The number of Covid-19 cases is increasing around the world, with many countries bracing to stretch their hospital staff and supplies as far as possible. During this preparation, the American College of Cardiology (ACC) released new guidelines on 24 March 2020 on how to defer Covid-19 testing and procedures during the pandemic.
Many areas of healthcare, even outside cardiology, are attempting to defer Covid-19 testing and procedures to prepare for the pandemic, as recommended by the Centers for Disease Control and Prevention (CDC). The goal of this exercise is not only to maximise the available space, personnel, and equipment for the care of patients, but also to limit the spread of the infection, thus protecting at-risk patients.
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ACC has recommended considering a test or procedure as elective if it is ‘unlikely to directly impact clinical care or outcomes over the next several months’. ACC has also urged physicians to give preference to testing by alternative means, such as remote testing, whenever possible. Decisions about which tests or procedures to defer should ultimately be made by the local physicians based on individual risk assessments. However, ACC has provided a short list of tests and procedures to consider for deferral. The full list is available on ACC’s website. It includes, but is not limited to:
- Implantable Cardioverter Defibrillator placement for primary prevention in stable, low-risk patients (outpatient)
- Atrial fibrillation ablation in stable patients (such as those without refractory heart failure, outpatient and inpatient)
- Supraventricular tachycardia ablation in stable patients (outpatient and inpatient)
- Coronary angiography with or without intervention for stable ischemic heart disease (outpatient and inpatient)
- Transcatheter aortic valve replacement (TAVR) in asymptomatic patients (outpatient and inpatient)
- Valve repair / replacement in asymptomatic patients (outpatient and inpatient)
- Coronary artery bypass graft (CABG) surgery for stable ischemic heart disease (outpatient and inpatient)
Some major themes have emerged from this list. Any procedure involving patients with stable disease are recommended for deferral. Similarly, any tests or procedures involving asymptomatic patients are also recommended for deferral.
While these guidelines were developed with patient health and safety in mind, this situation is unprecedented and it is unclear what the long-term effects of these deferrals will be on patient outcomes. In the past, the treatment of asymptomatic patients has been shown to lead to better outcomes in certain cases, so deferral of even these procedures may lead to worse outcomes for the patients whose procedures were deferred.
Similarly, it is unclear what impact these guidelines and the resulting changes in clinical practice will have on medical device markets. Some markets are more impacted by the guidelines, with more procedures recommended for deferral; these include electrophysiology, heart valves, and both coronary and peripheral angioplasty. GlobalData valued the TAVR market at just under $3.5bn globally in 2019. While these markets are likely to see a dip in growth over the next few months as procedures are delayed, most of the patients waiting for procedures will still need to receive them when the pandemic conditions are lifted. Therefore, any dip in market value will likely be offset by a spike in value post-outbreak, resulting in only a small or non-existent long-term effect.
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