The key slide from the SCAI 2021 NACMI late-breaking presentation showing the very high adverse rates for COVID STEMI heart attack patients (red) as compared to pre-pandemic STEMI patient controls (green).
May 3, 2021 – One third of patients will die who have COVID-19 (SARS-CoV-2) and suffer a ST-elevated myocardial infarction (STEMI), according to the latest comprehensive data from The North American COVID-19 Myocardial Infarction (NACMI) Registry. The data was presented as a late-breaking study at the Society for Cardiovascular Angiography and Interventions (SCAI) 2021 Scientific Sessions. The study showed there was an alarming one-in-three patients dying from the combination of STEMI and COVID, as compared to four-in-100 patients using a pre-pandemic control group.
Results reveal in these series of STEMI activations during the COVID era that patients who tested positive for COVID-19 were less likely to receive diagnostic angiograms. Those with COVID-19 positive status had higher in-hospital mortality. The prospective, ongoing observational registry was created under the guidance of the SCAI, Canadian Association of Interventional Cardiology (CAIC) and American College of Cardiology (ACC). The initial results of the registry were published in the Journal for American College of Cardiology (JACC) on April 27, 2021.
"The in-hospital outcome was terrible, and one-in-three did not make it — 33 percent died and did not make it out of the hospital," emphazised co-lead investigator Payam Dehghani, M.D., FSCAI, Prairie Vascular Research Network, Canada. "There has never been a study of all-comers STEMIs where one-in-three did not make it."
The registry data also found differences in how these COVID heart attack patients present, a very high percentage of minorities, and the odd findings on ECG and in the cath lab.
“We’re seeing an alarming trend of the deadly impact of this pandemic on high-risk minority heart attack patients. This ongoing registry’s goal is to help illuminate these disparity trends and inform future preventive and treatment strategies for this COVID-19 era,” Dehghani explained.
According to the American Heart Association (AHA), more than 930,000 people suffer from heart attacks every year and more than a quarter of those patients suffer the more severe STEMI type of heart attack, which is caused by the sudden, total blockage of a coronary artery. Qualifying patients often undergo a percutaneous coronary intervention (PCI). However, little is known on how the ongoing COVID-19 pandemic impacted the use of angiography procedures based on patient demographics and outcomes.
Watch the VIDEO: The Impact of COVID-19 on Heart Attack Patients — Interview with Payam Dehghani, M.D.
Incidence of No Culpirt Lesions and Other Key NACMI Findings
Early in the COVID pandemic last spring, cardiologists on social media shared a large number of PCI cases where a COVID-positive patient going to the cath lab with STEMI showed no culprit lesion blockages in their coronary arteries, which is usually the main cause of STEMI. There was speculation as to what the actual percentage of these presentations were, with estimates at 50 percent or more. The NACMI registry found it is lower than originally expected, but still high, at about 20 percent. Dehghani said in pre-pandemic times, this would have been classified as a "false STEMI activation" which occurred in 3-5 percent of STEMI cases.
"Initially myocarditis was thrown around as the cause in these patients, but thanks to some autopsy studies outside of this registry, the findings suggested it is due to multiple micro-emboli," Dehghani said.
He said angiograms from the NACIM study will be sent to a core lab for evaluation to see if this question can be answered.
Another possibility is spontaneous coronary artery dissection (SCAD), which is an uncommon emergency condition that occurs when a tear forms in a blood vessel in the heart.
Important key findings from the registry data include:
• Minorities were disproportionally affected: 55 percent of the STEMI patients had minority ethnicity, which was about evenly divided between Hispanics and blacks.
• In-hospital mortality was high: 33 percent (4 percent for controls without COVID).
• Symptoms were unique: majority (54 percent) presented with respiratory symptoms (shortness of breath) rather than chest pain.
• Significant proportion of COVID-positive patients presented with high-risk STEMI: cardiogenic shock (18 percent) and cardiac arrest (11 percent), which may explain the high fatality rate.
• Primary angioplasty remained the dominant revascularization modality during the pandemic with small treatment delays (at about 15 minutes).
• Diabetics are known to have some of the worst outcomes if they contract COVID, and this was reflected in the study, with 45 percent of patients having diabetes.
"The fact that the majority of these patients were non-white is a profound finding," Dehghani explained. He said all previous STEMI studies were majority white patients.
What Should Be Done With a COVID Patient in STEMI?
"I literally have had friends text me and say we are having COVID patients showing up in the cath lab, what should we do," Dehghani said. "The answer now is simple, and now I have some data behind it — take them to the cath lab and do not delay PCI. Of the ones with who have coronary artery disease and culprit disease, they do better if we get to them with PCI. It sounds like a slam-dunk, black-and-white answer, but it was really unsubstantiated a year ago and now we can point to this as evidence."
