key: cord-0732036-fhp1ox64
authors: Secco, Gioel Gabrio; Tarantini, Giuseppe; Mazzarotto, Pietro; Garbo, Roberto; Parisi, Rosario; Maggio, Silvia; Vercellino, Matteo; Pistis, Gianfranco; Audo, Andrea; Kozel, Daniela; Centini, Giacomo; Di Mario, Carlo
title: Invasive strategy for COVID patients presenting with acute coronary syndrome: The first multicenter Italian experience
date: 2020-05-12
journal: Catheter Cardiovasc Interv
DOI: 10.1002/ccd.28959
sha: 2bdf713b875058bc6a33d417f94f64b3819b4462
doc_id: 732036
cord_uid: fhp1ox64

OBJECTIVE: To report our initial experience of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2)/acute coronary syndrome (ACS) patients undergoing standard of care invasive management. BACKGROUND: The rapid diffusion of the SARS‐CoV‐2 together with the need for isolation for infected patients might be responsible for a suboptimal treatment for SARS‐CoV‐2 ACS patients. Recently, the group of Sichuan published a protocol for COVID/ACS infected patients that see the thrombolysis as the gold standard of care. METHODS: We enrolled 31 consecutive patients affected by SARS‐COV‐2 admitted to our emergencies room for suspected ACS. RESULTS: All patients underwent urgent coronary angiography and percutaneous coronary intervention (PCI) when required except two patients with severe hypoxemia and unstable hemodynamic condition that were conservatively treated. Twenty‐one cases presented diffuse ST‐segment depression while in the remaining cases anterior and inferior ST‐elevation was present in four and six cases, respectively. PCI was performed in all cases expect two that were diagnosed as suspected myocarditis because of the absence of severe coronary disease and three with apical ballooning at ventriculography diagnostic for Tako‐Tsubo syndromes. Two patients conservatively treated died. The remaining patients undergoing PCI survived except one that required endotracheal intubation (ETI) and died at Day 6. ETI was required in five more patients while in the remaining cases CPAP was used for respiratory support. CONCLUSIONS: Urgent PCI for ACS is often required in SARS‐CoV‐2 patients improving the prognosis in all but the most advanced patients. Complete patient history and examination, routine ECG monitoring, echocardiography, and careful evaluation of changes in cardiac enzymes should be part of the regular assessment procedures also in dedicated COVID positive units.

In late December 2019, a cluster of pneumonia cases caused by a novel coronavirus (nCoV) occurred in Wuhan, China and has spread rapidly initially throughout China and later in Europe. 1 with Italy as the third country with most confirmed cases (187,327). 3 The pathogen of this pneumonia was originally called 2019 nCoV and later officially named by the World Health Organization (WHO) severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In fact, SARS-CoV-2 targets the respiratory tract and shares many similar clinical symptoms with SARS-CoV and MERS-CoV both coronavirus responsible for 8,422 and 1,600 infections with 916 and 574 deaths, respectively. 4, 5 Common symptoms include fever, dry cough, fatigue, and worsening dyspnea usually associated with a significant increase in biomarkers of myocardial necrosis (a significant increase in highsensitivity cardiac troponin I-hs-cTnI-levels has been reported in SARS-nCOV-2 patients). [6] [7] [8] [9] Interstitial pneumonia might rapidly evolve in severe acute respiratory distress syndrome (ARDS) followed by respiratory failure needing invasive ventilation. This rapidly evolving ARDS explains the reason why acute medical treatment in SARS-CoV-2 patients is mainly focused in respiratory care reducing the attention to other active comorbidities often present in the elderly patients showing the worst compromise during these epidemics. In elderly patients, worsening dyspnea can be the only symptom of a concomitant cardiovascular injury. In this article, we report our initial experience of SARS-COV-2/acute coronary syndrome (ACS) NSTEMI/STEMI patients undergoing standard of care invasive management.

We prospectively collected data of 31 consecutive patients admitted for worsening dyspnea associated with significant increase in troponin and/or hemodynamic instability. Twelve-leads ECG showed diffuse or regional ST-segment depression in 21 cases; in the remaining, anterior or inferior ST-segment elevation was found in four and six patients, respectively. All patients reported a recent history of fever associated with dry cough and urgent chest X-ray showed signs of interstitial pneumonia and/or patchy edema at various grade of severity. All were initially diagnosed as "suspected for SARS-CoV-2" and confirmed thereafter using the appropriate test.

Patients signed an informed consent for data collection and the study was conducted according to the Declaration of Helsinki.

Patients not preloaded with oral aspirin and/or clopidogrel received a loading dose of intravenous aspirin (500 mg) followed by Cangrelor infusion followed by ticagrelor (180 mg) as standard practice. Crushed ticagrelor via a nasogastric tube was used to continue treatment in the intubated patients. Intravenous heparin (70 UI/kg body weight) was administered before the procedure with subsequent boluses aiming at achieving an activated clotting time between 250 and 300 s.

No GP IIb/IIIa inhibitors were used. All lesions were treated with stent implantation and high-pressure balloon postdilatation.

Angiographic results and in-hospital outcome were prospectively collected and entered into a dedicated interventional cardiology database. Clinical events were evaluated postprocedure, during hospitalization and after discharge by a telephone interview.

From February 20 to April 15, 2020, 31 SARS-CoV-2 patients admitted in our hospitals developed clinical and biochemical signs suggesting ACS STEMI/NSTEMI/TTS. Patients and lesion/procedural characteristics are shown in Table 1 . The average age was 72.3 ± 9 years with a prevalence of male sex (77.4%) and high prevalence of risk factors (hypertension 71%, diabetes 38.7%, current smoking 35.5%, dyslipidemia 58%). In 11 patients, a history of coronary artery disease (CAD) was present, with previous percutaneous coronary intervention/coronary artery bypass graft (PCI/CABG) in nine and six, respectively (four patients received both CABG and PCI). All patients presented to hospital because of dyspnea and fever and the suspicion of an ACS was raised only when the patients were already admitted to the dedicated COVID ward or intensive therapy unit because of sudden chest pain and/or ECG signs of ACS NSTEMI/STEMI, with confirmatory hs-cTnI increase and echocardiographic regional LV wall motion abnormalities. All patients underwent urgent angiography except two patients with severe hypoxemia and unstable hemodynamics that were conservatively treated. Coronary angiography/PCI Angiography and Intervention suggests that fibrinolysis can be considered as an option for the relatively stable STEMI patient with active COVID-19. 13 These findings might partially explain the high mortality rate in ICU admitted SARS-nCoV-2 patients compare with non-ICU ones. 6, 14 In our experience, we maintained the same proactive attitude recommended by Guidelines and standard in our hospitals. Despite a slight delay due to extra precautions during transportation and the preparation of the operators with appropriate individual protection means (surgical mask, double gloves, glasses, fully disposable complete sterile gowns, and caps), the average time from diagnosis to reperfusion for STEMI patients was 43 + 12 min, within recommended standards. A standard approach was also followed for the angioplasty, avoiding immediate multivessel treatment in the presence of a likely culprit for ischemia also in NSTEMI patients, in order to facilitate patients' tolerance in terms of respiratory distress (only one emergency intubation was required) and renal dysfunction. There was only one cardiac death in the group treated with PCI (a man with previous CABG and three-vessel disease associated with severe aortic stenosis), an incidence consistent with the good outcome of urgent PCI in ACS, while both patients treated conservatively without any angiographic examinations died. Despite this, we still support the avoidance of futile procedures in patients with too advanced respiratory failure SECCO ET AL.

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