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Khedr A, Hennawi HA, Khan MK, Elbanna M, Jama AB, Proskuriakova E, Mushtaq H, Mir M, Boike S, Rauf I, Eissa A, Urtecho M, Koritala T, Jain N, Goyal L, Surani S, Khan SA. Effect of fibrinolytic therapy on ST-elevation myocardial infarction clinical outcomes during the COVID-19 pandemic: A systematic review and meta-analysis. World J Cardiol 2023; 15:309-323. [PMID: 37397830 PMCID: PMC10308269 DOI: 10.4330/wjc.v15.i6.309] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/30/2023] [Accepted: 05/19/2023] [Indexed: 06/26/2023] Open
Abstract
BACKGROUND ST-elevation myocardial infarction (STEMI) is the result of transmural ischemia of the myocardium and is associated with a high mortality rate. Primary percutaneous coronary intervention (PPCI) is the recommended first-line treatment strategy for patients with STEMI. The timely delivery of PPCI became extremely challenging for STEMI patients during the coronavirus disease 2019 (COVID-19) pandemic, leading to a projected steep rise in mortality. These delays were overcome by the shift from first-line therapy and the development of modern fibrinolytic-based reperfusion. It is unclear whether fibrinolytic-based reperfusion therapy is effective in improving STEMI endpoints.
AIM To determine the incidence of fibrinolytic therapy during the COVID-19 pandemic and its effects on STEMI clinical outcomes.
METHODS PubMed, Google Scholar, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials were queried from January 2020 up to February 2022 to identify studies investigating the effect of fibrinolytic therapy on the prognostic outcome of STEMI patients during the pandemic. Primary outcomes were the incidence of fibrinolysis and the risk of all-cause mortality. Data were meta-analyzed using the random effects model to derive odds ratios (OR) and 95% confidence intervals. Quality assessment was carried out using the Newcastle-Ottawa scale.
RESULTS Fourteen studies including 50136 STEMI patients (n = 15142 in the pandemic arm; n = 34994 in the pre-pandemic arm) were included. The mean age was 61 years; 79% were male, 27% had type 2 diabetes, and 47% were smokers. Compared with the pre-pandemic period, there was a significantly increased overall incidence of fibrinolysis during the pandemic period [OR: 1.80 (1.18 to 2.75); I2= 78%; P = 0.00; GRADE: Very low]. The incidence of fibrinolysis was not associated with the risk of all-cause mortality in any setting. The countries with a low-and middle-income status reported a higher incidence of fibrinolysis [OR: 5.16 (2.18 to 12.22); I2 = 81%; P = 0.00; GRADE: Very low] and an increased risk of all-cause mortality in STEMI patients [OR: 1.16 (1.03 to 1.30); I2 = 0%; P = 0.01; GRADE: Very low]. Meta-regression analysis showed a positive correlation of hyperlipidemia (P = 0.001) and hypertension (P < 0.001) with all-cause mortality.
CONCLUSION There is an increased incidence of fibrinolysis during the pandemic period, but it has no effect on the risk of all-cause mortality. The low- and middle-income status has a significant impact on the all-cause mortality rate and the incidence of fibrinolysis.