COVID-19 STEMI Heart Attack Patient Statistics
As of April 9, 2021, more than 1,600 patients were included in the NACMI (331 STEMI with were COVID-19, 645 suspected COVID-19 positive patients and 662 control — a group of age and sex matched STEMI patients treated pre-COVID-19). The primary outcome was a composite of in-hospital death, stroke, recurrent myocardial infarction or repeat unplanned revascularization. The overall goal of the registry is to understand demographic characteristics, management strategies and outcomes of COVID-19 patients with STEMI.
Among COVID-positive patients who received angiography, 71 percent received PPCI and 20 percent received medical therapy. The primary endpoint was a composite of in-hospital death, stroke, recurrent myocardial infarction (MI) or unplanned revascularization and occurred in 36 percent of COVID-positive patients, 13 percent of persons under investigation for COVID-19 (PUIs) and 4 percent of control patients.
"About 70 percent underwent PCI, and if they got PCI, it was a good thing and they tended to do better," Dehghani said. "The finding supported the ACC and SCAI recommendations that PCI is a good thing."
Interestingly, he said the door-to-balloon times (DTB) were only slightly higher than pre-pandemic STEMI times. He said in the era of COVID, there is much more involved with cath lab staff needing to don full personal protective equipment (PPE), but this did not have a large impact on DTB, taking about 75 minutes.
Findings show COVID-19 positive patients were more likely to be of minority ethnicity, have diabetes and undergo medical therapy as a first-line treatment rather than PCI (all p <0.001 relative to PUI). Results also indicated that STEMI patients have higher survival rates when receiving timely access to primary PCI. Among COVID-19 positive patients who received angiography, 69 percent received PCI and 20 percent had no culprit vessels identified on angiography (both p <0.01 relative to controls). The primary outcome, composite of all-cause death or MI or stroke occurred in 35 percent of COVID-19 positive patients, 14 percent of suspected COVID-19 positive patients and 5 percent of control patients (p<0.001 relative to controls).
Dehghani said a small percentage of severely ill COVID patients with STEMI were treated with thrombolytics alone rather than PCI. The decision in most of these cases was due to numerous factors, including the patient being intubated, placed in the prone position to aid breathing and other factors such as patient stability, making them less than ideal to transport and intervene on in the cath lab.
NACMI Registry Hopes to Answer Many Questions About COVID Cardiovascular Presentations
Dehghani said the registry was created after numerous cardiologists on social media noted odd findings on COVID patient ECGs, and a sizable number of COVID-positive patients with STEMI showing no blockages on angiograms in the cath lab. He said the NACMI Registry was quickly organized between SCAI and CAIC as the first wave of COVID cases washed over Canada and the U.S. in the spring of 2020.
“Leading clinicians and researchers have quickly and efficiently come together to understand the relationship between COVID-19 and heart attacks. This registry is an amazing feat of collaboration, speed and scale involving more than 60 sites, and three leading medical societies across the United States and Canada,” Dehghani said. "We really wanted to pull our resources, because we had no idea really how they present, what do they look like, is it true they have less culprit disease, and is it true you should really consider thrombolytic therapy. There were a lot of questions with no data, so it was fertile ground to create a registry."
The authors of the investigational registry are planning to conduct additional research to further understand the impact on specific minority and diabetic patient populations. In addition, investigators plan to follow up at one year to verify findings.
Dehghani said there are remaining questions on the cause of STEMI in patients with no apparent blockage, which may be due to the presence of micro-emboli that are often found in severe COVID-19 patients and has been implicated in strokes, deep vein thrombosis (DVT), pulmonary embolism (PE), and ischemia or infarcts in other organs like the liver and kidneys. If emboli are the cause, there are open questions about how to best anti-coagulate these patients post PCI.
Another area of followup will be looking at patient ECG's from the registry to see if assumptions can be made about them and predict what will be found in the cath lab. He said some ECGs do not show a defined territory for the source of the STEMI. Dehghani said an ECG core lab will be evaluating the waveforms to see if there are additional insights.
Hear more details in the VIDEO: The Impact of COVID-19 on Heart Attack Patients — Interview with Payam Dehghani, M.D.
Related STEMI COVID Content:
VIDEO: Patients Fear COVID More than Heart Attacks — Interview with SCAI President Cindy Grines, M.D.
VIDEO: Where Have all the STEMI Cases Gone Amid COVID-19? — Interview with Thomas Maddox, M.D.
VIDEO: Antithrombotic Prophylaxis in COVID-19 Patients — Interview with Behnood Bikdeli M.D.