key: cord-0812063-72gdsgse authors: Abizaid, Alexandre; Campos, Carlos M.; Guimarães, Patrícia O.; Costa, José de Ribamar; Falcão, Breno A. A.; Mangione, Fernanda; Caixeta, Adriano; Lemos, Pedro A.; S. de Brito, Fabio; Cavalcante, Ricardo; Bezerra, Cristiano Guedes; Cortes, Leandro; Ribeiro, Henrique B.; de Souza, Francis R.; Huemer, Natassja; do Val, Renata M.; Caramelli, Bruno; Calderaro, Daniela; Lima, Felipe G.; Hajjar, Ludhmila A.; Mehran, Roxana; Filho, Roberto Kalil title: Patients with COVID‐19 who experience a myocardial infarction have complex coronary morphology and high in‐hospital mortality: Primary results of a nationwide angiographic study date: 2021-04-27 journal: Catheter Cardiovasc Interv DOI: 10.1002/ccd.29709 sha: 42e8f8e70466e1ff2ed445c5242f99b66d2297c0 doc_id: 812063 cord_uid: 72gdsgse OBJECTIVES: We aimed to explore angiographic patterns and in‐hospital outcomes of patients with concomitant coronavirus disease‐19 (COVID‐19) and myocardial infarction (MI). BACKGROUND: Patients with COVID‐19 may experience MI during the course of the viral infection. However, this association is currently poorly understood. METHODS: This is a multicenter prospective study of consecutive patients with concomitant COVID‐19 and MI who underwent coronary angiography. Quantitative and qualitative coronary angiography were analyzed by two observers in an independent core lab. RESULTS: A total of 152 patients were included, of whom 142 (93.4%) had COVID‐19 diagnosis confirmation. The median time between symptom onset and hospital admission was 5 (1–10) days. A total of 83 (54.6%) patients presented with ST‐elevation MI. The median angiographic Syntax score was 16 (9.0–25.3) and 69.0% had multi‐vessel disease. At least one complex lesion was found in 73.0% of patients, 51.3% had a thrombus containing lesion, and 57.9% had myocardial blush grades 0/1. The overall in‐hospital mortality was 23.7%. ST‐segment elevation MI presentation and baseline myocardial blush grades 0 or 1 were independently associated with a higher risk of death (HR 2.75, 95%CI 1.30–5.80 and HR 3.73, 95%CI 1.61–8.61, respectively). CONCLUSIONS: Patients who have a MI in the context of ongoing COVID‐19 mostly present complex coronary morphologies, implying a background of prior atherosclerotic disease superimposed on a thrombotic milieu. The in‐hospital prognosis is poor with a markedly high mortality, prompting further investigation to better clarify this newly described condition. a higher risk of death (HR 2.75, 95%CI 1.30-5.80 and HR 3.73, 95%CI 1.61-8.61, respectively). Conclusions: Patients who have a MI in the context of ongoing COVID-19 mostly present complex coronary morphologies, implying a background of prior atherosclerotic disease superimposed on a thrombotic milieu. The in-hospital prognosis is poor with a markedly high mortality, prompting further investigation to better clarify this newly described condition. While pathophysiologic mechanisms have been suggested, 3 including an imbalance between oxygen demand and supply, an intense inflammatory activity, a high thrombotic risk, and hemodynamic changes leading to atherosclerotic plaque instability, it is still not known whether MI in the context of a COVID infection shows similar angiographic patterns to "regular" acute coronary syndromes. Moreover, data are lacking on the prognosis of these patients. Therefore, we aimed to explore the angiographic characteristics and clinical outcomes of patients with COVID-19 presenting with MI, including ST-segment elevation MI (STEMI) and non-ST-segment elevation MI (NSTEMI), requiring coronary angiography, regardless of the need for percutaneous coronary intervention. The present work is a multicenter, retrospective and prospective, observational cohort study. The retrospective cohort includes patients who were identified by investigators from the beginning of the pandemic in Brazil, and before the prospective study start date. The prospective cohort included patients who fulfilled inclusion criteria after the study start date. This study was approved by the National Research Ethics Committee and by the local Institution Review Boards of each site. The informed consent form was waived for the retrospective cohort and the inclusion of patients prospectively occurred after signature of the informed consent form. We included consecutive patients presenting with suspected or confirmed COVID-19 and MI who underwent coronary angiography at 17 tertiary sites in Brazil from April 14, 2020 to June 28, 2020. The complete list of investigators is provided in the Data S1. The diagnosis of COVID-19 was confirmed by either a positive result of a SARS-CoV-2 polymerase chain reaction test on a nasopharyngeal swab or serologic tests. A suspected case of COVID-19 was defined as a patient with acute respiratory illness (fever and at least one sign/ symptom of respiratory disease, e.g., cough, shortness of breath) and radiological evidence by chest computed tomography showing pulmonary lesions compatible with COVID-19. A suspected case was only included when an independent committee reviewed the case and concluded that COVID-19 was the primary diagnosis for the patient. For the present study, types 1 and 2 MIs were considered, according to the Fourth International Definition of MI. For type 1 MI, the increase and/or decrease in troponin values were considered at least one value above the 99th percentile plus one of the following criteria: autopsy. For the diagnosis of type 2 MI, the same criteria above were considered, in addition to any evidence of an imbalance between oxygen supply and demand. The coronary angiograms were performed following standard procedures. The procedure could be performed using femoral or radial approach, following the internationally recommended standards for protection against viral exposure. If necessary, and