Comparison of thrombus burden in patients with COVID-19 presenting with ST-segment elevation myocardial infarction across the three waves of outbreak in the United Kingdom

Background: It has been previously reported during the first COVID outbreak that patients presenting with ST-Segment Elevation Myocardial Infarction (STEMI) and concurrent COVID-19 infection have increased thrombus burden and poorer outcomes [1]. Subsequently, there have been multiple further waves of the pandemic with the emergence of at least two new COVID-19 variants and the emergence of vaccinations. To-date, there have been no reports comparing the outcomes of COVID-19-positive STEMI patients across all waves of the pandemic. Purpose(s): The purpose of this study was to compare the baseline demographic, procedural and angiographic characteristics alongside the clinical outcomes of patients presenting with STEMI and concurrent COVID-19 infection across the COVID-19 pandemic in the UK. Method(s): This was a single-centre, observational study of 1250 consecutive patients admitted with confirmed STEMI treated with primary percutaneous coronary intervention (PCI) at Barts Heart Centre between 01/03/2020 and 10/03/2022. COVID +ve patients were split into 3 groups based upon the time course of the pandemic (Wave 1: March 2020-June 2020, Wave 2: Sept 2020-March 2021, Wave 3: October 2021-March 2022). Comparison was made between waves and with a control group of COVID-ve patients treated during the same timeframe. Result(s): A total of 135 COVID +ive patients with STEMI (1st Wave: 39 patients, 2nd Wave: 60 patients, 3rd wave 35 pts) were included in the present analysis;and compared with 1115 COVID negative patients. Significant changes in the baseline characteristics, angiographic features and clinical outcomes of COVID +ive patients occurred over time. Early during the pandemic (Wave 1 2020), STEMI patients presenting with concurrent COVID-19 infection had high rates of cardiac arrest, evidence of increased thrombus burden (higher rates of multi-vessel thrombosis, stent thrombosis, higher modified thrombus grade higher use of GP IIb/IIIa inhibitors and thrombus aspiration, coagulability (more heparin for therapeutic ACT), bigger infarcts (lower myocardial blush grade and left ventricular function) and worse outcomes (mortality). However, by wave 3 (late 2021/2022), no differences existed in clinical characteristics, thrombus burden, infarct size or outcomes between COVID +ive patients and those without concurrent COVID-19 infection with significant differences compared to earlier COVID +ve patients. Poor outcomes later in the study period were predominantly in unvaccinated individuals. Conclusion(s): Significant changes have occurred in the clinical characteristics, angiographic features and outcomes of STEMI patients with COVID- 19 infection treated by primary PCI during the course of the pandemic. Importantly it appears that angiographic features and outcomes of recent waves are no different to a non-COVID-19 population.

Specific characteristics of STEMI in COVID-19 patients and their practical implications: A systematic review

Introduction: STEMI is one of the cardiac emergencies whose management has been mostly challenged by the COVID-19 pandemic. Patients presenting with the "lethal combo" of STEMI and concomitant SARS-CoV- 2 infection have faced dramatic issues related to need for self-isolation, systemic inflammation with multi-organ disease, and difficulties to obtain timely diagnosis and treatment. Method(s):We performed a systematic search of three electronic databases from February 1st 2020 to January 31st 2022. We included all studies reporting crude rates of in-hospital outcomes of STEMI patients with concomitant COVID-19. Result(s): A total of 9 observational studies were identified, mainly conducted during the first wave of the pandemic. STEMI patients with COVID -19 were more likely Afro-American and displayed higher rates of hypertension and diabetes with lower smoking prevalence. Associated comorbidities, including coronary artery disease, prior stroke and chronic kidney disease were also more common in those with SARS-CoV-2 infection. At coronary angiography, a higher thrombus burden in COVID-19 positive STEMI patients was highlighted, with up to 10-fold higher rates of stent thrombosis and greater need for glycoprotein IIb/IIa inhibitors and aspiration thrombectomy;this was not always associated with prolonged times from symptom onset to hospital admission and door-to-balloon. COVID-19 positive STEMI patients were less likely to receive coronary angiography and primary PCI, and more likely to be treated with fibrinolytics only. At the same time, patients with Covid-19 were more prone to present MINOCA. In-hospital mortality ranged from 15% to 40%, with consistent variability across different studies and subjects who tested positive for SARS-CoV- 2 did also present higher rates of cardiogenic shock, cardiac arrest, prolonged ICU stay, mechanical ventilation, major bleeding, and stroke. Conclusion(s): The coexistence of STEMI and COVID-19 was associated with increased in-hospital mortality and poor short-term prognosis. This was not entirely attributable to logistic issues determining delayed coronary revascularization, since patients' specific clinical and angiographic characteristics, including higher burden of cardiovascular risk factors and greater coronary thrombogenicity might have substantially contributed to this trend. (Figure Presented).

