COVID-19: A United Kingdom National Health Service Cardiology Perspective.

The ongoing coronavirus disease-2019 (COVID-19) pandemic is testing the resilience of societies, services, families, and individuals across the world. Even though this virus causes a respiratory illness, cardiology patients and doctors will continue to be affected both directly and indirectly by the pandemic and its aftermath. Here we discuss the U.K. cardiological response to the pandemic in the provision of front-line care for COVID-19 patients, the redesign of clinical services, and the acquisition of new skills by cardiologists. We describe how the pandemic may affect cardiology patients, how cardiologists can help COVID-19 patients, and how we can support our patients and colleagues during this difficult period. We draw upon our personal experiences as cardiologists to contribute to the wider published discussion of how cardiology services are changing during this pandemic.

Cardiology Patients and COVID-19

Pre-existing cardiovascular disease puts patients at higher risk of the complications of COVID-19 (1). The precise reasons for this are not clear, but the presence of established cardiovascular disease or its associated risk factors such as hypertension, diabetes, obesity, smoking, age, and male sex are all associated with worse outcomes (1). Although these factors are not all immunocompromising in the classical sense, it seems possible that they contribute to a state of immune dysregulation that predisposes patients to severe infection and an exaggerated maladaptive immune response (2). Furthermore, patients with cardiac conditions such as heart failure, cardiomyopathy and ischemic heart disease may lack the cardiovascular reserve to mount an appropriate physiological response to the virus.

COVID-19 may have primary cardiac manifestations, although an associated viral myocarditis is unproven and requires more investigation. Furthermore, whereas COVID-19 can manifest with cardiac-sounding symptoms and has been associated with myocardial infarction, this link also remains unproven. It is likely that in the absence of typical symptoms the frequent finding of a mildly elevated serum troponin level is secondary to demand ischemia from hypoxemia, sepsis, distributive shock, and tachycardia rather than plaque rupture per se (1). Arrhythmias occur in 17% of patients (1). Cardiologists involved in the care of COVID-19 patients should be prepared to provide timely advice on the management of these cardiovascular complications and comorbidities.

In addition to the direct effects of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection, the downstream effects on cardiac patients who avoid infection are likely to be significant but will be difficult to quantify. Cardiac doctors, nurses, physiologists, and allied health care professionals all work with patients and are being affected by self-isolation and sickness. Reduced staffing levels and increasing health care demands are causing services to become overwhelmed. As a result, many outpatient clinics and elective procedures are being postponed; nonacute cardiac imaging has been reduced. The British Cardiovascular Society published guidance to help clinical leadership teams scale down cardiology services appropriately and proportionately during the pandemic (3). It is recommended that emergency pathways for cardiac bypass surgery, percutaneous coronary revascularization, and cardiac electronic device implantation be maintained. However, this may require increased patient transfers, treatment delays, and the requirement for less effective interim therapies such as thrombolysis for ST-segment elevation myocardial infarction. Furthermore, delays in the urgent invasive management of cardiac conditions such as aortic stenosis and non–ST-segment elevation acute coronary syndrome could indirectly contribute to downstream morbidity and mortality, even after the infection rate falls. Compounding these changes in health care provision, patients are choosing to avoid hospitals for fear of catching the virus. Yet unpublished data reveal a significant reduction in current admissions for ST-segment elevation myocardial infarction and non–ST-segment elevation acute coronary syndrome compared with this time last year. All of these deviations from established standards of care may negatively affect outcomes. It remains vital that patients who are unwell with cardiac-sounding symptoms such as chest pain, palpitations, and syncope are still encouraged to seek medical attention. Furthermore, it must be carefully considered whether the harms of delaying guideline-based therapy for cardiac disease are appropriately balanced against the harms of COVID-19 itself because neither group of patients is more or less deserving of effective health care than the other. One way that cardiologists can overcome the issue of reduced hospital attendance is to provide virtual or telephone outpatient consultations where feasible.

