IJCS | Volume 33, Nº3, May / June 2020

289 form of COVID-19; hospital support with isolation for patients with the severe forms of the disease; quarantine for the close contacts of suspected cases; priority allocation of healthcare resources to urgent and emergent cases; protection of the professionals involved in patients’ care. In addition, regarding specifically the CCL, the SBHCI recommends: to postpone elective procedures in patients with confirmed or suspected COVID-19; to limit the performance of CCL procedures to cardiovascular emergencies, and, for the other cases, procedures must be postponed until the non-infecting stage of disease; in CCLs with multiple procedure rooms, one should be dedicated to the treatment of suspected or confirmed COVID-19 patients. 5 During the COVID-19 pandemic, the general safety protocols and those concerningCCLprocedures, aswell as the safetymeasures for patients and healthcare personnel need to be reviewed, because that infection increases the requirements for indication and effectiveness of the procedures performed. Safety measures in the procedure preparation stage A study conducted in China with 72,314 patients with COVID-19 (44,672 laboratory-confirmed cases, 16,186 suspected cases, and 10,567 clinically diagnosed cases) has reported fever, cough, dyspnea, myalgia, fatigue and diarrhea as the most common symptoms. Other signs and symptoms have been reported, such as sore throat, chest pain, mental confusion, and lethargy. The authors have highlighted that COVID-19 had a benign course in 80% of the cases, and that many patients, although asymptomatic, could carry the virus. 6 It is worth noting the importance of the differential diagnosis of dyspnea and fatigue, especially when associated with the other symptoms. During a respiratory pandemic, patients and their families should be informed about the risks of contamination, despite all additional measures taken to minimize them. Because the number of elective procedures will be drastically reduced during that period, the length of hospital stay is predicted to be the minimum necessary for each protocol consensually elaborated. 7 Moreover, defining a procedure as elective requires clinical judgement, because postponing it might have effects that will increase the likelihood of decompensation and adverse events during the pandemic, such as in high-risk patients with unstable angina. Therefore, the decision about performing a procedure should be individualized and based on the patient’s risk and benefit analysis. 8 Despite the adoption of measures to reduce exposure, healthcare personnel shortage should be anticipated based on the likelihood of the removal of infected, exposed, at-risk and quarantined healthcare personnel. Particular attention should be given to avoid simultaneous exposure of healthcare professionals sharing the same skill set to prevent simultaneous contamination, especially in teaching institutions where the staff usually act together. 4 In addition, it is worth emphasizing the importance of reducing as much as possible the circulation in the procedure room to ensure the minimum safety threshold established in CCL procedural protocols. 4 It is worth noting that patients with suspected or confirmed COVID-19 should ideally undergo procedures at the end of the day or in CCL rooms dedicated to COVID-19, when available, because of the need for terminal disinfection. 4 Patients already intubated represent a lower risk of contamination to healthcare personnel, because they are on closed-loop ventilation. In patients with suspected or confirmed COVID-19 who need orotracheal intubation, this intervention should be performed before arrival to the CCL; in addition, intubation should be considered as early as possible in borderline patients to avoid the need for an urgent procedure and to minimize the contamination of the staff. 4 Safety measures concerning the procedures Healthcare personnel exposure and benefits to patients should be balanced for all interventional procedures. For example, during a respiratory epidemic, for hemodynamically stable patients with COVID19+ and ST-segment elevation myocardial infarction, fibrinolysis might be an alternative according to some authors; 6,9 however, the length of hospital stay waiting for coronary angioplasty after fibrinolysis should be carefully considered. It isworthnoting that COVID19 is spreadvia respiratory droplets and contact with surfaces on which the virus can last for long periods, such as cell phone, keyboard, mouse and door handles, thus, the procedure duration should be reduced to a minimum. 10,11 Moreover, patients with suspected or confirmed COVID-19 should be using a face mask upon arrival to the CCL and continue to use it during procedure preparation and the procedure itself. 4 Mariano et al. Covid-19 and safety in the cath lab Int J Cardiovasc Sci. 2020; 33(3):288-294 Viewpoint