Characteristics of patients with acute coronary syndrome in the COVID-19 pandemic: Acute coronary syndrome characteristics in patients with COVID-19

Aim: Coronavirus disease 2019 (COVID-19) has caused thrombotic disease. In this study, we aimed to determine the demographic and clinical characteristics of acute coronary syndrome (ACS) patients infected with COVID-19 and to investigate whether they differ from patients with ACS without COVID-19 in terms of these characteristics. Material(s) and Method(s): The study was designed as a single-center retrospective study. Thirty-three COVID-19 infected ACS patients (Group 1) and 100 ACS patients without COVID-19 infection (Group 2) were included in the study. Result(s): The groups were compared in terms of coronary angiographic data. Twenty-eight (84.8%) patients in Group 1 and 74 (74%) patients in Group 2 were presented as non-ST elevation myocardial infarctus. Patients were compared in terms of baseline Thrombolysis in Myocardial Infarctus (TIMI) flow, thrombus stage, myocardial blush (end), using of thrombus aspiration catheter, stent thrombosis, and TIMI flow after percutaneous coronary intervention, and it was observed that there was no statistical difference between the groups (p> 0.05). Discussion(s): COVID-19 infection can cause plaque rupture, myocardial damage, coronary spasm and cytokine storm by triggering the coagulation and inflammation process. The fact is that we did not encounter an increased thrombus load in this study.Copyright © 2022, Derman Medical Publishing. All rights reserved.

In-stent thrombosis and COVID-19 infection: Current insights on the mechanistic relationship.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been demonstrated as a major risk factor in inducing coronary stent thrombosis due to its propensity to create a pro-thrombotic state. In this review, we explore the mechanisms that may contribute to the increased thrombosis risk seen in COVID-19. Furthermore, we discuss the patient and haematological factors that predispose to an increased risk of stent thrombosis; as well as the role of certain antiplatelet and anticoagulation therapies, including ticagrelor and enoxaparin, that may reduce the likelihood and severity of in-stent thrombosis, in SARS-CoV-2 infection. To counter the pro-inflammatory and pro-thrombotic state shown in COVID-19, anti-thrombotic therapy in the future may be optimised using point-of-care platelet inhibition testing and inflammation-modifying therapies. Large scale randomised trials with long-term follow-up are increasingly necessary to assess the intersection of COVID-19 and stent optimisation as well as the reduction of stent thrombosis after drug-eluting stent (DES) implantation.

Double Trouble: Interrupting DAPT and COVID-19

Cardiovascular disorders have been described as relevant risk factor for severe COVID infection. Stent thrombosis is a life-threatening complication that may occur subacutely. We present an interesting case of a middle-aged woman who developed acute stent thrombosis while interrupting dual antiplatelet therapy (DAPT) ticagrelor, during an episode of coronavirus disease (COVID-19). In our case, the patient's not-compliance to DAPT, associated with COVID-19 infection and a hyperinflammatory and hypercoagulable state associated with it played a major role in the development of stent thrombosis. The hypercoagulable and hyperinflammatory state associated with COVID-19 has important implications for cardiac patients, especially those undergoing complex coronary intervention, predisposing them to an increased risk of post-PCI complications.

