North American COVID-19 Myocardial Infarction (NACMI) Risk Score for Prediction of In-Hospital Mortality.

Background: In-hospital mortality in patients with ST-segment elevation myocardial infarction (STEMI) is higher in those with COVID-19 than in those without COVID-19. The factors that predispose to this mortality rate and their relative contribution are poorly understood. This study developed a risk score inclusive of clinical variables to predict in-hospital mortality in patients with COVID-19 and STEMI. Methods: Baseline demographic, clinical, and procedural data from patients in the North American COVID-19 Myocardial Infarction registry were extracted. Univariable logistic regression was performed using candidate predictor variables, and multivariable logistic regression was performed using backward stepwise selection to identify independent predictors of in-hospital mortality. Independent predictors were assigned a weighted integer, with the sum of the integers yielding the total risk score for each patient. Results: In-hospital mortality occurred in 118 of 425 (28%) patients. Eight variables present at the time of STEMI diagnosis (respiratory rate of >35 breaths/min, cardiogenic shock, oxygen saturation of <93%, age of >55 â€‹years, infiltrates on chest x-ray, kidney disease, diabetes, and dyspnea) were assigned a weighted integer. In-hospital mortality increased exponentially with increasing integer risk score (Cochran-Armitage χ2, P â€‹< â€‹.001), and the model demonstrated good discriminative power (c-statistic â€‹= â€‹0.81) and calibration (Hosmer-Lemeshow, P â€‹= â€‹.40). The increasing risk score was strongly associated with in-hospital mortality (3.6%-60% mortality for low-risk and very high-risk score categories, respectively). Conclusions: The risk of in-hospital mortality in patients with COVID-19 and STEMI can be accurately predicted and discriminated using readily available clinical information.

Sex Differences in Clinical Characteristics, Management Strategies, and Outcomes of STEMI With COVID-19: NACMI Registry.

Background: Women with ST-segment elevation myocardial infarction (STEMI) had worse outcomes than men prior to the COVID-19 pandemic. Although concomitant COVID-19 infection increases mortality risk in STEMI patients, no studies have evaluated sex differences in this context. Methods: The North American COVID-19 STEMI registry is a prospective, multicenter registry of hospitalized STEMI patients with COVID-19 infection. We compared sex differences in clinical characteristics, presentation, management strategies, and in-hospital mortality. Results: Among 585 patients with STEMI and COVID-19 infection, 154 (26.3%) were women. Compared to men, women were significantly older, had a higher prevalence of diabetes and stroke/transient ischemic attack, and were more likely to be on statins on presentation. Men more frequently presented with chest pain, whereas women presented with dyspnea. Women more often had STEMI without an identified culprit lesion than men (33% vs 18%, P < .001). The use of percutaneous coronary intervention was significantly higher in men, whereas medical therapy was higher in women. In-hospital mortality was 33% for women and 27% for men (P = .22). Conclusions: In patients presenting with STEMI in the context of COVID-19, the in-hospital mortality rate was 30% and similar for men and women. Lack of an identifiable culprit lesion was common in the setting of COVID-19 for both sexes but more likely in women (1/3 of women vs 1/5 of men). Evaluation of specific underlying etiologies is underway to better define the full impact of COVID-19 on STEMI outcomes and better understand the observed sex differences.

Comparison of Coronary Artery Involvement and Mortality in STEMI Patients With and Without SARS-CoV-2 During the COVID-19 Pandemic: A Systematic Review and Meta-Analysis.

BACKGROUND: Cardiovascular injury with SARS-CoV-2 infection is well known. Several studies have outlined baseline characteristics in patients presenting with STEMI and SARS-CoV-2. Paucity in data exists in selective coronary involvement in patients with STEMI and SARS-CoV-2 during the COVID-19 pandemic. METHODS: A systematic search and meta-analysis of studies meeting the inclusion and exclusion criteria obtained from MEDLINE, Scopus, and Cochrane databases was performed utilizing PRISMA criteria. The main outcome was likelihood of coronary artery involvement among patients with STEMI and SARS-CoV-2 versus without SARS-CoV-2. The primary adverse outcome measured was in-hospital mortality. RESULTS: The final analysis included 5 observational studies with a total of 2,266 patients. There was no statistical significance in LM (OR 1.40; 95% CI: 0.68, 2.90), LAD (OR 1.09; 95% CI 0.83, 1.43), LCX (OR 1.17; 95% CI: 0.75, 1.85), or RCA (OR 0.59; 95% CI: 0.30, 1.17) disease among the 2 groups. LAD disease was the most prevalent coronary involvement among patients with STEMI and SARS-CoV-2 (49.6%). Higher in-hospital mortality was observed in the STEMI and SARS-CoV-2 group (OR 5.24; 95% CI: 3.63, 7.56). CONCLUSIONS: Our analysis demonstrated no statistical significance in selective coronary involvement in patients with STEMI and SARS-CoV-2 during the COVID-19 pandemic. The higher mortality among patients with SARS-CoV-2 and STEMI has been noted in prior studies with concerns being late presentation due to fear of infection, delayed care time, and poor resource allocation. Focus should be placed on identifying and managing comorbidities to reduce mortality.

