Stenting for STEMI Still Predominant Strategy Even with Covid-19 Onboard

Although patients whose ST-segment elevation myocardial infarction (STEMI) is complicated by a diagnosis of Covid-19 should be considered high risk, primary percutaneous coronary intervention (PPCI) such as stenting is not only feasible but is also the predominant treatment strategy used, according to an analysis of data from the North American Covid-19 and STEMI registry (NACMI).

Santiago Garcia, MD, of the Minneapolis Heart Institute Foundation, and colleagues, writing in the Journal of the American Collage of Cardiology, reported that 179 of 230 STEMI patients with confirmed Covid-19 underwent angiographic assessment and of those, 71% received PPCI. “Other reperfusion strategies included facilitated or rescue PCI (n=7, 4%), thrombolytic therapy (n=6, 3%), and coronary artery bypass grafting surgery (n=3, 2%)… 36 (20%) received medical management alone without reperfusion.”

When compared with age- and sex-matched controls, the majority of patients still underwent catheter-based reperfusion, but that majority was more robust: 93% versus just 2% who had medical management, in both cases there was a statistically significant difference compared with the Covid-19 STEMI patients (P<0.001).

Garcia and colleagues pointed out that in 23% of the Covid + STEMI patients who underwent angiography, no culprit vessel was detected. That result suggests the possibility of “different etiologies of ST-segment elevation including microemboli, myocarditis, takotsubo cardiomyopathy…”

NACMI is a collaborative project of the Society for Cardiovascular Angiography and Interventions (SCAI) and Canadian Association of Interventional Cardiologists in conjunction with the American College of Cardiology (ACC) Interventional Council.

Most of the registry participants were men (71%) and most were ages 56 to 75. About one in four Covid-19 positive participants (24%) were Black, as were 10% of those under investigation for Covid-19, while Whites comprised 39% of the Covid-19 positive participants and 76 of those suspected to have Covid-19. Hispanics accounted for 23% of the positive and 6% of suspected Covid-19 participants; only 6% of confirmed and 5% of suspected Covid-19 participants were Asian.

“Dyspnea was the most common presenting symptom (54%), and 46% of patients had [opacities on chest radiography]. A significant proportion of Covid + patients presented with high-risk pre-PCI conditions, including cardiogenic shock (18%) and cardiac arrest (11%),” they wrote.

The analysis included 495 STEMI patients under investigation for Covid-19 who were later found to be negative and 460 controls.

The primary outcome measure was a composite of in-hospital death, stroke, recurrent or unplanned revascularization and, as might be expected, the Covid-19 STEMI patients fared worse on this measure: 36% had a primary endpoint event, versus 13% of the suspected Covid-19 patients and 5% of controls (P<0.001 Covid-19 versus suspected Covid-19 patients and Covid-19 versus controls). “The difference was driven primarily by increased in-hospital mortality (Covid + patients 33%, PUIs 11%, and controls 4%;” P<0. 001 when compared to controls or suspected cases. Covid-19 patients also had a higher rate of stroke.

“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).”

In an editorial comment published with the registry findings, Ran Kornowski, MD, and Katia Orvin, MD from the Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel, and Tel Aviv University, wrote that the data once again point out how the Covid-19 toll is higher among minorities.

“One of the striking observations of the NACMI registry is that the patients with Covid-19 look very different than any other STEMI population seen in this registry (i.e., the patients under investigation for Covid-19 and the control group) or any other North American STEMI registry; for example, the percentage of Blacks and Hispanic/Latino Americans among patients in the STEMI group with Covid-19 is exceptionally high (47%). This finding may imply that STEMI care in the presence of Covid-19 may disproportionally affect minority groups and that future focus of care should be directed to a double challenge: addressing unique aspects of STEMI with Covid-19 and economic and social issues associated with STEMI in minority populations.”

Although the NACMI registry is the “largest prospective, multicentric STEMI Covid registry,” there are a number of limitations, including a lack of pre-hospital data and delays in STEMI presentations caused by the pandemic, which may be a factor in the worse observed outcomes.

1. The NACMI registry data suggest that patients with STEMI and concomitant Covid-19 infection are more likely to present with dyspnea, have diabetes mellitus, and to belong to an ethnic minority.

2. Stenting and PCI strategies are feasible for these patients, who are at high risk of stroke and in-hospital mortality.

Peggy Peck, Editor-in-Chief, BreakingMED™

Cat ID: 358

Topic ID: 74,358,358,190,926,192,927,151,928