Patients with STEMI, COVID-19 represent ‘unique and high-risk’ population
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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.
Future directions
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.
Perspective
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Srihari S. Naidu, MD, FACC, FAHA, FSCAI
The take-home message is that it was feasible to do a very rapid registry format between multiple sites in all of North America, including Canada, and to do that in a pandemic, in a very short duration, to provide timely answers.
It was very clear that of all the patients that were evaluated only about 30% were COVID-19 positive. A large percentage of patients that were under investigation still ended up being standard STEMI patients. It's important that we still manage that patient population since the minority is COVID-19 positive.
I was struck by the fact that COVID positive STEMI is a disease, in particular of African Americans and Hispanics, and that really jumps out the data almost to the point that if you're not African American or Hispanic, you're more likely to be COVID-negative.
Primary PCI was still the majority treatment across the board, 80% in COVID-negative and 70% in COVID-positive. The door-to-balloon times were still within acceptable metrics for all the patients. However, I was struck by the fact that the mortality was extremely high in the COVID-19 positive patients, even though the vast majority did have primary PCI with a good door-to-balloon time. I'm concerned that the benefits of primary PCI are unclear.
What happened to the patients with COVID-19 who underwent medical therapy, those 30% or so that did not get primary PCI? They may have had multiple comorbidities or cardiac arrest. Was their mortality rate even higher? It would be nice to see what the relative risk reduction of primary PCI was in the COVID-positive patients.
I'd also like to see why the COVID-negative patients still had mortality rates higher than a mass population. The control population is a Midwest population and may not be the same as throughout the country and throughout Canada. However, mortality was still twice as much in the COVID-negative population compared to a standard-of-care, non-COVID-19, non-pandemic based population.
That means either the population is different, which did not look like it in the demographics, or that there are other problems with processes. What happened to these patients, even though the door-to-balloon time was good? What happened to them afterwards? Were the ICUs full of COVID-19 patients? Are we able to prioritize these patients after the fact in terms of their care? Was the care standard or were the hospital systems distracted by the pandemic? Those are areas of system improvement we need to look at how do we address the whole system of care around MI, both in and out of the hospital, in the confines of a pandemic. You would imagine that the mortality should be to the same as the mass population, if they had a run-of-the-mill STEMI, were negative for COVID-19 and got primary PCI. That was concerning to me.
This data tell us that in suspected COVID-19, you need to work fast and assume that the majority of these patients are actually having a true STEMI with a true culprit lesion that can be fixed, and the mortality will be one-third of what the COVID-19 positive patients are. You have to assume those patients are more likely to be non-COVID-19 and will have a good outcome, including length of stay and mortality.
In the COVID-positive patients, we need more data. We need to understand whether primary PCI is benefiting or harming patients. We don't know that unless we do a randomized trial or we try to address all the confounders of selection bias in that population and do a comparison to the ones that get medical therapy.
My suspicion is that primary PCI is still the way to go. However, when you do primary PCI in a COVID-19 positive patient with dyspnea and lung findings that are related to the pneumonia, primary PCI may be helpful in terms of evaluating the cardiac situation, but it may be harmful in delaying other treatment, including potentially intubation, proning or ICU care for the COVID-19 pneumonia and other aspects of the COVID disease state. Some of these patients do not have culprit lesions that require a PCI and so it's very important to determine how best to treat that population. I think that this registry, while extremely helpful, still does not fully answer whether primary PCI benefits these patients or not.
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Henry TD, et al. Late-breaking clinical science session I, co-sponsored by Circulation. Presented at: TCT Connect; Oct. 14-18, 2020 (virtual meeting).
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