Should STEMI Care Change During The COVID-19 Pandemic?

Cardiologists differ regarding the management of ST-elevation myocardial infarction (STEMI) during the COVID-19 pandemic, with some favoring fibrinolytic therapy and others advocating continued use of primary percutaneous coronary intervention (PCI). Two new articles in Circulation: Cardiovascular Quality and Outcomes examine these contrasting perspectives.

Dr. Paul W. Armstrong of the University of Alberta, in Edmonton, Canada, and colleagues contend that the benefit of PCI relies on rapidly achieving first-medical-contact-to-device times. When reperfusion is delayed, PCI offers no survival advantage compared with fibrinolytic therapy.

Given the delays associated with the COVID-19 pandemic, they suggest that early fibrinolytic therapy offers a logical, effective, simple and safe alternative that also decreases the risk of COVID-19 exposure for healthcare providers.

They cite a recent consensus statement from the Society for Cardiovascular Angiography and Interventions, the American College of Cardiology and the American College of Emergency Physicians that supports fibrinolytic therapy for STEMI during the COVID-19 pandemic, especially at hospitals without PCI capability.

Dr. Armstrong told Reuters Health by email, "Disagreement will especially exist in those who are fixed on primary PCI. The evidence in support of their position is 17+ years old and fails to recognize new strategic directions associated with bolus lytic therapy (easily given in the field by paramedics) and timely PCI when needed."

"It also fails to recognize untoward delay in delivering primary PCI (which is great treatment if you can get it quickly) in more than half of patients receiving it and the penalty imposed with increased morbidity and mortality," he said.

Dr. Armstrong's main message: "Give the best reperfusion therapy you have as fast as you can, taking into account the risk of the MI, the risk of the therapy, and the time to deliver it. One size does not fit all for treatment of STEMI, and you need to have more than one arrow in your quiver."

Meanwhile, Dr. Ajay J. Kirtane and Dr. Sripal Bangalore of Columbia University Medical Center/New York-Presbyterian Hospital and NYU-Langone Medical Center in New York City assert that reperfusion with primary PCI is more reliable and durable than fibrinolytic therapy and provides lower rates of mortality, reinfection and bleeding.

They recognize the current delays in time to presentation but suggest that fibrinolytic therapy is even less likely to be effective in this setting, because these delays can lead to older, more organized clots that are less amenable to fibrinolysis.

Moreover, the modern approach to fibrinolytic therapy still involves secondary cardiac catheterizations, thus negating the theoretical advantage of fibrinolytic therapy in reducing staff exposure to SARS-CoV-2 and/or consumption of personal protective equipment (PPE).

Finally, they note that myopericarditis can be a cause of ST-elevation in COVID-19 and that potent fibrinolytic therapy in this setting is unlikely to be effective and incurs substantial bleeding risk while treating the incorrect pathophysiology.

Dr. Kirtane told Reuters Health by email, "Especially if there are on-site cath facilities with adequate PPE for the staff, primary PCI really ought to be preferred over fibrinolytic therapy that carries greater risks with lesser benefit, particularly given the presenting characteristics of STEMI patients in the pandemic."

"I don't think either position would be too controversial," he concedes. "Primary PCI is widely accepted as a superior strategy for STEMI patients. The arguments we make regarding reasons that it might be even more preferred in the COVID-19 pandemic are based upon both pathophysiologic as well as situational reasons. The points that the (other) viewpoint makes regarding delays and on-site availability of PCI at transferring hospitals are relevant, too."

Dr. Mladen I. Vidovich of the University of Illinois, in Chicago, who was not connected to the new papers, recently wrote about consensus recommendations that fibrinolytic therapy be considered for STEMI in settings of limited staffing and resources and where time-to-treatment is expected to be delayed significantly. He told Reuters Health by email, "We are learning as we go, and this is an extremely dynamic area. My take on this is: primary PCI is the way to go. Reserve thrombolytics for extremely rare circumstances, primarily for logistic inability to perform PCI."

Dr. Ehtisham Mahmud of the University of California, San Diego, who recently addressed the management of acute myocardial infarction during the COVID-19 pandemic, told Reuters Health by email, "Primary PCI is the standard of care for STEMI patients. Even in the most impacted region of the United States, cath lab directors are emphasizing the reasons to not pursue a fibrinolytic approach."

"Fibrinolysis is an inferior approach to primary PCI," stressed Dr. Mahmud, who also was not involved with the new reports. "During the COVID-19 pandemic, it is an even more dangerous proposition, as administering fibrinolysis to a STEMI mimic results in a patient with a 1%-2% risk of fatal intracranial bleed without any potential benefit. For a true STEMI, failure of fibrinolysis to achieve TIMI-3 flow is high, and ultimately rescue PCI still means that the patient needs to go to the cath lab and ends up occupying an ICU bed for a prolonged period of time. It is only an option in the absence of primary PCI availability."

"We need to emphasize to our patients with symptoms of a heart attack that coming to the hospital during the COVID-19 pandemic is safe, and we will continue to treat them with the optimal standards of care established over the past two decades," Dr. Mahmud said.

—Will Boggs MD

Source