key: cord-0067611-wxum7ge1
authors: Verdoia, Monica; De Luca, Giuseppe
title: Reply to: “Mortality and in-stent thrombosis in COVID-19 patients with STEMI: More work ahead”
date: 2021-09-15
journal: Atherosclerosis
DOI: 10.1016/j.atherosclerosis.2021.09.008
sha: c3c1335cf692fece84228a9c03f41f5c1d4887b0
doc_id: 67611
cord_uid: wxum7ge1

nan

In the letter to the Editor by Zuin et al. (1) , the authors raise several interesting points concerning the uncertainties linking coronavirus disease 2019 (COVID-19) to thrombosis, especially in the settings of acute coronary syndromes (ACS).

Despite the SARS-CoV-2 infection has been suggested to favour the occurrence of thrombotic phenomena in both the arterial and venous districts, the underlying pathophysiological mechanisms are still poorly understood, considering the complexity of data collection during the pandemic and the modest availability of experimental and clinical experience.

The ISACS-STEMI Registry (2, 3) provided, in this sense, a unique opportunity to assess the real impact of COVID-19 on the presentation, treatment and outcomes of ST elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI). In the recent study commented by Zuin However, several factors point at an increased pro-thrombotic state in COVID-positive patients, in addition to the higher rate of IST. In fact, De Luca et al. observed a higher trend for the use of GPIIbIIIa inhibitors and cangrelor, suggesting an enhanced thrombotic burden at presentation that could have promoted stent malapposition and inadequate sizing, and therefore the recurrence of ischemic events (5) . Deferred stenting has recently been proposed as a valid option in case of large thrombus persistence (6) , although this strategy could have J o u r n a l P r e -p r o o f been considered less applicable for infected patients, where the rapid stabilization of coronary lesions and conferment to COVID-units was required.

Nevertheless, a formal quantitative assessment of thrombus was not routinely performed due to the emergent nature of the PCI, preventing a large-scale use of intracoronary imaging.

Moreover, other clinical conditions promoting IST and mortality, as the rate of cardiogenic shock, were numerically higher in SARS-CoV-2 positive patients, although only a minority (less than 20%) required admission to the intensive care unit and less than 15% needed mechanical ventilation, probably not translating into a significant prognostic difference as compared to the control population.

In addition, other factors potentially increasing the risk of stent thrombosis, such as left main bifurcation lesions (7), were comparable or even more common in non-COVID patients.

Thus, considering the interesting and clinically relevant implications of the results of the ISACS-STEMI Registry and in similar cohorts of patients (2) (3) (4) 8) , further large studies are certainly needed to confirm whether SARS-CoV-2 patients undergoing PCI would potentially be at a different risk of IST and in-hospital mortality and to investigate the long-term outcomes.

Mortality and in-stent thrombosis in COVID-19 patients with STEMI: More work ahead

Impact of COVID-19 pandemic and diabetes on mechanical reperfusion in patients with STEMI: insights from the ISACS-STEMI COVID 19 Registry

Impact of SARS-CoV-2 positivity on clinical outcome among STEMI patients undergoing mechanical reperfusion: insights from the ISACS STEMI COVID 19 registry

Stent malapposition and the risk of stent thrombosis: mechanistic insights from an in vitro model

Role of deferred stenting in patients with ST elevation myocardial infarction treated with primary J o u r n a l P r e -p r o o f percutaneous coronary intervention: A systematic review and meta-analysis

Stent thrombosis in acute coronary syndromes: Patient-related factors and operator-related factors

High Thrombus Burden in Patients With COVID-19 Presenting With ST-Segment Elevation Myocardial Infarction

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.J o u r n a l P r e -p r o o f