Delays, Deaths, and More Cardiogenic Shock Among ACS Patients With COVID-19

Patients with ACS and COVID-19 took longer to get to the hospital, had a much higher rate of cardiogenic shock, and were more likely to die in the hospital compared with ACS patients treated in the prepandemic era, findings from a global COVID-ACS registry show.

Anthony Gershlick, MBBS (University of Leicester, England), reported the data during a TCT Connect 2020 session focused on interventional cardiology during the COVID-19 era. The “headline figure,” he said, is the high rate of cardiogenic shock at discharge—13.2% in the overall ACS population, 20.1% in the STEMI subgroup, and 5.0% in the NSTEMI subgroup. Pre-COVID data put those rates at 8.7% for STEMI and 1.4% for NSTEMI.

Moreover, in-hospital mortality was four to five times higher in patients with ACS and COVID-19 compared with historical data for STEMI (22.9% vs 5.7%) and NSTEMI (6.6% vs 1.2%; P < 0.001 for both).

“These novel data do indicate that COVID-19-positive ACS patients definitely present later [and] they have a higher incidence of cardiogenic shock and much higher mortality, which I think personally are likely to be interrelated,” Gershlick said during his presentation.

Commenting for TCTMD, Ajay Kirtane, MD (NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY), said these data are consistent with what has been seen around the world in terms of delays in presentation, the presence of thrombotic lesions, and high rates of shock and mortality. “For any clinician who’s been in the hospital taking care of these types of patients, these data will resonate with that experience,” he said.

Global COVID-ACS Registry

Early during the pandemic, Gershlick organized a pragmatic global registry to collect information on COVID-19 patients who were undergoing an invasive workup for suspected ACS on the background of initial reports that absolute numbers of patients presenting with ACS were down substantially, presentation times were longer, and thrombus formation was common.

From March through August, the registry collected anonymized data on 316 patients from 85 centers around the world. In all cases, there was a positive COVID-19 test result or high index of clinical suspicion for SARS-CoV-2 infection (clinical status plus chest X-ray or CT findings). All patients underwent coronary angiography for suspected ACS. Of those patients, 265 had confirmed ACS, including 144 with STEMI and 121 with NSTEMI.

Overall, there was a high rate of in-hospital mortality (15.5%) and other events, including repeat MI (4.9%), heart failure (21.5%), BARC type 3 to 5 bleeding (2.6%), and stroke (1.5%). The rate of stent thrombosis (0.8%) was not so high, Gershlick said. In addition, the median length of the hospital stay was 6.6 days, which is clearly prolonged compared with a typical ACS population, he noted.

The investigators compared the characteristics and outcomes of STEMI and NSTEMI patients with prepandemic data from the UK Myocardial Ischaemia National Audit Project (MINAP) and the British Cardiovascular Intervention Society (BCIS).

During the time of COVID-19, both STEMI and NSTEMI patients were younger, had heavier comorbidity burdens, and were more likely to have heart failure and chronic kidney disease. Of note, the time from symptom onset to admission was substantially higher during the pandemic for both STEMI (median 339.0 vs 173.0 min) and NSTEMI (417.0 vs 295.0 min). And for STEMI, door-to-balloon time was longer in COVID-19 patients (83.0 vs 37.0 min), which Gershlick said might be related to the time it takes to don and doff personal protective equipment (PPE).

In terms of procedural characteristics, COVID-19 patients were less likely to undergo PCI via the transradial approach and required greater use of ventilation, pressor support, and (for STEMI) mechanical circulatory support.

What Underlies Excess Mortality?

Gershlick and colleagues found that most deaths were determined to be due to cardiovascular reasons (58.5%), followed by respiratory (31.7%), neurological (4.9%), and unknown (4.9%). Of the CV deaths, cardiogenic shock was seen in three-quarters; the presence of shock was associated with a much longer ischemic time (1,271 vs 441 min). That suggests “long presentation times may have led to sicker patients with a high incidence of cardiogenic shock,” and that may explain the excess mortality seen during the COVID-19 pandemic, Gershlick said.

However, Valentin Fuster, MD, PhD (Icahn School of Medicine at Mount Sinai, New York, NY), commenting after the presentation, said he doubted the high mortality was due to delays in patients getting to the hospital. He suggested instead that it was related to the high thrombotic burden seen with COVID-19 and perhaps direct viral effects in the myocardium.

Gershlick disagreed with that assessment, pointing out that longer ischemic time has been shown to increase infarct size and that larger infarcts lead to cardiogenic shock. It’s important to try to understand all of the mechanisms, he said, but “we know that patients with COVID are anxious, and I think one of the messages from this is that patients took longer to come to hospital, they were sicker, they had more cardiogenic shock, and they died. And I don’t think it’s anything more complicated than that other than there will be other mechanisms perhaps making the cardiogenic shock worse.”

Kirtane said it might not necessarily matter what is causing such a high rate of mortality in patients with ACS and COVID-19 when it comes to patient management. “All we know is that we have to do everything for these patients in a multipronged approach” to treat or prevent COVID-19 and then provide appropriate coronary care. “And that’s why I think many of us have been advocates for being astute clinically, making sure patients truly have a STEMI and going to the lab and doing what’s definitively necessary,” he said.

For Gershlick, the findings have important implications when it comes to messaging about when to seek care during a pandemic. “Future public information strategies need to be different,” he said. “They need to be reassuring, proactive, simple, and certainly more effective, because we think patients stayed away” from hospitals.

Indeed, Timothy Henry, MD (The Christ Hospital, Cincinnati, OH), who earlier in the day presented results from the North American COVID-19 ST-Segment Elevation Myocardial Infarction (NACMI) registry, said there was a 30% to 40% reduction in STEMI activations in March and April, likely because people were scared. After an aggressive awareness campaign targeting both the public and physicians in Ohio, STEMI volumes increased in the second half of May and June.

Public health messaging has to depend somewhat on the dynamic nature of the pandemic, Kirtane said. Early on, hospitals were so overwhelmed that beds for non-COVID patients were scarce and PPE was in short supply, making messages about going to the hospital for other conditions tricky. But as time went on and PPE supplies were shored up, the medical community could be more aggressive in advocating for patients to seek necessary care, Kirtane said.