key: cord-0851148-zo2cgsi9
authors: Lopez, John J.; Ebinger, Joseph E.; Allen, Sorcha; Yildiz, Mehmet; Henry, Timothy D.
title: Adapting STEMI care for the COVID‐19 pandemic: The case for low‐risk STEMI triage and early discharge
date: 2020-06-01
journal: Catheter Cardiovasc Interv
DOI: 10.1002/ccd.28993
sha: 3369596169d731ab7396e4ba2f5c0d5b7f885be7
doc_id: 851148
cord_uid: zo2cgsi9

The coronavirus pandemic has resulted in the need for rapid assessment of resource utilization within our hospital systems. Specifically, the overwhelming need for intensive care unit (ICU) beds within epicenters of the pandemic has created a need for consideration as to how acute coronary syndrome cases, and specifically ST‐elevation myocardial infarction (STEMI) patients, are managed postprocedure. While most patients in the United States continue to be managed in coronary care units after primary percutaneous coronary intervention, there is a robust literature regarding the ability to triage STEMI patients safely and efficiently with low‐risk features to non‐ICU beds. We review the various risk scores for STEMI triage and the data supporting their usage. In summary, these findings support an approach to low‐risk STEMI triage that does not come at the expense of quality patient care or outcomes, where up to two‐thirds of patients with STEMI may be able to be safely managed without ICU‐level care.

patients in the United States continue to be managed in coronary care units after primary percutaneous coronary intervention, there is a robust literature regarding the ability to triage STEMI patients safely and efficiently with low-risk features to non-ICU beds. We review the various risk scores for STEMI triage and the data supporting their usage. In summary, these findings support an approach to low-risk STEMI triage that does not come at the expense of quality patient care or outcomes, where up to two-thirds of patients with STEMI may be able to be safely managed without ICUlevel care. infarction, and ischemic time > 4 hr), with a score of 0-3 considered low risk, and a score ≥4 considered high risk, based on 30-day mortality rates, with a strong discriminatory capacity (c statistic: 0.907) (Figure 1) . In a validation cohort of 747 patients, 65% of STEMI patients were deemed low risk, with a mortality rate of 0.6% at 30 days. 5 

The feasibility, effectiveness, and safety of utilizing such protocols have also been demonstrated in contemporary STEMI systems.

Recently, a small retrospective study in 228 patients over 2 years (42% of all STEMI patients) reported no adverse effects after 3 days and 0 deaths at 1 year using the Cadillac Risk Score. 6 We recently reported the results of a larger prospective trial using the Zwolle Risk Score for STEMI patient triage. 7 After initially validating the predictive ability of the score in 967 STEMI patients from our own retrospective data (death and major adverse cardiac events rates among low-risk patients of 0.2 and 0.9% at 30 days, respectively), the Zwolle Risk Score was incorporated into the electronic health record (EHR), adding out-of-hospital cardiac arrest as an automatic high-risk feature.

The EHR risk calculator was then prospectively applied to 549 STEMI patients, 62% (n = 266) of whom were determined to be low risk, with 62% of those (n = 177) treated per protocol, triaged to telemetry rather than CCU admission and targeted for early (<48 hr) hospital discharge. The remainder included 109 low-risk patients triaged to the CCU and 176 high-risk STEMI patients. Reasons for low-risk STEMI triaged to the CCU were multifactorial but appeared to be mostly related to procedural complications or the potential for bleeding (2.5% for "on protocol" vs. 8.9% "off protocol," p = .018). At 30 days, lowrisk patients triaged to telemetry did extremely well, with shorter index hospital length of stay (LOS), markedly lower hospital costs, no inhospital mortality, and only one death at 30 days related to a stroke on admission. These findings persisted at 1-year follow-up, with lower long-term mortality among the low-risk, on-protocol cohort (low-risk on-protocol, low-risk off-protocol, high risk: 2.3 vs. 6.4 vs. 17.1%, p < .001) (Figure 1 ). When used in conjunction with physician judgment, integration of the Zwolle Risk Score appropriately identifies STEMI patients who may be cared for in non-ICU settings, freeing these resources for critically ill patients who require ICU-level care. A recent meta-analysis of five randomized clinical trials demonstrated that an early discharge strategy (≤3 days) in selected low-risk STEMI patients significantly reduced LOS without an adverse effect on mortality or readmission rates. 8 

We believe that these findings support an approach to low-risk STEMI triage that does not come at the expense of quality of patient care or outcomes. Furthermore, during the current pandemic, we suggest that programmatic efforts utilizing this approach offer an evidence-based method of addressing the expected surge in the need for ICU beds. Finally, we propose that in this time of crisis, it is important for programs and their cardiology leaders to consider supporting a newly developed consortium of institutions to collect prospective data on the impact of the rapid enactment of a standardized protocol for STEMI risk stratification. We welcome sites and investigators to join us in this important endeavor.

John J. Lopez https://orcid.org/0000-0002-6727-3623

Sorcha Allen https://orcid.org/0000-0002-7781-4139

Timothy D. Henry https://orcid.org/0000-0003-1123-0533

Intensive care unit utilization in stable ST-segment elevation myocardial infarction patients treated with rapid reperfusion: a report from Chest Pain-MI Registry

ESC Guidelines for the management of acute myocardial infarction in patients presenting with STsegment elevation: the Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC)

Length of stay following percutaneous coronary intervention: an expert consensus document update from the Society for Cardiovascular Angiography and Interventions

Prediction of mortality after primary percutaneous coronary intervention for acute myocardial infarction: the CADILLAC risk score

Prognostic assessment of patients with acute myocardial infarction treated with primary angioplasty: implications for early discharge

Identifying patients for safe early hospital discharge following ST-elevation myocardial infarction

Value-based ST-segmentelevation myocardial infarction care using risk-guided triage and early discharge

Safety of early discharge after primary angioplasty in low-risk patients with ST-segment elevation myocardial infarction: a meta-analysis of randomised controlled trials

ACC/AHA statement on cost/value methodology in clinical practice guidelines and performance measures: a report of the American College of Cardiology/American Heart Association Task Force on performance measures and task force on practice guidelines