STEMI care 2021: Addressing the knowledge gaps.

Tremendous progress has been made in the treatment of ST-segment elevation myocardial infarction (STEMI), the most severe and time-sensitive acute coronary syndrome. Primary percutaneous coronary intervention (PCI) is the preferred method of reperfusion, which has stimulated the development of regional STEMI systems of care with standardized protocols designed to optimize care. However, challenges remain for patients with cardiogenic shock, out-of-hospital cardiac arrest, an expected delay to reperfusion (>120 min), in-hospital STEMI, and more recently, those with Covid-19 infection. Ultimately, the goal is to provide timely reperfusion with primary PCI coupled with the optimal antiplatelet and anticoagulant therapies. We review the challenges and provide insights into the remaining knowledge gaps for contemporary STEMI care.

Patient voluntarily delays call to emergency medical system for ST-elevation myocardial infarction during COVID-19 pandemic.

BACKGROUND: An increase in the time from the symptoms onset to first medical contact and to primary percutaneous coronary intervention (pPCI) has been observed in countries with high-incidence of COVID-19 cases. We aimed to verify if there was any change in the patient delay and in the EMS response times up to the pPCI for STEMI patients in Swiss Ticino Canton. METHODS: We assessed STEMI management including time from symptoms onset to EMS call, time of EMS response, time to pPCI in Swiss Canton Ticino. Data were retrieved from the Acute-Coronary-Syndrome-Ticino-Registry. We considered the patients included in the registry from March to May 2020 (pandemic period) and then from June to August 2020 (post-pandemic period) in whom a pPCI was performed. We compared these patients to those undergoing a pPCI in the same months in the year 2016-2019. RESULTS: During the pandemic period, the time from symptoms onset to pPCI significantly increased compared to non-pandemic periods. This was due to a significant prolongation of the time from symptoms onset to EMS call, that nearly tripled. In contrast, after the pandemic period, there was a significantly shorter time from symptom onset to EMS call compared to non-pandemic years, whereas all other times remained unchanged. CONCLUSION: Patients delay the call to EMS despite symptoms of myocardial infarction during the COVID-19 pandemic also in a region with a relatively low incidence of COVID-19.

Myocardial Infarction incidence during national lockdown in two French provinces unevenly affected by COVID-19 outbreak: An observational study.

BACKGROUND: A reduction of admission for MI has been reported in most countries affected by COVID-19. No clear explanation has been provided. METHODS: To report the incidence of myocardial infarction (MI) admission during COVID-19 pandemic and in particular during national lockdown in two unequally affected French provinces (10-million inhabitants) with a different media strategy, and to describe the magnitude of MI incidence changes relative to the incidence of COVID-19-related deaths. A longitudinal study to collect all MIs from January 1 until May 17, 2020 (study period) and from the identical time period in 2019 (control period) was conducted in all centers with PCI-facilities in northern "Hauts-de-France" province and western "Pays-de-la-Loire" Province. The incidence of COVID-19 fatalities was also collected. FINDINGS: In "Hauts-de-France", during lockdown (March 18-May 10), 1500 COVID-19-related deaths were observed. A 23% decrease in MI-IR (IRR=0.77;95%CI:0.71-0.84, p<0.001) was observed for a loss of 272 MIs (95%CI:-363,-181), representing 18% of COVID-19-related deaths. In "Pays-de-la-Loire", 382 COVID-19-related deaths were observed. A 19% decrease in MI-IR (IRR=0.81; 95%CI=0.73-0.90, p<0.001) was observed for a loss of 138 MIs (95%CI:-210,-66), representing 36% of COVID-19-related deaths. While in "Hauts-de-France" the MI decline started before lockdown and recovered 3 weeks before its end, in "Pays-de-la-Loire", it started after lockdown and recovered only by its end. In-hospital mortality of MI patients was increased during lockdown in both provinces (5.0% vs 3.4%, p=0.02). INTERPRETATION: It highlights one of the potential collateral damages of COVID-19 outbreak on cardiovascular health with a dramatic reduction of MI incidence. It advocates for a careful and weighted communication strategy in pandemic crises. FUNDING: The study was conducted without external funding.

