key: cord-1047333-8ezj6voi
authors: Xiao, Zhichao; Xu, Chang; Wang, Daowen; Zeng, Hesong
title: The experience of treating patients with acute myocardial infarction under the COVID‐19 epidemic
date: 2020-04-29
journal: Catheter Cardiovasc Interv
DOI: 10.1002/ccd.28951
sha: 299388a2280d5ef5e5958d841e5e0cd1d0a849b4
doc_id: 1047333
cord_uid: 8ezj6voi

Worldwide Coronavirus Disease 2019 (COVID‐19) epidemic makes the management of acute myocardial infarction (AMI) more complicated, effective treatment without further dissemination is thus quite challenging. Recently, we successfully treated three representative AMI cases, by sharing these detailed procedures, we summarized some important issues including patient screening, reperfusion strategy selecting, personnel/catheter lab protection principle, as well as operation tactics, which may lend precious experience on AMI treating during the ongoing COVID‐19 pandemic situation.

The COVID-19 is a widespread disease mainly involving the respiratory system that broke out since December 2019 and infected almost 200,000 people worldwide, resulting in a pandemics situation. 1 It is highly infective, has long incubation period, presents with relatively mild symptoms mostly, 2,3 and even can be transmitted by asymptomatic patients. 4, 5 Thus, any inappropriate medical behavior, especially an invasive procedure, may result in further dissemination amongst healthcare professionals. All these events result in hardship in the routine management of patients with AMI, a condition highly prevalent during the winter season. Thus, safe, effective, and timely management of this subset of patients in Wuhan, the most seriously affected area, became really challenging. Recently, our team successfully treated three patients presenting with AMI in this epidemic area and now report below.

Case 1: A 62-year-old man, residing in Wuhan, came to the emergency department (ED) with the complaint of sudden chest pain for 4 hrs, no history of hypertension, diabetes or dyslipidemia was reported. Electrocardiogram (ECG) revealed ST-segments elevations (>0.2 mV) in leads II, III, aVF, and a diagnosis of inferior wall AMI was made. No fever or respiratory symptoms such as cough or dyspnea was complained, no history of close contact with COVID-19 patients was reported. The lymphocyte count was normal and chest computed tomography (CT) did not reveal any findings suggestive of viral pneumonia. Thus, a fibrinolytic therapy in the form of bolus intravenous (IV) infusion of enoxaprin (30 mg) followed by recombinant tissue plasminogen activator (r-tPA, 50 mg) IV within 90 min was immediately initiated. The door-to-needle time was 95 min. Following this, the patient was transferred to an isolation ward for further monitoring and treatment. Within 2 hrs after administering r-tPA, a complete relief of chest pain was reported coupled with >50% resolutions in ST-segments on the ECG, indicating the restoration of myocardial blood flow (Figure 1) . The virus antibodies were tested twice and were both negative. The patient was discharged 7 days later and no chest pain or recurrent ischemic event was complained. The coronary angiography (CAG) was not performed but was advised when the epidemic was over. All these medical activities were completed under the second-level protection. patient, as well as the symptoms such as fever, cough; gathering laboratory findings including white blood cell/lymphocytes count, chest CT image; and finally, an etiologic evidence of virus nucleic acid test from the oropharyngeal swabs and/or antibodies (IgM/IgG) from blood sample. 9 All this information should be collected as soon as possible, and then reperfusion strategy can be made and protection level could be stratified.

