Developing Credible Knowledge During the COVID-19 Pandemic

Call for COVID-19 Clinical Cases Under JACC: Case Reports

When the World Health Organization declared coronavirus disease-2019 (COVID-19) a pandemic, we moved to understand its complications and, most important, its cardiovascular (CV) and thromboembolic manifestations. We were fully aware that our first evidence would be coming from clinical cases as anecdotal evidence until we had big data from randomized trials or prospective studies.

On the March 20, we initiated a call for clinical cases on COVID-19, with a deadline of June 1. At the beginning of April, all JACC journals decided to waive publication fees for papers reporting on COVID-19 cases, as an effort to help frontline colleagues publish their findings. It was an opportunity to learn from all of you, to learn from your patients, and to read evidence from across the world.

Our very first publication on COVID-19 was by Bettari et al. (1), on personal protection during high-risk percutaneous coronary intervention in a patient with COVID-19. This was a time when we were not entirely sure about the level of protection needed while performing procedures, as we were still discussing how contagious COVID-19 was. A few hours later, JACC published a landmark paper by Welt et al. (2) on catheterization laboratory considerations during the COVID-19 pandemic. Furthermore, at the beginning of the pandemic, a clever paper by Gage et al. (3) reacquainted cardiologists with mechanical ventilation. We felt that this paper was extremely useful for all of us who were deployed in intensive care units helping with patients with COVID-19.

Subsequently, as we are receiving more papers, we have decided to divide JACC: Case Reports publications into 5 sections: acute coronary syndromes, heart failure, arrhythmias, thromboembolic events, and stories from the front line, in the format of “Voices of Cardiology” papers. All these papers have been highlighted in this issue (4).

Recognizing the value of not overloading our audience with publications, and in an effort to keep the quality high and up to the standards of JACC journals, we accepted approximately 8% to 10% of the manuscripts submitted. We selected the best of the best cases and brought together world-renowned specialists to write editorials.

Limitations

Although we understand that clinical cases have been of crucial importance for our understanding of COVID-19, it is of equal importance that they cannot substitute for large studies and pharmacological trials. Therefore, unless we were dealing with an impressive side effect of a medicine, we have been very cautious in publishing pharmacological evidence, as large trials would prove the benefits and side effects of these medicines currently under trial. Another important task of JACC: Case Reports is that we have tried to connect the dots in bridging clinical cases with publications in sister journals, including the main title, Journal of the American College of Cardiology.

COVID-19 Hub

As the COVID-19 pandemic developed, early reports suggested that CV disease was associated with COVID-19 morbidity and mortality. Accordingly, CV providers needed guidance on how to prevent COVID-19 infection in vulnerable patients and management advice for infected patients. In addition, they needed to understand how best to protect themselves and their teams from infection. All of these priorities necessitated rapid communication of credible information.

The American College of Cardiology (ACC) is a global organization, with approximately 20,000 of its 52,000 members hailing from non-U.S. countries, including those, such as China and Italy, with early experience in combating COVID-19. As such, the College was uniquely positioned to gather, collate, and disseminate information about the CV aspects of COVID-19. Under the guidance of the ACC Science and Quality Committee (SQC) and staff members, ACC members with expertise in virology and its impact on the CV system reviewed the emerging data on COVID-19 morbidity and mortality in CV patients and provided general guidance for its management. They noted that COVID-19 infection was more severe for those with underlying CV conditions and appeared to directly affect the CV system, potentially leading to acute heart failure, myocardial infarction, myocarditis, and cardiac arrest. They also addressed the contagiousness of COVID-19 and the need to protect the CV team taking care of these patients, not only for health care workers’ health but also to ensure that we had a sufficiently healthy workforce to assist with the growing COVID-19 population. They also issued calls for additional studies of these populations and development of care protocols.

In addition to this clinical bulletin development and release, several webinars developed by the ACC and the Chinese Cardiovascular Association were created to share early experiences with COVID-19 and CV disease, which were broadcast to the entire College. In the webinars, Chinese cardiologists presented their initial data and experience in managing patients with COVID-19 and cardiac complications. They also discussed initial considerations and experience with management protocols, and how they use personal protective equipment to protect themselves and their teams.

The demand for this information was huge. To date, there have been 7,400 downloads of the clinical bulletin, making it the most downloaded document in ACC history. Similarly, more than 18,000 people have viewed the Chinese webinar series. In recognition of this demand and the need to rapidly absorb, synthesize, and distribute information about COVID-19 and CV disease in “real time,” an online ACC COVID-19 information “hub” was created and featured on the ACC.org web site. A Hub executive team, consisting of ACC SQC and JACC leadership, met daily to review Hub activity, assess current needs, commission needed content, and govern its distribution on the Hub. Content was generally produced by ACC member experts and vetted by the SQC. In addition, the ACC often partnered with sister CV societies to develop and issue joint statements of mutual clinical interest.

