COVID-19 pandemic, mechanical reperfusion and 30-day mortality in ST elevation myocardial infarction

OBJECTIVE

The initial data of the International Study on Acute Coronary Syndromes - ST Elevation Myocardial Infarction COVID-19 showed in Europe a remarkable reduction in primary percutaneous coronary intervention procedures and higher in-hospital mortality during the initial phase of the pandemic as compared with the prepandemic period. The aim of the current study was to provide the final results of the registry, subsequently extended outside Europe with a larger inclusion period (up to June 2020) and longer follow-up (up to 30 days).

METHODS

This is a retrospective multicentre registry in 109 high-volume primary percutaneous coronary intervention (PPCI) centres from Europe, Latin America, South-East Asia and North Africa, enrolling 16 674 patients with ST segment elevation myocardial infarction (STEMI) undergoing PPPCI in March/June 2019 and 2020. The main study outcomes were the incidence of PPCI, delayed treatment (ischaemia time >12 hours and door-to-balloon >30 min), in-hospital and 30-day mortality.

RESULTS

In 2020, during the pandemic, there was a significant reduction in PPCI as compared with 2019 (incidence rate ratio 0.843, 95% CI 0.825 to 0.861, p<0.0001). This reduction was significantly associated with age, being higher in older adults (>75 years) (p=0.015), and was not related to the peak of cases or deaths due to COVID-19. The heterogeneity among centres was high (p<0.001). Furthermore, the pandemic was associated with a significant increase in door-to-balloon time (40 (25-70) min vs 40 (25-64) min, p=0.01) and total ischaemia time (225 (135-410) min vs 196 (120-355) min, p<0.001), which may have contributed to the higher in-hospital (6.5% vs 5.3%, p<0.001) and 30-day (8% vs 6.5%, p=0.001) mortality observed during the pandemic.

CONCLUSION

Percutaneous revascularisation for STEMI was significantly affected by the COVID-19 pandemic, with a 16% reduction in PPCI procedures, especially among older patients (about 20%), and longer delays to treatment, which may have contributed to the increased in-hospital and 30-day mortality during the pandemic.

TRIAL REGISTRATION NUMBER

NCT04412655.

Acute myocardial infarction system of care in the third world

BACKGROUND

We studied the characteristics of ST-elevation myocardial infarction (STEMI) patients from a local acute coronary syndrome (ACS) registry in order to find and build an appropriate acute myocardial infarction (AMI) system of care in Jakarta, Indonesia.

METHODS

Data were collected from the Jakarta Acute Coronary Syndrome (JAC) registry 2008-2009, which contained 2103 ACS patients, including 654 acute STEMI patients admitted to the National Cardiovascular Center Harapan Kita, Jakarta, Indonesia.

RESULTS

The proportion of patients who did not receive reperfusion therapy was 59% in all STEMI patients and the majority of them (52%) came from inter-hospital referral. The time from onset of infarction to hospital admission was more than 12 h in almost 80% cases and 60% had an anterior wall MI. In-hospital mortality was significantly higher in patients who did not receive reperfusion therapy compared with patients receiving acute reperfusion therapy, either with primary percutaneous coronary intervention (PPCI) or fibrinolytic therapy (13.3% vs 5.3% vs 6.2%, p < 0.001).

CONCLUSION

The Jakarta Cardiovascular Care Unit Network System was built to improve the care of AMI in Jakarta. This network will harmonise the activities of all hospitals in Jakarta and will provide the best cardiovascular services to the community by giving two reperfusion therapy options (PPCI or pharmaco-invasive strategy) depending on the time needed for the patient to reach the cath-lab.

Impact of renin-angiotensin-aldosterone system inhibition on mortality in critically ill COVID-19 patients with pre-existing hypertension: a prospective cohort study

BACKGROUND

The influence of renin-angiotensin-aldosterone system (RAAS) inhibitors on the critically ill COVID-19 patients with pre-existing hypertension remains uncertain. This study examined the impact of previous use of angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) on the critically ill COVID-19 patients.

METHODS

Data from an international, prospective, observational cohort study involving 354 hospitals spanning 54 countries were included. A cohort of 737 COVID-19 patients with pre-existing hypertension admitted to intensive care units (ICUs) in 2020 were targeted. Multi-state survival analysis was performed to evaluate in-hospital mortality and hospital length of stay up to 90 days following ICU admission.

RESULTS

A total of 737 patients were included-538 (73%) with pre-existing hypertension had received ACEi/ARBs before ICU admission, while 199 (27%) had not. Cox proportional hazards model showed that previous ACEi/ARB use was associated with a decreased hazard of in-hospital death (HR, 0.74, 95% CI 0.58-0.94). Sensitivity analysis adjusted for propensity scores showed similar results for hazards of death. The average length of hospital stay was longer in ACEi/ARB group with 21.2 days (95% CI 19.7-22.8 days) in ICU and 6.7 days (5.9-7.6 days) in general ward compared to non-ACEi/ARB group with 16.2 days (14.1-18.6 days) and 6.4 days (5.1-7.9 days), respectively. When analysed separately, results for ACEi or ARB patient groups were similar for both death and discharge.