Takotsubo Syndrome: Cardiotoxic Stress in the COVID Era.

Takotsubo syndrome (TTS), also known as stress cardiomyopathy and broken heart syndrome, is a neurocardiac condition that is among the most dramatic manifestations of psychosomatic disorders. This paper is based on a systematic review of TTS and stress cardiomyopathy using a PubMed literature search. Typically, an episode of severe emotional or physical stress precipitates regions of left ventricular hypokinesis or akinesis, which are not aligned with a coronary artery distribution and are out of proportion to the modest troponin leak. A classic patient with TTS is described; one who had chest pain and dyspnea while watching an anxiety-provoking evening news program on the coronavirus disease 2019 (COVID-19) pandemic. An increase in the incidence of TTS appears to be a consequence of the COVID-19 pandemic, with the TTS incidence rising 4.5-fold during the COVID-19 pandemic even in individuals without severe acute respiratory syndrome coronavirus 2 infection. Takotsubo syndrome is often mistaken for acute coronary syndrome because they both typically present with chest pain, electrocardiographic changes suggesting myocardial injury/ischemia, and troponin elevations. Recent studies report that the prognosis for TTS is similar to that for acute myocardial infarction. This review is an update on the mechanisms underlying TTS, its diagnosis, and its optimal management.

Status of Acute Myocardial Infarction in Southern India During COVID-19 Lockdown: A Multicentric Study.

There has been a reduction in the reported cases of acute myocardial infarction (MI) across the globe during the outbreak of coronavirus disease 2019 (COVID-19) (severe acute respiratory distress syndrome coronavirus 2). An attempt was made to find out the number of acute MI cases treated during the COVID-19 lockdown period (April 2020) and highlight the possible reasons for the changes in the occurrence. A multicentric retrospective observational study was performed to collect the selected data from 12 private hospitals distributed in 4 cities-Madurai, Trichy (Thiruchirapalli), Erode, and Salem-of the Tamil Nadu state in southern India. There was a significant (P<.001) reduction in ST-segment elevation MI (STEMI), non-STEMI (NSTEMI), and total (STEMI and NSTEMI together) cases during the lockdown period (April 1 to 30, 2020) as compared with no-lockdown periods such as January and February 2020 and April 2019 and April 2018 in all cities, whereas the reduction was not significant for NSTEMI in Trichy when data for the lockdown period was compared with those for January and February 2020. Overall, there is a reduction in acute MI cases, which may be due to alterations in modifiable risk factors during the COVID-19 lockdown period. Hence, implementation of public education and polices on controlling modifiable risk factors is likely to pay dividends.

Incidence of acute myocardial infarction-related cardiogenic shock during corona virus disease 19 (COVID-19) pandemic.

AIMS: The hospitalization of patients with MI has decreased during global lockdown due to the COVID-19 pandemic. Whether this decrease is associated with more severe MI, e.g. MI-CS, is unknown. We aimed to examine the association of Corona virus disease (COVID-19) pandemic and incidence of acute myocardial infarction with cardiogenic shock (MI-CS). METHODS: On March 11, 2020, the Danish government announced national lock-down. Using Danish nationwide registries, we identified patients hospitalized with MI-CS. Incidence rates (IR) and incidence rate ratios (IRR) were used to compare MI-CS before and after March 11 in 2015-2019 and in 2020. RESULTS: We identified 11,769 patients with MI of whom 696 (5.9%) had cardiogenic shock in 2015-2019. In 2020, 2132 MI patients were identified of whom 119 had cardiogenic shock (5.6%). The IR per 100,000 person years before March 11 in 2015-2019 was 9.2 (95% CI: 8.3-10.2) and after 8.9 (95% CI: 8.0-9.9). In 2020, the IR was 7.5 (95% CI: 5.8-9.7) before March 11 and 7.7 (95% CI: 6.0-9.9) after. The IRRs comparing the 2020-period with the 2015-2019 period before and after March 11 (lockdown) were 0.81 (95% CI: 0.59-1.12) and 0.87 (95% CI: 0.57-1.32), respectively. The IRR comparing the 2020-period during and before lockdown was 1.02 (95% CI: 0.74-1.41). No difference in 7-day mortality or in-hospital management was observed between study periods. CONCLUSION: We could not identify a significant association of the national lockdown on the incidence of MI-CS, along with similar in-hospital management and mortality in patients with MI-CS.

