Management of Acute Myocardial Infarction During the COVID-19 Pandemic

Abstract

The worldwide pandemic caused by the novel acute respiratory syndrome coronavirus 2 (SARS-CoV2) has resulted in a new and lethal disease termed coronavirus disease 2019 . Although there is an association between cardiovascular disease and COVID-19, the majority of patients who need cardiovascular care for the management of ischemic heart disease may not be infected with COVID-19. The objective of this document is to provide recommendations for a systematic approach for the care of patients with an acute myocardial infarction (AMI) during the COVID-19 pandemic. There is a recognition of two major challenges in providing recommendations for AMI care in the COVID-19 era. Cardiovascular manifestations of COVID-19 are complex with patients presenting with AMI, myocarditis simulating a STelevation MI presentation, stress cardiomyopathy, non-ischemic cardiomyopathy, coronary spasm, or nonspecific myocardial injury and the prevalence of COVID-19 disease in the US population remains unknown with risk of asymptomatic spread. This document addresses the care of these patients focusing on 1) the varied clinical presentations; 2) appropriate personal protection equipment (PPE) for health care workers; 3) role of the Emergency Department, Emergency Medical System and the Cardiac Catheterization Laboratory; and 4) Regional STEMI systems of care. During the COVID-19 pandemic, primary PCI remains the standard of care for STEMI patients at PCI capable hospitals when it can be provided in a timely fashion, with an expert team outfitted with PPE in a dedicated CCL room. A fibrinolysis-based strategy may be entertained at non-PCI capable referral hospitals or in specific situations where primary PCI cannot be executed or is not deemed the best option.

ST-Segment–Elevation Myocardial Infarction Care and COVID-19

“…Those presenting to hospitals without PCI-capability are subject to transfer delays for primary PCI, or even transfer refusal, due to COVID-19 demands. Those presenting by ambulance directly to hospitals with PCI-capability are not receiving the benefit of prehospital cardiac catheterization laboratory activation because it has been suspended 3 Approximately three-quarters of fibrinolytic patients will achieve infarct artery reperfusion allowing for delayed angiography in stable patients (and perhaps avoidance of coronary angiography during these unprecedented times). If rescue PCI is required, time for COVID-19 Downloaded from http://ahajournals.org by on May 23, 2020 screening and PCI preparation is extended.…”

“…A recent consensus statement from the Society for Cardiovascular Angiography and Interventions, the ACC, and the American College of Emergency Physicians on STEMI therapy during the COVID-19 pandemic supports the fibrinolytic therapy and pharmacoinvasive strategy that we have outlined, especially at hospitals without PCI-capability. 3 Some North American hospitals with PCI-capability, including the New York-Presbyterian/Columbia University Irving Medical Center, 4 have adopted a selective fibrinolytic therapy and pharmacoinvasive strategy on a case-by case basis through a tiered approach, whereas others use it for low-risk patients. In Canada, a pharmacoinvasive strategy has been endorsed as an alternative strategy for treating Downloaded from http://ahajournals.org by on May 23, 2020 STEMI patients in circumstances where restriction in regular services exist during the COVID pandemic.…”

COVID-19: Famotidine, Histamine, Mast Cells, and Mechanisms

“…In these rst few days however, COVID-2 may also be associated with anosmia, a unique feature 64 Patients may also present with additional neurological symptoms and complications including ischemic stroke [67][68][69] . Cardiac complications of later COVID-19 include myocarditis, acute myocardial infarction, heart failure, dysrhythmias, and venous thromboembolic events 70,71 .…”

Cardiac Echocardiography in COVID-19 Infection

“…• The presence of myocardial injury is an independent risk factor associated with increased mortality in COVID patients. [5][6][7][8] 3) Rupture of atherosclerotic plaque on a preexisting critical/noncritical coronary artery disease, causing acute myocardial infarction (MI), usually ST elevated myocardial infarction (STEMI). • The management of patients with MI could either be using thrombolytic therapy (provided no C/I exist) or be directly referred to a percutaneous coronary intervention (PCI) center.…”

“…However, the advantage of PCI approach avoids unnecessary delays arising from changes in the appearance of classical findings of ECG in STEMI. [5][6][7][8] 4) Myocardial ischemia precipitated by myocardial supply/demand mismatch due to tachycardia, hypoxia, pyrexia, and systemic inflammation which could lead to severe left ventricle (LV) dysfunction. 9,10 5) Cardiac arrhythmias varying from benign atrial/ventricular ectopics to life-threatening ventricular arrhythmias like Torsades de pointes, which could occur as a result of the following: Myocardial inflammation; use of cardiotoxic medications like chloroquine, hydroxychloroquine, azithromycin antiviral drugs; congenital disorders such as Brugada syndrome and long QT; electrolyte imbalance 11,12 (►Table 2).…”