|Year : 2021 | Volume
| Issue : 3 | Page : 95-97
Strategy for discharges from the stress test laboratory for ambulatory patients with chest pain/dyspnea in COVID-19 times
Jesus Peteiro1, Alberto Bouzas-Mosquera1, Cayetana Barbeito-Caamaño1, Jose Manuel Vazquez-Rodriguez2
1 Laboratory of Stress Echocardiography, Complejo Hospitalario Universitario de A Coruña, CIBER-CV, University of A Coruña; Department of Cardiology, Complejo Hospitalario Universitario de A Coruña, CIBER-CV, University of A Coruña, A Coruña, Spain
2 Department of Cardiology, Complejo Hospitalario Universitario de A Coruña, CIBER-CV, University of A Coruña, A Coruña, Spain
|Date of Submission||22-Feb-2021|
|Date of Acceptance||08-Jul-2021|
|Date of Web Publication||29-Sep-2021|
Dr. Jesus Peteiro
Laboratory of Stress Echocardiography, Department of Cardiology, Complejo Hospitalario Universitario de A Coruña, As Xubias, 84. 15006. A Coruña
Source of Support: None, Conflict of Interest: None
Introduction: To reduce contacts during the COVID-19 pandemic, we elaborated a protocol for ambulatory referrals for exercise testing that included discharges from the stress test laboratory (STL). Methods and Results: From 403 patients referred for chest pain (68%) or dyspnea (32%), 219 were straight discharged from the STL (54%), without findings of coronary artery disease in 192 (88%), whereas in 120 (29.5%), further visits were recommended. Medical treatment was modified after the tests in 116 patients (29%). Conclusions: A strategy consisting of discharge from the STL for patients with negative/spurious stress test results, making therapeutic recommendations, seems feasible, effective, and overall opportune in the current situation.
Keywords: COVID-19, exercise electrocardiography, stress echocardiography
|How to cite this article:|
Peteiro J, Bouzas-Mosquera A, Barbeito-Caamaño C, Vazquez-Rodriguez JM. Strategy for discharges from the stress test laboratory for ambulatory patients with chest pain/dyspnea in COVID-19 times. Heart Mind 2021;5:95-7
|How to cite this URL:|
Peteiro J, Bouzas-Mosquera A, Barbeito-Caamaño C, Vazquez-Rodriguez JM. Strategy for discharges from the stress test laboratory for ambulatory patients with chest pain/dyspnea in COVID-19 times. Heart Mind [serial online] 2021 [cited 2022 Jun 25];5:95-7. Available from: http://www.heartmindjournal.org/text.asp?2021/5/3/95/326966
| Introduction|| |
From the beginning of 2020, the human population has been threatened by the COVID-19 pandemic. As human contact must be restrained as a measure to fight this disease, we wanted to elaborate a protocol for ambulatory referrals for exercise echocardiography (ExE) and exercise electrocardiography (Ex-ECG) testing. This protocol also included the possibility of further discharge straight from the stress test laboratory (STL) to the primary care physician (PCP) in case of negative or spurious results. This research letter informs of this experience.
| Methods|| |
In May 2020, we sent a letter to the cardiology team involved in the outpatient clinic emphasizing the opportunity to stick to current clinical practice guidelines, particularly regarding requests for stress tests in patients with low/very low pretest probability of coronary artery disease (CAD), and also with regard to considering the switch from stress echocardiography to Ex-ECG testing (less interhuman contact) for patients with already known CAD, based on the recent ISCHEMIA trial results. As the ISCHEMIA trial showed that the amount of ischemia was not predictive of improvement with revascularization, the importance of depicting ischemia in patients with known CAD seems to lose importance. The ISCHEMIA trial demonstrated that an invasive strategy was similar to a conservative strategy for the different endpoints, although it was better for symptom relief in the more symptomatic cases. Thus, from this study, symptoms evaluation seems more important that amount of ischemia for deciding further invasive evaluation/revascularization; and for this purpose standard exercise ECG testing is enough (an human contact is less than in ExE).
Since the beginning of this experience, patients with negative/spurious results were discharged to their PCP with current recommendations, particularly regarding hypertension, lipid management, and antiplatelet treatment. Nevertheless, all patients had optional scheduled visits afterward. The protocol's name was “QUEDANACASA” (stay at home in Galician), and it was approved by our local ethical committee.
| Results|| |
A total of 403 patients referred from outpatient cardiology clinic or other specialty clinics for chest pain (n = 273, 68%) or dyspnea (n = 129, 32%) were included. ExE was performed in 322 (80%) and Ex-ECG in 77 (19%)., Ex-ECG was chosen for patients with pretest probabilities of CAD <5% or between 5% and 15% in the absence of coronary risk factors and also for patients with known CAD and available anatomical information in the last 1.5 years. The study period extended from June 1, 2020, to December 1, 2020. Informed written consent was obtained before the tests. All patients and staff were wearing masks. A CO2 measuring system was used for most of the patients during the last 2 months of the study to assess ventilation of the room, achieving maximal levels per examination of <950 for all these studies (mean +1 standard deviation 519 ± 161). Furthermore, during the last month of this investigation, antigen testings were performed in each patient before entering the stress room. The mortality COVID rates in our region during the period of study ranged between 400 and 500 deaths per million. There were not COVID-19 infections among the staff during the study time.
