Dr. Mehta comments, “I started a 7-day STEMI on-call that was intensely stressful primarily because a close colleague is struggling with his life, on a ventilator and with multi-organ failure. He acquired COVID-19 last week from a STEMI intervention performed on a patient who subsequently ruled positive for COVID-19.” [Editor’s note: Sadly, this physician has since passed away.]
What is COVID-19?
Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2. Pneumonia associated with the 2019 novel coronavirus (2019-nCoV) first emerged in Wuhan, China, in December 2019.1 Since its initial identification, the disease has spread across the world. The infectivity of COVID-19 is greater than that of influenza, with higher rates in elderly patients and those with comorbidities.1 The clinical presentation for COVID-19 is quite variable. Reports from China demonstrate that a significant majority of patients (81%) had mild symptoms (no pneumonia or mild pneumonia), 14% experienced severe symptoms (dyspnea, respiratory rate ≥30/min, blood oxygen saturation ≤93%, partial pressure of arterial oxygen to fraction of inspired oxygen ratio <300, and/or lung infiltrates >50% within 24 to 48 hours), and 5% were critical (respiratory failure, septic shock, and/or multiple organ dysfunction or failure).2,3 The prevalence of higher hypertension, cardiac and cerebrovascular disease, and diabetes was higher in ICU/severe cases than in non-ICU/severe counterparts. At least 8.0% patients with COVID-19 suffered acute cardiac injury.3,4
Implications for Cardiovascular Care
The impact of the virus can vary depending on selection bias, testing strategies, and care-seeking behavior, and hospitalization thresholds vary in different settings, biasing the denominators and numerators affecting differences in prevalence estimates. However, an increasing number of patients have been diagnosed with COVID-19, and there are significant implications for the cardiovascular care of patients:5
- COVID-19 with preexisting cardiovascular disease increases the risk of severe disease and death;
- COVID-19 is associated with multiple direct and indirect cardiovascular complications, including acute myocardial injury, myocarditis, arrhythmias, and venous thromboembolism;
- COVID-19 therapies under investigation can have cardiovascular side effects;
- Healthcare workers providing cardiovascular care can become vulnerable as they become hosts or vectors of virus transmission.
COVID-19 and Cardiovascular Sequelae
Reports suggest that acute cardiac injury with elevation of cardiac biomarkers and electrocardiographic and echocardiographic abnormalities is highly prevalent in patients with COVID-19, and is associated with more severe disease and worse prognosis.6 Among 68 deaths in a case series of 150 patients with COVID-19, 7% of deaths were attributed to myocardial damage with circulatory failure and in 33% of cases, patients died of both respiratory and circulatory failure.7,8 Case reports of acute coronary syndromes (ACS) (Type 1 MI) in the setting of COVID-19 have yet to be published. Profound inflammatory response and hemodynamic changes associated with severe disease may confer risk for atherosclerotic plaque rupture in susceptible patients. An analysis by Kwong et al demonstrated that patients with acute respiratory infections are at an elevated risk for the subsequent development of acute MI both after influenza and after non-influenza viral illnesses.9,10,11 Due to the potential overlapping symptomatology between ACS and COVID-19, developing care pathways and protocols for COVID-19 patients with ST-elevation myocardial infarction (STEMI) is crucial.
STEMI Care and Challenges
The COVID-19 pandemic is a dynamic situation with limited data in regard to STEMI care. Based on China’s prior epidemics of Middle East respiratory syndrome coronavirus (MERS) and severe acute respiratory syndrome (SARS), treatment patterns are variable.12,13 China is adopting principles of maximum protection in patients with acute MI, fever, and respiratory symptoms. Below is a summary of the STEMI protocols from Sichuan Provincial People’s Hospital in China:14
• Stable STEMI
Less than 12 hours onset time: Thrombolytic therapy is performed in an isolation ward if no contraindications. After successful thrombolysis, treatment is continued in the isolation ward. After the patient has recovered from COVID-19 pneumonia and a test of nucleic acid is twice negative, elective percutaneous coronary intervention (PCI) is considered.
Greater than 12 hours onset time: evaluated risk of PCI vs infection.
