Authors

Andrew D. Choi, MD FSCCT¹; Suhny Abbara MD, MSCCT²; Kelley R. Branch, MD, FSCCT³; Gudrun M. Feuchtner MD⁴; Brian Ghoshhajra MD, FSCCT⁵; Koen Nieman MD, PhD, FSCCT⁶, Gianluca Pontone, MD, PhD, FSCCT⁷; Todd C. Villines, MD, MSCCT⁸; Michelle C. Williams, MBChB, PhD, FSCCT⁹; Ron Blankstein, MD, MSCCT¹⁰

Use of cardiac computed tomography amidst the COVID-19 pandemic
Endorsed by the American College of Cardiology (ACC)
Updated: May 13, 2020

The world is currently suffering through a pandemic outbreak of severe respiratory syndrome coronavirus 2 (SARS-CoV-2) known as Coronavirus Disease 2019 (COVID-19). The United States (US) Centers for Disease Control and Prevention (CDC) currently advises medical facilities to “reschedule non-urgent outpatient visits as necessary” ¹.  The European Centre for Disease Prevention and Control, the United Kingdom National Health Service and several other international agencies covering Asia, North America and most regions of the world have recommended similar “social distancing” measures^{2, 3}. 

The Society of Cardiovascular Computed Tomography (SCCT) offers guidance that fully support and extend these international recommendations specifically for cardiac CT (CCT) practitioners to decrease risk of COVID-19 transmission in their facilities while allowing for optimal timing considerations for effective utilization of CCT to improve cardiovascular health outcomes.  While many institutions will have their own guidelines for clinicians and imagers to follow, these recommendations are meant to help CCT labs which are interested in developing or refining such policies. It is important to emphasize the SCCT’s commitment to the health and well-being of CCT technologists, imagers, trainees, and research community, as well as the patients served by CCT by preventing the spread of disease. 

As this represents initial guidance for a rapidly evolving pandemic, the SCCT advises that CCT practitioners work closely with their referring physicians to determine the appropriateness and timing of each individual study on a case by case basis, while also considering the local epidemiology of COVID-19 and local institutional guidelines for practice. 

Download a statement as a PDF

Basic concepts

• Social distancing — keeping at least six feet (1.8 meters) between individuals in waiting rooms and work spaces as much as feasible. 
• Encourage sick employees to stay home. Personnel who develop respiratory symptoms (e.g., cough, shortness of breath) or unexplained fever should be instructed not to report to work.
• Ensure that your sick leave policies are flexible and consistent with public health guidance and that employees are aware of these policies.  Make contingency plans for increased absenteeism
• Screen patients and visitors for symptoms of acute respiratory illness (e.g., fever, cough, difficulty breathing) or gastrointestinal symptoms and coronavirus exposure in the last 2 weeks before entering one’s healthcare facility ⁴. 
• Ensure technologist and CCT imager hand hygiene best practices.  If soap and water are not readily available, use of a hand sanitizer that contains at least 60% alcohol. 
• Consider standard droplet precautions for patients and healthcare personnel as per institutional infection control protocols.
• Increase scheduling intervals or appointment times to allow adequate time to clean equipment as needed.
• Leverage telemedicine technologies and isolated workstations to allow for reading and interpretation, that allow for social distancing to limit staff exposure, when possible.
• Assign a team member to monitor and incorporate regular updates from the CDC and appropriate regional jurisdictions. 

Patients under investigation (PUI) and confirmed COVID-19

In patients under investigation (PUI) and with confirmed COVID-19, the benefit of CCT scanning in most clinical scenarios will likely be lower than the risk of COVID-19 exposure and infection to healthcare personnel.  These cases should be considered on a case-by-case basis. 