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Affiliation(s)
- Anwar Khedr
- Department of Internal Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Hussam Al Hennawi
- Department of Internal Medicine, Jefferson Abington Hospital, Abington, PA 19001, United States
| | - Muhammed Khuzzaim Khan
- Department of Internal Medicine, Dow University of Health Science, Karachi 74200, Pakistan
| | - Mostafa Elbanna
- Department of Internal Medicine, Rochester Regional Health, Rochester, NY 14621, United States
| | - Abbas B Jama
- Department of Critical Care, Mayo Clinic Health System, Mankato, MN 56001, United States
| | | | - Hisham Mushtaq
- Department of Internal Medicine, St. Vincent's Medical Center, Bridgeport, CT 06606, United States
| | - Mikael Mir
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, United States
| | - Sydney Boike
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, United States
| | - Ibtisam Rauf
- Department of Medicine, St. George's University, School of Medicine, St George SW17 0RE, Grenada
| | - Aalaa Eissa
- Department of Medicine, KFS University, KFS 33511, Egypt
| | - Meritxell Urtecho
- Department of Medicine, Robert D and Patricia E. Kern Center of Health Care Delivery, Mayo Clinic, Rochester, MN 55905, United States
| | - Thoyaja Koritala
- Department of Hospital Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Nitesh Jain
- Department of Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Lokesh Goyal
- Department of Hospital Medicine, Christus Sphon Hospital-shoreline, Corpus Christo, TX 78404, United States
| | - Salim Surani
- Department of Pulmonary, Critical Care & Sleep Medicine, Texas A&M University, College Station, TX 77843, United States
| | - Syed A Khan
- Department of Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
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Cancro FP, Bellino M, Esposito L, Romei S, Centore M, D'Elia D, Cristiano M, Maglio A, Carrizzo A, Rasile B, Alfano C, Vecchione C, Galasso G. Acute Coronary Syndrome in Patients with SARS-CoV-2 Infection: Pathophysiology and Translational Perspectives. Transl Med UniSa 2022; 24:1-11. [PMID: 36447945 PMCID: PMC9673986 DOI: 10.37825/2239-9754.1034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/01/2022] [Accepted: 06/08/2022] [Indexed: 01/12/2023] Open
Abstract
Acute coronary syndromes (ACS) may complicate the clinical course of patients with Coronavirus Disease 2019 (COVID-19). It is still unclear whether this condition is a direct consequence of the primary disease. However, several mechanisms including direct cellular damage, endothelial dysfunction, in-situ thrombosis, systemic inflammatory response, and oxygen supply-demand imbalance have been described in patients with COVID-19. The onset of a prothrombotic state may also be facilitated by the endothelial dysfunction secondary to the systemic inflammatory response and to the direct viral cell damage. Moreover, dysfunctional endothelial cells may enhance vasospasm and platelet aggregation. The combination of these factors promotes atherosclerotic plaque instability, thrombosis and, consequently, type 1 myocardial infarction. Furthermore, severe hypoxia due to extensive pulmonary involvement, in association with other conditions described in COVID-19 such as sepsis, tachyarrhythmias, anemia, hypotension, and shock, may lead to mismatch between oxygen supply and demand, and cause type 2 myocardial infarction. A deeper understanding of the potential pathophysiological mechanisms underlying ACS in patients with COVID-19 could help the therapeutic management of these very high-risk patients.
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Affiliation(s)
- Francesco P. Cancro
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno,
Italy
| | - Michele Bellino
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno,
Italy,Corresponding author at: Department of Medicine, Surgery and Dentistry, University of Salerno, University Hospital San Giovanni di Dio e Ruggi d’Aragona, Largo Città di Ippocrate, 84131 Salerno, Italy. Fax: +39 089 089 672805. E-mail address: (M. Bellino)
| | - Luca Esposito
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno,
Italy
| | - Stefano Romei
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno,
Italy
| | - Mario Centore
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno,
Italy
| | - Debora D'Elia
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno,
Italy
| | - Mario Cristiano
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno,
Italy
| | - Angelantonio Maglio
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno,
Italy
| | - Albino Carrizzo
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno,
Italy,Vascular Pathophysiology Unit, IRCCS Neuromed, Pozzilli, Isernia,
Italy
| | - Barbara Rasile
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno,
Italy
| | - Carmine Alfano