Ventricular Septal Rupture in 2 Patients Presenting Late after Myocardial Infarction during the COVID-19 Pandemic.

Ventricular septal rupture (VSR) following myocardial infarction is rare in the reperfusion era. The decrease in patients presenting with myocardial infarction during the coronavirus-2019 (COVID-19) pandemic could result in more frequent VSR. This report describes two patients with VSR presenting late after myocardial infarction and treated at a single institution. (Level of Difficulty: Beginner.).

Surge in Delayed Myocardial Infarction Presentations: An Inadvertent Consequence of Social Distancing During the COVID-19 Pandemic.

This case series summarizes our experience of delayed acute myocardial infarction presentations during the coronavirus disease-2019 pandemic predominantly driven by patient fear of contracting the virus in the hospital. Many presented with complications rarely seen in the primary percutaneous coronary intervention era including ventricular septal rupture, left ventricular pseudoaneurysm, and right ventricular infarction. (Level of Difficulty: Beginner.).

Subacute Left Ventricular Free Wall Rupture after Delayed STEMI Presentation During the COVID-19 Pandemic.

The coronavirus disease-2019 (COVID-19) pandemic is causing delayed ST-segment elevation myocardial infarction (STEMI) presentations associated with now unusual postinfarction complications. We describe a delayed (5-day) STEMI presentation because the patient feared contracting COVID-19 in the hospital. The patient experienced an extensive anterolateral STEMI complicated by subacute left ventricular free wall rupture that required a rapid surgical repair. (Level of Difficulty: Intermediate.).

Acute Myocardial Infarction and Papillary Muscle Rupture in the COVID-19 Era.

Mechanical complications of acute myocardial infarction are infrequent in the modern era of primary percutaneous coronary intervention, but they are associated with high mortality rates. Papillary muscle rupture with acute severe mitral regurgitation is one such life-threatening complication that requires early detection and urgent surgical intervention. (Level of Difficulty: Beginner.).

Delayed Presentation of STEMI Complicated by Ventricular Septal Rupture in the Era of COVID-19 Pandemic.

A significant concern in current coronavirus disease-2019 (COVID-19) pandemic era is delay in first medical contact in patients with ST-segment elevation myocardial infarction (STEMI), due to reluctance to visit the hospital. We report a case of delayed presentation of STEMI as ventricular septal rupture during the COVID-19 pandemic, a rare presentation in the current age of primary percutaneous coronary intervention. (Level of Difficulty: Beginner.).

Takotsubo Syndrome in the Setting of COVID-19.

A 58-year-old woman was admitted with symptoms of coronavirus disease-2019. She subsequently developed mixed shock, and an echocardiogram showed mid-distal left ventricular hypokinesis and apical ballooning, findings typical of stress, or takotsubo, cardiomyopathy. Over the next few days her left ventricular function improved, the further supporting the reversibility of acute stress cardiomyopathy. (Level of Difficulty: Beginner.).

Acute Multivessel Coronary Occlusion Revealing COVID-19 in a Young Adult.

A 42-year-old man was admitted for an ST-segment elevation myocardial infarction revealing an acute thrombosis of the left anterior descending and right coronary arteries. Following this acute multivessel coronary occlusion in a young individual at low cardiovascular risk, he tested positive for severe acute respiratory syndrome-coronavirus-2 infection. (Level of Difficulty: Beginner.).

A Case Series of Stent Thrombosis During the COVID-19 Pandemic.

Coronavirus disease-2019 (COVID-19) triggers a hypercoagulable state with a high incidence of thrombotic complications. We have noted a higher than expected incidence of stent thrombosis in these patients. (Level of Difficulty: Intermediate.).

Papillary Muscle Rupture Due to Delayed STEMI Presentation in a Patient Self-Isolating for Presumed COVID-19.

A 57-year-old man acutely developed chest tightness and dyspnea. Given concern that his symptoms were consistent with COVID-19, the patient self-isolated. After 1 week of worsening symptoms, the patient presented with hypoxia and hypotension. He was found to have an occluded right coronary artery and ruptured posteromedial papillary muscle. (Level of Difficulty: Beginner.).

Complication of Late Presenting STEMI Due to Avoidance of Medical Care During the COVID-19 Pandemic.

Patients are avoiding hospitals for fear of contracting severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). We are witnessing a re-emergence of rare complications of myocardial infarctions (MI) due to delayed revascularization. Herein, we describe a case of hemorrhagic pericarditis from thrombolytics administered to a patient with late presenting MI. (Level of Difficulty: Beginner.).