For these PUI and confirmed COVID-19 patients in which CCT scanning is determined to be necessary, the following issues should be considered:

• Ensure proper use of personal protection equipment (PPE). Healthcare personnel including technologists, radiologists and cardiac imagers who come in close contact with confirmed or suspected COVID-19 should wear the appropriate personal protective equipment^{5, 6}.  Patients should wear a surgical mask during imaging to ensure standard droplet precautions.
• Appropriate environmental cleaning and decontamination of rooms by thorough cleaning of the surfaces by a staff member with appropriate PPE as per CDC and local institutional guidelines for airborne viral diseases⁷.  
•  

Cardiac CT indications and timing

To advise practitioners of cardiovascular CT on how to implement the CDC recommendation of rescheduling non-urgent visits as necessary and international guidelines on social distancing, the SCCT offers the following guiding points (Table 1) and suggestions for CCT timing based on various indications (Table 2).  As this is not an exhaustive list, the SCCT advises CCT practitioners to work with referring physicians on a case by case basis.  

Table 1: Guiding points to consider when deciding on the role and timing of CCT.

Table 2:  Timing considerations for common indications for CCT amidst COVID-19

*Especially in institutions that will delay such elective cases. ⁺ When cardioversion is deemed necessary. 

CAD = coronary artery disease; SHD = structural heart disease; A-Fib = atrial fibrillation; LAA = left atrial appendage; TAVR = transcatheter aortic valve replacement/implantation; TMVR = transcatheter mitral valve replacement/implantation; LVAD = left ventricular assist device

 LISTen TO THE AUTHORS DISCUSS THIS DOCUMENT ON THE JCCT PULSE PODCAST

Have a question or information to add? Post it in our COVID-19 forum.

^#CCTA for Myocardial Injury and Possible ACS in known or suspected COVID-19

• Coronary CTA (CCTA) may be useful in carefully selected patients who have elevated cardiac enzymes, inconclusive electrocardiogram, and symptoms of possible acute coronary syndrome (ACS) in order to exclude obstructive coronary artery disease. 
• The use of coronary CTA in such settings should only be considered if it can be performed at centers that have high-level of expertise and when diagnostic quality imaging can be achieved.  Furthermore, CTA in this setting should only be considered if it expected to result in a meaningful change to patient management or outcomes. 
• CCTA is not recommended to evaluate patients with definitive ST elevation myocardial infarction. These should proceed directly to definitive therapy as per local institutional protocol.
  

Initial experience in COVID-19(+) patients suggest that at least 7-20% of hospitalized patients have elevated troponin levels^8-11.  In such patients the differential diagnosis may include ACS, myocarditis, or myocardial injury^{12, 13}.  The use of coronary CTA in such settings should only be considered if it can be performed at centers that have high-level of expertise and when diagnostic quality imaging can be achieved.   CCTA in this setting should only be considered if it is expected to result in a meaningful change to patient management or outcomes, as well as reduce resource utilization (i.e. avoid invasive angiography).  Depending on the available technology, patients with elevated heart rates, and those who may not be able to perform a proper breath-hold may not be suitable candidates for coronary CTA.   

The decision to proceed with coronary CTA versus invasive angiography should be made in collaboration with local clinical staff from the Heart Team, including cardiac catheterization laboratory.  It is expected for the vast majority of COVID-19(+) patients, invasive or non-invasive coronary visualization will not change management.  

Incidental pulmonary findings in patients at risk of COVID-19 exposure

COVID-19 is a viral pneumonia, with a spectrum of findings ranging from normal lungs to acute respiratory distress syndrome. Typical chest CT findings in known cases are described elsewhere^{14, 15}. If typical or atypical pulmonary findings are encountered, consultation with a radiologist with thoracic expertise is encouraged, and appropriate documentation and timely communication of these findings is important, especially in cases not known or suspected to have the disease.

^∏ Additional considerations for Cardiac CT and Pediatric Congenital Heart Disease 

• Cardiac CT may enable evaluation of cardiac and extra-cardiac anatomy for conditions deemed by the Congenital Heart Team to be of clinical, hemodynamic and/or or surgical relevance prior to urgent intervention to include, but not limited to assessment of suspected following conditions: significant coronary artery anomaly, coronary artery course in proximity to the right ventricular outflow tract, thoracic vasculature abnormality, pulmonary vasculature obstruction^{16, 17, 18}. 

The impact of COVID-19 in pediatric patients are significantly reduced (<1%) when compared to the adult and elderly population, yet over 15% of children may be asymptomatic carriers^{19, 20}.  Patients with unrepaired or palliated congenital heart disease may constitute a high-risk group, though current evidence is uncertain.  Cardiac CT in patients with congenital heart disease should be reserved for scenarios in which it is expected to provide unique diagnostic information, at centers with high expertise and at minimal risk. 

