Rapid guide to the management of cardiac patients during the COVID-19 pandemic in Egypt: “a position statement of the Egyptian Society of Cardiology”

COVID-19 pandemic poses an enormous challenge to healthcare system in Egypt. This document is a position statement from the Egyptian Society of Cardiology. It aims to provide information to cardiovascular healthcare providers in Egypt to guarantee delivery of quality patient care and ensure adequate levels of protection against infection during the COVID-19 pandemic. Older patients and those with cardiovascular disease are at higher risk of mortality. The current situation requires unusual allocation of resources which may negatively impact the care of patients with cardiovascular disease. Cardiologists should be prepared in the COVID-19 pandemic. The challenge is in providing the best quality of care despite limited resources while keeping all medical staff as safe as possible. Consider deferring elective procedures whenever possible. All medical staff should undergo rigorous training on infection control and the use of high-quality personal protection equipment. Cardiologists should promote telemedicine in the outpatient setting, prioritize outpatient contacts, and avoid nosocomial dissemination of the virus to patients and healthcare providers. A much conservative approach for emergent cardiac patients is recommended, and invasive interventions are reserved for high risk hemodynamically unstable patients. During the pandemic, the most important principles of treatment should be controlling the spread of infection as the first priority, prompt assessment of patient risk, recommending conservative medical therapy rather than invasive interventions, and strict infection control measures to limit infection spread within the hospital and to healthcare workers.

Background COVID-19 pandemic poses an enormous challenge to healthcare system in Egypt. Older patients and those with cardiovascular disease are at higher risk of mortality. The current situation requires unusual allocation of resources which may negatively impact the care of patients with cardiovascular disease [1][2][3]. This document is a position statement from the Egyptian Society of Cardiology. It aims to provide information to cardiovascular healthcare providers in Egypt to guarantee the delivery of quality patient care and ensure adequate levels of protection against infection during the COVID-19 pandemic.

COVID-19 pandemic and cardiovascular disease patients
During the COVID-19 pandemic, cardiologists might deal with these scenarios: A. Cardiac patient with symptoms suspicious of COVID-19. B. Undiagnosed patient with symptoms suspicious of COVID-19. C. COVID-19 patient with cardiac complication.
COVID-19 patients with cardiac problems are at higher risk of morbidity and mortality. They might have the following cardiac complications: exacerbation of previous cardiac problem, acute heart failure, acute myocarditis, acute coronary syndrome, acute stent thrombosis, venous thromboembolism, and various forms of arrhythmias. Some patients may present with ECG findings of ACS but with non-significant lesions. Other patients may present with severe cardiomyopathy and normal coronaries (Takotsubo-like syndrome). Some patients might suffer from side effects of COVID-19 treatment like hydroxychloroquine-azithromycin combination which might cause fatal prolonged QT interval [4][5][6][7][8]. These patients should be investigated as follows: CBC, ESR, CRP, D dimers, cardiac troponin, ECG (to assess ischemia, arrhythmia, and QT interval), CXR (to assess signs of cardiomegaly or pneumonia), echocardiography (to assess LV diastolic dysfunction, LVEF, valvular lesions, and pericardial effusion), coronary angiography if indicated, PCR to nasopharyngeal swabs and CT chest. (Table 1 and Table 2) Most cardiac drugs, such as antiplatelets, statins, and RAS blockers can be safely continued after the diagnosis of COVID-19 [4][5][6][7][8].

Principle recommendations during COVID-19 pandemic
During the pandemic, hospitals should be divided into two main categories: this puts cardiologists at risk of getting the infection [9][10][11].
Consult with the infection control unit in your hospital to establish a management system that minimizes nosocomial infections. Separate workers into groups so that possible quarantines can be applied to groups within each unit rather than the unit as a whole. All medical teams should also discuss and implement backup policies and schedules, in case that one staff member becomes ill or is quarantined and cannot participate in clinical coverage for a period of time.
For invasive procedures, a single cath lab should be designated for the care of COVID-19 patients. Consider deferring elective procedures whenever possible. Deferral minimizes the risk of exposure to COVID-19 for patients and staff, and maximizes the availability of inpatient beds in anticipation of a surge in hospitalization required for COVID-19 infected patients. High-quality personal protection equipment (PPE) should be provided to all the staff dealing with these patients. All medical staff should undergo rigorous nosocomial infection training before they start work. The steps for donning and doffing PPE are critically important. It may be desirable to minimize medical staff older than 65 years and those with chronic diseases from being directly exposed to presumed or confirmed COVID-19 cases. The government should provide special free accommodation facilities for medical staff participating in the management of COVID-19 during the pandemic to minimize the dissemination of infection to their family members if they return home.
Inpatients can only be accompanied by at most one family member who must complete the COVID-19 investigation and should wear face masks. Daily monitor body temperature and screen for COVID-19 related symptoms. No other visits during hospitalization [9][10][11].