The Pragmatic Role of COVID-19 on the Thrombus Grade of Patients with Contemporary ST-Segment-Elevation Myocardial Infarction

Background: Limited data exist on the clinical outcomes of patients with coronavirus disease 2019 (COVID-19) presenting with ST-segment-elevation myocardial infarction (STEMI). Method(s): This multicenter study, conducted in 6 centers in Iran, aimed to compare baseline clinical and procedural data between a case group, comprising STEMI patients with COVID-19, and a control group, comprising STEMI patients before the COVID-19 pandemic, and to determine in-hospital infarct-related artery thrombus grades and major adverse cardio-cerebrovascular events (MACCEs), defined as a composite of deaths from any cause (cardiovascular and noncardiovascular), nonfatal strokes, and stent thrombosis. Result(s): No significant differences were observed between the 2 groups regarding baseline characteristics. Primary percutaneous coronary intervention (PPCI) was performed in 72.9% of the cases and 98.5% of the controls (P=0.043), and primary coronary artery bypass grafting was performed in 6.2% of the cases and 1.4% of the controls (P=0.048). Successful PPCI procedures (final TIMI flow grade III) were significantly fewer in the case group (66.5% vs 93.5%;P=0.001). The baseline thrombus grade before wire crossing was not statistically significantly different between the 2 groups. The summation of thrombus grades IV and V was 75% in the case group and 82% in the control group (P=0.432). The rate of MACCEs was 14.5% and 2.1% in the case and control groups, respectively (P=0.002). Conclusion(s): In our study, the thrombus grade had no significant differences between the case and control groups;however, the in-hospital rates of the no-reflow phenomenon, periprocedural MI, mechanical complications, and MACCEs were statistically significantly higher in the case group. Copyright © 2022 Tehran University of Medical Sciences.

Coronary Heart Disease and Coronavirus Disease 2019: Pathogenesis, Epidemiology, Association with Myocardial Revascularization

BACKGROUND: Coronavirus disease 2019 (COVID-19) causes a hypercoagulable state with a high incidence of thrombotic complications. Patients with a history of myocardial revascularization have more severe complications due to COVID-19. Coronary stent thrombosis has become significantly more common during the COVID-19 pandemic. AIM: The aim of our study is to analyze scientific information on the risks of stent thrombosis in patients who underwent COVID-19. METHODS: A search was made for scientific publications in evidence-based medicine databases and web resources: PubMed, MEDLINE, UpToDate, TripDatabase, ResearchGate, and Google Scholar. Inclusion criteria were: (1) Observational studies or case series involving patients with a confirmed diagnosis of COVID-19 and myocardial infarction requiring myocardial revascularization;(2) the division of the population into survivors and non-survivors;and (3) data on the presence of the previous myocardial revascularization. Exclusion criteria: Case description and editorials/bulletins. In all articles selected for further analysis, 49 sources were considered that met the inclusion criteria and excluded duplication or repetition of information. RESULTS: Coronavirus infection has contributed to the change in the course of myocardial infarction in patients undergoing myocardial revascularization. The incidence of stent thrombosis has a positive correlation with the severity of the coronavirus infection. The previous myocardial revascularization procedures significantly increase the risk of mortality in patients with coronavirus infection. This is especially actual for elderly patients. CONCLUSION: One of the most vulnerable groups is elderly patients who have undergone myocardial revascularization after myocardial infarction in the past and have concomitant diseases. An analysis of scientific publications has shown that further larger-scale clinical studies are needed to confirm the hypothesis about the negative impact of coronavirus infection on stent thrombosis in patients who have undergone COVID-19.

