PRIORITY PLAN
The overarching principle is that all invasive cardiac electrophysiology procedures that can be reasonably postponed without compromising patient safety should be, until further guidance is available. It is unclear how long postponement of elective procedures will continue to be advised. Reasonable non-invasive options that allow for expedited discharge are preferred.
Challenges for cardiac electrophysiology, like many medical and surgical specialties, are present when differentiating elective versus non-elective procedures.10 However, guidelines and consensus statements have been issued by ACC, AHA, and HRS. These have standardized systems that categorize therapies by “Classification of Recommendation.”11 The following priority plan, presented in the Figure , builds upon these documents.
The first consideration, “Guideline or Consensus Statement Classification of Recommendation”, allows for the assessment of a multitude of procedures already systematically studied by several guideline and consensus statement committees. It avoids the need for an exhaustive list of procedures and clinical scenarios. The second consideration, “Anticipated Short-term Morbidity or Mortality Benefit”, allows for tailoring to the unique clinical characteristics and presentations of each patient. A 30- to 90-day definition of “short-term” may be adjusted based on individual scenarios and projected time frames to reschedule procedures. Procedures and scenarios with class IIb recommendations, by definition, have weak support, so there are no circumstances to expect high short-term benefit. This priority plan allows for adoption by other countries and regions with their own guidelines and consensus statements that use a similar “Classification of Recommendation” system.12 It may also be used or adapted for future pandemics.
Pacemaker and implantable cardioverter-defibrillator (ICD) generator changes are not addressed well in guidelines. Devices within the elective replacement interval should be considered emergent/urgent or equivocal, depending on the indication and the estimated remaining battery life. Same-day discharges for new implants may be encouraged to lower inpatient time and resource utilization.
Hospitalization status may have some bearing on determining potential benefit, particularly if an arrhythmia incited the index hospitalization and may recur in the near future. Hospitalization per se is not a justification for recommending expedited therapy as some may be safely discharged at low risk.
Legal issues should be considered since CMS recommendations were issued.8 Hospitals were investigated and fined by the United States Department of Justice nearly one decade ago, in part due to violating CMS policies for the primary prevention ICD. Gross violations to the “no elective procedures” recommendation during the COVID-19 pandemic could conceivably trigger investigations. Proactively documenting the rationale for non-elective procedures is worth considering.