Improving Cardiac Triage with ECG Diagnosis during COVID-19

New information regarding COVID-19 continues to emerge daily. This content was based on the sources available at the time of writing.

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ECG diagnosis remains a time-tested, reliable tool for rapid assessment and triage of cardiac patients. Even as the COVID-19 pandemic pushes medical professionals and facilities across the globe to their limits, patients with cardiac emergencies, regardless of whether or not they have COVID-19, still require timely and effective care. In many cases, ECG can provide a key piece during triage and risk assessment that guides appropriate treatment of cardiac patients during the pandemic and beyond.

Management of Acute Myocardial Infarction during COVID-19

The American College of Cardiology (ACC), the Society for Cardiovascular Angiography and Interventions (SCAI), and the American College of Emergency Physicians (ACEP) have released recommendations for managing patients with acute myocardial infarction (MI) during the COVID-19 pandemic. The pre-proof of the guideline statement, published in April 2020 in the Journal of the American College of Cardiology, states that PCI, when it can be accomplished in a timely fashion, remains the standard of care for patients presenting with STEMI to PCI-capable hospitals.

Cardiac care teams should wear personal protection equipment (PPE) in such situations and perform the cardiac catheterization in a dedicated cardiac catheterization laboratory with the express purpose of treating cardiac patients with known or suspected COVID-19. To maximize the safety of the cardiac care team, patients should be masked when possible, and PPE should be used throughout the patient encounter.

The guideline also highlights the importance of exercising caution in ECG interpretation of ST-segment elevation in order to avoid reperfusion therapy for patients with other, noncoronary causes of ST-segment elevation.

Triaging Urgent and Emergent Electrophysiology Procedures

Similarly, the Heart Rhythm Society COVID-19 Task Force, in coordination with the Electrophysiology Section of the ACC and the ECG and Arrhythmias Committee of the AHA's Council on Clinical Cardiology, has provided guidance for urgent and emergent cardiac electrophysiology (EP) procedures during the COVID-19 pandemic. The document, published in the March 31, 2020 issue of Circulation, notes that more than 40% of cardiology encounters are arrhythmia-related and recommends that urgent or emergent procedures be performed based on a risk-benefit analysis. Such procedures may include, but are not limited to:

  • VT ablation when necessary for medically uncontrollable electrical storm
  • Catheter ablation for the ECG diagnosis of WPW syndrome or pre-excited A-fib with syncope or cardiac arrest
  • Pacemaker implant for ECG diagnosis of complete heart block or high-grade AV block
  • Catheter ablation of incessant, severely symptomatic supraventricular tachycardias refractory to medical therapy or cardioversion
  • Pacemaker or ICD lead revisions in patients who are pacemaker-dependent or receiving inappropriate ICD shocks
  • Pacemaker or ICD generator changes at end of battery life
  • Lead or device extraction due to infection
  • Cardioversion for hemodynamically significant or severely symptomatic atrial arrhythmias, particularly those with rapid ventricular rates uncontrolled by medication

The EP guidance statement also recommends that direct current or chemical cardioversions for hemodynamically significant arrhythmias be performed at the bedside in the ICU to minimize transport of infected patients. For general anesthesia cases, elective intubation should be performed in the ICU or in a negative ventilation pressure room prior to entering the EP lab, and same-day discharges should be considered after device implants to minimize patient risk of nosocomial infection.

Because patients admitted to the emergency department during the COVID-19 pandemic may present with a wide range of signs and symptoms indicative of cardiac conditions, ECG plays an important role in diagnosis and treatment decisions.

Assessing Patients with ECG amid the Pandemic

ECG assessment as a rapid first-line diagnostic tool is critical to identifying cardiac emergencies and improving triage and risk stratification. Therefore, the majority of patients with suspected COVID-19 should have a baseline ECG performed upon presentation, as a review article from the New England Journal of Medicine notes.

The ECG is a long-established and powerful tool in the armamentarium of cardiologists and other healthcare professionals, and it can be harnessed effectively for guideline-directed cardiac triage during the COVID-19 pandemic.