key: cord-1053716-dpbkt9jj
authors: Medranda, Giorgio A.; Brahmbhatt, Kunal; Alawneh, Basem; Marzo, Kevin P.; Schwartz, Richard K.; Green, Stephen J.
title: Initial Single Center ST-Segment Elevation Myocardial Infarction Experience in New York Before and During the COVID-19 Pandemic
date: 2021-01-26
journal: Cardiovasc Revasc Med
DOI: 10.1016/j.carrev.2021.01.026
sha: 3f0d638bcf6c7edc5ff28236e620dda63c0f237c
doc_id: 1053716
cord_uid: dpbkt9jj

Background/Purpose Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has emerged as a highly contagious and lethal virus, devastating healthcare systems throughout the world. Following a period of stability, the coronavirus disease 2019 (COVID-19) pandemic appears to be re-intensifying globally. As the virus continues to evolve, so does our understanding of its implications on ST-segment elevation myocardial infarction (STEMI). We sought to describe a single center STEMI experience at one of the epicenters during the COVID-19 pandemic. Methods/Materials We conducted a retrospective, observational study comparing STEMI patients during the pandemic period (March 1, 2020 to August 31, 2020) to those with STEMI during the pre-pandemic period (March 1, 2019 to August 31, 2019) at NYU Langone Hospital – Long Island, a tertiary care center in Nassau County, New York. Additionally, we describe our subset of COVID-19 patients with STEMI during the pandemic. Results The acute myocardial infarction (AMI) team was activated for a total of 183 patients during both periods. There were a similar number of AMI team activations during the pandemic period (n=93) compared to the pre-pandemic period (n=90). Baseline characteristics did not differ during both periods however, infection control measures and additional investigation were required to clarify the diagnosis during the pandemic, resulting in a signal towards longer door-to-balloon times (95.9 minutes vs. 74.4 minutes, p=0.0587). We observed similar inpatient length of stay (LOS) (3.6 days vs. 5.0 days, p=0.0901) and mortality (13.2% vs. 9.2%, p=0.5876). There was a total of 6 COVID-19 positive patients who presented with STEMI, of which 4 were emergently taken to the cardiac catheterization laboratory with successful percutaneous coronary intervention (PCI) performed in 3 patients. The 2 patients who were not offered primary PCI expired, as both were treated medically, one with thrombolytics. Conclusions Our single center study, in New York, at one of the epicenters of the pandemic, demonstrated a similar number of AMI team activations, mimicking the seasonal variability seen in 2019, but with a signal towards longer door-to-balloon time. Despite this, inpatient LOS and mortality remained similar.

This was a retrospective, observational study, which included consecutive suspected STEMI patients from March 1 2019 -August 31 2019 (pre-pandemic period) comparing them to the same time period in 2020 (pandemic period), at a 591-bed tertiary referral center in Nassau County, New York. We compared acute myocardial infarction (AMI) team activations during both periods, as well as door-to-balloon time and inpatient outcomes. Additionally, we sought to describe the subset of COVID-19 positive patients with suspected STEMI.

All patients in both cohorts had activation of the AMI team with high clinical suspicion for STEMI. Patients in both cohorts who were referred for emergent cardiac catheterization, signed informed consent forms for cardiac catheterization with possible percutaneous coronary intervention (PCI) and hemodynamic support prior to the procedure. Cardiac catheterization was performed in a sterile cardiac catheterization laboratory. Arterial access was obtained either via the transfemoral or transradial approach.

Patients during the pandemic period who were referred for emergent cardiac catheterization were treated with the presumption that all could have COVID-19. We converted one dedicated cardiac catheterization laboratory to a negative pressure room. Furthermore, we adopted a practice of maximum protection using personal protective equipment for all cases with a terminal cleaning protocol following every procedure. All patients during the pandemic period were tested with reverse-transcriptase-polymerase-chain-reaction to detect SARS-CoV-2 on at least two nasopharyngeal swab specimens collected 24 hours apart. Testing for SARS-CoV-2 did not delay transportation to the cardiac catheterization laboratory. Point of care ultrasonography was performed in the emergency department when necessary to help clarify the diagnosis. There was a low threshold to perform early intubation in the emergency department in patients with tenuous respiratory status before cardiac catheterization.