To avoid the possible cross-infection, a conservative strategy was principally preferred, but an invasive strategy sometimes became mandatory. Thus, the benefit/risk ratio of either approach should be weighed carefully. For a STEMI patient with low bleeding risk, shorter ischemic time, relative less or less important myocardium (e.g., inferior wall) involved, the fibrinolytic therapy with third generation of fibrinolytic agent may be preferred. On the contrary, for elderly, patients with massive myocardium in jeopardy, longer ischemic time, or not satisfactorily reperfusion conservatively, resulting in recurrent ischemic events and/or electric/hemodynamic instability, the invasive strategy is strongly indicated. Complying with this principle, rt-PA was administered in case 1, and a satisfactory result was achieved. Case 2 suffered from a re-infarction with a massive cardiomyocyte involvement, and the failure of timely fibrinolysis led to hemodynamic instability, which made an invasive procedure the best choice, even though he was clinically diagnosed as COVID-19. Case 3 was an elderly diagnosed as extensive anterior AMI, considering the increased bleeding risk and a relatively longer patient-related delay, which would result in decreased success rate, an invasive procedure was finally chosen. Finally, it should be noted that the epidemic induced delay (for COVID-19 screening) might prolong the door-to-needle/balloon time significantly.

All the patients requiring an invasive procedure were reported to the hospital for record. Complying with the guidelines for prevention and control COVID-19 in hospitals, 10 the catheter lab and all the passages were redesigned and reconstructed, including creating a transition zone between the procedure room and control room. The ventilation system was shut down, and all the ventilating outlets were sealed. Moreover, organizing a team with as less as possible members can further minimize the risk of cross infection. The procedure could be carried out only after all the processes were finished. The medical staff attending the procedure must be at least with a second-level protection, namely equipped with N95 respirators and surgical masks, protective eye wears, face shields, disposable caps(2 layers, covering both ears), gowns and personnel protective equipment(PPE) gowns, two layers of surgical gloves and shoe covers; while during the PCI, besides the sterile gowns outside the leads apron and sterile gloves, the protection level was upgraded to third level: the face shield was replaced by a full face mask in case of a possible blood splash. Moreover, a surgical mask was also worn on the patient's face to minimize the infectious risk. All staff should be isolated thereafter at least 14 days, the body temperature and any discomfort that caused by COVID-19 should be reported daily.

The tactics adopted in PCI were also important. All the procedures were carried out under full protection, and the visual field and tactile feeling were severely affected. Thus, the manipulations requiring highly fine techniques might not only increase the operative risk, but also the risk of transmission of COVID-19 to the medical staff involved in the process. Thus, PCI only on the culprit lesion is the principle rule and any attempt on complex lesion or additional procedure should generally be avoided. However, in Case 2, in order to identify the underlying cause of the sub-acute thrombosis, and ultimately avoid another possible ischemic event, IVUS was used despite all the obstacles, and reached an optimal final result.

Managing an AMI during the epidemic is challenging. Preventing the dissemination of COVID-19 amongst the healthcare workers is the priority, and a conservative strategy is often the first choice. However, in patients strongly indicated for an invasive strategy mentioned above, PCI should be performed after weighing the benefit/risk ratio carefully. As long as the procedures are strictly followed, and most important, the protection is stratified and guaranteed, an optimal result can be anticipated. The successful management of these three cases mentioned above not only resulted in an improved patient prognosis, but also brought precious experience on how to handle cardiovascular emergencies properly, especially under such a serious epidemic situation.

Situation report-62 Coronavirus disease 2019 (COVID-19)

Clinical features of patients infected with 2019 novel coronavirus in Wuhan

Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia

Asymptomatic cases in a family cluster with SARS-CoV-2 infection

Transmission of 2019-nCoV infection from an asymptomatic contact in Germany

AHA/ACC clinical performance and quality measures for adults with ST-elevation and non-ST-elevation myocardial infarction

Chinese Society of Cardiology (CSC) guidelines for the diagnosis and management of patients with ST-segment elevation myocardial infarction

Expert consensus on principal of clinical management of patients with severe emergent cardiovascular diseases during the epidemic period of novel coronavirus pneumonia

Chinese clinical guidelines for COVID-19 diagnosis and treatment

National Health Committee of the People's Republic of China. Guidelines of prevention and control of COVID-19 in medical institution

The experience of treating patients with acute myocardial infarction under the COVID-19 epidemic

The authors declare no potential conflict of interest.

https://orcid.org/0000-0001-5160-4427