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International Registry of Acute Coronary Syndromes in Patients With COVID-19
Quick Takes
- Compared with the pre-COVID era, there were significant delays in patients seeking medical care, and longer door-to-balloon times in COVID-STEMI patients, significantly higher rates of cardiogenic shock, and requirement for intensive care unit admission and ventilatory and/or hemodynamic support.
- There was quadrupling of in-hospital mortality in ACS compared with pre-COVID cohort databases.
- There is a need for clear and simple public health messages for patients to present expeditiously to the hospital when they first experience symptoms of ACS during the ongoing COVID-19 and future pandemics.
Study Questions:
What were the demographics, angiographic findings, and in-hospital outcomes of coronavirus disease 2019 (COVID-19) acute coronary syndrome (ACS) patients in comparison with pre–COVID-19 cohorts?
Methods:
The investigators designed a prospective COVID-ACS Registry and entered data from 55 international centers spanning March 1, 2020–July 31, 2020. Patients entered were COVID-19 positive (or had a high index of clinical suspicion) and underwent invasive coronary angiography for suspected ACS. Outcomes were in-hospital major cardiovascular events (all-cause mortality, re–myocardial infarction, heart failure, stroke, unplanned revascularization, or stent thrombosis). Results were compared with national pre–COVID-19 databases (MINAP [Myocardial Ischaemia National Audit Project] 2019 and BCIS [British Cardiovascular Intervention Society] 2018–2019). A propensity score–based inverse probability treatment weights method was then used to calculate the difference in mortality between patients recorded in the COVID-STEMI subgroup and pre–COVID-STEMI databases, further adjusted for cardiogenic shock status and ischemia time.
Results:
In 144 ST-segment elevation myocardial infarction (STEMI) and 121 non–ST-segment elevation acute coronary syndrome (NSTE-ACS) patients, symptom-to-admission times were significantly prolonged (COVID-STEMI vs. BCIS: median 339.0 min vs. 173.0 min; p < 0.001; COVID NSTE-ACS vs. MINAP: 417.0 min vs. 295.0 min; p = 0.012). Mortality in COVID-ACS patients was significantly higher than BCIS/MINAP control subjects in both subgroups (COVID-STEMI: 22.9% vs. 5.7%; p < 0.001; COVID NSTE-ACS: 6.6% vs. 1.2%; p < 0.001), which remained following multivariate propensity analysis adjusting for comorbidities (STEMI subgroup odds ratio, 3.33; 95% confidence interval, 2.04-5.42). Cardiogenic shock occurred in 20.1% of COVID-STEMI patients versus 8.7% of BCIS patients (p < 0.001).
Conclusions:
The authors concluded that COVID-19–positive ACS patients presented later and had increased in-hospital mortality compared with a pre–COVID-19 ACS population.
Perspective:
This prospective registry reports that compared with the pre-COVID era, there were significant delays in patients seeking medical care, and longer door-to-balloon times in COVID-STEMI patients, significantly higher rates of cardiogenic shock, and requirement for intensive care unit admission and ventilatory and/or hemodynamic support and quadrupling of in-hospital mortality compared with pre-COVID cohort databases. There is a need for clear and simple public health messages for patients to present expeditiously to the hospital when they first experience symptoms of ACS during the ongoing COVID and future pandemics. Additional research is indicated to elucidate the mechanisms that trigger ACS in patients with COVID-19, their impact on the incidence and outcomes of cardiogenic shock, and implications for optimal management.
Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, COVID-19 Hub, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging
Keywords: Acute Coronary Syndrome, Coronary Angiography, Coronavirus, COVID-19, Heart Failure, Hemodynamics, Hospital Mortality, Intensive Care Units, Myocardial Infarction, Myocardial Revascularization, Primary Prevention, Shock, Cardiogenic, Stents, Stroke, Thrombosis
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