VERY LATE STENT THROMBOSIS AFTER JOHNSON & JOHNSON/JANSSEN VACCINATION

Background: Stent thrombosis (ST) is a dreaded complication of percutaneous coronary intervention (PCI), however incidence has been declining with improvement in stent design and pharmacological treatments. While ST can occur at any time after placement of a stent, the rate of ST declines as time from implantation progresses. Case: A 54 year-old man with a history of hypertension, hyperlipidemia, type two diabetes mellitus and coronary artery disease status PCI to the left anterior descending artery (LAD) six years prior presented with substernal chest discomfort for three hours. Vital signs were within normal limits, and his electrocardiogram showed two-to-three-millimeter ST elevation across the precordial leads with reciprocal ST depressions. He was brought emergently to the cardiac catheterization lab where coronary angiography revealed a large thrombus within the previously placed LAD stent. The patient underwent aspiration thrombectomy, balloon angioplasty and stenting of the LAD. The patient was discharged in good condition on dual-antiplatelet therapy three days after his presentation. Decision-making: Since the beginning of the COVID-19 pandemic, physicians on the front lines have been learning more and more about the virus including prevention and treatment. In a stunning collaboration of science and enterprise, several vaccines were created including the Johnson & Johnson/Janssen (J&J) single dose COVID-19 immunization. However, although effective at preventing serious COVID-19 infections, anecdotal evidence of thrombotic events has been reported. Given this patient's thrombotic event, a hypercoagulable workup was undertaken but unrevealing. Conclusion: We describe a case of very late ST of a six year-old drug eluting stent occurring three weeks after the patient received a J&J COVID-19 vaccine. While temporally the timing of the stent thrombosis is surprising and possibly related, this is yet another case to add to the body of evidence as we learn more about the 2019 Novel Coronavirus and the COVID-19 vaccines as we navigate this pandemic together.

Subacute dual stent thromboses in a COVID-19-positive patient.

The hypercoagulable state of COVID-19 is resulting in an increasing number of unexpected venous and arterial thromboses in patients. We report a case of subacute dual coronary stent thrombosis in the setting of COVID-19 and we provide a brief review of current management recommendations.

Kounis syndrome following COVID-19 vaccination.

Coronary stent thrombosis is a life-threatening condition induced by multiple factors, including allergic reactions. A 64-year-old man presented with stent thrombosis in the left anterior descending artery and multiple cardiorespiratory arrests immediately after the first dose of the BNT162b1 mRNA vaccine. He underwent emergent percutaneous coronary intervention. Anaphylaxis-induced stent thrombosis, or type III Kounis syndrome, is a highly possible diagnosis. Cardiogenic shock can hide the skin manifestations of anaphylaxis, making this syndrome challenging to diagnose. This clinical case underscores the importance of surveillance for at least 30 minutes after vaccine administration, especially in patients at risk.

Double Whammy: Subacute Stent Thrombosis While Being Adherent to Dual Antiplatelet Therapy Including Ticagrelor, Followed by Multiple Coronary Artery Aneurysms in a COVID-19 Patient.

Coronavirus disease 2019 (COVID-19), although predominantly a respiratory illness, can have important cardiovascular implications, which include the development of myocardial injury/myocarditis, acute coronary syndromes, arrhythmias, pericarditis, and the occurrence of arterial and venous thrombosis. We describe a rare case of a middle-aged COVID-19 patient who developed sub-acute stent thrombosis after implantation of second-generation drug-eluting stents (DES) despite being adherent to dual antiplatelet therapy including ticagrelor and who subsequently developed multiple coronary artery aneurysms within a few weeks of the DES implantation.

Coronary Stent Thrombosis in COVID-19 Patients: A Systematic Review of Cases Reported Worldwide.

Approximately 5 million percutaneous coronary interventions are performed worldwide annually. Therefore, stent-related complications pose a serious public health concern. Stent thrombosis, although rare, is usually catastrophic, often associated with extensive myocardial infarction or death. Because little progress has been made in outcomes following stent thrombosis, ongoing research is focusing on further understanding the predictors as well as frequency and timing in various patient subgroups. Coronavirus disease-2019 (COVID-19), a viral illness caused by the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), activates inflammatory mechanisms that potentially create a prothrombotic environment and increases the risk of local micro thromboembolism and all types of stent thrombosis. In-stent thrombosis occurrence increased during the COVID-19 pandemic, however, there is still lack of comprehensive studies describing this population. This review and worldwide analysis of coronary stent thrombosis cases related to COVID-19 summarizes all available data.