• Unstable STEMI
Severe pneumonia: Transferred to isolation ward for conservative treatment.
Mild to moderate pneumonia: Assess onset time of STEMI; if less than 12 hours, treatment similar to stable STEMI.
Lessons from Hong Kong
A single-center experience in Hong Kong showed changes in normal STEMI care times. Data from 108 STEMI patients treated with primary PCI 2 years prior was compared with seven STEMI patients who presented between January 25th to February 10th of this year, after implementation of emergency infection control protocols to contain COVID-19. Study showed time from symptom to first medical contact was longer in current-year STEMI patients compared to patients 2 years prior, with 318 min vs 82 min (office hours) vs 91.5 minutes (non-office hours). There were longer door-to-device times: 129 min vs 84.5 min, respectively, with longer cath lab arrival to device times: 33 min compared to 20.5 min, respectively.15
Delays in STEMI Care are Multifactorial
- Screening for COVID-19, with detailed travel and contact history, symptomatology and chest x-ray, before transferring patients to the catheterization laboratory can increase delays in diagnosis and staff activation.
- Cath lab: staff need time to don protective gear. Performing primary PCI while in full protective gear can lead to longer treatment times.
- Limited emergency medical services due to sick staff or systemic overload.
- Patient fears of contracting an infection from the healthcare system.
Frontline Cardiac Teams in the United States
COVID-19 may be asymptomatic or symptomatic in a large proportion of patients. Inadequate testing capabilities in most areas are leading to frequent underdiagnosis, especially in patients with less serious illness. Importantly, the vast number of catheterization labs generally have either normal or positive ventilation systems, and COVID-19 infection inside these rooms can theoretically cause widespread contamination of the surrounding environment. Therefore, catheterization labs will require a terminal clean following the procedure. The rising global rate of COVID-19 brings both direct cardiovascular effects resulting from the virus and an indirect impact on frontline healthcare workers, including cardiologists and the patients in their care. Cardiologists and cath lab staff need increased vigilance, since a significant proportion of cardiac patients are going to be affected by COVID-19 at some point. The limited availability of rapid testing for COVID-19 in the U.S. makes the use of lytic therapy controversial. For patients with known COVID-19 and STEMI, the balance of staff exposure and patient benefit will need to be weighed carefully:5,16 Recommendations from the joint statement released by the American College of Cardiology’s Interventional Council and the Society for Cardiovascular Angiography and Interventions (SCAI) suggest fibrinolysis can be considered an option for the relatively stable STEMI patient with active COVID-19. When primary PCI is performed in patients with active COVID-19, appropriate personal protective equipment (PPE) should be provided by the institution and utilized.
Protecting Patients and Healthcare Workers17,18
- Adopt the principle of maximum protection;
- Maintain appropriate distancing of at least 2 meters between patients with suspected or confirmed COVID-19;
- Use medical masks for symptomatic patients, and, ideally, patients with suspected disease should be admitted to private rooms;
- Ensure hospital staff are well trained in standard, contact, and droplet infection prevention and control precautions, including the use of relevant personal protective equipment;
- Clinicians involved with aerosol-generating procedures such as endotracheal intubation and diagnostic testing using bronchoscopy should additionally use airborne precautions, including N95 respirators or equivalent facemasks and face shields or goggles for eye protection.
Cardiac centers should consider deferring elective procedures and carefully monitor employee health and availability. Internal process delays need to be anticipated, due to stresses on the system affecting critical supply chains for essential medicines and equipment. 12,16,18
1Sridevi Pitta, MD, MBA, FACC, FSCAI, RPVI
Associate Professor of Clinical Medicine, University of Missouri School of Medicine (Springfield); Associate Professor, Adjunct Clinical Faculty, Kansas City University of Medicine and Bio Sciences; Interventional Cardiologist, Cox Health Systems; Medical Director, CV Quality Council and STEMI Program, Cox Health Systems, Springfield, Missouri.
Dr. Pitta can be contacted at firstname.lastname@example.org.
2Sameer Mehta, MD, FACC, MBA
Chair, Lumen Foundation, Miami, Florida.
