Optimal management of acute coronary syndromes in the era of COVID-19

Impact of the SARS-CoV-2 pandemic on acute coronary syndrome patients admitted to an urban academic hospital in Soweto, South Africa

Introduction

recent worldwide data has shown a concerning decline in the number of acute coronary syndrome (ACS) related admissions and percutaneous coronary intervention (PCI) procedures during the coronavirus disease 2019 (COVID-19) pandemic. We suspected a similar trend at Chris Hani Baragwanath Hospital (CHBAH).

Methods

a retrospective descriptive study was conducted to evaluate and compare all ACS-related admissions to the cardiac care unit (CCU) at CHBAH in the pre-COVID-19 (November 2019 to March 2020) and during COVID-19 periods (April 2020 to August 2020).

Results

the study comprised 182 patients with a mean age of 57.9 ±10.9 years (22.5% females). Of these, 108 (59.32%) patients were admitted in the pre-COVID-19 period and 74 (40.66%) during COVID-19 (p=0.0109). During the pre-COVID-19 period, 42.9% of patients had ST-segment-elevation myocardial infarction (STEMI), 39.2% with non-ST-segment -elevation myocardial infarction (NSTEMI) and unstable angina (UA) was noted in 18.52%. In contrast, STEMI was noted in 50%, NSTEMI in 43.24% and UA in 6.76% of patients during the COVID-19 period. A statistically significant difference in STEMI and NSTEMI-related admissions was not noted, however, there was a greater number of admissions for UA during the pre-COVID-19 period (18.52% vs 6.76%, P =0.013). Only a third of the patients with STEMI received thrombolysis during the pre-and COVID-19 periods (30.4% vs 37.8%, P=0.47). No difference in the number of PCI procedures was noted between the pre-and during the COVID-19 periods (78.7% vs 72.9%, P=0.37).

Conclusion

there was a difference in overall ACS admissions to the CCU between pre-and during COVID-19 periods, however no difference between STEMI and NSTEMI in both periods. A higher number of UA admissions was noted during the pre-COVID-19 period. During both periods, the use of thrombolysis was low for STEMI and no difference in PCI was noted.

Comparison of the Efficacy and Safety Profiles of Different P2Y12 Inhibitors in Patients With ST-Segment Elevation Myocardial Infarction in the COVID-19 Era

BACKGROUND/AIM

Coronavirus Disease 2019 (COVID-19) is characterized by an increased risk of thrombotic and hemorrhagic events resulting from endothelial dysfunction. In patients with ST-elevation myocardial infarction (STEMI), the dual antiplatelet therapy used to reduce mortality may increase the risk of bleeding. The study aimed to compare the efficacy and safety profiles of P2Y12 inhibitors used during the COVID-19 era.

MATERIALS AND METHODS

Three hundred and ninety patients who underwent primary percutaneous intervention for STEMI between January 1, 2020, and December 31, 2021, were included in this study, retrospectively. The patients were divided into groups according to their COVID-19 history and all-cause mortality, cardiac mortality, stent thrombosis, and bleeding complications during hospitalization and at one-year follow-up were compared.

RESULTS

The mean age of the patients was 64.3 years and the mean follow-up period was 10.2 months; 80% of the patients were male and 44.6% had a history of COVID-19 infection. The in-hospital mortality rate was 11.3%. Cardiac mortality was significantly higher in the clopidogrel group compared to the other groups, regardless of COVID-19 history (21.9% in the clopidogrel group, 1.6% in the prasugrel group, and 6.7% in the ticagrelor group (p<0.001)). There was no significant difference between the groups in terms of bleeding complications and relation to COVID-19.

CONCLUSION

In STEMI patients treated with different P2Y12 inhibitors, there was no significant difference in mortality, bleeding, stroke, and thrombotic complications, regardless of the presence or absence of COVID-19 infection.

Site-level variability in the processes of care and outcomes over time among patients with COVID-19 and myocardial injury: Insights from the American Heart Association's COVID-19 Cardiovascular Disease Registry

Background

Elevated cardiac troponin (cTn) levels in patients with COVID-19 has been associated with worse outcomes. Guidelines on best practices of those patients remain uncertain.

Methods

We included patients with COVID-19 and cTn above the assay-specific upper limit of normal (ULN) enrolled in the American Heart Association's COVID-19 registry between March 2020-January 2021. Site-level variability in invasive coronary angiography, LVEF assessment, ICU utilization, and inpatient mortality were determined by calculating adjusted median odds ratio (MOR) using hierarchical logistic regression models. Temporal trends were assessed with Cochran-Armitage trend test.

