COVID-19 Resource Center

COVID-19 Resource Center

Disclosures: Mahmud reports he received clinical trial research support from Abbott Vascular, Corindus and CSI; consulted for Abiomed and Medtronic; and has equity in Abiomed. Please see the study for all other authors’ relevant financial disclosures.
April 28, 2020
4 min read
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Primary PCI should remain STEMI standard of care during COVID-19 pandemic, societies say

Disclosures: Mahmud reports he received clinical trial research support from Abbott Vascular, Corindus and CSI; consulted for Abiomed and Medtronic; and has equity in Abiomed. Please see the study for all other authors’ relevant financial disclosures.
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Ehtisham Mahmud

Primary PCI should continue to be the standard of care for patients with STEMI during the COVID-19 pandemic, according to a consensus statement released by the Society for Cardiovascular Angiography and Interventions, the American College of Cardiology and the American College of Emergency Physicians.

“The writing committee and all three major societies involved felt that it was very important to provide a uniform approach for the care of acute myocardial infarction patients during the COVID-19 pandemic in the United States,” SCAI President Ehtisham Mahmud, MD, FACC, FSCAI, division chief of cardiovascular medicine, executive director of medicine at the Cardiovascular Institute, director of the Interventional Cardiology and Cardiac Cath Lab and professor of medicine at UC San Diego, told Healio. “We were concerned that a small experiential study from China suggesting using fibrinolysis as an initial strategy for STEMI was affecting the use of primary PCI for STEMI patients. Furthermore, the majority of people experiencing heart attacks don’t have COVID-19, and we wanted to ensure that the tremendous advances made in reducing cardiovascular morbidity and mortality over the past 3 decades is maintained during this pandemic.”

The consensus statement was published in the Journal of the American College of Cardiology.

Definite STEMI

Patients with definite STEMI should undergo primary PCI as standard of care if they present at PCI centers, with several caveats, especially since the prevalence of the disease in the U.S. has not been firmly established, according to the statement. All patients with suspected STEMI should be treated as COVID-19 possible. These patients should be transferred to the cardiac catheterization laboratory as quickly as possible, although more time may be needed to establish an acute MI diagnosis and/or to perform a COVID-19 status assessment and treatment. Further evaluation in the ED may be required in certain circumstances before transferring to the cardiac catheterization laboratory, which may lead to longer door-to-balloon times.

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SCAI President Ehtisham Mahmud, MD, FACC, FSCAI, division chief of cardiovascular medicine, executive director of medicine at the Cardiovascular Institute, director of the Interventional Cardiology and Cardiac Cath Lab and professor of medicine at UC San Diego.

“It is important to emphasize that primary PCI should remain the standard of care including for COVID-19-confirmed or probable patients,” Mahmud and colleagues wrote. “Once primary PCI is performed on the infarct-related artery, if clinically safe and indicated, any high-grade disease in a noninfarct-related artery should also be treated during the index procedure to minimize further exposure of the cardiac catheterization laboratory staff during a staged procedure.”

Additional noninvasive evaluation in the ED should be performed in patients with an unclear diagnosis of STEMI for reasons including delayed presentation, atypical ECG findings and atypical symptoms. This tactic can help further risk stratify a patient for their COVID-19 status and to assess the potential of coronary thrombotic occlusion or other pathologies, according to the statement. This can be done through traditional transthoracic echocardiographic evaluation or a point-of-care ultrasound of the heart. Coronary CTA can also be considered if the findings of transthoracic echocardiography and findings of ST elevation are contradictory.

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“Available clinical, ECG, laboratory and imaging data can inform a decision between the ED physician and interventional cardiologist regarding cardiac catheterization laboratory activation,” Mahmud and colleagues wrote.

Patients who present with STEMI to hospitals that are incapable of performing PCI should be transferred within 120 minutes of first medical contact at the referral hospital, according to the statement. A pharmacoinvasive approach with initial fibrinolysis should be considered before transfer if rapid reperfusion with primary PCI is not possible. If this patient has established COVID-19, a discussion with health care providers should be done regarding their transfer to a PCI center.

Fibrinolysis may be ideal as a first therapeutic strategy in areas with limited primary PCI centers, according to the statement.

“In the era of COVID-19, each regional STEMI system will need to closely monitor transfer processes and times with active adjustment to a fibrinolysis-first approach if delays ensue that might not have been present prior to the pandemic,” Mahmud and colleagues wrote.

The highest-risk subgroup of patients with acute MI continues to be those with cardiogenic shock and/or resuscitated out-of-hospital cardiac arrest. These patients also have the highest risk for the spread of COVID-19 via droplets. These patients should be treated by a health care team with appropriate personal protective equipment in the ED and the cardiac catheterization laboratory regardless of COVID-19 status.

“Patients with resuscitated out-of-hospital cardiac arrest should be selectively considered for cardiac catheterization laboratory activation in the presence of persistent ST elevation on their electrocardiogram and a concomitant wall motion abnormality on echocardiographic evaluation,” Mahmud and colleagues wrote.

Patients with non-STEMI should be medically managed regardless of COVID-19 status, according to the statement. These patients should be taken for urgent coronary angiography and possible PCI if they have hemodynamic instability or high-risk features. Those without high-risk features can be managed with guideline-indicated medical therapies for acute MI.

Standard medical therapy with an early invasive approach should be used for patients admitted with ACS who may have COVID-19.

The statement also addressed the need for initial assessment of all patients with STEMI in the ED to ensure the correct diagnosis and care plan.

“The attending interventional cardiologist should be notified but without activation of the entire STEMI team until the plan for cardiac catheterization laboratory activation is confirmed,” Mahmud and colleagues wrote.

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Highly engaged cardiovascular community

Despite the importance of receiving care during STEMI, a recent study in the Journal of the American College of Cardiology found that the number of STEMI activations in U.S. cardiac catheterization laboratories has decreased by 38% during the COVID-19 pandemic.

“Patients need to know that it is safe to come to the hospital or call EMS during this COVID-19 pandemic for chest pain, arm or jaw discomfort, shortness of breath or any symptoms suggestive of having a heart attack,” Mahmud said in an interview. “The risk is much higher for patients if they don’t undergo the diagnostic testing and treatment for their cardiac symptoms than their risk of exposure to COVID-19. Nationwide, we have a highly engaged cardiovascular community of physicians and health care workers committed to the safety and best outcomes for our patients with heart disease.” – by Darlene Dobkowski

For the latest news on COVID-19 including case counts, information about the global public health response and emerging research, please visit the COVID-19 Resource Center on Healio.

For more information:

Ehtisham Mahmud, MD, FACC, FSCAI, can be reached at emahmud@ucsd.edu; Twitter: @scai_prez.

Disclosures: Mahmud reports he received clinical trial research support from Abbott Vascular, Corindus and CSI; consulted for Abiomed and Medtronic; and has equity in Abiomed. Please see the study for all other authors’ relevant financial disclosures.