Don't stop renin-angiotensin-aldosterone system (RAAS) drugs over COVID-19 coronavirus concerns, but consider making some drastic changes to the catheterization lab, professional societies urged in two separate statements.
SARS-CoV-2 virus that causes the pandemic illness enters human cells via angiotensin converting enzyme 2 (ACE2) receptors. Speculation has circulated whether ACE inhibitor and angiotensin receptor blocker (ARB) upregulation of ACE2 expression in the heart could be harming hypertensive and other heart disease patients who get infected.
"We understand the concern -- as it has become clear that people with cardiovascular disease are at much higher risk of serious complications including death from COVID-19," said Robert Harrington, MD, president of the American Heart Association (AHA), in a statement to the media.
However, there's just not any data to support that fear, according to a from the Heart Failure Society of America, American College of Cardiology (ACC), and AHA.
Indeed, it's possible that the link is actually related to the population that has hypertension treated with these medications, which tends to be an older population at higher risk anyway, commented AHA spokesperson Nancy Sweitzer, MD, PhD, of the University of Arizona Sarver Heart Center in Tucson, in an interview monitored by AHA media relations.
"Furthermore, in experimental studies, both ACE inhibitors and ARBs have been shown to reduce severe lung injury in certain viral pneumonias, and it has been speculated that these agents could be beneficial in COVID-19," the statement noted. The document did not comment specifically on angiotensin II (Giapreza) IV infusion used as a vasoconstrictor to increase blood pressure in critically ill patients.
Prescriptions shouldn't be changed unless there's a clinical reason to do so, it added. And even if patients with cardiovascular disease are diagnosed with COVID-19, "individualized treatment decisions should be made according to each patient's hemodynamic status and clinical presentation."
There are known risks with not continuing ACE and ARB drugs, commented Andrew Perry, MD, of the University of Washington in Seattle. "How long are you going to hold their medications? Two months is kind of a long time if someone has heart failure."
What is actionable, is preparing the cath lab for the pandemic, according to from the ACC's Interventional Council and the Society for Cardiovascular Angiography and Interventions (SCAI).
Many already have a moratorium on elective procedures to preserve resources and avoid patient exposure to the hospital environment where COVID-19 may be more prevalent, noted the document published online in the Journal of the American College of Cardiology.
Even where the virus is not yet highly prevalent, "to preserve hospital bed capacity, it would seem reasonable to avoid elective procedures on patients with significant comorbidities or in whom the expected length of stay is >1 to 2 days (or anticipated to require the intensive care unit)," it added.
That might include deferring stenting for stable ischemic heart disease, endovascular intervention for iliofemoral disease in claudication, and patent foramen ovale closure.
"Case decisions should be individualized, taking into account the risk of COVID-19 exposure versus the risk of delay in diagnosis or therapy," the document noted.
Urgent cases still need to be dealt with, and that will undoubtedly even include some with COVID-19.
The document noted a report from China on a for acute MI for patients with symptoms of both.
While controversial for U.S. areas where primary PCI is the routine for ST-segment elevation MI (STEMI), and with limited access to rapid testing, "the balance of staff exposure and patient benefit will need to be weighed carefully," the ACC/SCAI group wrote. "Fibrinolysis can be considered an option for the relatively stable STEMI patient with active COVID-19."
For non-STEMI with suspected COVID-19, "timing should allow for diagnostic testing for COVID-19 prior to cardiac catheterization, and allow for a more informed decision regarding infection control," they added.
Rapid discharge after revascularization and telehealth follow-up afterward would likely be "satisfactory" for most such patients.
One thing that has proven useful in Seattle's hard-hit medical centers is applying the kind of careful approach to personal protective equipment and other resource use outlined in the document more broadly, noted Perry, whose AP Cardiology podcasts are featured on 番茄社区app.
"Really any procedure that requires another healthcare worker to enter the room or interact with those patients are reviewed very carefully -- do they need that procedure?" he said. "Is the info from your echo really going to change management? Are we going to expose a sonographer to coronavirus?"
This approach takes a lot more coordination and slows down care, Perry noted, but there could be some long-term good from this kind of retraining to focus on actionable, necessary testing and diagnostics.