Key points Ask In patients with ST-segment elevation myocardial infarction (STEMI), is a concomitant diagnosis of COVID-19 associated with differences in clinical outcome? Findings In this retrospective cohort study that included 80,449 patients, in-hospital mortality rates for patients with vs without a concomitant diagnosis of COVID-19 were 15.2% vs 11.2% among those with out-of-hospital STEMI and 78.5% vs . 46.1% among those with in-hospital STEMI; both differences were statistically significant. Meaning Among patients with STEMI, a concomitant diagnosis of COVID-19 was associated with significantly higher rates of in-hospital mortality. |
The COVID-19 pandemic has negatively affected the care of patients with ST-segment elevation myocardial infarction (STEMI). The number of patients presenting with STEMI decreased substantially during pandemic waves, reperfusion strategies were modified, and delays in reperfusion were observed worldwide.
Worse STEMI-related outcomes have been reported throughout the pandemic, including higher rates of in-hospital mortality. It is unclear whether these results have been the result of factors related to the pandemic or SARS-CoV-2 infection.
Data from relatively small cohort studies suggest that outcomes after out-of-hospital STEMI may be worse among those with COVID-19 than those without COVID-19, but few broadly representative data exist. There are few data characterizing acute in-hospital STEMI among patients hospitalized with COVID-19.
To better understand the association between COVID-19 outcome and STEMI in a large, nationally representative patient cohort, the present study used a multicenter clinical database to evaluate patients with COVID-19 versus those without COVID-19. 19 who presented outside the hospital. STEMI or developed STEMI while hospitalized.
To differentiate between the direct and pandemic-related association between COVID-19 and clinical outcome, separate control patients from the same year and the previous year were used when comparing patients with and without a diagnosis of COVID-19.
Significance Limited research has been conducted in patients with ST-segment elevation myocardial infarction (STEMI) and COVID-19.
Objective To compare the characteristics, treatment and outcomes of STEMI patients with and without COVID-19 infection.
Design, scope and participants
Retrospective cohort study of consecutive adult patients admitted between January 2019 and December 2020 (end of follow-up January 2021) with out-of-hospital or in-hospital STEMI at 509 US centers in the Vizient clinical database ( N = 80,449).
Exhibitions
Active COVID-19 infection present during the same encounter.
Main results and measures
The primary outcome was in-hospital mortality. Patients were propensity matched based on the probability of COVID-19 diagnosis. In the main analysis, patients with COVID-19 were compared to those without COVID-19 during the previous calendar year.
Results
The out-of-hospital STEMI group included 76,434 patients (551 with COVID-19 vs 2755 without COVID-19 after matching) from 370 centers (64.1% aged 51 to 74 years; 70.3% men).
The in-hospital STEMI group included 4015 patients (252 with COVID-19 vs. 756 without COVID-19 after matching) from 353 centers (58.3% aged 51 to 74 years; 60.7% men).
In patients with out-of-hospital STEMI, there were no significant differences in the likelihood of undergoing primary percutaneous coronary intervention by COVID-19 status; Patients with in-hospital STEMI and COVID-19 were significantly less likely to undergo invasive diagnostic or therapeutic coronary procedures than those without COVID-19.
Among patients with out-of-hospital STEMI and COVID-19 versus out-of-hospital STEMI without COVID-19, in-hospital mortality rates were 15.2% versus 11.2% (absolute difference, 4.4%). P = 0.007).
Among patients with in-hospital STEMI and COVID-19 versus in-hospital STEMI without COVID-19, in-hospital mortality rates were 78.5% versus 46.1% (absolute difference, 32.4% [95% CI, 29 .0%-35.9% ]; P < 0.001).
Discussion
In this retrospective cohort study, patients with out-of-hospital or in-hospital STEMI and a concomitant diagnosis of COVID-19 had a higher rate of in-hospital mortality compared to groups of propensity-matched patients without COVID-19 admitted during the period. previous calendar year. The results were consistent across multiple sensitivity analyses, including an analysis with a control group of non-COVID-19 patients from the same calendar year.
