key: cord-0767722-t3yvm6kf authors: Choudry, Fizzah A.; Hamshere, Stephen M.; Rathod, Krishnaraj S.; Akhtar, Mohammed M.; Archbold, R. Andrew; Guttmann, Oliver P.; Woldman, Simon; Jain, Ajay K.; Knight, Charles J.; Baumbach, Andreas; Mathur, Anthony; Jones, Daniel A. title: High Thrombus Burden in Patients With COVID-19 Presenting With ST-Segment Elevation Myocardial Infarction date: 2020-09-08 journal: J Am Coll Cardiol DOI: 10.1016/j.jacc.2020.07.022 sha: e2f9ce41b04804aa3758fc1071972e9897a396dc doc_id: 767722 cord_uid: t3yvm6kf BACKGROUND: Coronavirus disease-2019 (COVID-19) is thought to predispose patients to thrombotic disease. To date there are few reports of ST-segment elevation myocardial infarction (STEMI) caused by type 1 myocardial infarction in patients with COVID-19. OBJECTIVES: The aim of this study was to describe the demographic, angiographic, and procedural characteristics alongside clinical outcomes of consecutive cases of COVID-19–positive patients with STEMI compared with COVID-19–negative patients. METHODS: This was a single-center, observational study of 115 consecutive patients admitted with confirmed STEMI treated with primary percutaneous coronary intervention at Barts Heart Centre between March 1, 2020, and May 20, 2020. RESULTS: Patients with STEMI presenting with concurrent COVID-19 infection had higher levels of troponin T and lower lymphocyte count, but elevated D-dimer and C-reactive protein. There were significantly higher rates of multivessel thrombosis, stent thrombosis, higher modified thrombus grade post first device with consequently higher use of glycoprotein IIb/IIIa inhibitors and thrombus aspiration. Myocardial blush grade and left ventricular function were significantly lower in patients with COVID-19 with STEMI. Higher doses of heparin to achieve therapeutic activated clotting times were also noted. Importantly, patients with STEMI presenting with COVID-19 infection had a longer in-patient admission and higher rates of intensive care admission. CONCLUSIONS: In patients presenting with STEMI and concurrent COVID-19 infection, there is a strong signal toward higher thrombus burden and poorer outcomes. This supports the need for establishing COVID-19 status in all STEMI cases. Further work is required to understand the mechanism of increased thrombosis and the benefit of aggressive antithrombotic therapy in selected cases. C oronavirus disease-2019 (COVID-19) caused by the severe acute respiratory syndromecoronavirus-2 (SARS-CoV-2) has been shown to result in coagulation abnormalities and predisposes patients to thrombotic disease, both in the venous and arterial circulations (1) . This is believed to be secondary to inflammation, platelet activation, endothelial dysfunction, and stasis (2) . Despite this exaggerated risk, reduced presentations with STsegment elevation myocardial infarction (STEMI) and other thrombotic disorders such as cerebrovascular accident have been seen during the pandemic, mainly as a result of social isolation and behavioral changes. Furthermore, emergency cardiac catheterization reveals a variety of findings in patients with COVID-19 with ST-segment elevation, including classic type 1 myocardial infarction (obstructive coronary artery disease), angiographically normal epicardial coronary arteries, and/or left ventricular dysfunction due to myocarditis or stressinduced cardiomyopathy (3) (4) (5) . Some institutions and opinion leaders have suggested thrombolytic therapy as the preferred initial mode of reperfusion to protect health care providers (6) , although clinical bodies have advocated continuation of primary percutaneous coronary intervention (PCI) as the default strategy (7, 8) . There are limited reports of treating COVID-19-positive patients presenting with type I myocardial infarction leading to STEMI who receive primary PCI, highlighted by recent studies finding only 10 of 18 patients with STEMI on electrocardiogram having obstructive disease (4) . Understanding the natural history and treatment responses of patients with COVID-19 presenting with STEMI is essential to inform patient management decisions and protect health care workers. As the largest coronary intervention center in the United Kingdom, Barts Heart Centre is well placed to provide contemporary analysis of STEMI cases during the COVID-19 era. We describe the demographic, angiographic, and procedural characteristics as well as clinical outcomes in consecutive cases of COVID-19positive patients with STEMI comparing outcomes with COVID-19-negative patients. All patient data were anonymized before analysis. The local ethics committee advised that formal ethical approval was not required. Descriptive statistical analyses were performed using fibrinogen, and ferritin were seen in the 2 groups, although trends to higher levels in the COVID-19 group were seen in all 3 measurements (p ¼ 0.14, p ¼ 0.08, and p ¼ 0.09, respectively). PROCEDURAL CHARACTERISTICS. All patients underwent a primary PCI procedure in both groups ( Table 2) . Median door-to-balloon times were within 60 min and similar for both groups. There was evidence of higher thrombogenicity in the COVID-19 group with significantly higher rates of multivessel thrombosis (p ¼ 0.0003) and stent thrombosis Increased thrombogenicity in acute ischemic stroke also has been described (18) . Moreover, emerging data from large COVID-19 cohorts without STEMI Mechanisms that trigger presentation with STEMI and its associated higher arterial thrombus burden in patients with COVID-19 are as yet unknown. Relative Non-COVID-19 In-hospital outcomes including intensive care admission, in-hospital mortality, and admission length. COVID-19 ¼ coronavirus disease-2019. *p < 0.01, †p < 0.05, ‡p<0.001. protocols. Despite these challenges, primary PCI was delivered within existing guidelines (median door-toballoon times 50 min). The strength of this study is that it presents real-world consecutive data from all patients with STEMI admitted to a single center during the COVID-19 outbreak in the United Kingdom, both with and without the infection. The compared COVID-19 and non-COVID-19 group faced the same health care restrictions and were managed according to the same, modified, COVID-19 primary PCI pathway and protocol. Moreover, our center had an early adoption of COVID-19 testing for all patients with STEMI. All patients with STEMI received a nasal/pharyngeal swab as well as chest imaging and laboratory testing for markers of severe COVID-19 infection to assist in diagnosis in the event of a negative nasal/pharyngeal swab. STUDY LIMITATIONS. Despite this being the largest series to date, it is a relatively small retrospective observational study in a single center and therefore has all the limitations of this type of analysis including bias and the potential for confounding. Furthermore, as has been universally accepted, the sensitivity of diagnostic testing for SARS-CoV-2 is modest at approximately 60% to 70% with nasal/ pharyngeal swab (27) . 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