key: cord-1055969-tdtys9ij
authors: Zhang, Lin; Fan, Yongzhen; Lu, Zhibing
title: Compromised STEMI reperfusion strategy in the era of COVID-19 pandemic: pros and cons
date: 2020-09-30
journal: Eur Heart J
DOI: 10.1093/eurheartj/ehaa744
sha: 44f4de1539c12006a4f950f53d0810ef3598d8ac
doc_id: 1055969
cord_uid: tdtys9ij

nan

Indeed, daily practice may be altered in response to the sudden outbreak of COVID-19 as we did in cardiology. We proposed previously a modified workflow for managing STEMI patients which had undergone repeated discussions as to achieve optimal benefits over risks. 1 However, we have to admit that 1 the workflow renewed is not a universal guideline but rather a local guidance which is the result of experiences from Chinese cardiologists at the forefront of the COVID-19 pandemic 2 ; there is currently no evidence to support or oppose the rationality of this altered reperfusion strategy, and we believe it will surely change over time with changes in the pandemic.

In the renewed workflow, the role of fibrinolysis was somewhat strengthened mainly out of the following considerations. First, at the initial stage of the outbreak, the preparedness was insufficient in terms of medical personnel training for infection prevention and control, shortage of PPE, and lack of negative pressure catheterization rooms, etc. Medical treatment (i.e. fibrinolysis) in this sense may reduce possible nosocomial transmissions compared with mechanic reperfusion with primary percutaneous coronary intervention (PCI). Second, although primary PCI is preferred within indicated timeframes (e.g. <12 h of symptom onset), fibrinolytic therapy remains a valid choice of treatment for STEMI especially with the advent of tissue-specific thrombolytic agents. As stated in ESC guideline: 'if timely primary PCI cannot be pinterventionerformed after STEMI diagnosis, fibrinolytic therapy is recommended within 12 h of symptom onset in patients without contraindications'. 2 Actually, many ex-ternal factors may cause PCI delay, such as transfer difficulty from non-PCI-capable health facilities to PCI-capable ones, limited speed of virus nucleic acid testing (couple of hours), time taken for the proper preparation of catheterization room, etc. Instead, fibrinolysis has the ease for administration and is available in most hospitals, though it may achieve a relatively lower rate of restoring TIMI 3 flow than PCI. Meanwhile, the protection of medical staff is equally important when saving lives. Third, the role of PCI was not really overlooked. As indicated in the workflow, in case of fibrinolysis contraindication or failed fibrinolysis, or in high-risk patients (those who presented unrelieved ischaemia-related symptoms, malignant arrhythmias haemodynamic instability), emergent PCI would be quickly initiated. All staff engaged should be under level-3 protection, and terminal disinfection must be planned.

Taken together, the fibrinolysis-first approach has both pros and cons, and it is a compromise under some specific scenario in the context of COVID-19 pandemic rather than a universal rule. Prospective observational studies are still warranted.

Conflict of interest: none declared.

Experiences and lesson strategies for cardiology from the COVID-19 outbreak in Wuhan, China, by 'on the scene' cardiologists

ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment 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)