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno,
Italy
| | - Carmine Vecchione
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno,
Italy,Vascular Pathophysiology Unit, IRCCS Neuromed, Pozzilli, Isernia,
Italy
| | - Gennaro Galasso
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno,
Italy
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The coronavirus disease-19 pandemic and acute coronary syndrome: a specific impact in the elderly. J Geriatr Cardiol 2022; 19:325-334. [PMID: 35722030 PMCID: PMC9170908 DOI: 10.11909/j.issn.1671-5411.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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4
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Altobelli E, Angeletti PM, Marzi F, D’Ascenzo F, Petrocelli R, Patti G. Impact of SARS-CoV-2 Outbreak on Emergency Department Presentation and Prognosis of Patients with Acute Myocardial Infarction: A Systematic Review and Updated Meta-Analysis. J Clin Med 2022; 11:jcm11092323. [PMID: 35566450 PMCID: PMC9102296 DOI: 10.3390/jcm11092323] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/13/2022] [Accepted: 04/14/2022] [Indexed: 12/23/2022] Open
Abstract
We performed an updated meta-analysis to robustly quantify admission trends of patients with ST-segment elevation MI (STEMI) and non-ST-segment elevation MI (NSTEMI) during the first wave of the pandemic and to characterize on a large basis the risk profile and early prognosis. Studies having the same observation period for the comparison between SARS-CoV-2 outbreak in 2020 versus control period in 2019 were included. Primary endpoints were the relative variation of hospital admissions, the difference of in-hospital mortality for STEMI and NSTEMI. Secondary were: mortality according to countries, income levels and data quality; cardiogenic shock, mechanical complications, door-to-balloon time, time from symptom onset to first medical contact, left ventricular ejection fraction (LVEF) and troponin. In total, 61 observational studies with 125,346 patients were included. Compared with 2019, during the pandemic for STEMI were observed: a 24% reduction of hospitalizations with an impact on early survival (OR = 1.33 in-hospital mortality); the time from symptom onset to first medical contact was 91.31 min longer, whereas door-to-balloon time was increased (+5.44 min); after STEMI, the rate of cardiogenic shock was 33% higher; LVEF at discharge was decreased (−3.46); elevated high-sensitivity troponin levels (1.52) on admission. For NSTEMI, in the COVID-19 period, we observed a 31% reduction of hospitalizations and higher in-hospital deaths (OR = 1.34). The highest mortality rates among countries were: Italy OR = 3.71 (high income), Serbia OR = 2.15 (upper middle) and Pakistan OR = 1.69 (lower middle). Later hospital presentation was associated with larger infarctions, as well as with increased cardiogenic shock and in-hospital mortality.
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Affiliation(s)
- Emma Altobelli
- Department of Life, Public Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (P.M.A.); (F.M.)
- Correspondence: ; Tel.: +39-0862-434-666
| | - Paolo Matteo Angeletti
- Department of Life, Public Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (P.M.A.); (F.M.)
- Cardiac Surgical Intensive Care Unit, Giuseppe Mazzini Hospital, 64100 Teramo, Italy
| | - Francesca Marzi
- Department of Life, Public Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (P.M.A.); (F.M.)
| | - Fabrizio D’Ascenzo
- Cardiovascular and Thoracic Department, Division of Cardiology, University of Turin, 10126 Turin, Italy;
| | | | - Giuseppe Patti
- Department of Translational Medicine, Maggiore della Carità Hospital, University of Eastern Piedmont, 28100 Novara, Italy;
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Ponde C, Jain D, Suresh M, Gunasekaran S, Mishra S, Alexander T, Nair T. Impact of COVID-19 pandemic induced lockdown on management of myocardial infarction: An Indian survey report from the experiences by 1083 cardiologists. JOURNAL OF CLINICAL AND PREVENTIVE CARDIOLOGY 2022. [DOI: 10.4103/jcpc.jcpc_55_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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6
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Numasawa Y. Impact of Concomitant Novel Coronavirus Disease 2019 in Patients With ST-Elevation Acute Myocardial Infarction. Circ J 2021; 85:1708-1709. [PMID: 33854006 DOI: 10.1253/circj.cj-21-0184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yohei Numasawa
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital
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7
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COVID-19 and Acute Coronary Syndromes: From Pathophysiology to Clinical Perspectives. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2021; 2021:4936571. [PMID: 34484561 PMCID: PMC8410438 DOI: 10.1155/2021/4936571] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 08/09/2021] [Indexed: 02/08/2023]
