Management of AMI During COVID-19 Pandemic

Mahmud E, Dauerman HL, Welt FG, et al.
Management of Acute Myocardial Infarction During the COVID-19 Pandemic. J Am Coll Cardiol 2020;Apr 20:[Epub ahead of print].

The following are key points to remember from a Consensus Statement from the Society for Cardiovascular Angiography and Interventions (SCAI), American College of Cardiology (ACC), and American College of Emergency Physicians (ACEP) about management of acute myocardial infarction (AMI) during the COVID-19 pandemic:

  1. The worldwide pandemic caused by the novel severe acute respiratory syndrome coronavirus-2 (SARS–CoV-2) has resulted in a new and lethal disease termed coronavirus disease 2019 (COVID-19). The objective of this document is to provide recommendations for a systematic approach for the care of patients with an AMI during the COVID-19 pandemic.
  2. Two point-of-care assays have recently received Food and Drug Administration approval for rapidly making the diagnosis of COVID-19. As these tests become widely available, they should be routinely implemented in all ST-segment elevation myocardial infarction (STEMI) patients to better characterize patient diagnosis and risk, optimize the treatment plan for a given patient (for AMI ± COVID-19), and guide appropriate placement within the hospital, including a dedicated cardiac catheterization laboratory (CCL) and post-procedure unit.
  3. Ensuring adequate protection of all health care workers in the emergency medical service (EMS), transfer hospitals, percutaneous coronary intervention (PCI) Center emergency department (ED), and the CCL team is critical. At this time, all patients requiring emergent activation of the CCL should be treated as COVID-19 possible. Given the potential risk of aerosol generation during all emergency AMI procedures, this writing group recommends personal protection equipment (PPE) with aerosolization protection (including gowns, gloves, full face mask, and an N95 respiratory mask) for the entire CCL staff during PCI for all AMI patients during this COVID-19 pandemic.
  4. Primary PCI is the standard of care for patients presenting to PCI centers (within 90 minutes of first medical contact). This should remain the standard of care for STEMI patients during the COVID-19 pandemic with some important caveats.
  5. Each primary PCI center will need to monitor the ability to provide timely primary PCI based on staff and PPE availability, need for additional testing, as well as a designated CCL, which will require terminal cleaning after each procedure. In the absence of these resources, a fibrinolysis first approach should be considered.
  6. Additional time to establish an AMI diagnosis may be indicated (e.g., in some cases, echocardiography to assess for wall motion), and/or for COVID-19 status assessment and potential treatment (e.g., respiratory support). Thus, during the COVID-19 pandemic, there may be longer door-to-balloon times.
  7. Due to the logistical issues and time delays secondary to diagnostic uncertainty of STEMI with COVID-19, direct transport of the patient to the CCL is not felt to be prudent at this time. The authors recommend initial assessment of all STEMI patients in the ED during the COVID-19 pandemic to ensure the correct diagnosis and care plan. The attending interventional cardiologist should be notified, but without activation of the entire STEMI team until the plan for CCL activation is confirmed.
  8. This document notes that not all COVID-19 patients with ST elevation with/without an acute coronary occlusion will benefit from any reperfusion strategy or advanced mechanical support. In COVID-19 confirmed patients with severe pulmonary decompensation (adult respiratory distress syndrome) or pneumonia who are intubated in the intensive care unit and felt to have an excessively high mortality, consideration for compassionate medical care may be appropriate.
  9. Regarding non–ST-segment elevation acute coronary syndrome, COVID-19 positive or probable patients should be managed medically and only taken for urgent coronary angiography and possible PCI in the presence of high-risk clinical features (GRACE [Global Registry of Acute Coronary Events] score >140) or hemodynamic instability.
  10. These recommendations will need to be adapted to each regional system’s PCI Center, STEMI referral hospitals, and EMS system and will need to be communicated clearly between cardiology and emergency medicine providers within each hospital. For now, each system must recognize the competing and equally important principles of: a) timely reperfusion of STEMI patients, b) safe regional transport and treatment of potentially high-risk patients, and c) additional emphasis on protection and safety of all health care personnel.

Clinical Topics: Acute Coronary Syndromes, COVID-19 Hub, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Interventions and ACS, Interventions and Imaging, Angiography, Echocardiography/Ultrasound, Nuclear Imaging

Keywords: Acute Coronary Syndrome, Cardiac Catheterization, Coronary Angiography, Coronary Occlusion, Coronavirus, COVID-19, Echocardiography, Emergency Service, Hospital, Fibrinolysis, Health Personnel, Myocardial Infarction, Percutaneous Coronary Intervention, Personal Protective Equipment, Point-of-Care Systems, Respiratory Distress Syndrome, Secondary Prevention, severe acute respiratory syndrome coronavirus 2, Standard of Care

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