Reperfusion of STEMI in the COVID-19 Era

Daniels MJ, Cohen MG, Bavry AA, Kumbhani DJ.
Reperfusion of STEMI in the COVID-19 Era – Business as Usual? Circulation 2020;Apr 13:[Epub ahead of print].

The following are key points to remember from this perspective on how patients with ST-segment elevation myocardial infarction (STEMI) should be managed during the COVID-19 pandemic:

  1. The authors pose the question of whether STEMI treatment during the COVID-19 pandemic be re-examined and if the fibrinolytic first approach should be considered the primary treatment choice over primary percutaneous coronary intervention (PCI).
  2. Currently in US practice, 13% of all STEMI patients receive pharmacoinvasive therapy, which includes a ‘drip and ship’ approach of fibrinolytic therapy (FT) followed by transfer to a PCI center for coronary angiography and PCI within 6-24 hours.
  3. Given its established efficacy, authors make a case for considering FT as primary therapy during the COVID-19 pandemic for STEMI patients presenting within 3 hours of symptoms and without any high-risk clinical findings.
  4. FT potentially could mitigate delays in reperfusion related to increased overall time in the emergency room (establish history, sick contacts, and any additional testing to rule out COVID-19) and additional time needed for cath teams to be appropriately protected.
  5. Door-to-needle time may be a quicker way to reperfusion even when primary PCI capabilities exist at the hospital.
  6. FT may also be advantageous from the standpoint of resource utilization and protection of essential health care staff such as cath teams.
  7. Patients can be considered for completion of a pharmacoinvasive strategy once COVID-19 has been ruled out.
  8. A proposed algorithm retains emergent PCI for patients who are ‘high risk’ and those who fail reperfusion therapy.
  9. As with other aspects of life, continuing with business as usual for STEMI care in the COVID-19 pandemic era may need to be reconsidered and FT may provide a viable alternative option.

Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Acute Coronary Syndrome, Coronary Angiography, Coronavirus, COVID-19, Delivery of Health Care, Emergency Service, Hospital, Fibrinolytic Agents, Myocardial Infarction, Myocardial Reperfusion, Percutaneous Coronary Intervention, Reperfusion, severe acute respiratory syndrome coronavirus 2, Thrombolytic Therapy

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