key: cord-0943010-leg982aq
authors: Vidovich, Mladen I.; Fischman, David L.; Bates, Eric R.
title: COVID-19 STEMI 2020: It’s Not What You Know, It’s How You Think
date: 2020-04-27
journal: JACC. Case reports
DOI: 10.1016/j.jaccas.2020.04.016
sha: 601864b63dd2bd88c5d69882ffc389713c1e5115
doc_id: 943010
cord_uid: leg982aq

[Figure: see text]

Not now. We live in the COVID-19 era and how we approach STEMI has changed for the immediate future.

The authors employed a cognitive process to determine whether to perform emergent angiography instead of automatically activating the STEMI team. They established a low pre-test probability (29-years-old, absence of atherosclerotic risk factors), used information from the chest CT (absence of coronary calcification), demonstrated normal left ventricular ejection fraction and absence of wall motion abnormalities on echocardiography and supported their decision with negative cardiac biomarkers (troponin and myoglobin). They made another important decision -they did not administer fibrinolytic therapy for what turned out to be a STEMI mimic.

COVID-19 has introduced new clinical and logistical challenges in the treatment of STEMI. (5) We are learning that ST-elevation in the COVID-19 era may represent STEMI mimics; myocarditis, microvascular thrombosis, cytokine-mediated injury, and stress-induced cardiomyopathy are now clinical possibilities. Logistically, we now understand that the decision to proceed with angiography carries a significant risk for nosocomial spread of the virus endangering hospital staff. We are also learning that acute kidney injury is quite prevalent and highly associated with mortality in COVID-19 patients.(6) One should think twice before administering intravenous contrast medium in these patients.

have resurrected considering the use of fibrinolytic therapy for STEMI. (7) In a setting of limited staffing and resources, and where time-to-treatment is expected to be significantly delayed, fibrinolytic therapy provides a more rapid and logistically easier approach to reperfusion therapy while reducing staff exposure to infection. However, contraindications for fibrinolytic therapy have to be absent and STEMI mimics have to be excluded. The fibrinolytic strategy is probably most reasonable for hospitals without PCI-capability or immediate availability. At PCI-capable hospitals with adequate staffing, primary PCI is still preferred. (8, 9) Until there is universal availability of rapid testing (< 5 min) for both the virus and the antibodies, our approach to STEMI will have to be modified. This is primarily due to new 4 infection control considerations that will have to be included in our daily workflow. The current door-to-balloon time quality metric should be suspended by hospital quality improvement committees as a measure of system performance because of the current diagnostic and logistical challenges in delivering STEMI care. In the ACC NCDR CathPCI Registry reporting form, noting a "system delay" as a reason for a prolonged door-to-balloon time will avoid any external quality of care penalties.

We now work in the era of COVID-19 STEMI care. The days of reflexively activating the STEMI team for immediate primary PCI have to be modified as we work through the challenges of STEMI mimics and delays in time-to-treatment.

Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China. JAMA Cardiol

Outbreak on ST-Segment-Elevation Myocardial Infarction Care in Hong Kong, China. Circ Cardiovasc Qual Outcomes

Considerations for cardiac catheterization laboratory procedures during the COVID-19 pandemic

Pseudo acute myocardial infarction in a young COVID-19 patient

Reperfusion of STEMI in the COVID-19 Era-Business as Usual? Circulation

Kidney disease is associated with in-hospital death of patients with COVID-19

Recommendations from the Peking Union Medical College Hospital for the management of acute myocardial infarction during the COVID-19 outbreak

Catheterization laboratory considerations during the coronavirus (COVID-19) pandemic: from ACC's Interventional Council and SCAI

Precautions and procedures for coronary and structural cardiac interventions during the COVID-19 pandemic: guidance from Canadian Association of Interventional Cardiology