STEMI and COVID-19: Angiographic Outcomes

Quick Takes

  • Symptoms of STEMI were the main reason for presentation, and abnormal wall motion was seen on echo in the majority of patients.
  • Culprit lesion was identified in 60% of the STEMI patients, while the rest had type 2 acute MI.
  • The impact of primary PCI on time to reperfusion and outcomes during the pandemic remains to be determined.

Study Questions:

What are the incidence, clinical presentation, angiographic characteristics, and clinical outcomes of patients with ST-segment elevation myocardial infarction (STEMI) and coronavirus disease 2019 (COVID-19)?

Methods:

This is a retrospective analysis from Lombardy, Italy. Data from all confirmed COVID-19 patients who underwent coronary angiography due to STEMI from February to March 2020 were analyzed. STEMI was defined based on the presence of typical symptoms associated with STEMI or new left bundle branch block (LBBB). A stenosis was considered a culprit lesion in case of angiographic evidence of thrombotic occlusion/subocclusion. Obstructive coronary artery disease was defined based on the angiographic evidence of a stenosis >50% on visual estimation.

Results:

A total of 28 patients with COVID-19 and STEMI were included. The mean age was 68 ± 11 years; eight patients (28.6%) were women. For 24 patients (85.7%), the STEMI represented the first clinical manifestation of COVID-19, and did not have a COVID-19 test result at the time of coronary angiography. The remaining four patients suffered from a STEMI during hospitalization for confirmed COVID-19. The majority had localized wall motion on echocardiography (82.1%). Of these patients, 17/28 (60.7%) had evidence of a culprit lesion requiring revascularization and 11 patients (39.3%) did not have obstructive coronary artery disease. As of March 31, 2020 (median follow-up 13 days, interquartile range 2-20 days), 11 patients (39.3%) died, one (3.6%) was still hospitalized in the intensive care unit, and 16 (57.1%) had been discharged.

Conclusions:

STEMI may represent the first clinical manifestation of COVID-19. In approximately 40% of COVID-19 patients with STEMI, a culprit lesion is not identifiable by coronary angiography. A dedicated diagnostic pathway should be delineated for COVID-19 patients with STEMI, aimed at minimizing patients’ procedural risks and healthcare providers’ risk of infection.

Perspective:

This single-center retrospective analysis from Northern Italy provides a review of COVID-19 patients with STEMI. Symptoms of STEMI were the reason for presentation in the majority of patients from this analysis. Emergent coronary angiography confirmed an obstructive thrombotic lesion in 60% of the patients, while 40% were due to type 2 acute MI. Authors did not show door-to-balloon times for the cohort. Delay in reperfusion related to providing adequate protection to healthcare staff has been one of several concerns of primary percutaneous coronary intervention (PCI) during the pandemic. Use of fibrinolytics as an alternative has been considered; however, based on these data, 40% of patients would receive therapy in the absence of a thrombotic culprit lesion. As per society recommendations, COVID-19 patients with STEMI should be considered for primary PCI as the default approach with utilization of alternative management strategies in select patients. The impact of COVID-19 on STEMI outcomes remains to be determined.

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Atherosclerotic Disease (CAD/PAD), EP Basic Science, Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Echocardiography/Ultrasound, Nuclear Imaging

Keywords: Acute Coronary Syndrome, Bundle-Branch Block, Constriction, Pathologic, Coronary Angiography, Coronary Artery Disease, Coronavirus, Coronary Occlusion, Coronavirus Infections, COVID-19, Echocardiography, Myocardial Infarction, Myocardial Revascularization, Patient Discharge, Percutaneous Coronary Intervention, severe acute respiratory syndrome coronavirus 2, ST Elevation Myocardial Infarction


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