Henry TD, et al. Late-breaking clinical science session I, co-sponsored by Circulation. Presented at: TCT Connect; Oct. 14-18, 2020 (virtual meeting).
Patients with STEMI, COVID-19 represent ‘unique and high-risk’ population
Initial outcomes from the North American COVID-19 STEMI Registry provide a snapshot of the characteristics, presentation, treatment strategies and clinical outcomes of patients with STEMI and confirmed COVID-19.
Much concern in the cardiology community this year has focused on the implications of COVID-19 on the heart, as patients with CVD are at higher risk for COVID-19. An unintended consequence of the pandemic has been a 30% to 50% reduction in patients presenting to the hospital with STEMI and other CV issues and, of those who are admitted, 15% to 30% will have a positive troponin, Timothy D. Henry, MD, medical director of the Carl and Edyth Lindner Center for Research and Education at The Christ Hospital in Cincinnati, said during a press conference at the virtual TCT Connect.
Henry noted that there has been “considerable controversy” on the appropriate management of patients with STEMI and COVID-19 coming to the cath lab. To date, there have been five publications on STEMI in COVID-19, with a total of 174 patients. Key findings from the five studies show that patients with COVID-19 and STEMI have more frequent in-hospital presentations; more thrombotic lesions and pathologic reports of microthrombi; more frequent nonculprit lesions; and higher mortality, Henry said.
This uncertainty spurred the launch of the North American COVID-19 STEMI Registry (NACMI), a multicenter, observational, collaborative effort between the Society for Cardiovascular Angiography and Interventions, the Canadian Association of Interventional Cardiology, the American College of Cardiology and the Midwest STEMI Consortium. The goal of NACMI was to create a multicenter database of patients who tested positive for COVID-19 or individuals with suspected COVID-19 who present with STEMI or new left bundle branch block. The registry was designed to compare demographics, clinical findings, outcomes and management strategies of patients with COVID-19 and STEMI vs. a propensity-matched historical control of STEMI activation patients from the Midwest STEMI Consortium, and to develop data-driven treatment plans, guidelines and diagnostic acumen regarding this unique patient population, Henry said.
Characteristics in STEMI, COVID-19
During a late-breaking science session at TCT Connect, Henry presented results from the initial 594 patients enrolled at 64 U.S. sites who presented with STEMI or new-onset LBBB on 12-lead ECG or had a clinical correlate of myocardial ischemia, including chest or abdominal discomfort, dyspnea, cardiac arrest, cardiogenic shock or need for mechanical ventilation. Of those, 171 had a confirmed diagnosis of COVID-19 and 423 had suspected COVID-19 but tested negative.
Black patients comprised 27% of those who tested positive for COVID-19 but only 11% of those who tested negative, while Hispanic patients comprised 24% of those who tested positive but only 6% of those who tested negative, Henry said. A positive test for COVID-19 also occurred more frequently in those with diabetes (44% of COVID-19-positive group vs. 33% of COVID-negative group). There were no differences by sex or age.
Other main findings included:
- Patients with STEMI and COVID-19 were more likely to present with cardiogenic shock than the COVID-19-negative group and the control group (20% vs. 17% vs. 55). Those who tested positive had more infiltrates on chest X-ray (49% vs. 17%), more dyspnea (58% vs. 38%) and slightly higher in-hospital presentation (6% vs. 2%) than those who tested negative for COVID-19.
- The rate of primary PCI was 71% in patients with STEMI and COVID-19, 80% in the COVID-19-negative group and 81% in the control group. Those with COVID-19 were more likely to not receive angiography (21% vs. 5% vs. 0%) and more likely to receive medical therapy (20% vs. 12% vs. 10%). Use of thrombolytics was uncommon (6% vs. 2% vs. 3%).
- Median door-to-balloon times was similar across the three groups (COVID-19 positive, 80 minutes; COVID-19-negative, 78 minutes; controls, 86 minutes).
- Patients with STEMI and COVID-19 had the highest rates of in-hospital mortality (32% vs. 12% vs. 6%; P < .001) and in-hospital stroke (3.4% vs. 2% vs. 0.6%; P vs. controls = .039) and a longer length of hospital stay (6 days vs. 3 days vs. 3 days; P < .001).
“Primary PCI is preferrable, and feasible, in COVID-19-positive patients with door-to-balloon times similar to [patients with suspected but negative for COVID-19], supporting current SCAI/ACC/AHA recommendations,” Henry said.
Enrollment in NACMI and expansion to other sites is ongoing, Henry said. The registry is expected to have up to 100 sites participating in the U.S. and Canada. Sites in Mexico and South America are being added to compile data from both North and South America, he said.
Some of the future topics of interest will focus on race/ethnicity; differences by country and region; time to treatment, including chest pain onset to arrival; transfer patients; and no-hospital patients, Henry said.
It is also important, he said, to look at changes over time and glean whether there are differences at the start of the pandemic compared with now.
The registry will also report long-term outcomes, he said.