Initial Findings From North American COVID-19 MI Registry
- COVID+ patients with STEMI represent a high-risk group of patients, with one in three patients succumbing to the disease even among patients selected for invasive angiography (28% mortality).
- It disproportionately affects ethnic minorities with diabetes mellitus.
- COVID+ patients with STEMI are less likely to undergo PCI, and the reported door-to-balloon times are longer in this group.
What are the demographic characteristics, management strategies, and outcomes of coronavirus disease 2019 (COVID-19) patients with ST-segment elevation myocardial infarction (STEMI)?
The study authors created a prospective, ongoing observational registry, NACMI (North American COVID-19 and STEMI). It includes STEMI patients with confirmed COVID+ (group 1) or suspected (person under investigation [PUI]) (group 2) COVID-19 infection. A group of age- and sex-matched STEMI patients (matched to COVID+ patients in a 2:1 ratio) treated in the pre-COVID era (2015-2019) served as the control group for comparison of treatment strategies and outcomes (group 3). The primary outcome was a composite of in-hospital death, stroke, recurrent MI, or repeat unplanned revascularization.
The study cohort was comprised of 1,185 patients in the NACMI registry including 230 COVID+ patients, 495 PUIs, and 460 control patients. COVID+ patients were typically male (71%) and between 56 and 75 years of age. COVID+ patients were more likely to have minority ethnicity (Hispanic 23%, Black 24%, Asians 6%, with Whites representing only 39% of patients) and had a higher prevalence of diabetes mellitus (46%) (all p < 0.001 relative to PUIs). COVID+ patients were more likely to present with cardiogenic shock (18%) and cardiac arrest (11%) but were less likely to receive invasive angiography (78%) (all p < 0.001 relative to control patients). Among COVID+ patients who received angiography, 71% received primary percutaneous coronary intervention (PCI) and 20% received medical therapy (both p < 0.001 relative to control patients). The primary outcome (a composite of in-hospital death, stroke, recurrent MI, or repeat unplanned revascularization) occurred in 36% of COVID+ patients, 13% of PUIs, and 5% of control patients (p < 0.001 relative to control patients). Among COVID+ patients, mortality was higher for those who did not undergo coronary angiography (n = 24 of 50, 48%) versus those who did (n = 49 of 179, 28%) (p = 0.006). COVID+ patients also had longer length of stay and intensive care unit stay.
The study authors concluded that COVID+ patients with STEMI represent a high-risk group of patients with unique demographic and clinical characteristics. And the authors opined that primary PCI is feasible and remains the predominant reperfusion strategy.
The worse prognosis of STEMI in COVID+ patients is multifactorial including possible higher thrombus burden, comorbidities such as diabetes, and delay in revascularization because of factors such as atypical presentation. The findings of this study should prompt health systems and health care providers to recalibrate their approach to STEMI in COVID+ patients.
Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Stable Ischemic Heart Disease, Vascular Medicine, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and SIHD, Acute Heart Failure, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Nuclear Imaging, Chronic Angina
Keywords: Coronary Angiography, Coronavirus, COVID-19, Diabetes Mellitus, Ethnic Groups, Intensive Care Units, Length of Stay, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention, Primary Prevention, Reperfusion, Shock, Cardiogenic, ST Elevation Myocardial Infarction, Stroke, Thrombosis
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