Outpatient management of cardiac patients
Because some symptoms of COVID-19 look like those due to cardiovascular disease exposure risk exists in outpatient settings. Telemedicine via telephone or video calls can be used to triage patients as regards the need for face to face consultation.
All medical staff should put on proper PPE (including gloves, protection suits, N95 masks, work caps, and goggles/protective screens) to avoid cross infection.
Patients' temperature should be checked first, and only those with a normal temperature could enter the waiting area. Patients in the waiting area should be seated more than 1 m apart. During the consultation, the number calling system should be used with strict implementation of "one doctor, one patient, and one consultation room" with no attendants allowed.  1).
A. If COVID-19 was already diagnosed positive, he/she would be immediately transferred to the designated Chest X-ray is not recommended because of a high rate of false-negative diagnosis.
Modified from CSC expert consensus [11] hospital and followed there by a cardiologist if his cardiac condition is stable. If an urgent cardiac procedure is needed, then it should be done under strict precautions against infection (see management of ACS below). B. If COVID-19 cannot be ruled out, he/she would be transferred to an isolation ward in the infectious department for treatment. C. If COVID-19 was "excluded" temporarily, he/she would be transferred to the emergency buffer ward for treatment. Cardiologists will be on duty in the emergency department, the isolation ward and the emergency buffer ward. After admission, these patients would be re-examined for COVID-19 to comprehensively assess whether there was a risk of COVID-19. D. If COVID-19 was still "excluded," he/she would be transferred to CCU in the Cardiology Department.
The CCU ward should adopt the strict principle of single room admission.
E. After 5-7 days of observation in the CCU, a comprehensive assessment of COVID-19 should be performed. If COVID-19 is excluded and the cardiovascular condition is stable, he/she could be transferred to the regular medicine floor ward with shared rooms (Fig. 1).

Cath lab management of cardiac patient
Before Entry to Cath Lab. Minimize pre-and postprocedure waiting times in waiting areas. Use surgical masks in all patients while they wait.
Questioning of all patients about respiratory symptoms, fever, and close contacts before entry to the lab; we also recommend temperature-taking in all patients. Allow only essential staff to enter the lab.   equipment. Labs should be cleaned at least 1 h after the procedure, rather than immediately, to allow aerosol deposition. Thorough cleaning procedures may require extra time; therefore, if feasible, such cases should be performed as the final procedure of the day [14][15][16].

Management of emergent cardiovascular diseases during COVID-19 pandemic
Some experts suggest that if the hospital is still not overwhelmed, all STEMI patients should be brought for primary PCI. However, if the prevalence of COVID-19 increases causing overburden of the health system resources, the primary PCI options may have to change to be thrombolytic therapy. PCI should only be performed to the culprit vessel unless a non-culprit lesion is deemed unstable or multiple culprit lesions are present (Fig. 4).
Other experts recommend fibrinolytic therapy (except for anterior STEMI or cardiogenic shock), a potential downside is that these patients then often require prolonged ICU level of care and may end up utilizing vital finite resources. Primary PCI is reserved for high-risk STEMI patients, e.g., those with anterior MI (Fig. 5). Most experts agree that NSTEMI patients should be triaged according to their risk stratification (Fig. 6). Patients with severe emergent cardiovascular diseases for whom hospitalization and conservative medical treatment are recommended during COVID-19 epidemic are mentioned in Table 3, while severe cardiovascular diseases requiring urgent or emergent intervention or surgery are mentioned in Table 4

Conclusion
Cardiologists should be prepared in the COVID-19 pandemic. The challenge is in providing the best quality of care despite limited resources while keeping all medical staff as safe as possible. Consider deferring elective procedures whenever possible. All medical staff should undergo rigorous training on infection control and the use of highquality personal protection equipment. A much conservative approach for ACS patients is recommended in which invasive interventions are reserved for high risk hemodynamically unstable patients. Cardiologists should promote telemedicine in the outpatient setting, prioritize outpatient contacts, and avoid nosocomial dissemination of the virus to patients and healthcare providers. According to the Chinese Society of Cardiology, during the epidemic, the most important principles of treatment should   5. Pulmonary embolism presenting with hemodynamic instability for whom regular intravenous thrombolytic therapy might lead to excessively risk of intracranial bleeding, and trans-catheter low-dose thrombolysis in the pulmonary artery may be required.
Modified from CSC expert consensus [11] be the following: control the pandemic as the first priority, prompt patient risk assessment, preference for conservative medical therapy rather than invasive procedures, and strict measures to limit infection spread within the hospital and to healthcare workers.