Cardio-onco-hematology patients’ management in the context of the current COVID-19 pandemic

To the Editor,

In the context of the current COVID-19 pandemic, the European Association of Cardiovascular Imaging has published recommendations on precautions, indications, prioritization and protection (for parents and health care workers alike) regarding cardiac imaging studies.¹ However, in this context, there are still insufficient studies on the treatment of cardiotoxicity in patients with cancer to provide official guidelines or a consensus statement. However, the Council of Cardio-Oncology of the European Society of Cardiology has just published an expert opinion on the subject.² They emphasize that delaying or avoiding any care required due to the COVID-19 pandemic could result in an increased rate of adverse events. Therefore, a careful risk-benefit assessment should be made for each echocardiogram or cardiology consultation arranged, and the recommendations of the European Association of Cardiovascular Imaging should be followed.¹.

During the current pandemic, patient visits to hospital have decreased to a minimum of essential visits only. In our hospital, cardio-onco-hematology assessment of outpatients is performed in a clinic that is dedicated exclusively to this activity and that has its own echocardiography facilities. Before scheduling any in-person hospital appointment for oncology patients for requested cardiological or echocardiographic review, we carry out a telephone consultation. This telephone consultation firstly may be able to replace certain selected in-person visits, and secondly can also determine the patient's priority. In addition, due to the telephone consultation, we can detect patients with symptoms suspicious for COVID-19 before their in-person visit to organize further assessment.

It should be noted that all the cardio-onco-hematology visits have been coordinated with other essential visits to the hospital (oncology or hematology appointments, intravenous treatment, or blood tests) to ensure these are all done in the same morning and minimize the time in hospital. Patients and hospital staff use the personal protective measures recommended by the health authorities (hand washing or alcohol-based hand gel, masks etc.). Inpatient echocardiograms are performed with a different machine, also in line with the recommendations of the European Association of Cardiovascular Imaging¹.

In our hospital, with these precautions and an individual risk-benefit assessment, we have continued to assess as a priority patients whose cardiac condition may require starting or continued hemo-oncological treatment and those who develop new signs or symptoms compatible with cardiotoxicity or significant cardiovascular complications. For now, the long-term cardiotoxicity prevention programs for asymptomatic patients are being managed by telephone, and echocardiogram is delayed unless there are any concerning signs. The organization of the Cardio-Onco-Hematology Program will continue to adapt to the evolution and management of the pandemic in our hospital.

Regarding the cardiological treatment of our patients, it is important to reflect on the importance of angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers not only in hypertension,³ but also in ventricular dysfunction. It has been reported that treatment with angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers could facilitate infection with coronavirus.⁴ However, to date, there is an insufficient evidence base for withdrawing these treatments in patients who are already taking them. As has already been discussed in this journal, the complications of their indiscriminate withdrawal could be worse than their theoretical adverse effects.⁵

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