CONCLUSIONS

In critically ill COVID-19 patients with comorbid hypertension, use of ACEi/ARBs prior to ICU admission was associated with a reduced risk of in-hospital mortality following adjustment for baseline characteristics although patients with ACEi/ARB showed longer length of hospital stay. Clinical trial registration The registration number: ACTRN12620000421932; The date of registration: 30, March 2020; The URL of the registration: https://www.australianclinicaltrials.gov.au/anzctr/trial/ACTRN12620000421932 .

Outcome in early vs late intubation among COVID-19 patients with acute respiratory distress syndrome: an updated systematic review and meta-analysis

Timing of endotracheal intubation in COVID-19 patients with acute respiratory distress syndrome (ARDS) remains controversial regarding its risk and benefit in patient outcomes. Our study aims to elucidate early versus late intubation outcomes among COVID-19 patients with ARDS. A protocol of this study is registered at the international prospective register of systematic reviews (PROSPERO) (CRD42021230272). We report our systematic review based on PRISMA and MOOSE guidelines. We searched the Cochrane Library, EBSCOhost, EMBASE, Grey Literature Report, OpenGrey, ProQuest, PubMed, and ScienceDirect from inception until 4 December 2021. Titles and abstracts were reviewed for their relevance. The risk of bias in each study was evaluated using the risk of bias in non-randomised studies-of interventions (ROBINS-I) guideline. Trial sequential analysis is done to elucidate firm evidence. We retrieved 20 observational studies that assessed an intervention (early vs. late intubation). Meta-analysis for in-hospital mortality reduction showed 119 fewer deaths per 1000 patients in early intubation. Early intubation reduces 2.81 days of ICU length of stay (LOS) and 2.12 days of ventilation duration. Benefits for mortality and ICU LOS reduction were based on studies with low to moderate risk of bias while ventilation duration was based on low disease burden setting. According to the contextualized approach, the benefit of mortality reduction showed a trivial effect, while ICU LOS and ventilation duration showed a small effect. GRADE certainty of evidence for mortality reduction in early intubation is moderate. The certainty of evidence for ICU length of stay, ventilation duration, ventilator-free days, and continuous renal replacement therapy are very low. This updated systematic review provided new evidence that early intubation might provide benefits in treating COVID-19 patients with ARDS. The benefits of early intubation appear to have an important but small effect based on contextualized approach for ICU LOS and ventilation duration. In reducing in-hospital mortality, the early intubation effect was present but only trivial based on contextualized approach. TSA showed that more studies are needed to elucidate firmer evidence.

Key challenges in prehospital and emergency care in Indonesia and Malaysia: a survey of frontline clinicians

Rapid economic growth in Indonesia and Malaysia has widened the gap in emergency care supply and demand, intensifying challenges. Our study, from August to November 2022, assesses current diverse challenges in both countries' emergency care systems from frontline staff perspectives. The online survey involved emergency department (ED) personnel from 11 hospitals in Indonesia and Malaysia, drawing from an existing network. The survey collected data on respondents' characteristics, factors affecting prehospital and ED care quality, missing clinical information, and factors influencing patients' ED stay duration. With 83 respondents from Indonesia and 109 from Malaysia, the study identified common challenges. In both countries, inadequate clinical information from ambulances posed a primary challenge in prehospital care quality, while crowdedness during night shifts affected ED care quality. Frequent gaps in essential clinical information, such as family and medication history, were observed. Prolonged ED stays were associated with diagnostic studies and their turnaround time. This study offers insights into shared challenges in Indonesia and Malaysia's emergency care systems. Our findings stress recognizing common and country-specific challenges for enhanced emergency care quality in Southeast Asia, supporting tailored interventions.

Impact of Timing of Eptifibatide Administration on Preprocedural Infarct-Related Artery Patency in Acute STEMI Patients Undergoing Primary PCI

The appropriate timing of eptifibatide initiation for acute ST segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) remains unclear. This study aimed to analyze the impact of timing of eptifibatide administration on infarct-related artery (IRA) patency in STEMI patients undergoing primary PCI. Acute STEMI patients who underwent primary PCI (n = 324) were enrolled in this retrospective study; 164 patients received eptifibatide bolus ≤ 30 minutes after emergency department (ED) admission (group A) and 160 patients received eptifibatide bolus > 30 minutes after ED admission (group B). The primary endpoint was preprocedural IRA patency. Most patients in group A (90%) and group B (89%) were late presenters (> 2 hours after symptom onset). The two groups had similar preprocedural thrombolysis in myocardial infarction 2 or 3 flow of the IRA (26 vs. 24%, p = not significant [NS]), similar creatine kinase-MB (CK-MB) levels at 8 hours after admission (339 vs. 281 U/L, p = NS), similar left ventricular ejection fraction (LVEF) (52 vs. 50%, p = NS), and similar 30-day mortality (2 vs. 7%, p = NS). Compared with group B, patients in group A had shorter door-to-device time (p < 0.001) and shorter procedural time (p = 0.004), without increased bleeding risk (13 vs. 18%, p = NS). Earlier intravenous administration of eptifibatide before primary PCI did not improve preprocedural IRA patency, CK-MB level at 8 hours after admission, LVEF and 30-day mortality compared with patients who received intravenous eptifibatide that was administered later.

