Adverse outcomes elevated in concomitant COVID-19, STEMI
Patients with STEMI and COVID-19 were less likely to undergo primary PCI and were more likely to experience adverse outcomes compared with those who presented with STEMI before the pandemic, researchers reported.
Also, according to new data from the North American COVID-19 STEMI Registry, underrepresented groups more often tested positive for COVID-19 when presenting with STEMI.
As Healio previously reported, initial outcomes from the North American COVID-19 STEMI (NACMI) registry presented at the virtual TCT Connect indicated a 30% to 50% reduction in patients presenting to the hospital with STEMI and other CV issues. Updated data as of December 6, 2020 were published in the Journal of the American College of Cardiology.
“The NACMI registry was prospectively designed ... as an investigator-initiated, collaborative effort encompassing three North American societies (Society for Cardiovascular Angiography and Interventions, Canadian Association of Interventional Cardiology and the American College of Cardiology Interventional Council) and 64 clinical sites to date,” Santiago Garcia, MD, staff interventional cardiologist at the Minneapolis Heart Institute and associate professor of medicine at the University of Minnesota, and colleagues wrote. “Because early in the COVID-19 pandemic we noted a significant decline in cardiac catheterization laboratory activations for STEMI in the United States, the NACMI registry was purposely designed to include all STEMI patients irrespective of revascularization modality and utilization of invasive angiography.”
For the present analysis, researchers divided patients into those with STEMI and confirmed COVID-19 (n = 230), those with STEMI and suspected COVID-19 infection (n = 495) and age- and sex-matched patients with STEMI treated from 2015 to 2019, who served as controls (n = 460). The primary outcome was a composite endpoint that comprised in-hospital death, stroke, recurrent MI or repeat unplanned revascularization.
Researchers observed that patients who tested positive for COVID-19 were mostly men (71%) and from an underrepresented group (23% Hispanic; 24% Black; 6% Asian). White patients represented 39% of those who tested positive. Among the cohort who tested positive for COVID-19, 18% had cardiogenic shock and 11% had cardiac arrest.
Treatment and in-hospital outcomes
Among patients with STEMI and confirmed COVID-19, 78% underwent angiography and 71% of those who had angiography had primary PCI, compared with 93% of controls who had primary PCI (P < .001), while 20% of those with STEMI and COVID-19 who underwent angiography received medical therapy alone without reperfusion compared with 2% of controls, according to the researchers.
In addition, among those who underwent primary PCI, researchers observed slightly longer median door-to-balloon times compared with controls for patients who with confirmed COVID-19 (79 minutes vs. 66 minutes; P = .008) and those with suspected COVID-19 (77 minutes vs. 66 minutes; P < .001).
Moreover, those who tested positive for COVID-19 were more likely to have no culprit vessel identified on angiography compared with the control group (23% vs. 1%; P < .001) and those with suspected infection (23% vs. 11%; P < .001).
According to the researchers, the primary composite endpoint occurred in 36% of patients with confirmed COVID-19, 13% of those with suspected COVID-19 and 5% of the control group (P < .001 for both COVID-19 groups vs. controls).
This association was mainly driven by in-hospital mortality (confirmed COVID-19, 33%; suspected COVID-19, 11%; controls, 4%; P for confirmed group vs. other groups < .001) and stroke (confirmed COVID-19, 3%; suspected COVID-19, 2%; controls, 0%; P for confirmed vs. suspected patients < .27; P for confirmed vs. controls = .03).
Among patients with STEMI and COVID-19, mortality was higher among individuals who did not undergo coronary angiography compared with those who did (48% vs. 28%; P = .006).
Researchers reported that patients with confirmed COVID-19 had longer hospital and ICU stays.
‘Very different’ population
“One of the striking observations of the NACMI registry is that the patients with COVID-19 look very different than any other STEMI population seen in this registry (ie, the patients under investigation for COVID-19 and the control group) or any other North American STEMI registry; for example, the percentage of Blacks and Hispanic/Latino Americans among patients in the STEMI group with COVID-19 is exceptionally high (47%),” Ran Kornowski, MD, and Katia Orvin, MD, of the department of cardiology at Rabin Medical Center in Petah Tikva, and faculty of medicine at Tel Aviv University, Israel, wrote in a related editorial. “This finding may imply that STEMI care in the presence of COVID-19 may disproportionally affect minority groups and that future focus of care should be directed to a double challenge: addressing unique aspects of STEMI with COVID-19 and economic and social issues associated with STEMI in minority populations.”