at the discretion of the local interventional team accompanying the case, percutaneous coronary intervention with stent implantation was performed as needed. All procedures were performed in accordance with national and international guidelines and equipments and devices used were left at the discretion of the operators and the institution where it was performed. The coronary angiography films were analyzed by two observers in an independent core lab at the Heart Institute, InCor, University of Sao Paulo. In case of disagreement between the two observers, a third observer was invited for final opinion. These analyses were blinded to patients' baseline characteristics and clinical presentation. The images were evaluated for the detection and location of luminal stenoses, as well as the morphological pattern of the lesions. The Synergy between PCI with TAXUS and cardiac surgery (SYNTAX) score was calculated using an electronic calculator available online (www.syntaxscore.com). 5 Lesions were also categorized as complex or not using a classification previously described. 6, 7 Lesions were considered complex if they caused at least 50% stenosis and had one or more of the following morphologic features: (a) an intraluminal filling defect consistent with thrombus, defined as abrupt vessel cutoff with persistence of contrast, or an intraluminal filling defect in a vessel within or adjacent to a stenotic region with surrounding homogeneous contrast opacification; The thrombus burden was assessed using as previously described. 8 Anterograde coronary flow was classified according to the TIMI flow criteria from 0 to 3. 9 Myocardial blush grade has been defined previously as follows 10 : 0, no myocardial blush or contrast density; 1, minimal myocardial blush or contrast density; 2, moderate myocardial blush or contrast density but less than that obtained during angiography of a contralateral or ipsilateral non-infarct-related coronary artery; and 3, normal myocardial blush or contrast density, comparable with that obtained during angiography of a contralateral or ipsilateral non-infarct-related coronary artery. analysis. The lumen contour was delineated automatically and manual correction performed as appropriate. A 3D anatomical vessel model without side branches was derived from the software and QFR computation was performed using a specific flow model: contrast-flow QFR as previously described. Data on demographic characteristics, medical history, clinical presentation, laboratory results, treatments, and clinical outcomes were assessed through medical records and collected in a case report form by local investigators. Participants had their data collected until hospital discharge and/or death. No intervention was carried out through this study. The registry utilized a web-based case report form, and remote electronic data monitoring was performed in all cases, to actively search and correct missing and/or inconsistent information. We describe in-hospital events, including all-cause death, acute respiratory distress syndrome, and need for mechanical ventilation. The angiographic findings according to survival status are presented in Overall, median hospitalization days was 14 In the univariate analysis, age, prior coronary artery disease, presentation as STEMI, reduced TIMI and myocardial blush grades were associated with a higher risk of death ( To the best of our knowledge, our multicenter national study presents the largest cohort of COVID-19 patients with detailed angiographic evaluation for MI, including both STEMI and NSTEMI. The majority of patients had severe coronary artery disease that extended to multiple territories. The overall mortality was high and was related to poor myocardial perfusion (ST-segment elevation and blush 0/1). and cardiovascular events, especially in patients admitted to intensive care units. 12 In a more detailed assessment of CAD complexity, we demonstrated a relatively much higher SYNTAX score, when compared with the SYNTAX score of previous studies including patients with acute coronary syndromes. 17 Our findings should be interpreted in light of some limitations. First, we included patients with COVID-19 and MI, therefore we did not have a control group. Since several reports showed that the incidence of MI during the pandemic was lower than the one from other periods of time, 22 we believe that including a control group with non-COVID MI patients may not truly represent the overall MI population. Second, even though the majority of patients in our cohort had COVID-19 diagnosis confirmation, 6.6% tested negatively. Still, these few cases fulfilled pre-specified inclusion criteria for a suspected case of COVID-19 based on clinical symptoms and chest tomography imaging findings and were adjudicated by an independent committee which concluded that COVID-19 was still the main diagnosis for those patients. Third, our number of clinical events was somewhat low, which limited the analysis of predictors of death. However, to our knowledge, our study comprises the largest cohort of COVID-19 patients undergoing coronary angiography so far. Patients who have a MI in the context of ongoing COVID-19 mostly present complex coronary morphologies, implying a background of prior atherosclerotic disease superimposed on a thrombotic milieu. The in-hospital prognosis is poor with a markedly high mortality, prompting further investigation to better clarify this newly described condition. 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Dr. Abizaid receives consulting fees from Boston Scientific.All other authors have nothing to disclose. The data that support the findings of this study are available from the corresponding author upon reasonable request. Additional supporting information may be found online in the Supporting Information section at the end of this article.