7/18/2021 The Role of Critical Care Cardiology During the COVID-19 Pandemic - American College of Cardiology

The Role of Critical Care Cardiology During

the COVID-19 Pandemic
Sep 01, 2020
  |  Prashant Rao, MBBS; Dhruv Kazi, MBBS, MS, FACC; Arthur R Garan, MD,
FACC

Expert Analysis

Quick Takes

Critical care cardiologists may be uniquely positioned to improve the care

for critically ill patients with COVID-19 because of frequent respiratory and
cardiac complications.
In addition to managing acutely ill patients, critical care cardiologists can
help triage patients from community sites, guide expansion of critical care
services to other sites within the hospital, support colleagues without
critical care experience who may be called upon to serve in ICUs, and help
restructure healthcare delivery at the institutional, regional, and national
levels.

Introduction

As of August 3rd 2020, the coronavirus SARS-CoV-2 (severe acute respiratory

syndrome coronavirus type 2), responsible for the disease COVID-19 (coronavirus
disease 2019), had infected more than 18 million people worldwide and caused
nearly 700,000 deaths.1 After an initial wave that predominantly affected the
northeastern United States, there has recently been a resurgence in cases across
many states. The clinical spectrum of COVID-19 is wide, ranging from
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asymptomatic infection and mild upper respiratory tract illness to acute
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respiratory distress syndrome (ARDS), shock, and death. Critically ill patients
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frequently have extra-pulmonary manifestations, including myocardial injury, with
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elevated biomarkers,2 electrocardiographic changes,3 or echocardiographic

abnormalities.4 Herein, we outline the central role for critical care cardiologists
during this pandemic, changes to pre-pandemic practices in the cardiac intensive
care unit (CICU), and the need for change at an institutional, regional, and national
level in response to a surge in CICU COVID-19 patients.

The Genesis of the Cardiac Intensive Care Unit

The inception of the first coronary care unit (CCU) in 1962 by the late Professor
Desmond Julian transformed the care of critically ill cardiac patients.5 Prompt
care, close monitoring, and meticulous follow-up improved cardiovascular
outcomes in critically ill patients, and led to the rapid development of CCUs across
the world. Importantly, the demographics of CCU patients have changed markedly
over the decades; CCU patients are now older, with more co-morbidities such as
renal dysfunction or obstructive lung disease.6 As a result, the importance of
general critical care medicine has been amplified in the CCU to optimally manage
a medically-complex patient population with advanced cardiac pathology. It is
against this background that CICUs have formed and cardiac critical care has
developed as an essential subspecialty with a focus on good critical care practices
in addition to cardiovascular care.

Hospital Level Re-organization to Accommodate Surge in CICU Patients

With progression of the COVID-19 pandemic and a dramatic increase in the

demand for critical care delivery, hospitals have made several changes to
maximize CICU resources. These have included the cancellation of elective cardiac
procedures, particularly those requiring recovery in the CICU, as well as new
guidelines for patient triage to maximize the benefit of critical care delivery in the
CICU and other ICUs. These changes not only act to maximize CICU bed availability
but also CICU personnel including cardiac critical care physicians, nurses, trainees,
and allied health professionals. Katz et al. provide a useful illustration to guide
hospital-level CICU restructuring during different stages of the pandemic.7
According to their report, as hospitals reach >100% capacity, additional
intermediate care and recovery units may be converted to ICUs and the nurse to
patient ratios may reach 1:6 or higher. While it may be necessary to implement
such nurse to patient ratios, other strategies to address this imbalance may be
considered, including rapid training of floor level nurses practicing under the close
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supervision more to improve yourICU
experienced experience.
staff. In addition, rapid testing in the
emergency department has been instrumental in the early identification of COVID-
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19 patients, many of whom have similar OK symptoms to those with acute

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7/18/2021 The Role of Critical Care Cardiology During the COVID-19 Pandemic - American College of Cardiology

cardiovascular disease. This has led to improved CICU workflows and a reduction
in the number of cases requiring isolation in COVID-19 ICUs due to an
undetermined infective status.

Adaptations to Cardiovascular Care Delivery

In order to expand the ability of healthcare systems to provide cardiovascular care

during the pandemic, and particularly to COVID-19 patients, Katz et al. highlight
important changes to the pre-pandemic norms of cardiovascular medicine. For
example, they highlight the use of point-of-care ultrasound as an initial means to
evaluate COVID-19 patients with suspected cardiac pathology. This serves to
provide both rapid diagnostic information to more patients and, to the extent that
it reduces other imaging needs, may reduce the exposure of other healthcare
providers to infection. Another important adaptation that will allow improved
access to cardiovascular care is the expansion of cardiovascular consultation via
inpatient telemedicine. Critical care cardiologists can provide virtual consultative
care to other ICU patients, and access virtual consultative services from other
services. Technology can also be leveraged to provide real-time multi-disciplinary
collaboration without additional exposure risk to patient populations treated in
the CICU (e.g. cardiogenic shock patients evaluated for mechanical circulatory
support [MCS] by the "Shock team") or to providers.