In previous studies, the incidence of cardiovascular events, including cardiovascular death and myocardial infarction, was higher among people with influenza and influenza-like illnesses, such as SARS-CoV-1 and respiratory syndrome-related coronavirus. Middle East. Furthermore, the probability of admission for acute myocardial infarction during a 7-day risk interval after a laboratory diagnosis of influenza increased 6-fold.
As in other COVID-19 studies, patients with COVID-19 were younger, less likely to be white, and more likely to be Hispanic compared to those who did not have COVID-19. COVID-19 patients were also more likely to experience cardiac arrest, consistent with the increase in in-hospital and out-of-hospital cardiac arrest rates seen elsewhere during the pandemic.
In contrast, the study’s observations on primary treatment strategies were novel. Fibrinolytics have been used as reperfusion therapy in patients with out-of-hospital STEMI more frequently in those with a diagnosis of COVID-19 than without, but the efficacy and safety of this strategy relative to primary PCI in patients with COVID-19 is unknown . 19. PCI remained the dominant therapy in both groups, with overall rates approaching those reported in other large national cohorts.
In contrast, among patients with in-hospital STEMI, coronary revascularization rates were significantly lower in those with COVID-19 than without COVID-19, although rates were quite low in both groups. It is unknown whether this change in approach was due to the perceived futility of invasive therapy in these patients, the perceived risk to healthcare workers, or both.
Conclusions and relevance Among patients with out-of-hospital or in-hospital STEMI, a concomitant COVID-19 diagnosis was significantly associated with higher rates of in-hospital mortality compared to patients without a prior-year COVID-19 diagnosis. More research is required to understand the possible mechanisms underlying this association. |
Editorial comment
Possible mediators of this excess mortality include late presentation, increased incidence of cardiogenic shock and cardiac arrest, different pathophysiological mechanisms (e.g., more thrombogenic lesions and microthrombi), and deviations from standard treatment protocols. Although more basic mechanistic research is needed to elucidate the unique pathophysiology of STEMI in patients with COVID-19, substantial information is available related to care delivery systems for these patients.
For example, the study by Saad et al highlights the frequency with which STEMI occurs while patients with COVID-19 are hospitalized and the degree to which this is associated with the increased mortality observed in this population. In the study by Saad et al, one-third of STEMIs among COVID-19 patients occurred in patients hospitalized for other reasons, most commonly COVID-19.
In contrast, only 5% of STEMIs in non-COVID-19 patients were among those hospitalized for other reasons. Patients with in-hospital STEMI have higher mortality than those with out-of-hospital STEMI for reasons related to both comorbidities and systems of care, and outcomes in COVID-19 patients who develop STEMI while hospitalized are dismal (mortality rate of 78%). % in the study by Saad et al ).
Current evidence also underscores the potential harms associated with deviations from evidence-based STEMI protocols that occurred during the early phases of the pandemic. Multiple studies have documented treatment delays and reduced access to primary PCI for patients with STEMI and COVID-19, with these changes in patterns of care associated with increased risks of mortality and heart failure.
The current study by Saad et al, as well as previous analyses, support current recommendations from the Society for Cardiovascular Angiography and Interventions and the American College of Cardiology demonstrating that primary PCI is feasible in COVID-19 patients with STEMI and should remain the primary reperfusion modality in the absence of markers of futility.
Negative alterations in STEMI care delivery during the pandemic extended beyond deviations from previous hospital protocols. Early reports demonstrating a reduction in cardiac catheterization laboratory activations for STEMI and an increase in home cardiac arrests raised concerns that many patients with acute MI were not seeking medical care during the pandemic, which could derail 3 decades of scientific progress.
Lockdowns instituted during the first wave of the pandemic may not have adequately emphasized to the public the differences between hospitals (essential service) and non-essential services, such as bars, restaurants and gyms. Additionally, recommendations to "self-quarantine" for 2 weeks when COVID-19 symptoms were present, some of which may be indistinguishable from symptoms of heart disease, such as dyspnea and cough, may have contributed to many patients delay or forgo necessary medical care. careful. As the pandemic continues and in potential public health emergencies in the future, it is imperative to emphasize the importance of timely care for patients with acute myocardial infarction.