First Asian validation of ORBI score in predicting in-hospital cardiogenic shock in patients with ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention

Background

Cardiogenic shock (CS) complicating an acute coronary syndrome still worsening the prognosis with 30-day mortality rates approximating 40–45%, despite improvements in the acute management of ST-segment elevation myocardial infarction (STEMI), particularly the widespread use of timely primary percutaneous coronary intervention (pPCI). The ORBI risk score provides a readily useable and efficient tool to identify patients at high-risk of developing CS during hospitalization following STEMI which may aid in further risk-stratification and thus potentially facilitate pre-emptive clinical decision making. This is essential in developing countries with wide variation in health care facilities, scarce resources and increasing burden of cardiovascular diseases.

Purpose

To validate ORBI Score in identifying patients at high-risk of in-hospital STEMI related cardiogenic shock in a multi-ethnic developing country.

Method

The ORBI risk score was evaluated in 1934 patients STEMI without CS on admission and treated by primary percutaneous coronary intervention (pPCI) in our national cardiovascular centre included this study. Model discrimination and calibration was tested in the overall population. Eleven variables from the ORBI score were independently associated with the development of in-hospital CS: age &gt;70 years, prior stroke/transient ischaemic attack, cardiac arrest upon admission, anterior STEMI, first medical contact-to-pPCI delay &gt;90min, Killip class, heart rate &gt;90/min, a combination of systolic blood pressure &lt;125 mmHg and pulse pressure &lt;45 mmHg, glycaemia &gt;10 mmol/L, culprit lesion of the left main coronary artery, and post-pPCI thrombolysis in myocardial infarction flow grade &lt;3. The score derived from these variables allowed the classification of patients into four risk categories: low (0–7), low- to-intermediate (8–10), intermediate-to-high (11–12), and high (≥13).

Results

Observed in-hospital CS rates were 0.3%, 6.4%, 19.5%, and 32.12%, across the four risk categories, respectively. The score demonstrated high discrimination (c-statistic of 0.91 (CI 95% 0.88–0.93), p&lt;0.001 in the validation cohort)

Conclusion

The ORBI risk score is valid and can be used for predicting the development of cardiogenic shock in STEMI patients for better targeted treatment.

Funding Acknowledgement

Type of funding sources: None. ROC curveObserved in-hospital CS rates

Characteristics and outcomes of patients with severe COVID-19 in Indonesia: Lessons from the first wave

BACKGROUND

Indonesia's national response to COVID-19 evolved rapidly throughout 2020. Understanding pandemic response and outcomes is crucial for better mitigation strategies ahead. This study describes the characteristics and outcomes of patients admitted to ICU during the early stages of the pandemic.

METHODS

This is a multi-centre prospective observational study including patients from twelve collaborating hospitals in Indonesia. All patients were clinically suspected or laboratory-confirmed COVID-19 cases admitted to ICU between January 2020 and March 2021. The primary outcome was monthly ICU mortality. Descriptive statistics of patient characteristics and treatment were generated as secondary outcomes.

RESULTS

From 559 subjects, the overall mortality was 68% and decreased over the study period, while the mortality of patients that received mechanical ventilation was 92%, consistently high over the study period. Fatal cases showed 2- and 4-day delays from symptoms onset to hospital admissions and ICU admissions, respectively. Evidence-backed approaches which could influence patient outcome, such as extracorporeal membrane oxygenation, prone positioning, renal replacement therapy, and neuromuscular blockade were scarcely administered.

CONCLUSIONS

The mortality rate of COVID-19 patients in Indonesia was extremely high during the first major outbreak of disease, particularly in those mechanically ventilated. Delayed admission and unavailability of evidence-based approaches due to high burden on health facility during COVID-19 crisis could be addressed by efficient public health measures and enhancing health infrastructure to improve the future pandemic response.

Ventricular Septal Rupture Complicating an Acute ST-Segment Elevation Myocardial Infarction during the COVID-19 Pandemic

Ventricular septal rupture (VSR) is rare but a lethal complication of acute myocardial infarction (MI). Definite treatment requires the surgical closure of the VSR and coronary artery bypass grafting (CABG). However, the optimal timing for surgery is still controversial, particularly during the novel coronavirus disease 2019 (COVID-19) pandemic where medical procedures should be performed within the safest environment. Before surgery, a proper management in the intensive cardiovascular care unit is essential to maintain the stability of the hemodynamic profile related with VSR and determines the prognosis of the patient. We described a case of VSR complicating an anterior wall MI in a patient who admitted to our hospital during the COVID-19 pandemic that was treated successfully by surgical closure of the VSR and CABG.