Management of Infarction During the COVID-19 Pandemic

Patients with cardiovascular disease infected with COVID-19 are at a particular risk for morbidity and mortality. In any case, it should be noted that most patients requiring cardiovascular care due to ischemic heart disease, peripheral vascular disease, or structural heart disease are not infected.

Being prepared to face this pandemic is as important as guaranteeing the availability of the same care that has benefited the population for the past 30 years.

In that sense, there are critical data that should be taken into account:

• The risk of exposure to the infection should be minimized so that emergency departments can continue providing the same quality care in cases of acute ischemic heart disease.
• Whenever possible, we should use primary angioplasty in patients with ST-segment elevation myocardial infarction. Patients admitted at sites without primary angioplasty capabilities should receive thrombolysis. These strategies (specially thrombolysis) should be avoided in cases when a type I infarction diagnosis is unclear.
• We should maximize the safety of all personnel through the use of personal protection equipment.

Patients presenting with defined ST-segment elevation myocardial infarction at sites with primary angioplasty capabilities

Primary angioplasty within 90 minutes of first medical contact is still the standard of care at sites with angioplasty capabilities.

This is still true in times of pandemic, even for suspected and confirmed COVID-19 patients, but longer door-to-balloon times are expected given the required protective measures.

Read also: Procedural Rescheduling Criteria in the Pandemic Era.

In a COVID-19 setting, many of these patients may experience symptoms and electrocardiographic changes mimicking an infarction, such as myocarditis or cardiomyopathy associated with COVID-19 infection. Fibrinolysis of these patients offers no clinical benefit and increases the risk for bleeding.

Patients with “possible” infarction

For patients whose diagnosis is unclear due to atypical symptoms, atypical or diffuse electrocardiographic changes, or delayed presentation, additional assessment before deciding on a reperfusion strategy is highly recommended.

Thus:

• First, the risk of COVID-19 infection for the patient should be re-assessed.
• Then, we should clarify whether we are dealing with an infarction due to thrombotic occlusion of an epicardial artery. An electrocardiography may be useful, since it can show us wall motion abnormalities consistent with electrocardiographic findings.

Patients with futile prognosis

Not all COVID-19 patients with ST elevation (due to plaque rupture or not) will benefit from a reperfusion strategy.

COVID19 confirmed patients with severe respiratory failure or pneumonia (who require mechanical respiratory support) have an excessively high mortality and in their case compassionate medical care can be considered.

Patients at sites without primary angioplasty capabilities

The standard of care is transferring these patients within 120 minutes of first medical contact.

If this is not feasible, a pharmacoinvasive approach can be considered, with initial fibrinolysis within 30 minutes followed by transfer to a capable site, if necessary.

Patients with NON-ST-segment elevation

A significant proportion of patients with COVID-19 have elevated troponin levels, which indicate a poor prognosis.

While a Type I infarction due to plaque rupture is possible, it can also be due to myocarditis, stress cardiomyopathy, coronary spasm, ventricular strain, right heart failure, or Type II infarction due to critical clinical status.

Read also: ECS Guidelines for COVID-19 Management.

Until additional data are available, all COVID-19 positive or probable patients with NON-ST-segment elevation myocardial infarction should be managed with medical treatment, and an invasive strategy should only be considered in the presence of high-risk features (Global Registry of Acute Coronary Events [GRACE] score >140) or hemodynamic instability.

Original Title: Management of Acute Myocardial Infarction During the COVID-19 Pandemic. A Consensus Statement from the Society for Cardiovascular Angiography and Interventions (SCAI), American College of Cardiology (ACC) and the American College of Emergency Physicians (ACEP).

Reference: Ehtisham Mahmud et al. https://doi.org/10.1016/j.jacc.2020.04.039.

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