Reperfusion in the Time of COVID-19. What Has Changed?

We are living a pandemic due to the new COVID-19, but the world was already in the midst of a pandemic of cardiovascular disease. Both challenges defy healthcare systems worldwide, and the worst part is that they can coexist.

Some symptoms for both diseases can overlap (such as respiratory distress) and they are unreliable, like many diagnostic tests.

Most COVID-19 screening tests offer up to 30% false negative results, and 80% of all infections are asymptomatic.

The Chinese physicians were the first to deal with COVID-19 (by now, we can already call them the greatest “experts” on this subject). In the setting of this COVID-19 pandemic, they recommended fibrinolytic therapy over primary angioplasty in cases of ST-segment elevation myocardial infarction.

Many considered it a reasonable recommendation in order to offer the earliest possible reperfusion using the lowest number of resources from collapsing hospitals.

Read also: Cardiology in Times of Coronavirus: The Perfect Storm.

Everybody acknowledges that, at this time, damage control is the main objective, as we strive to do our best with what little we have.

Fibrinolytic therapy was the first reperfusion strategy to be implemented systematically. Afterwards, primary angioplasty was proven superior even in the very long term, and it became the standard treatment for ST-segment elevation acute coronary syndrome. This does not mean that fibrinolytic therapy ceased to be used; there are still some isolated regions, small towns, and countries with scarce resources where it is used as the only alternative.

Strategic Reperfusion Early After Myocardial Infarction (STREAM) is a contemporary trial that included patients with ST-segment elevation myocardial infarction less than 3 hours of symptom onset without access to primary angioplasty within 60 minutes from first medical contact.

Read also: Coronavirus and the Heart: How Should Cardiologists Prepare?

Patients were randomized to fibrinolytic therapy, with angioplasty after 6-24 hours, or primary angioplasty (mean difference between fibrinolytic administration and primary angioplasty ≥78 minutes). Outcomes of fibrinolytic therapy vs. primary angioplasty were similar for the composite of death, shock, heart failure, or reinfarction.

Need for emergency angiography in the fibrinolytic arm was 36%, while mortality was <5% in both groups.

Intracranial hemorrhage was higher with thrombolysis (1.0% vs. 0.5%; p = 0.02). Despite all of that, thrombolysis did not do so bad in the P2Y12 inhibitor era.

Read  also: Cath Lab Management Protocol for the COVID-19 Outbreak.

The time to primary angioplasty may be delayed due to overcharge in the systems of care, not just because of individual operators. Before primary angioplasty, even among COVID-19 negative patients, we are required to establish contact history, symptomatology (not only related to infarction), etcetera, before transferring the patient to the cath lab.

Interventional professionals are also required to don personal protective equipment, and all of that may hinder or slow down their work.

Despite all protective measures, contagion may occur, and the subsequent isolation may reduce the number of interventional cardiologists on call during this pandemic.

Original title: Reperfusion of STEMI in the COVID-19 Era – Business as Usual?

Reference: Matthew J. Daniels et al. CIRCULATION 2020, article in press. 

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