Abstract
Acute coronary syndromes (ACS) are frequently reported in patients with coronavirus disease 2019 (COVID-19) and may impact patient clinical course and mortality. Although the underlying pathogenesis remains unclear, several potential mechanisms have been hypothesized, including oxygen supply/demand imbalance, direct viral cellular damage, systemic inflammatory response with cytokine-mediated injury, microvascular thrombosis, and endothelial dysfunction. The severe hypoxic state, combined with other conditions frequently reported in COVID-19, namely sepsis, tachyarrhythmias, anemia, hypotension, and shock, can induce a myocardial damage due to the mismatch between oxygen supply and demand and results in type 2 myocardial infarction (MI). In addition, COVID-19 promotes atherosclerotic plaque instability and thrombus formation and may precipitate type 1 MI. Patients with severe disease often show decrease in platelets count, higher levels of d-dimer, ultralarge von Willebrand factor multimers, tissue factor, and prolongation of prothrombin time, which reflects a prothrombotic state. An endothelial dysfunction has been described as a consequence of the direct viral effects and of the hyperinflammatory environment. The expression of tissue factor, von Willebrand factor, thromboxane, and plasminogen activator inhibitor-1 promotes the prothrombotic status. In addition, endothelial cells generate superoxide anions, with enhanced local oxidative stress, and endothelin-1, which affects the vasodilator/vasoconstrictor balance and platelet aggregation. The optimal management of COVID-19 patients is a challenge both for logistic and clinical reasons. A deeper understanding of ACS pathophysiology may yield novel research insights and therapeutic perspectives in higher cardiovascular risk subjects with COVID-19.
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Rattka M, Dreyhaupt J, Winsauer C, Stuhler L, Baumhardt M, Thiessen K, Rottbauer W, Imhof A. Effect of the COVID-19 pandemic on mortality of patients with STEMI: a systematic review and meta-analysis. Heart 2020; 107:heartjnl-2020-318360. [PMID: 33334863 PMCID: PMC7747495 DOI: 10.1136/heartjnl-2020-318360] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/24/2020] [Accepted: 11/30/2020] [Indexed: 12/27/2022] Open
Abstract
AIMS Since the beginning of the SARS-CoV-2 outbreak, hospitals reported declining numbers of patients admitted with ST-segment elevation myocardial infarction (STEMI), indicating that the pandemic might keep patients from seeking urgent medical treatment. However, data on outcomes and mortality rates are inconsistent between studies. METHODS A literature search and meta-analysis were performed on studies reporting the mortality of patients with STEMI admitted before and during the COVID-19 pandemic using PubMed, Embase and Web of Science. Additionally, prehospital and intrahospital delay times were evaluated. RESULTS Outcomes of a total of 50 123 patients from 10 studies were assessed. Our study revealed that, despite a significant reduction in overall admission rates of patients with STEMI during the COVID-19 pandemic (incidence rate ratio=0.789, 95% CI 0.730 to 0.852, I2=77%, p<0.01), there was no significant difference in hospital mortality (OR=1.178, 95% CI 0.926 to 1.498, I2=57%, p=0.01) compared with patients with STEMI admitted before the outbreak. Time from the onset of symptoms to first medical contact was similar (mean difference (MD)=33.4 min, 95% CI -10.2 to 77.1, I2=88%, p<0.01) while door-to-balloon time was significantly prolonged in those presenting during the pandemic (MD=7.3 min, 95% CI 3.0 to 11.7, I2=95%, p<0.01). CONCLUSION The significant reduction in admission of patients with STEMI was not associated with a significant increase of hospital mortality rates. The causes for reduced incidence rates remain speculative. However, the analysed data indicate that acute and timely medical care of these patients has been maintained during the pandemic in most countries. Long-term data on mortality have yet to be determined.
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Affiliation(s)
- Manuel Rattka
- Department of Cardiology, Ulm University Medical Center, Ulm, Germany
| | - Jens Dreyhaupt
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | - Claudia Winsauer
- Department of Cardiology, Ulm University Medical Center, Ulm, Germany
| | - Lina Stuhler
- Department of Cardiology, Ulm University Medical Center, Ulm, Germany
| | - Michael Baumhardt
- Department of Cardiology, Ulm University Medical Center, Ulm, Germany
| | - Kevin Thiessen
- Department of Cardiology, Ulm University Medical Center, Ulm, Germany
| | | | - Armin Imhof
- Department of Cardiology, Ulm University Medical Center, Ulm, Germany
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