STEMI Spectrum in COVID-19 Captured by Multinational Case Series

A case series of symptomatic COVID-19 patients with STEMI spanning four countries, including hard-hit Italy, is the largest to date on this unique population, researchers say, with implications for decision-making and future research. Details on the 78 hospitalized people were published online earlier this week in the American Journal of Cardiology.

Altogether, the results echo reports coming in from frontline clinicians across the world: beyond standard STEMI, COVID-19 has been linked to an unusual preponderance of thrombotic events, ECG changes in the absence of obstructive CAD, and cardiac injury.

Anas Hamadeh, MD (Baylor University Medical Center, Dallas, TX), lead author of the new paper, told TCTMD that what stands out to him as the “most striking finding” in their data is the high rate of stent thrombosis: 21%, or four of the 19 PCI-treated patients.

“To me, that is concerning, because it challenges the standard treatment protocols for patients who come in with ST-elevation myocardial infarction, where the recommendation is to take them into the cath lab immediately and put a stent in,” he said. “I’m hoping that this will increase awareness [that] will change how we manage [COVID-19] patients after they get a stent: what choice of antiplatelets and anticoagulants to use for those particular types of patients.”

Although fibrinolysis-based STEMI strategies are being explored in the COVID-19 era, Hamadeh cautioned that their data shouldn’t sway practice in that direction. “I don’t think the level of evidence is strong enough to generalize to the point that everybody should get fibrinolysis if they’re stable. I just think we need to look into this a lot deeper,” he said.

In March, a joint statement by the American College of Cardiology and the Society for Cardiovascular Angiography and Interventions (SCAI) upheld primary PCI as the gold standard but said fibrinolytics could be considered. A second statement from SCAI took a similar stance favoring primary PCI and acknowledging that fibrinolysis could play a role in low-risk patients, especially at hospitals where a high COVID-19 burden is straining staff and resources.

An Eye Toward Stent Thrombosis

Hamadeh and colleagues did a retrospective chart review of 78 patients hospitalized between February 1 and April 15, 2020, at four hospitals in Iraq, Italy, Lithuania, and Spain. All had experienced STEMI and had tested positive for COVID-19; median age was 65 and 63% were men. Common comorbidities included dyslipidemia (92%), hypertension (73%), smoking (53%), and diabetes (27%). Eighty percent had three or more comorbidities.

During their hospital stays, 10% developed acute respiratory distress syndrome and 18% needed mechanical ventilation. Three-quarters were treated with fibrinolysis, while the rest underwent primary PCI. Ultimately, 17% required cardiac resuscitation and 11% died. Median length of stay was 14 days.

Choice of reperfusion strategy was made by the treating clinician and in accordance with each hospital’s guidelines. “Generally, patients presenting with COVID-19 and STEMI in Lithuania, Italy, and Iraq without hemodynamic instability or high-risk features were treated with fibrinolytic therapy,” the researchers explain. “If successful, patients were discharged home and brought back for invasive revascularization after testing negative for COVID-19 at least 14 days after diagnosis. In Spain, most patients with suspected or confirmed COVID-19 who presented with STEMI were treated via primary PCI.”

Within the fibrinolysis subset of 59 patients, the treatment was successful in 85% (defined as ST-segment resolution > 50% within 60 to 90 minutes, no chest pain, and no signs of hemodynamic or electrical instability), with a median time to reperfusion of 27 minutes. Hemorrhagic stroke occurred in 9%, while 10% needed mechanical ventilation and 9% had cardiac resuscitation. In all, 7% died.

In the primary PCI subset of 19 patients, 42% were intubated and 42% required cardiac resuscitation. Fully 21% had stent thrombosis and 26% died in the hospital.

Hamadeh pointed out to TCTMD that the patients in the PCI cohort tended to be sicker than those in the fibrinolysis cohort, as well as sicker than typical STEMI patients who don’t have COVID-19. The latter, he said, may explain why their stent thrombosis rates were unusually high. It may also be that SARS-CoV-2 itself is responsible, given that systemic viral infections have been shown to trigger plaque rupture and thrombosis.

Overall, two patients in the study were found to have no obstructive CAD but rather were diagnosed with myocarditis. Median peak troponin I levels were 70 and 83 ng/mL, respectively, in the fibrinolysis and primary PCI groups.

“This study fills a critical knowledge gap by describing the baseline characteristics and comorbidities, presenting laboratory tests, clinical course, revascularization strategies, and outcomes of patients admitted with COVID-19 disease and STEMI,” the researchers conclude.