key: cord-266456-10tjzqep authors: Sadeghipour, Parham; Talasaz, Azita H.; Eslami, Vahid; Geraiely, Babak; Vojdanparast, Mohammad; Sedaghat, Mojtaba; Moosavi, Abouzar Fakhr; Alipour‐Parsa, Saeed; Aminian, Bahram; Firouzi, Ata; Ghaffari, Samad; Ghasemi, Massoud; Saleh, Davood Kazemi; Khosravi, Alireza; Kojuri, Javad; Noohi, Feridoun; Pourhosseini, Hamid; Salarifar, Mojtaba; Salehi, Mohamad Reza; Sezavar, Hashem; Shabestari, Mahmoud; Soleimani, Abbas; Tabarsi, Payam; Parsa, Amir Farhang Zand; Abdi, Seifollah title: Management of ST‐segment‐elevation myocardial infarction during the coronavirus disease 2019 (COVID‐19) outbreak: Iranian“247” National Committee's position paper on primary percutaneous coronary intervention date: 2020-04-22 journal: Catheter Cardiovasc Interv DOI: 10.1002/ccd.28889 sha: doc_id: 266456 cord_uid: 10tjzqep World Health Organization has designated coronavirus disease 2019 (COVID‐19) as a pandemic. During the past several weeks, a considerable burden has been imposed on the Iranian's healthcare system. The present document reviewed the latest evidence and expert opinion regarding the management of ST‐segment‐elevation myocardial infarction during the outbreak of COVID‐19 and outlines a practical algorithm for it. Middle East respiratory syndrome, are a major problem allied to COVID-19. 8, 9 The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is highly contagious, even from the asymptomatic population, with a large portion of nosocomial transmissions occurring through contacts between clinicians and visitors with no or mild symptoms of COVID-19. 8 Very few catheterization laboratories (Cath labs) are equipped with negative ventilation systems and, consequently, the risk of transmission remains high with each encounter. 5 The success of the safety measures adopted is further compromised by limited access to personal protective equipment (PPE), staff exhaustion, and multiple reexposures. Such safety concerns, along with the acceptable mortality benefit of the new generation of fibrinolytic agents, have placed thrombolytic therapy as a potential first choice on several occasions during the outbreak. The following points should be considered before the application of the protocol: 1. This is a consensus-based protocol, and the majority of its recommendations have been provided based on expert opinion. 2. It is strongly recommended that each and every "247" primary PCI-dedicated center continue registration of patients admitted with STEMI to the national database. 3. Due to the high transmission rate from asymptomatic patients, patient transport between centers regardless of the COVID-19 status should be restricted. c. SO 2 < 93%. d. Lymphopenia (less than 1,500 lymphocytes/μl). e. Thrombocytopenia (less than 100,000 platelets/μl). 6 . Critical patients with COVID-19 pneumonia (Figure 1 ) should be defined as those that meet one of the following three criteria: (1) respiratory failure, (2) septic shock, and (3) multiple organ failure. Patients with those criteria have a mortality rate of 49% and, consequently, supportive care should be the main strategy. 8 7. In many occasion (Figure 1 ), thrombolytic therapy is the main reperfusion strategy in patients admitted less than 12 hr following the onset of chest pain. Our major concerns apropos the present recommendation are personal safety and nosocomial transmissions. 8. While primary PCI is considered the gold standard therapy in the management of primary PCI, the following statements strongly suggest that thrombolytic therapy may be a suitable substitute on special occasions: a. During the first 3-6 hr from the symptom onset, thrombolytic therapy has gained comparable results with primary PCI. 10, 11 b. Delay in reperfusion therapy is widely acknowledged as a key determinant for poor survival. 12 c. The emotional stress generated by the present outbreak, combined with the high burden imposed on healthcare systems, might significantly delay patient transfer to the Cath lab. 13 9. During the outbreak, primary PCI should be permitted only in "247" primary PCI-dedicated centers in which appropriate PPE is adhered to (see below). It is vital that primary PCI be postponed and replace by thrombolytic therapy, if PPE is not guaranteed. 11 . In patients with STEMI, the fibrinolytic agent of choice is tenecteplase according to the ESC and ACC guidelines due to its superior efficacy in terms of the patency rate (90 min of TIMI flow Grade 2 or 3) (Table 1) , unless the patient has the contraindications shown in Table 2 . [14] [15] [16] Nonetheless, another factor that should be considered is the difference between fibrinolytics in terms of bleeding. As patients with COVID-19 could be at higher risk of bleeding, in particular in severe cases, the fibrinolytic with the least potential of bleeding should be applied. [17] [18] [19] Fortunately, tenecteplase appears to be the superior agent because of its association with less fibrin depletion. In light of the higher success rate of tenecteplase, it can be recommended as the agent of choice. [14] [15] [16] In elderly patients (older than 75 years old), a half dose of tenecteplase is recommended. 14 14, 15 Enoxaparin is also preferred to UFH for anticoagulation extending beyond 48 hr. 14, 15 Still, if the patient is at high risk of bleeding due to COVID-19, UFH would be a better option because of the availability of protamine as a reversal agent. It should be noted that clopidogrel also has significant interactions with lopinavir/ritonavir, which may reduce its conversion to active metabolites. 16 The following points should be considered with regard to optimal medical therapy: f. Mouth-to-mouth ventilation and pocket mask use should be avoided. g. If the patient is already receiving supplemental oxygen therapy through a facemask, the mask should be left on the patient's face during chest compressions as this may limit aerosol spread. Otherwise, a facemask should be placed on the patient's face. h. The number of staff in the room (if a single room) should be minimized. i. All equipment used during CPR should be disposed of or cleaned. The present document, in compliance with the available evidence and clinical judgment, seeks to provide a practical protocol for the management of STEMI. Indubitably, all the aforementioned recommendations are subject to change given the fluidity of the COVID-19 epidemic status. World Health Organization. WHO Director-General's opening remarks at the media briefing on COVID-19 Third report from epidemiological COVID-19 committee COVID-19 clinical guidance for the cardiovascular care team Society for Cardiovascular Angiography and Interventions. 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