Mortality high, PCI common in patients with concomitant STEMI, COVID-19: NACMI Registry
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In-hospital mortality remains high and primary PCI is common in patients with STEMI and COVID-19, according to new data from the North American COVID-19 Myocardial Infarction Registry.
“One in three [patients with STEMI and COVID-19] does not make it out of the hospital,” Payam Dehghani, MD, FRCPC, FACC, FSCAI, co-director of Prairie Vascular Research Inc. and associate professor at the University of Saskatchewan, said during a press conference at the virtual Society for Cardiovascular Angiography and Interventions Scientific Sessions. Moreover, he said, “primary PCI is common, it’s feasible and it’s associated with reduced mortality. That’s in keeping with our current guidelines.”
Dehghani reported results from nearly 1,000 patients with a positive diagnosis of COVID-19 or individuals with suspected COVID-19 who presented with STEMI to various sites in the U.S. and Canada and were enrolled in the North American COVID-19 Myocardial Infarction (NACMI) Registry.
NACMI is an ongoing, prospective, observational registry that was created under the guidance of SCAI, the American College of Cardiology and the Canadian Association of Interventional Cardiology. The aim of the registry is to compare demographics, clinical findings, outcomes and management strategies of patients with COVID-19 and STEMI compared with a matched historical control of STEMI activation patients from the Midwest STEMI Consortium, and to develop data-driven treatment plans, guidelines and diagnostic acumen for this unique patient population.
“Over 64 sites were activated in less than 6 months. Sites are continuing to enroll. It is a fantastic collaboration,” Dehghani said.
New insights on presentation, characteristics
As of April 9, more than 1,600 patients were included in the NACMI Registry: 331 with STEMI and a positive diagnosis of COVID-19, 645 with STEMI and suspected COVID-19 who turned out to be negative and 661 age- and sex-matched controls who were treated before the COVID-19 pandemic.
The registry’s inclusion criteria were as follows: age 18 years and older, STEMI or new left bundle branch block, positive COVID-19 diagnosis or suspected COVID-19 infection and a clinical correlate of myocardial ischemia, including chest or abdominal discomfort, dyspnea, cardiac arrest, shock and/or mechanical ventilation.
Patients with COVID-19 were more likely to be nonwhite (55% vs. 25%; P < .001) and have diabetes (44% vs. 33%; P < .001) compared with those who tested negative. In addition, those with COVID-19 had more dyspnea (51% vs. 35%; P < .001) and in-house presentation of STEMI (7% vs. 2%; P < .001), but were less likely to present with chest pain (53% vs. 80%; P < .001) than those who tested negative. Chest X-rays were different between the two groups, with infiltrates seen in nearly half of those with COVID-19.
There was no difference in other symptoms on presentation, including cardiac arrest or syncope.
Differences in outcomes, management
The primary outcome — a composite of in-hospital death, stroke, recurrent MI or repeat unplanned revascularization — occurred in 35% of patients with COVID-19 compared with 14% of those who tested negative (P < .001) and 5% of age- and sex-matched controls (P < .001).
“Most of this in-hospital outcome is driven significantly by mortality,” Dehghani said during the presentation. According to the researchers, 33% of those with COVID-19 died compared with 11% of those who tested negative (P < .001) and 4% of controls (P < .001).
Patients with COVID-19 were more likely to undergo medical therapy as a first-line treatment than primary PCI.
“It is fascinating to look at how we are treating these patients across the two countries which have very similar metrics in STEMI standards of care,” he said. “STEMI was not being treated very commonly with thrombolytic use. There was significant work and publications done in China and in Europe about the importance of thrombolytics, but the ACC and SCAI guidelines came out saying that’s probably not a good idea, and you can see that reflected in the way patients were being treated.”
Fewer than 3% of patients with COVID-19 received thrombolytic therapy.
Primary PCI was the dominant reperfusion modality in patients with COVID-19. Timely access to primary PCI was associated with higher survival rates in this population, Dehghani said.
One in five patients who underwent angiography had no culprit vessel identified. In those with culprit disease identified, use of PCI was similar in both those with COVID-19 and those who tested negative (87% vs. 88%).
Door-to-balloon times less than 90 minutes were achieved more than 70% of the time, according to Dehghani.
In addition, those with COVID-19 had longer stays in the ICU and overall.
Multivariate predictors of death in patients with STEMI and COVID-19 were intubation, shock before PCI, in-house presentation of STEMI, diabetes and older age.
The registry investigators are still recruiting and aim to answer many more questions about this patient population, Dehghani said.
For more information on initial results from the NACMI Registry, see Healio’s previous coverage here and here.
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Dehghani P, et al. Featured Clinical Research: Acute coronary and cardiogenic shock. Presented at: Society for Cardiovascular Angiography and Interventions Scientific Sessions: April 28-May 1, 2021 (virtual meeting).
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