Inter-institution Collaboration

Patients with acute severe cardiac disease including complex STEMI, cardiogenic
shock, acute aortopathies, and massive pulmonary embolism are typically
managed at tertiary or quaternary centers. While the 'hub-and-spoke' model has
efficiently streamlined critical care resources and healthcare delivery, the
pandemic has put 'hub' hospitals at risk, as they are increasingly overwhelmed
with critically ill patients. As a result, when 'hub' hospitals operate at >100%
capacity, it may become difficult to proceed with inter-hospital transfers. Critical
care cardiologists serve an important role in triaging patients for transfer,
prioritizing those most likely to benefit from tertiary or quaternary center care, as
well as providing remote guidance to physicians caring for patients in community
hospitals. In order to continue the 'hub-and-spoke' model and help maximize CICU
capacity, hospital networks will need to make a concerted effort to repatriate
convalescing patients back into community hospitals to make CICU beds at the
tertiary and quaternary centers available for other patients.
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Equitable Resource Allocation

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In the early phases of the pandemic there were serious concerns regarding the
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7/18/2021 The Role of Critical Care Cardiology During the COVID-19 Pandemic - American College of Cardiology

availability of life-saving ventilators in hard-hit areas such as New York City.

During this period, critical care physicians faced serious ethical dilemmas relating
to the allocation of life-saving resources. Katz et al. highlighted the need to apply
standardized protocols when considering resource-intensive but potentially
lifesaving procedures, such as mechanical ventilation.7 This framework may be
based on illness acuity, likelihood of survival to discharge and possibility of long-
term survival. In addition to ventilator allocation, critical care cardiologists will
likely encounter discussions regarding candidacy for MCS. Venoarterial (VA) or
venovenous (VV) extra-corporeal membrane oxygenation (ECMO) in particular may
be useful to treat critically ill COVID-19 patients with severe cardiopulmonary
deterioration. However, questions often arise as to whether withholding or
withdrawing these potentially life-sustaining treatments is appropriate.

These therapies are perhaps the most resource intensive of those considered for
COVID-19 patients and should not be used in futile circumstances to simply
prolong the dying process. They require carefully delineated institutional
guidelines for candidacy, prioritizing those with a high likelihood of survival.
Medical ethicists, palliative care specialists, as well as critical care cardiologists
should all engage in shared decision making with the patient or the patient's
caregivers. This multi-disciplinary care team provides important and additional
support to the critical care cardiologist when considering transition from
aggressive care to comfort-focused measures for critically ill patients. In addition
to embracing other specialties to help guide optimal resource allocation,
collaboration between centers capable of providing these technologies and
services within a defined geographic area will be important for the triage of
patients outside of hospital networks above their capacity to maximize the benefit
to the population as a whole.

Conclusion

As cases of COVID-19 continue to rise in parts of the US, CICU beds in these highly
prevalent regions will be filled with severely ill patients. Several changes to pre-
pandemic practices in the CICU are required to accommodate this surge in patient
volume. The expertise of critical care cardiologists is vital in not only managing
acutely ill patients at their local institution, but in aiding hospital and government
leaders reorganize healthcare delivery. In addition, their knowledge and expertise
are
Thisessential in assisting
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to improve physicians to manage cardiovascular
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sequelae
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intensive therapies. Finally, while the pandemic OK
has paused trials and halted

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7/18/2021 The Role of Critical Care Cardiology During the COVID-19 Pandemic - American College of Cardiology

research efforts in non-COVID-19 related fields, an entirely new COVID-19 research

enterprise has been established in the last few months. It is in this capacity that
critical care cardiologists may adopt a central role in leading pivotal research
studies to determine optimal therapies for patients with severe COVID-19 related
disease.

Figure 1: The Role of the Critical Care Cardiologist During COVID-19

Abbreviations: CICU: cardiac intensive care unit; MCS: mechanical circulatory support; COVID-19:
coronavirus disease 2019

References

1. Dong E, Du H, Gardner L. An interactive web-based dashboard to track COVID-

19 in real time. Lancet Infect Dis 2020;20:533-4.
2. Guo T, Fan Y, Chen M, et al. Cardiovascular implications of fatal outcomes of
patients with coronavirus disease 2019 (COVID-19). JAMA Cardiol 2020;5:1-8.
3. Kochav SM, Coromilas E, Nalbandian A, et al. Cardiac arrhythmias in COVID-19
infection. Circ Arrhythm Electrophysiol 2020;13:e008719.
4. Churchill TW, Bertrand PB, Bernard S, et al. Echocardiographic features of
COVID-19
This illness to
site uses cookies and association
improve with cardiac biomarkers. J Am Soc
your experience.
Echocardiogr
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7/18/2021 The Role of Critical Care Cardiology During the COVID-19 Pandemic - American College of Cardiology

5. Julian DG. Treatment of cardiac arrest in acute myocardial ischaemia and

infarction. Lancet 1961;2:840–4.
6. Quinn T, Weston C, Birkhead J, Walker L, Norris R. Redefining the coronary care
unit: an observational study of patients admitted to hospital in England and
Wales in 2003. QJM 2005;98:797–802.
7. Katz JN, Sinha SS, Alviar CL, et al. COVID-19 and disruptive modifications to
cardiac critical care delivery: JACC Review Topic of the Week. J Am Coll Cardiol
2020;76:72–84.

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Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and

Cardiomyopathies, Noninvasive Imaging, Implantable Devices, SCD/Ventricular
Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart
Failure

Keywords: Heart Failure, Arrhythmias, Cardiac, Cardiac Imaging Techniques, Diagnostic

Imaging, COVID-19, Pandemics, Coronavirus, Coronavirus Infections, severe acute respiratory
syndrome coronavirus 2, Coronary Care Units, Critical Illness, Respiratory Distress Syndrome,
Adult, Palliative Care, Triage, Patient Discharge, Point-of-Care Systems, Shock, Cardiogenic,
Caregivers, Hospitals, Community

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