Coronary angioplasty and stenting in acute coronary syndromes with very low contrast volume using Cordis 6F diagnostic catheters and improved cardiovascular and renal outcomes

Background: To perform safely angioplasties in acute coronary syndromes with very low contrast volume using Cordis 6F diagnostic catheters, and thereby improve the cardiovascular and renal outcomes. Methods: In 1652 patients (2138 lesions/2447 stents) with acute coronary syndromes, angioplasty was performed with Cordis 6F diagnostic catheters. Primary angioplasty was performed in 525 cases. In 75% of cases, iodixanol was used. A regular follow-up of the patients was performed 30 days after the procedure. All the procedures were performed through the femoral route. Tirofiban was used in 99% cases with adjusted dosages based on the creatinine values. Covid19 was positive in 23 cases by RT PCR. Results: The mean contrast volume used per patient was 28 ml (±6 ml) including the angiogram prior to the angioplasty. 103 patients had crea-tinine more than 2mg/dl before the angioplasty procedures. Left main angioplasty was performed in 41 patients using single stents. 87 patients had cardiogenic shock at presentation. 77% of the cases had diabetes. IVUS was used in only two patients. Mild reversible nephropathy (CIN) was observed in six patients. Six patients were already on dialysis, and dialysis was continued thereafter. Switch-over of angioplasty to the radial route was performed in six cases. 32 deaths in total were observed in this series;19 of these patients had cardiogenic shock (10 late presenters), and three patients expired after discharge due to possible acute stent thrombosis. Groin haematoma was seen in seven cases requiring one unit of blood transfusion. Proximal mild edge dissection in the deployed stent was seen in 3 cases. Acute in-hospital stent thrombosis was seen in 7 cases, which were managed with balloon dilatations and stents. Conclusions: Angioplasty and stenting can be performed safely in patients with acute coronary syndromes using Cordis diagnostic catheters and a very low volume of contrast with improved clinical outcomes.

Early, Subacute Coronary Stent Thrombosis: A Complication of COVID-19 Infection

Soon after it was discovered in Wuhan, China, in December 2019, coronavirus disease 2019 (COVID-19) blow-out very fast and became a pandemic. The usual presentation is respiratory tract infection, but cardiovascular system involvement is sometimes fatal and also a serious personal and health care burden. We report a case of a 57-year-old man who was admitted with anterior wall acute myocardial infarction secondary to early coronary stent thrombosis and associated with COVID-19 infection. He was managed with primary coronary angioplasty and discharged home. Procoagulant and hypercoagulability status associated with severe acute respiratory syndrome coronavirus 2 infection is the most likely culprit. Choosing aggressive antithrombotic agents after coronary angioplasty to prevent stent thrombosis during the COVID-19 pandemic may be the answer but could be challenging.

Case report of a very late dual coronary stent thrombosis in a patient with coronavirus disease 2019.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is associated with hypercoagulability and a high rate of thrombosis. Few cases of coronary stent thrombosis associated with COVID-19 have been reported. CASE SUMMARY: In this report, we describe the case of a 65-year-old man with a history of coronary artery disease (CAD) who was admitted following an out-of-hospital cardiac arrest related to an ST-segment elevation myocardial infarction revealing a very late dual coronary stent thrombosis of the left anterior descending and posterior descending arteries. Ten days prior to admission, he was diagnosed with COVID-19 pneumonia and treated with dexamethasone, which led to rapid clinical improvement. After resuscitation, coronary angiography revealed an acute thrombotic occlusion in the two previous drug-eluting stents (implanted in 2010 and 2018), with a high thrombus burden. He was successfully treated by percutaneous coronary intervention. The patient did not present any further complications during his hospital stay and was transferred to a cardiac rehabilitation centre. DISCUSSION: Dual stent thrombosis is an exceptional event highlighting the high procoagulant state promoted by coronavirus 19. This case suggests that strengthening of antithrombotic therapy in CAD patients presenting with COVID-19 should be discussed.

Effects of Simulated COVID-19 Cytokine Storm on Stent Thrombogenicity.