Dr. Mehta can be contacted at email@example.com.
- COVID-19 dashboard by the Center for Systems Science Engineering (CSSE) at Johns Hopkins University (JHU). Available online at https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6. Accessed April 27, 2020.
- Zhang H, Penninger JM, Li Y, et al. Angiotensin-converting enzyme 2 (ACE2) as a SARS-CoV-2 receptor: molecular mechanisms and potential therapeutic target. Intensive Care Med. 2020 Apr; 46(4):586-590.
- Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA. 2020 Feb 7. doi: 10.1001/jama.2020.1585. [Epub ahead of print]
- Li B, Yang J, Zhao F, et al. Prevalence and impact of cardiovascular metabolic diseases on COVID-19 in China. Clin Res Cardiol. 2020 May;109(5):531-538.
- Driggin E, Madhavan MV, Bikdeli B, et al. Cardiovascular considerations for patients, health care workers, and health systems during the coronavirus disease 2019 (COVID-19) pandemic. J Am Coll Cardiol. 2020 Mar; pii: S0735-1097(20)34637-4.
- Lippi G, Lavie CJ, Sanchis-Gomar F. Cardiac troponin I in patients with coronavirus disease 2019 (COVID-19): evidence from a meta-analysis. Prog Cardiovasc Dis. 2020 Mar; pii:S0033-0620(20)30055-4.
- Ruan Q, Yang K, Wang W, et al. Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China. Intensive Care Med. 2020 Apr 6. doi: 10.1007/s00134-020-06028-z. [Epub ahead of print]
- Chen C, Zhou Y, Wang DW. SARS-CoV-2: a potential novel etiology of fulminant myocarditis. Herz. 2020 Mar 5. doi: 10.1007/s00059-020-04909-z. [Epub ahead of print]
- Kwong JC, Schwartz KL, Campitelli MA. Acute myocardial infarction after laboratory-confirmed influenza infection. N Engl J Med. 2018;378(26):2540-2541.
- Yang X, Yu Y, Xu J, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med. 2020 Feb 24. pii: S2213-2600(20)30079-5. doi: 10.1016/S2213-2600(20)30079-5. [Epub ahead of print]
- Alhogbani T. Acute myocarditis associated with novel middle east respiratory syndrome coronavirus. Ann Saudi Med. 2016;36(1):78-80.
- Cox CE. COVID-19 poised to upend the cath lab, ACC and SCAI say. TCTMD.com. March 18, 2020. Available online at https://www.tctmd.com/news/covid-19-poised-upend-cath-lab-acc-and-scai-say. Accessed April 26, 2020.
- Welt FGP, Shah PB, Aronow HD, et al. Catheterization laboratory considerations during the coronavirus (COVID-19) pandemic: from ACC’s Interventional Council and SCAI. J Am Coll Cardiol. 2020 Mar 16. pii: S0735-1097(20)34566-6.
- Zeng J, Huang J, Pan L. How to balance acute myocardial infarction and COVID-19: the protocols from Sichuan Provincial People’s Hospital. Intensive Care Med. 2020 Mar 11. doi: 10.1007/s00134-020-05993-9. [Epub ahead of print]
- Tam CF, Cheung KS, Lam S, et al. Impact of Coronavirus Disease 2019 (COVID-19) Outbreak on ST-segment-elevation myocardial infarction care in Hong Kong, China. Circ Cardiovasc Qual Outcomes. 2020 Apr;13(4): e006631.
- Mahmud E. The evolving pandemic of COVID-19 and interventional cardiology. Society for Cardiovascular Angiography and Interventions (SCAI). March 16, 2020. Available online at http://www.scai.org/press/detail/evolving-pandemic-of-covid-19-interventional-cardi#.Xn_dhEBFyUk. Accessed March 31, 2020.
- Murthy S, Gomersall CD, Fowler RA. Care for critically ill patients with COVID-19. JAMA. 2020 Mar;323(15):1499-1500.
- Mandrola J. COVID-19 and PPE: some of us will die because of the shortage. Medscape. March 20, 2020. Available online at https://www.medscape.com/viewarticle/927206. Accessed March 31, 2020.