This study was HIPAA compliant and reviewed by our institutional review board and deemed exempt. A single author had full access to all data in the study and takes responsibility for its integrity and the data analysis. Study data were collected and managed using Research Electronic Data Capture.

We summarize patients' demographic and clinical characteristics using mean ± standard deviation or median with interquartile range, and frequency (%). Comparisons with respect to continuous variables were performed using two-sample t-test. Comparisons with respect to binary variables were performed using Chi-square test. A p-value <0.05 was considered statistically significant. All analyses were done using SAS 9.4®.

The AMI team was activated for a total of 183 patients during both periods. There were no differences among the clinical characteristics of all patients in both cohorts (Table 1) . There were a similar number of AMI team activations during the pandemic period (n=93) compared to the pre-pandemic period (n=90). (Figure 1 ) For those taken emergently to the cardiac catheterization laboratory, chest pain remained the predominant symptom during the pandemic as it was pre- 

From March 1 2020 through August 31 2020 there were a total of 6 activations of the AMI team for COVID-19 positive patients with high clinical and electrocardiographic suspicion for STEMI. Of these, 2 patients were not offered emergent cardiac catheterization.

The first patient was a 75-year-old male with hypertension who presented with non-productive cough, dyspnea and fever found to be in sepsis secondary to COVID-19 pneumonia. On the 6 th day, the patient developed substernal chest pressure with electrocardiogram demonstrating inferior STEMI. Given his increasing oxygen requirements and tenuous respiratory status, emergent cardiac catheterization was deferred. The patient was administered half-dose alteplase as there were no absolute contraindications to fibrinolytic therapy. He was subsequently intubated and died from respiratory arrest.

The second patient was a 75-year-old male with hypertension who presented with fatigue, myalgias and fevers found to be in sepsis secondary to COVID-19 pneumonia. On the 7 th day, his troponin-I was found to be 32.9ng/mL with electrocardiogram demonstrating inferior STEMI with Q-waves. Given the lack of chest pain, tenuous respiratory status and unclear timing of myocardial infarction, emergent cardiac catheterization was deferred. The patient was not offered fibrinolytic therapy because of the unclear timing of his event and thus was medically managed, passing from respiratory arrest.

The remaining 4 patients presented to the emergency department and were referred for emergent cardiac catheterization with high-clinical suspicion and electrocardiographic evidence of STEMI.

One of the patients was a 49-year-old with substernal chest pain found to be hemodynamically stable with inferior STEMI referred for emergent cardiac catheterization. The culprit vessel was an approximately 6mm diameter aneurysmal mid-right coronary artery with thrombolysis in myocardial infarction (TIMI) thrombus grade 5 thrombus treated with eptifibatide, aspiration thrombectomy and balloon angioplasty. Despite this, percutaneous coronary intervention was unsuccessful, with complete occlusion of the vessel at the mid-portion and the patient was treated medically, discharged home two days later. The rest of the patients (3) were successfully treated with primary PCI. Summary of clinical characteristics, laboratory data, presenting data, cardiac catheterization and outcomes of the subset of patients during the pandemic with confirmed COVID-19 can be found in figure 2.

In our series of patients at our single tertiary referral center in New York, with suspected STEMI, comparing those before and during the initial emergence of the COVID-19 pandemic, there were a similar number of AMI team activations, mimicking the seasonal variability seen in 2019, with chest pain remaining the predominant symptom, and the majority of patients demonstrating angiographic evidence of STEMI yielding similar inpatient outcomes. For patients referred for emergent cardiac catheterization during the pandemic, additional investigation and use of personal protective equipment for each case resulted in a signal towards increased door-toballoon times. Despite this we observed similar inpatient outcomes during the pandemic as was observed prior to the pandemic. Among the subset of 6 COVID-19 patients with STEMI, those offered primary PCI (4) survived their hospitalization, whereas the remaining 2 expired, one of which was treated with thrombolytics.