BACKGROUND: Cytokine storm-related hypercoagulation may be important in the pathogenesis of stent thrombosis in patients with SARS-CoV-2. Whether stent polymers behave differently under such conditions has never been explored. METHODS: Fluorinated polymer-nanocoated and uncoated COBRA stents (CeloNova), BioLinx-polymer-coated Resolute Onyx stents (Medtronic), and Synergy stents (Boston Scientific), which are abluminally coated with a bioabsorbable polymer, were exposed to human blood from healthy donors which was supplemented with 400 pg/mL IL-6 and 100 pg/mL TNF-α, similar to what is seen in cytokine storm caused by SARS-CoV-2. Platelet adhesion and neutrophil activation, assessed by immunofluorescence, were compared under cytokine storm and control conditions (untreated blood) (n = 4 experimental runs). RESULTS: Platelet adhesion values, defined as %platelet-covered area x staining intensity, were significantly lower in coated and uncoated COBRA and in Resolute Onyx than in Synergy under control conditions (1.28 × 107 ± 0.43 × 107 vs. 2.92 × 107 ± 0.49 × 107 vs. 3.57 × 107 ± 0.73 × 107 vs. 9.94 × 107 ± 0.99 × 107; p ≤0.0001). In cytokine storm, platelet adhesion values remained low in coated COBRA-PzF (1.78 × 107 ± 0.38 × 107) compared to all other devices (uncoated COBRA: 5.92 × 107 ± 0.96 × 107; Resolute Onyx: 7.27 × 107 ± 1.82 × 107; Synergy: 11.28 × 107 ± 1.08 × 107; p ≤ 0.0001). Although cytokine storm conditions significantly increased neutrophil activation in all stents, it was significantly less in coated and uncoated COBRA, and in Resolute Onyx than in Synergy. CONCLUSIONS: Blood-biomaterials interactions may determine the thrombogenic potential of stents. Under simulated cytokine storm conditions, fluoropolymer-coated stents showed the most favorable anti-thrombogenic and anti-inflammatory properties.

Subacute Stent Thrombosis in a Patient With COVID-19 Despite Adherence to Antiplatelets.

The coronavirus disease 2019 (COVID-19) creates a significant burden on the cardiovascular system. Moreover, diagnosing coronary artery disease in patients with COVID-19 may be clinically challenging. Herein, we present a case of in-hospital stent thrombosis and thrombotic occlusion of the right coronary artery after initial revascularization and adherence to antiplatelet therapy.

COVID-19 pandemic and stent thrombosis in a post percutaneous coronary intervention patient-a case report highlighting the selection of P2Y12 inhibitor.

The current pandemic of novel coronavirus disease 2019 (COVID-19) has posed a great threat to people's health worldwide, with specific implications on patients with underlying heart diseases. During this challenging period, nearly all major societies have recommended for conservative approach, even for patients with relatively stable acute cardiovascular diseases. Selection of specific antiplatelet therapy in an uncomplicated post percutaneous coronary intervention (PCI) patient can, at times, be crucial issue in such strained circumstances. We report a case of 64-year-old male, who was taken for urgent coronary angiogram (CAG) in view of non ST elevation acute coronary syndrome. Successful PCI with implantation of drug eluting stent was done for right coronary artery (RCA) and left anterior descending (LAD) artery lesions. On day 5th post-PCI, he developed acute inferior wall STEMI due to subacute stent thrombosis (ST), and despite all efforts, patient could not be saved as he didn't receive timely intervention. Increased travel time to emergency department due to lockdown because of COVID-19 and along with extra time required for donning of personal protection equipment (PPE) and other COVID-19 related safety measures prolonged the ischemic time. Potent P2Y12 inhibitor based dual antiplatelet therapy might have prevented this subacute ST, and thus mortality, as the patient was discharged on clopidogrel after PCI. While selecting specific P2Y12 inhibitor in a post PCI patient, apart from clinical condition of patient and complexity of procedure, we should also consider current COVID-19 pandemic. Current circumstances may favour ticagrelor over other P2Y12 inhibitors in view of its potent, rapid, and reversible antiplatelet action along with its optimistic effect in pneumonia.