key: cord-0799074-zaboshcs
authors: Sudhakar, Deepthi; Jneid, Hani; Lakkis, Nasser; Kayani, Waleed T.
title: Primary Percutaneous Coronary Intervention or Fibrinolytic therapy in COVID 19 Patients Presenting with ST- Segment Elevation Myocardial Infarction
date: 2020-08-22
journal: Am J Cardiol
DOI: 10.1016/j.amjcard.2020.08.021
sha: cbcad7f164f7b471144f231132ae7ebc851e3cfe
doc_id: 799074
cord_uid: zaboshcs

nan

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.

The timely diagnosis and management of patients with suspected ST-segment myocardial infarction (STEMI) or acute coronary syndrome (ACS) in the COVID-19 era is an area of wide concern given variable presentation as well associated risks of infection to healthcare teams. The recent manuscript by Hamadeh et al (1) , published in the journal adds to our existing knowledge by reporting the largest, multicenter case series on the clinical presentation, management and outcomes of patients with symptomatic COVID-19 infection and STEMI (1) . There are several key findings in this study and we commend the authors on their investigation. However, certain aspects of the study merit attention before definite conclusions can be drawn, especially regarding the high incidence of stent thrombosis in this cohort and advocating broader use of fibrinolytic therapy in healthcare systems where access to primary PCI is more prevalent.

First and foremost, this is a retrospective case study where many known and unknown factors confound the relation being examined. The finding of strikingly high rates of stent thrombosis needs to be interpreted with caution as patients in the PCI cohort were sicker and more likely to present with shock, develop acute respiratory distress syndrome and need mechanical ventilation. Given the smaller sample size of the study, especially the primary PCI cohort, any potential beneficial or harmful effect of a therapy may be amplified. Although the overall proportion of patients with stent thrombosis (21%) in the cohort is concerning, the absolute number (n=4) is still relatively low. The authors did use the 4 th universal definition of myocardial infarction for stent thrombosis, but it will be interesting to know more about angiographic factors in these patients. In our anecdotal practice in a high-volume public healthcare system in the US, we have managed COVID-19 STEMI patients with primary PCI and used prolonged infusions of cangrelor or GP IIb/IIIa inhibitors after successful reperfusion given the heavy thrombus burden with good outcomes.

Secondly, outcomes in the fibrinolytic group of unsuccessful reperfusion (n= 9/59; 15%) and high incidence of hemorrhagic stroke (n= 5/59, 9%) question both efficacy and safety of fibrinolytic therapy in this cohort. This is also of considerable importance as two contemporary case series have suggested that between 30-39% of patients who undergo urgent coronary angiography for suspected STEMI in setting of COVID-19 do not have angiographic diagnosis to suggest coronary obstruction (2, 3) , which make advocating fibrinolytic therapy for COVID-19 patients who present with suspected STEMI, unnecessary and potentially dangerous.

We propose that whenever possible, COVID-19 patients with findings suggestive of STEMI should be transferred to a PCI-capable facility. The recent statement published by the American College of Cardiology (ACC), Society for Cardiovascular Angiography and Interventions (SCAI) and American College of Emergency Physicians (ACEP) recommends primary PCI as the standard of care for COVID-19 patients who present with STEMI (4).

It is becoming increasingly apparent that ACS in COVID-19 infected patients is not the same disease process compared to ACS without COVID-19 infection. The dichotomy of both increased mimickers of STEMI as well as a signal of higher thrombus burden in patients with angiographic STEMI adds to the already complex management of COVID-19 patients (2, 3, 5) .

Characteristics and Outcomes in Patients Presenting With COVID-19 and ST-Segment Elevation Myocardial Infarction

Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention

ST-Elevation Myocardial Infarction in Patients With COVID-19: Clinical and Angiographic Outcomes

ST-Segment Elevation in Patients with Covid-19 -A Case Series

Management of acute myocardial infarction during the COVID-19 pandemic: A Consensus Statement from the Society for

Cardiovascular Angiography and Interventions (SCAI), the American College of Cardiology (ACC), and the American College of Emergency Physicians (ACEP)

Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19)

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