Results

Among 32,636 patients, we included 6234 (19.4 %) with cTn above ULN (age 68.7 ± 16.0 years, 56.5 % male, 51.5 % Caucasian), of whom 1365 (21.6 %) had ≥5-fold elevations. Across 55 sites, the median rate of invasive coronary angiography was 0.1 % with adjusted MOR 1.5(1.0,2.3), median LVEF assessment was 25.5 %, MOR 3.0(2.2,3.9), ICU utilization was 41.7 %, MOR 2.2(1.8,2.6), and mortality was 20.9 %, MOR 1.7(1.5,2.0). Over time, we noted a significant increase in invasive coronary angiography (p-trend = 0.001), and LVEF assessment (p-trend<0.001), and reduction in mortality (p-trend<0.001), without significant change in ICU admissions (p-trend = 0.08). Similar variability and temporal trends were seen among patients with ≥5-fold cTn elevation.

Conclusions

The use of invasive coronary angiography among patients with COVID-19 and myocardial injury was very low during the early pandemic. We found moderate institutional variability in processes of care with an uptrend in invasive catheterization and LVEF assessment, and downtrend in mortality. Comparative effectiveness studies are needed to examine whether variability in care is associated with differences in outcomes.

Acute Coronary Syndromes and SARS-CoV-2 Infection: Results From an Observational Multicenter Registry During the Second Pandemic Spread in Lombardy

Background

COVID-19 had an adverse impact on the management and outcome of acute coronary syndromes (ACS), but most available data refer to March-April 2020.

Aim

This study aims to investigate the clinical characteristics, time of treatment, and clinical outcome of patients at hospitals serving as macro-hubs during the second pandemic wave of SARS-CoV-2 (November 2020-January 2021).

Methods and Results

Nine out of thirteen "macro-hubs" agreed to participate in the registry with a total of 941 patients included. The median age was 67 years (IQR 58-77) and ST-elevation myocardial infarction (STEMI) was the clinical presentation in 54% of cases. Almost all patients (97%) underwent coronary angiography, with more than 60% of patients transported to a macro-hub by the Emergency Medical Service (EMS). In the whole population of STEMI patients, the median time from symptom onset to First Medical Contact (FMC) was 64 min (IQR 30-180). The median time from FMC to CathLab was 69 min (IQR 39-105). A total of 59 patients (6.3%) presented a concomitant confirmed SARS-CoV-2 infection, and pneumonia was present in 42.4% of these cases. No significant differences were found between STEMI patients with and without SARS-CoV-2 infection in treatment time intervals. Patients with concomitant SARS-CoV-2 infection had a significantly higher in-hospital mortality compared to those without (16.9% vs. 3.6%, P < 0.0001). However, post-discharge mortality was similar to 6-month mortality (4.2% vs. 4.1%, P = 0.98). In the multivariate analysis, SARS-CoV-2 infection did not show an independent association with in-hospital mortality, whereas pneumonia had higher mortality (OR 5.65, P = 0.05).

Conclusion

During the second wave of SARS-CoV-2 infection, almost all patients with ACS received coronary angiography for STEMI with an acceptable time delay. Patients with concomitant infection presented a lower in-hospital survival with no difference in post-discharge mortality; infection by itself was not an independent predictor of mortality but pneumonia was.

Factors associated with hospital readmissions among patients with COVID-19: A single-center experience

Identify factors associated with readmission after an index hospital admission for coronavirus disease 2019 (COVID-19) infection in a single center serving an underserved and predominantly minority population. This retrospective descriptive study included 275 patients who tested COVID-19 positive via reverse transcriptase-polymerase chain reaction assay at our institution and who survived the index hospitalization. The main outcomes were 1- and 6-month readmission rates after an index hospitalization for COVID-19. The mortality rate among the readmitted patients was also determined. Factors independently associated with readmission were investigated using multivariable logistic regression. A final sample of 275 patients was included. The mean age was 64.69 ± 14.64 (SD), 133 (48%) were female and 194 (70%) were African American. Their chronic medical conditions included hypertension 203 (74%) and diabetes mellitus 121 (44%). After the hospitalization, 1-month readmission rate was 7.6%, while 6-month readmission rate was 24%. Nine percent of patients who were readmitted subsequently died. Coronary artery disease (CAD) was significantly associated with 6-month readmission odds ratio (OR), 2.15 (95% confidence interval [CI]: 1.04-4.44; p = 0.039) after adjustment for age, gender, ethnicity, and comorbidities. Readmissions were due to cardiac, respiratory, and musculoskeletal symptoms. Hispanic ethnicity was associated with increased readmission OR, 3.16 (95% CI: 1.01-9.88; p = 0.048). No significant difference was found between inflammatory markers or clinical outcomes during the index hospitalization among patients who were readmitted compared to those who were not. A significant number of patients hospitalized for COVID-19 may be readmitted. The presence of CAD is independently associated with high rates of 6-month readmission.