Additional support is available. The British Cardiovascular Society rapidly established guidance for hospitals and a COVID-19 Clinicians Resource Hub, which are both accessible to all clinicians in all countries. The National Institute for Health and Care Excellence has also published relevant guidance on the appropriate use of critical care for COVID-19 patients (3).

Cardiology Doctors and COVID-19: Clinical Contributions

Cardiologists also have an important role in applying their transferrable skills to the care of noncardiac patients with COVID-19. Many cardiologists have already transitioned from existing roles in subspecialty rotas, research, and training to front-line management of COVID-19 patients in medical or intensive care units. Many cardiologists dual train in internal medicine and are currently expanding their existing contributions in the acute medical take. Cardiologists offer “hard” clinical skills such as the management of respiratory failure, sepsis, resuscitation, and escalation planning, as well as “soft” skills such as team leadership, rota management, communication, teaching, and supervision. In critical care, cardiologist’s translatable skill sets include vascular access, transthoracic echocardiography, and the management of unstable patients. Most critically unwell COVID-19 patients require arterial lines, central venous access, cardiovascular support, and careful fluid balance management—all familiar areas for cardiologists. Some cardiologists may have already undertaken intensive care rotations, although up-skilling, retraining, and supervised support will still be needed to assist with this transition. A subset of patients may also require transthoracic echocardiography, extracorporeal membrane oxygenation, and antiarrhythmic drugs. The value that cardiologists can bring to the critical care management of COVID-19 patients should therefore not be underestimated, and in our experience our contributions have been well supported and well received by intensivists and acute care physicians alike.

The current focus on COVID-19 may require cardiologists to learn new knowledge and skills specific to this disease, such as the management of acute respiratory distress syndrome, mechanical ventilators, and ventilated patients. For cardiology trainees, learning cardiac skills such as angiography, echocardiography, and device implantation takes time, and there is a risk that this pandemic will generate lost skill and opportunity costs. To this we would say 3 things. First, training authorities have been sympathetic to our predicament; end of year assessments have already been modified accordingly. Second, we have found that the sacrifices made in contributing to this crisis are as rewarding as they are a privilege. Finally, it is possible that the unforeseen benefits outweigh these foreseen negatives; among health care professionals we are already seeing increased collaboration, a strengthened sense of community, and a greater appreciation for our respective contributions.

Cardiology Doctors and COVID-19: Nonclinical Contributions

Beyond their clinical contributions, cardiologists can assist with nonclinical roles, including research, education, leadership, and management. There will be countless examples, but to name a few, cardiologists from our hospitals have helped create COVID-19 protocols, redesign medical rotas, deliver vascular access teaching, and streamline the return of researchers back into clinical work. All established U.K. research funders are supporting this move, as well as the repurposing of research funds from cardiovascular research to COVID-19–based research. The principal investigator for the COVID-19 Healthcare Worker Bioresource study and the managing director of the new National Health Service (NHS) Nightingale critical care COVID-19 field hospital at the ExCeL Conference Centre in London, are both practicing consultant cardiologists at our hospitals.

Cardiology Doctors and COVID-19: Staying Safe

Last but not least, we must protect our health and the health of our colleagues. Without healthy hospital workers, inpatients cannot receive excellent care. Physical health must be protected with appropriate training in and use of personal protective equipment, rest between shifts, and time off when health sector workers become unwell. Psychological health must be protected with counseling, debriefing after clinical events, mentoring, bereavement support, and time away from work. Social well-being can be helped by providing food, transport, and accommodation where required. The NHS is well suited to supporting key workers in this way; at our hospitals we have access to discounted or free transport, accommodation, food, and counseling.

Conclusions

To say that these are stressful or uncertain times is an understatement. The personal perspectives described here are not exhaustive, and new issues will be identified en route. During pandemics such as this, focussing first and foremost on the needs of patients is of paramount importance. In addition to the personal challenges faced by everyone, we as physicians also face the greatest professional challenge of our lives. This is our reality, and as cardiologists we have a great deal to offer. We appreciate your support and wish you all the best during this testing pandemic.