Adversity as a Catalyst for Change

Dear Editors:

We were glad to read the commentary published in the Journal of Invasive Cardiology in April 2020 about COVID-19 as an unintended force for medical revolution. We wholeheartedly agree with the authors on this. Multiple challenges exist during this period, with a drastic increase in the demand on healthcare resources. There are also increased barriers to effective patient care​​.¹ The cath lab is no different. The goal of the interventional service during this period of “war” is to enable patients requiring percutaneous coronary intervention (PCI) to safely receive appropriate and timely therapy. The pandemic has forced us to adapt and renew our practices. 

At our center in Singapore, we have been heavily affected by the COVID-19 pandemic. To make resources available to affected patients, drastic measures have been introduced, including deferment of elective PCIs​.² Yet, there remains a steady number of patients admitted with acute coronary syndrome (ACS). Routine post-PCI care in the majority of ACS patients in Singapore includes overnight high-dependency (HD) monitoring in a coronary or intensive care unit. With HD beds in high demand, patients at our institution have faced delays in intervention, potentially placing them at risk of decompensation.

Our heart team has used the impetus of the crisis to update our protocols. We reviewed prior evidence establishing the safety of same-day discharge following PCI.​^3-5 ​By extrapolating similar inclusion and exclusion criteria, we implemented a protocol to manage post-PCI ACS patients in the general ward with overnight telemetry monitoring. Patients with ST-segment elevation myocardial infarction (STEMI), hemodynamic instability, procedural complications, and decompensated cardiac failure would be excluded.  

We are happy to report that, to date, we have successfully managed 8 patients using the new protocol. Initial patients included were ACS patients with PCI done via radial access. The safety profile of the new protocol has been excellent, with no inpatient complications of bleeding, stroke, recurrent ACS, repeat revascularization, or arrhythmia. Many more patients are being managed using this protocol, to safely allow PCI to continue without the need to compete with scarce HD resources.  

The authors of this letter aim to encourage healthcare practitioners globally to use adversity as a catalyst to review our practices. Although there is generalized disruption to many services, the crisis also allows an unprecedented opportunity to expedite the implementation of more efficient protocols. For this to happen, traditional practices based on perceived safety have to be examined carefully and new ways found to improve the care of our patients. There are inherent risks involved. However, gradual implementation of evidence-based practices through the use of feasibility studies will ensure this can be done in a safe manner.  

In our case, this has enabled the implementation of general ward monitoring in patients with ACS undergoing PCI. We look forward to sharing more data from the study once it is available.

Sincerely,

Mayank Dalakoti​​, MBBS, MRCP; ​Koo Chieh Yang​​, MBBS, MRCP; ​Saurabh Rastogi​, MD, FACC; Pipin Kojodjojo, MD, PhD

From the ​Department of Cardiology, Ng Teng Fong General Hospital, Singapore.

Address for correspondence: Mayank Dalakoti, MBBS, MRCP, National University Heart Centre, Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 9, Singapore 119228. Email: mayank_dalakoti@nuhs.edu.sg

1. Wang X, Bhatt DL. COVID-19: an unintended force for medical revolution? J Invasive Cardiol. 2020;32:E81-E82.
2. Welt FGP, Shah PB, Aronow HD, et al; for the American College of Cardiology (ACC) Interventional Council and the Society of Cardiovascular Angiography and Intervention (SCAI). Catheterization laboratory consideration during the coronavirus (COVID-19) pandemic from ACC’s Interventional Council and SCAI. J Am Coll Cardiol. 2020;75:2372-2375. Epub 2020 Mar 19. 
3. Seto AH, Shroff A, Abu-fadel M, et al. Length of stay following percutaneous coronary intervention: an expert consensus document update from the Society for Cardiovascular Angiography and Interventions. Catheter Cardiovasc Interv. 2018;92:717-731. 
4. Abdelaal E, Rao SV, Gilchrist IC, et al. Same-day discharge compared with overnight hospitalization after uncomplicated percutaneous coronary intervention: a systematic review and meta-analysis. JACC Cardiovasc Interv. 2013;6:99-112.
5. Slagboom T, Kiemeneij F, Laarman GJ, Van der Wieken R. Outpatient coronary angioplasty: feasible and safe. Catheter Cardiovasc Interv. 2005;64:421-427.