COVID-19 and Acute Myocardial Injury and Infarction: Related Mechanisms and Emerging Challenges

In the era of the coronavirus disease 2019 (COVID-19) pandemic, acute cardiac injury (ACI), as reflected by elevated cardiac troponin above the 99th percentile, has been observed in 8%-62% of patients with COVID-19 infection with highest incidence and mortality recorded in patients with severe infection. Apart from the clinically and electrocardiographically discernible causes of ACI, such as acute myocardial infarction (MI), other cardiac causes need to be considered such as myocarditis, Takotsubo syndrome, and direct injury from COVID-19, together with noncardiac conditions, such as pulmonary embolism, critical illness, and sepsis. Acute coronary syndromes (ACS) with normal or near-normal coronary arteries (ACS-NNOCA) appear to have a higher prevalence in both COVID-19 positive and negative patients in the pandemic compared to the pre-pandemic era. Echocardiography, coronary angiography, chest computed tomography and/or cardiac magnetic resonance imaging may render a correct diagnosis, obviating the need for endomyocardial biopsy. Importantly, a significant delay has been recorded in patients with ACS seeking advice for their symptoms, while their routine care has been sharply disrupted with fewer urgent coronary angiographies and/or primary percutaneous coronary interventions performed in the case of ST-elevation MI (STEMI) with an inappropriate shift toward thrombolysis, all contributing to a higher complication rate in these patients. Thus, new challenges have emerged in rendering a diagnosis and delivering treatment in patients with ACI/ACS in the pandemic era. These issues, the various mechanisms involved in the development of ACI/ACS, and relevant current guidelines are herein reviewed.

Clinical Profile and 30-Day Mortality of Invasively Managed Patients with Suspected Acute Coronary Syndrome During the COVID-19 Outbreak

The COVID-19 pandemic severely disrupted cardiovascular care during the spring of 2020 in Europe. Our study analyzed the clinical profile, COVID-19 impact, and 30-day prognosis of invasively managed patients with acute coronary syndrome (ACS) compared to a historical cohort.All invasively managed ACS patients from March 1st to April 30th, 2020 were compared to a cohort from the same timeframe of 2019 (n = 316). COVID-19 confirmed cases were defined by a positive SARS-CoV-2 polymerase chain reaction (PCR) test (CoV+). The primary outcome was all-cause 30-day mortality and multivariable predictors of this outcome.A 40.4% reduction in ACS patients was noted (198 cases in 2019 to 118 in 2020), and 11% of 2020 ACS patients were CoV+. Baseline characteristics were similar between groups. There were significantly more in-hospital patients with ACS (15.3% versus 6.1%, P = 0.007), and fewer patients were found to have a culprit lesion (58.5% versus 74.2%, P = 0.004) in 2020 compared to 2019. Thirty-day mortality in 2020 (7%) was not different from that in 2019 (4.2%), P = 0.294, but it was significantly higher in CoV+ patients (23.1%) compared to that in negative SARS-CoV-2 PCR test (CoV-) patients (5%), P = 0.047, in the 2020 group. In the multivariate analysis, CoV+ was an independent mortality predictor (OR = 9.8, 95% CI = 1.48-64.78), along with the left ventricular ejection fraction (LVEF) (OR = 0.91, 95% CI = 0.86-0.97), P = 0.0006.This study found increased 30-day mortality of invasively managed CoV+ ACS patients compared to that of CoV- patients during the 2020 COVID-19 spring outbreak. In the multivariable analysis, a SARS-CoV-2 positive test was independently associated with 30-day mortality. Further investigations of the underlying physiopathological relations between COVID-19 and ACS are warranted.

Thrombosis and Coagulopathy in COVID-19: Current Understanding and Implications for Antithrombotic Treatment in Patients Treated With Percutaneous Coronary Intervention

Coronavirus disease 2019 (COVID-19), a respiratory syndrome, is a global pandemic. Therefore, there is an urgent need to explore mechanisms implicated in the pathogenesis of the disease. Clinical and autopsy studies show a complex chain of events preceding COVID-19-related death. The disease is characterized by endothelial dysfunction, platelet activation, thrombosis, coagulopathy, and multiple organ failure. Globally, millions of patients with coronary heart disease undergo percutaneous coronary intervention (PCI) each year. These patients undergo high-intensity antithrombotic therapy during hospitalization and dual antiplatelet therapy (DAPT) for at least 6 months post PCI. COVID-19 is characterized by changes in platelet counts. Treatment of ischemic events that occur during stent implantation is associated with bleeding complications in patients following PCI complicated by COVID-19. This review summarizes recent progress in activation status and levels of COVID-19-related platelet changes. These findings will provide information on the effectiveness of antithrombotic therapy for the management of platelet changes in COVID-19 patients.