^€ Safe Reintroduction of Cardiovascular Services during the COVID-19 Pandemic: Guidance from North American Society Leadership including SCCT 

As written in the Wood, et al statement²⁰:

There should be a sustained reduction in the rate of new COVID-19 admissions and deaths in the relevant geographic area for a prespecified time interval as determined by local public health officials before changes can be implemented. Importantly, if COVID-19 admissions and deaths start to increase, there must be immediate and transparent cessation of most elective invasive procedures and tests. Resumption of these services would occur in collaboration with regional public health policy makers. As discussed below, COVID-19 testing of potential patients and health care workers (HCW), as well as personal protective equipment (PPE), must also be carefully monitored to minimize the risk of shortages as the pandemic escalates and abates.

Conclusion

As this situation is shifting rapidly, the information contained within this document is likely to evolve.SCCT will maintain an updated version of this statement as more information becomes available on the Society’s website.SCCT advises that members keep informed regarding future updates from the medical and radiological communities on protecting patients, staff, trainees and providers from COVID-19 while deciding on the optimal timing of outpatient and inpatient CCT exams.  

SCCT among societies asking for more coverage during this trying time. Read more. 

Other Resources:

• American College of Cardiology COVID-19 Bulletin
• American College of Radiology Recommendations for the use of Chest Radiography and Computed Tomography (CT) for Suspected COVID-19 Infection
  
• British Society of Thoracic Imaging: COVID-19 Resources
• Centers for Disease Control and Prevention Steps for Healthcare Facilities
• Coronavirus (COVID-19): UK government response
• COVID-19: An Unintended Force for Medical Revolution?  Journal of Invasive Cardiology, Vol 32(4), April 2020.  Wang X and Bhatt DL.  Discussed by Dr. Bhatt on SCCT’s COVID-19 Webinar April 15, 2020 **New  
• ESC Guidance for the Diagnosis and Management of CV Disease during the COVID-19 Pandemic **New 
• European Centre for Disease Prevention and Control: COVID-19
• European Association of Cardiovascular Imaging COVID-19 pandemic and cardiac imaging: EACVI Recommendations on precautions, indications, prioritization and protection for patients and healthcare personnel
• Radiology Department Preparedness for COVID-19: Radiology Scientific Expert Panel
• Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19.  Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA 
• RSNA COVID-19 Task Force:  Best Practices for Radiology Departments **New
• RSNA COVID-19 Task Force: Post-COVID Surge Radiology Preparedness **New
• Safe Reintroduction of Cardiovascular Services during the COVID-19 Pandemic: Guidance from North American Society Leadership
• SCCT President’s Page: The Impact of the COVID-19 Pandemic on Cardiac CT **New
• Society of Thoracic Radiology/American Society of Emergency Radiology COVID-19 Position Statement
• TCTMD COVID-19 Daily Dispatch
• The Role of Chest Imaging in Patient Management during the COVID-19 Pandemic: A Multinational Consensus Statement from the Fleischner Society