[Table 1] depicts clinical characteristics, tests performed, and results. Of the 403 patients, 219 were straight discharged from the STL (54%), without findings of CAD in 192 (88%), whereas in 120 (29.5%), further visits were recommended due to abnormal results in 86 (72%), being by Fast Tack in 4 patients. In 9 patients (2.2%), other imaging tests were asked directly from the STL for diagnosis or treatment (coronary angiography, 4; coronary computed tomography [CCT], 3; magnetic resonance, 1; and stress echo, 1), whereas 6 patients (1.5%) were referred to dedicated clinics for suspicion/diagnosis of hypertrophic cardiomyopathy [Figure 1].
|Figure 1: Number and percentage of patients discharged from the laboratory to their primary care physician, sent to the outpatient clinic, sent to special clinics, referred for other tests, and patients from special protocols|
Click here to view
Medical treatment was modified after the tests in 116 patients (29%). Main changes consisted of an increase of antihypertensive doses/drugs in 31, an increase of doses of statins or ezetimibe in 32, withdrawal of ASA in 42, prescription of ASA in 13, prescription/dose modification of beta-blockers in 10, prescription of coronary vasodilators in 10, withdrawal of coronary vasodilators in 5, prescription of drugs for smoking cessation in 7 (bupropion/varenicline), and prescription or modification of diuretic regimes in 4. The time needed for checking the clinical history, explain the patient the situation, and give new recommendations/change medications was of 9 ± 3 min. We followed up with the first 61 patients who were discharged from the STL, finding no events or hospital admittances in them. There were further visits to the former physician who have asked for the test in 23 (38%), which were by phone in 15 and face to face in 8. As a result of these visits, we registered 2 new test requests (1 CCT and 1 echocardiogram), whereas the rest of the patients were discharged without further tests.
| Discussion|| |
Recent European guidelines for the use of echocardiography during the COVID-19 pandemic state that indications for stress echocardiography seem very limited and that the use of coronary CCT angiography should be a preferred method., However, local availability for CCT might be significantly lower. On the other hand, American guidelines recognize that ExE can be considered a potentially aerosol-generating procedure, and advocate for switching to pharmacological stress echo.
One of the effects of the COVID-19 pandemic has been the need for reorganization of outpatient clinics to avoid agglomerations of people. Telephonic consults and less consults by unit of time have been some of the taken measures. Our approach could also be a relief in this matter.
We have performed ExE and Ex-ECG safely in these symptomatic patients by a more restrictive strategy. We must state that preventive measures have evolved during the study period leading to increased ventilation, masks always, switching to exercise ECG testing if possible, and antigen testing lately. With this protocol, we have found that discharge from the STL is feasible and no time-consuming at all.
This study has several limitations. First, these adaptive strategies are likely being used all over the world in COVID pandemic but are highly variable and dependent on local practices, legal issues, and availability of facilities. Therefore, they cannot be generalized. Second, it should be pointed out that it could not be translated to centers without these fast diagnostic techniques. ExE and Ex-ECG results are available in a few minutes. The third limitation includes the lack of assessment of patient's satisfaction with this rapid discharge although we have felt the relief in most of the cases. Fourth, sometimes symptoms such as chest pain or dyspnea are not due to cardiac diseases but are related to pulmonary diseases and other diseases, including psychological problems. With this protocol, we discharge the responsibility of further evaluations to the PCP.
We do not want to minimize the risk of contagion during stress testing in the COVID-19 situation but rather emphasize that, if performed, discharge from the laboratory in a significant number of cases is feasible.
| Conclusions|| |
A strategy consisting of discharge from the STL for patients with negative/spurious stress test results and making current therapeutic recommendations seems feasible, effective, and overall reasonable in the current situation.
Declaration of ethical approval and patient consent
The study was approved by our local Ethical Committee in 21/09/20 (Ref 2020/256). The authors certify that they have obtained all appropriate patient consent forms.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Knuuti J, Wijns W, Saraste A, Capodanno D, Barbato E, Funck-Brentano C, et al.
2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 2020;41:407-77.
Maron DJ, Hochman JS, Reynolds HR, Bangalore S, O'Brien SM, Boden WE, et al.
Initial invasive or conservative strategy for stable coronary disease. N Engl J Med 2020;382:1395-407.
Barbeito-Caamaño C, Bouzas-Mosquera A, Peteiro J, López-Vázquez D, Quintas-Guzmán M, Varela-Cancelo A, et al.
Exercise testing in COVID-19 era: Clinical profile, results and feasibility wearing a facemask. Eur J Clin Invest 2021;51:e13509.
Peteiro J, Bouzas-Mosquera A, Broullón FJ, Garcia-Campos A, Pazos P, Castro-Beiras A. Prognostic value of peak and post-exercise treadmill exercise echocardiography in patients with known or suspected coronary artery disease. Eur Heart J 2010;31:187-95.
Peteiro-Vázquez J, Monserrrat-Iglesias L, Mariñas-Davila J, Garrido-Bravo IP, Bouzas-Caamaño M, Muñiz-García J, et al.
Prognostic value of treadmill exercise echocardiography. Rev Esp Cardiol 2005;58:924-33.
Skulstad H, Cosyns B, Popescu BA, Galderisi M, Salvo GD, Donal E, et al.
COVID-19 pandemic and cardiac imaging: EACVI recommendations on precautions, indications, prioritization, and protection for patients and healthcare personnel. Eur Heart J Cardiovasc Imaging 2020;21:592-8.
Hung J, Abraham TP, Cohen MS, Main ML, Mitchell C, Rigolin VH, et al.
ASE statement on the reintroduction of echocardiographic services during the COVID-19 Pandemic. J Am Soc Echocardiogr 2020;33:1034-9.
Barrios V, Cosín-Sales J, Bravo M, Escobar C, Gámez JM, Huelmos A, et al.
Telemedicine consultation for the clinical cardiologists in the era of COVID-19: Present and future. Consensus document of the Spanish Society of Cardiology. Rev Esp Cardiol 2020;73:910-8.