer. personnel should use Level II or above infectious disease protection measures and should not during the transfer. members are not allowed to the cardiac catheterization laboratory and should in the the procedure, a informed should be and with patient family members should be The transfer should be undertaken in a if a The should be immediately by the after the patient is out of the the and should be The patient is transferred to the operating by medical staff Level II or above infectious disease protection measures on at the cardiac catheterization and oxygen is the nasal The face mask is not from the patient and the if the patient is is covered with an impermeable sterile the for procedure is coronary intervention from adherence to the and requirements for urgent the should be procedures should be undertaken and to avoid contamination by blood and or from other should be by other personnel for use and should not be from the operating who have come with patients should not other areas the of the personnel should not be allowed in the control and the operating the control and the operating should be and if necessary, should be the operating if a has come with from the return to the control is The should and new return to the control coronary intervention and In to routine the should be The interventional personnel should the and transfer the patient by Level II or above infectious disease protection measures to a separate isolation ward for further treatment and investigation of COVID-19. The patient is transferred to the ward for further treatment if COVID-19 is ruled out and to a COVID-19-designated hospital for treatment if COVID-19 is confirmed. The and the are first in the operating by rapid the is by The or face is by and of and of the and the are of in the medical the interventional personnel the zone and the and face the cardiac catheterization the interventional personnel take a and of the cardiac catheterization laboratory and the The operating the control and the transfer are first with for All should be if the of and blood or areas are with and after The of the and are with a is the and after the is the in the The disposable is in the medical and and are in and with in a of for and after the is in the medical are and with by is out. It should be that in the after with high may cause and should be to of and reporting COVID-19 cases should be reported to the public health authorities a The procedure should be with or by the and the time and the should be in according to the for case The urgent percutaneous coronary intervention and the cardiac catheterization laboratory A urgent PCI should be for the cases at hospitals with such PCI should be undertaken for all suspected/confirmed COVID-19 patients by Level III infectious disease protection measures. Medical staff who are to infection risk during the period should be placed under according to the epidemic prevention Once COVID-19 is confirmed in the medical staff in the urgent PCI are recommended to undergo for if develop during the they should be reported to the public health authorities and PCI-capable COVID-19-designated hospitals are recommended to set up a COVID-19-designated cardiac catheterization if the condition allows, for and protection. Algorithm for the of acute patients The workflow for the of remains to that of as should be confirmed by CT angiography and transfer of patients with suspected/confirmed COVID-19 should be undertaken under Level II or above infectious disease is the decision is made after consideration of the stability of vital signs and clinical manifestations, of the of isolation operating and whether the hospital is a COVID-19-designated hospital [Figure If hospitals in CT and can be the Chest Pain Center regional collaborative rescue Algorithm for diagnosis and treatment of patients during the coronavirus infectious disease-19 for the of acute patients For acute the is that patients should complete diagnosis and treatment at hospital where they are initially Thrombolytic therapy can be for under the guidance by Therefore, the transfer should not be made in patients who are contraindicated for thrombolytic therapy can be managed by to the algorithm for urgent PCI for and interventional therapy can be conducted under prevention and protection. Treatment of Chest Pain Patients Medical the latency period of COVID-19 is up to more than it is challenging to whether a with chest pain has COVID-19 or not by a of Medical Center the emergency Therefore, during the COVID-19 epidemic, the protection of the staff on with the task of emergency care should be In the COVID-19 infected all personnel are recommended to take Level II or above infectious disease protection measures for should wear face masks upon initial with patients and family A isolation should be on the if the condition and disposable and for diagnosis and treatment should be during patient if possible. The face and that have come with the patient during are as and should be treated according to the infection control requirements. The should be and after each and other from the patient during the may be if the is with disposable as and in and should be if the is with or or with disposable In the as a are first to and is the at is a patient with acute onset of chest pain a to the emergency the physician in the apart from the of chest should the COVID-19 symptoms and epidemiological of the ECG is on-site or on the if and then immediately to the Chest Pain The routine of Chest Pain Center should be if COVID-19 is completely ruled out Patients with suspected COVID-19 are at the fever clinic. If the diagnosis of COVID-19 remains based on clinical manifestations, patients are at the ED [Figure In the COVID-19 infected patients are to a COVID-19-designated hospital with a Chest Pain Center for further investigation without The flowchart for emergency care during the coronavirus infectious disease-19 the patient is within the time as as the physician is in thrombolytic therapy and the prevention and protection condition is thrombolytic therapy can be conducted in patients with STEMI by initial ECG on the and confirmed by The patient is to the ED/fever clinic for further treatment after thrombolytic therapy based on whether COVID-19 can be ruled out according to the the Chest Pain Patients Chest Pain Centers regional coordination and that patients with acute chest pain are in the time to a for therapy. during the COVID-19 epidemic, the infectious disease prevention and control is given and the the regional collaborative rescue of Chest Pain Centers should be fully so that the patients with acute chest pain are diagnosed and receive therapy based on the In principle, local treatment is and transfer is to COVID-19 Patients are only to other medical when the patients have initially seen a lack of diagnostic and treatment The rules for to other hospitals are Chest Pain Centers, after diagnosis and treatment of chest pain patients according to the triage may with hospitals for patients who have demonstrated for urgent transfer to including STEMI patients who have failed or are contraindicated for thrombolytic therapy, very NSTE-ACS patients who remain unstable conservative therapy, and patients urgent interventional therapy or patients. Chest Pain routine procedures for are after COVID-19 are explicitly ruled out. Medical staff responsible for chest pain patients with suspected/confirmed COVID-19 should take Level II or above infectious disease protection measures during and Level III protection measures should be undertaken if If the diagnosis of COVID-19 remains or cannot be ruled patients with acute chest pain diagnosis remains and who transfer to hospitals for diagnosis should be transferred under infection control measures as for suspected COVID-19 cases to the ED/fever clinic of an urgent interventional COVID-19-designated hospital for further without the of the ED. and of transfer and and should be at based on their actual conditions and transfer the of CT in COVID-19 infected patients, Chest Pain Centers with such are recommended to set up a separate CT for suspected COVID-19 and personnel who are in with patients should under Level II or above infectious disease protection. should be conducted after each CT The should be in chest pain patients with suspected COVID-19, especially patients suspected of and acute infection control requirements should not be of on the CT within The requirements for of chest pain patients with suspected COVID-19 are to for in principle, the transfer of suspected COVID-19 patients to the should be and is should by Level II or above infectious disease protection measures. COVID-19 epidemic, time and treatment are recommended under the that the infection control requirements and COVID-19 infection are time should be and should be reported due to infection control or for COVID-19 should be and in the and in the and and the COVID-19 epidemic, and and on cases should be or conducted the It is recommended that each should take full use of and for and that is or due to the epidemic should be and in Chest Pain Center and should be conducted as soon as after the epidemic to an and on should be experts support and of are of

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