References

1. Centers for Disease Control and Prevention: Steps Healthcare Facilities Can Take Now to Prepare for Coronavirus Disease 2019 (COVID-19)
2. European Centre for Disease Prevention and Control: COVID-19
3. NHS England: Coronavirus guidance for clinicians
4. Centers for Disease Control and Prevention: What Healthcare Personnel Should Know about Caring for Patients with Confirmed or Possible COVID-19 Infection
5. Centers for Disease Control and Prevention: Infection Control 
6. Centers for Disease Control and Prevention: Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings
7. Centers for Disease Control and Prevention: Environmental Infection Control Guidelines
8. Lippi G, Lavie CJ, Sanchis-Gomar F. Cardiac troponin I in patients with coronavirus disease 2019 (COVID-19): Evidence from a meta-analysis. Prog Cardiovasc Dis. 2020.
9. Januzzi JL. Troponin and BNP Use in COVID-19 2020 [updated March 18, 2020. Available from: https://www.acc.org/latest-in-cardiology/articles/2020/03/18/15/25/troponin-and-bnp-use-in-covid19.
10. Shi S, Qin M, Shen B, Cai Y, Liu T, Yang F, et al. Association of Cardiac Injury With Mortality in Hospitalized Patients With COVID-19 in Wuhan, China. JAMA Cardiol. 2020.
11. Driggin E, Madhavan MV, Bikdeli B, Chuich T, Laracy J, Bondi-Zoccai G, et al. Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the Coronavirus Disease 2019 (COVID-19) Pandemic. J Am Coll Cardiol. 2020.
12. Linde JJ, Kelbaek H, Hansen TF, Sigvardsen PE, Torp-Pedersen C, Bech J, et al. Coronary CT Angiography in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome. J Am Coll Cardiol. 2020;75(5):453-63.
13. Smulders MW, Kietselaer B, Wildberger JE, Dagnelie PC, Brunner-La Rocca HP, Mingels AMA, et al. Initial Imaging-Guided Strategy Versus Routine Care in Patients With Non-ST-Segment Elevation Myocardial Infarction. J Am Coll Cardiol. 2019;74(20):2466-77.
    
14. Mossa-Basha M, Meltzer CC, Kim DC, Tuite MJ, Kolli KP, Tan BS. Radiology Department Preparedness for COVID-19: Radiology Scientific Expert Panel. Radiology. 2020:200988.
15. British Society of Thoracic Imaging: COVID-19 Resources
16. Morray BH, G.B., Crystal MA, Goldstein BH, Quereshi AM, Torres AJ, Epstein SM, Crittendon I, Ing FF, Sathanandam SK, Resource Allocation and Decision Making for Pediatric and Congenital Cardiac Catheterization During the Novel Coronavirus SARS-CoV-2 (COVID-19) Pandemic: A U.S. Multi-Institutional Perspective. Journal of Invasive Cardiology, 2020. 32.
17. Han, B.K., et al., Computed Tomography Imaging in Patients with Congenital Heart Disease Part I: Rationale and Utility. An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT): Endorsed by the Society of Pediatric Radiology (SPR) and the North American Society of Cardiac Imaging (NASCI). J Cardiovasc Comput Tomogr, 2015. 9(6): p. 475-92.
18. Stephens, E.H., et al., COVID-19: Crisis Management in Congenital Heart Surgery. Ann Thorac Surg, 2020.
19. Cruz, A.T. and S.L. Zeichner, COVID-19 in Children: Initial Characterization of the Pediatric Disease. Pediatrics, 2020.
20. Wood DA, M.E., Thourani VH, Sathananthan J, Virani A, Poppas A, Harrington RA, Dearani JA, Swaminathan M, Russo AM, Blankstein R, Dorbala S, Carr J, Virani S, Gin K, Packard A, Dilsizian V, Legare J-F, Leipsic J, Webb JG, Krahn AD, Safe Reintroduction of Cardiovascular Services during the COVID-19 Pandemic: Guidance from North American Society Leadership. Journal of the American College of Cardiology, 2020. May 2020.
    

Author reference 

¹Division of Cardiology & Department of Radiology, The George Washington University School of Medicine, Washington, DC, United States

²Division of Cardiothoracic Imaging, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, United States 

³ Division of Cardiology, Department of Medicine, University of Washington Medical Center, Seattle, WA, United States

⁴Department of Radiology, Innsbruck Medical University, Vienna, Austria

⁵ Division of Cardiovascular Imaging, Massachusetts General Hospital, Boston, MA, United States

⁶ Department of Cardiovascular Medicine and Radiology, Stanford University, Stanford, CA, United States

⁷ Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, University of Milan, Italy

⁸Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, United States

⁹University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Edinburgh, United Kingdom

¹⁰ Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women’s Hospital, Boston, MA, United States

 ^# New section amended to the original statement on April 15, 2020 that represents Society of Cardiovascular Computed Tomography guidance only.

^∏ The writing group would like to acknowledge Dr. Kanwal M. Farooqi, MD of Columbia University, New York, NY for her contributions.  This section was amended to the original statement on May 13, 2020 that represents Society of Cardiovascular Computed Tomography guidance only.  

^€ New section amended to the original statement on May 13, 2020.