Following a brief period of stability in cases, the COVID-19 pandemic appears to be re-J o u r n a l P r e -p r o o f intensifying, overwhelming healthcare systems across the world.(1-4) Cardiovascular manifestations of COVID- 19 have not yet been fully clarified but early literature has demonstrated that patients with preexisting cardiovascular disease are among the highest risk. (5) (6) (7) (8) 13) Furthermore, there has been significant uncertainty of the diagnosis and management of STEMI given the heterogeneity of presentations during the pandemic. (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) There is a paucity of STEMI literature directly comparing time periods prior to and during the pandemic.

Our study, albeit relatively small, directly compared data regarding patients at a single tertiary care referral center with suspected STEMI at an epicenter during the initial emergence of the current pandemic, to data from the same time period in 2019 before the pandemic demonstrating a similar number of AMI team activations between both periods, increasing by just 3.3% during the pandemic. This is in contrast to previously published data reporting a decrease in the volume of patients presenting with STEMI by as much as 50%. (15) (16) (17) (18) (19) (20) (21) 23 ) None of the studies directly compared data from the same time period before and during the pandemic. For many parts of the United States, the pandemic is surpassing previous infection rates, and for parts of the world, the pandemic is only now reaching the height of its intensity. For this reason, we strongly believe that despite the modest sample size, this study offers insight in preparation for subsequent surges of infection and to those suffering through the pandemic as New York was just a few months earlier.

A Chinese study compared only 7 patents from January 25 2020 through February 10 2020 to week, demonstrated a signal towards increased door-to-balloon times. Despite this, inpatient length of stay and inpatient mortality were similar in both cohorts.

In Bergamo, Italy, protocols were put into place to concentrate personnel and STEMI centers during the pandemic. (19) STEMI volume decreased by 37% in March 2020 when compared to the monthly average from the previous year. Our study directly compared data from six months (March through August) in consecutive years (2019 to 2020), which best accounts for seasonal variation. In Italy, formal use of personal protective equipment and early intubation lead to an increase in delays as it did in China. (19, 20) We saw increased door-to-balloon times during the pandemic as well. The majority of patients in Italy were offered primary PCI, as was the case in our study (69.9%). Increased thrombus burden was reported in the Italian study as well, although we did not see this trend in our study (mean TIMI thrombus grade of 4.7 in 2019 to 4.2 in 2020, p=0.0730).

Spain was among the hardest hit countries early in the pandemic, which peaked in early April 2020. In Madrid, Spain, saturation of emergency medical services led to significant delays in presentation as well. (19) They reported a decrease of STEMI patients presenting to hospital of 50% when compared to the weeks before the pandemic. We chose to compare consecutive months during the pandemic to the same months in 2019 to more accurately account for normal disparities in monthly STEMI volume. This resulted in a similar pattern of seasonal variability in the spring and summers of 2019 and 2020. Spain also observed an increase in the use of fibrinolytics, predominantly used at non-PCI capable centers. (19) Our tertiary referral center is a PCI capable center which, before this pandemic, had not used fibrinolytics in many years. In our J o u r n a l P r e -p r o o f Journal Pre-proof cohort, just one patient with COVID-19 pneumonia and severe respiratory failure was treated with alteplase, suffering respiratory arrest and death.

In the United States, a study of 9 high-volume primary PCI centers across the country compared STEMI data after March 1 2020 to STEMI data from January 1 2019 to February 28 2020. (16) They reported a decrease in STEMI volume of 38% between the two time periods with a mean decrease in STEMI activations of 8. 

There are several key limitations to our descriptive study. This study was retrospective which reflected the treatment biases of our physicians. Our study was limited to one tertiary care center in Nassau County, New York. Thus, our sample sizes were smaller than larger multi-centered studies and inpatient outcomes must be cautiously interpreted as such. We were unable to evaluate whether or not there were patients with STEMI who did not or could not seek care during the pandemic. Furthermore, we were not able to accurately collect data on symptomonset-to-balloon time in our patients. Delays in seeking or deferring care have a significant impact on outcomes but could not be fully assessed.

In conclusion, the ongoing COVID-19 pandemic continues to rapidly evolve, as does our Values are mean±SD or n/N (%). 

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