To ease navigation on the ACC COVID-19 Hub, its content was organized into sections on clinical guidance, practice considerations, and frontline perspectives. Given the novelty and rapidity of the COVID-19 pandemic, most of the initial content was based on analyses of frontline experiences and expert opinion. The Hub executive team and SQC worked to ensure that the content struck a balance between reasonable, actionable suggestions and acknowledgment that more rigorous research was needed to better inform the best approach to COVID-19 management.

Hub content development occurred in direct response to emerging questions from ACC membership and the CV community. Examples of such content included the role of troponin and pro–brain natriuretic peptide measurement and interpretation in COVID-19, the management of patients with COVID-19 with acute cardiomyopathy or heart failure, the role of thrombosis and CV disease in COVID-19, and the impact of multisystem inflammatory syndrome in children on cardiac disease. Content was also developed about potential COVID-19 treatments and their CV effects. For example, there were questions about the interaction of the angiotensin-converting enzyme 2 receptor and renin-angiotensin-aldosterone system inhibitors, and the potential for either accelerating or retarding the progression of COVID-19. After review and synthesis of the data, the ACC issued a statement on the Hub indicating that there was no apparent impact of renin-angiotensin-aldosterone system inhibitors on COVID-19 and that no acute changes should be made to its use in COVID-19 patients, with a call for more research into potential interactions. Similarly, a joint statement by the ACC, American Heart Association, and Heart Rhythm Society was released highlighting the known arrhythmogenic effects of hydroxychloroquine and azithromycin, a potential COVID-19 treatment. It advised close QT monitoring in treated patients and enrollment in clinical trials.

Practice considerations were another important subject of Hub content. As hospitals deferred elective CV care in preparation for the initial COVID-19 surge, expert consensus statements were developed to guide cardiologists in the safe triage of their CV patients and, where possible, management of their patient populations virtually. As the pandemic spread, the CV community noted a significant decline in acute myocardial infarction and stroke presentations, potentially due to patients’ fear of accessing medical services during the pandemic. This observation was bolstered by early studies objectively demonstrating the decline in acute CV events across multiple U.S. and international health systems. As a result, a patient-facing campaign was organized and disseminated through the Hub and the College’s patient education web site, CardioSmart. The messaging focused on the need for patients to monitor for symptoms of unstable CV disease and seek immediate care. It highlighted the fact that the natural fear of COVID-19 should not dissuade patients from receiving this care and that health systems were well equipped to treat them while preventing COVID-19 infection. The Hub also featured content directed at health care providers and their health. Guidance for personal protective equipment, staffing considerations, and maintaining mental and physical health was provided.

The Hub also served as a conduit to the emerging research on COVID-19 and CV disease. All of the JACC journal content related to COVID-19 was featured on the Hub. In addition, the Hub relied heavily on the ACC Journal Scan program. This program continually scans the broader cardiology research for important CV research and features it on the ACC web site. During the pandemic, their focus turned to COVID-19 and reviewing the emerging research on CV trends in COVID-19 and treatment options. Much of this material and analysis was featured on the Hub.

Metrics tracking COVID-19 Hub engagement indicate that ACC membership and the general population have found it to be a valuable resource. To date, the site has had more than 1.5 million page views, with readers distributed worldwide. At its peak in mid-March, the site was accessed by more than 300,000 people daily. The most accessed content to date has included an article outlining the infectivity and spread of COVID-19 (222,000 views), arrhythmia risks of hydroxychloroquine and azithromycin (199,400 views), and renin-angiotensin-aldosterone system inhibitor use in patients with COVID-19 (124,600 views).

Going forward, the Hub will continue to generate content but now turn its attention to highlighting the growing peer-reviewed research on COVID-19 and CV disease. The ACC has commissioned a task force to promote research in this area, and the Hub will serve as a primary dissemination platform, in conjunction with JACC and other cardiology-focused journals. In addition, the Hub will highlight best practices and frontline experiences from its membership on “reopening” protocols. With projections that COVID-19 will ebb and flow worldwide over the next several years, our membership will need to navigate the best way to continue to treat CV disease during this time.

The ACC COVID-19 Hub has proved to be a useful resource to assembling and distributing information broadly during a rapidly evolving pandemic. Lessons learned include the need to build a nimble process to commission, organize, and distribute content, an ability to engage with experts to generate content, a method to closely monitor of member and community needs to inform content development, and an emphasis on highlighting rigorously conducted research and expert consensus over mere opinion and speculation.