Hong Kong Med J 2021 Apr;27(2):152–3 | Epub 7 Apr 2021
© Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
COMMENTARY
Managing acute myocardial infarction in patients
with COVID-19 at a cardiac catheterisation laboratory
Alan KC Chan, MB, BS, FHKAM (Medicine)1; CF Tsang, MB, ChB, FHKAM (Medicine)1; SF Chui, MB, ChB, FHKAM (Medicine)1; Eric CY Wong, MB, BS, FHKAM (Medicine)1; SY Au, MB, BS, FHKAM (Medicine)2; George WY Ng, MB, BS, FHKAM (Medicine)2; KT Chan, MB, BS, FRCP1; Michael KY Lee, MB, BS, FRCP1
1 Department of Medicine, Queen Elizabeth Hospital, Hong Kong
2 Intensive Care Unit, Queen Elizabeth Hospital, Hong Kong
Corresponding author: Dr Alan KC Chan (chkmkckk@gmail.com)
![](https://www.hkmj.org/sites/default/files/mjimage/pdficon.png)
Coronavirus disease 2019 and
cardiovascular disease
Patients with cardiovascular disease who develop
coronavirus disease 2019 (COVID-19) have a
higher risk of mortality. They can develop various
cardiovascular complications during their course
of disease including acute myocardial infarction,
myocarditis mimicking ST elevation myocardial
infarction (STEMI), stress cardiomyopathy, coronary
spasm, or myocardial injury.1 Patients presenting
with STEMI pose a substantial dilemma to healthcare
providers in the COVID-19 era. Patients with STEMI
typically require emergency reperfusion therapy
which include primary percutaneous coronary
intervention (PPCI) in the cardiac catheterisation
laboratory (CCL) or thrombolytic therapy. The
former approach is the preferred strategy according
to latest clinical evidence.2 3 After STEMI is
diagnosed, PPCI must be performed quickly, and
COVID-19 status might not be available. Some
patients who present with cardiogenic shock shortly
after STEMI or failed thrombolysis may also require
emergency revascularisation in CCL. Most CCL
facilities in Hong Kong are not equipped with
negative pressure ventilation systems and may share
common ventilation with the control room next door
where healthcare providers are working. Various
international cardiology professional societies have
issued recommendations on treating this group of
patients. The Chinese Society of Cardiology, for example, recommends a conservative
approach including thrombolytic therapy and
guideline-directed medical therapies for patients
with STEMI unless clinically unstable4; in contrast,
the American College of Cardiology recommends the
PPCI approach where possible.5
There have been advances in treating patients
with cardiogenic shock using invasive mechanical
circulatory support devices.6 Furthermore, during
the severe acute respiratory syndrome outbreak in 2003, doctors in Hong Kong described their
approach to treating patients with the CCL
using full personal protective equipment and
portable machines to simulate a negative pressure
environment.7 More recently, the American College
of Cardiology’s Interventional Council and Society
for Cardiovascular Angiography and Interventions
have described CCL preparation during the
COVID-19 pandemic.8
Change in practice
In our unit, PPCI is offered to all patients with STEMI
unless contra-indicated. It remains the standard of
practice in our referring hospital for eligible patients
with STEMI during COVID-19 period unless they
have signs or symptoms suggestive of COVID-19,
including fever, abnormal lung infiltrates, or contact
history. For patients with suspected COVID-19,
thrombolytic therapy is given, and earlier PPCI
arranged only after COVID-19 has been ruled out.
Good preparation of the medical team and
the patients is the key to success in providing timely
invasive cardiac interventions, while minimising
the chance of in-hospital transmission of the
virus. Patients presenting with STEMI are usually
in an unstable condition with high possibility
of deterioration resulting from heart failure or
malignant arrhythmia. These patients may also
develop desaturation requiring intubation or
ventricular arrhythmia requiring defibrillation in
the CCL during PPCI. Patients with COVID-19
with borderline respiratory function receive
early intubation in the isolation area first; and
invasive mechanical circulatory support devices
are initiated early for patients with high risk of
haemodynamic collapse that may otherwise require
cardiopulmonary resuscitation in the CCL. The
CCL environment has been checked by the hospital
engineering team, who confirmed that the CCL
procedural room does not share the same ventilation system with the control room or other CCL areas
that would otherwise contaminate the environment
and risk infecting unprotected medical staff. In one
designated CCL procedural room in our hospital,
two high-efficiency particulate air filters were
installed and the ventilation system was upgraded
in order to provide temporary negative pressure
environment when needed and to achieve more
than 12 air changes per hour. This designated CCL
procedural room was left with essential equipment
only to avoid contamination of other consumable
items. Fixed equipment, such as the X-ray machine
and cabinets were adequately covered before
procedures. As training and preparation, the
cardiac and anaesthetic teams simulated the PPCI
of an unstable patient with COVID-19 in the CCL
who required intubation and cardiopulmonary
resuscitation. In order to limit the number of
personnel involved, two interventional cardiologists
and one CCL nurse perform the PPCI procedure.
All personnel in the CCL wear lead aprons and full
personal protective equipment—N95 respirator,
cap, face shield, gown, surgical gloves, and boots—in
accordance with local infection control guidelines.
Immediate showering after procedures in a sanitary
area of the CCL was provided. The designated CCL
room had terminal cleaning after the procedure. The
logistics of transferring the critically ill patient with
COVID-19 was discussed and organised with staff
from the intensive care unit in advance, to minimise
emergent aerosol-generating procedures in the
CCL.
Experience and conclusions
We have performed three coronary angiograms,
two percutaneous coronary interventions, and
one endomyocardial biopsy for three patients with
confirmed COVID-19. All three patients were
in critical condition and required mechanical
ventilatory support. One patient required
venoarterial extracorporeal membrane oxygenation
for circulatory support for fulminant cardiogenic
shock.
Our approach may provide useful
information to other hospitals providing emergency
interventional cardiology service for patients with
suspected or confirmed COVID-19. Teamwork and
close communication between cardiologists and
intensive care unit specialists are essential before
performing invasive cardiac procedures in the CCL.
Author contributions
All authors contributed to the concept or design of the study,
acquisition of the data, analysis or interpretation of the
data, drafting of the manuscript, and critical revision of the
manuscript for important intellectual content. All authors
had full access to the data, contributed to the study, approved
the final version for publication, and take responsibility for its
accuracy and integrity.
Conflicts of interest
The authors have no conflicts of interest to disclose.
Funding/support
This commentary received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
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