Debra L. Beck and Eugene Braunwald, MD

Date Published: April 24, 2020

Although there are associations between cardiovascular disease and COVID-19, the disease caused by the novel coronavirus SARS-CoV-2, most patients who need cardiovascular care during the COVID-19 pandemic will not be infected with COVID-19. Mahmud et al, representing the Society for Cardiovascular Angiography and Interventions (SCAI), American College of Cardiology (ACC), and the American College of Emergency Physicians (ACEP) wrote a joint consensus statement offering a systematic approach to the management of acute myocardial infarction (AMI) during the COVID-19 pandemic.

The authors identified two major challenges in providing AMI care during this time. The first is that the cardiovascular manifestations of COVID-19 are complex: patients present with AMI, myocarditis simulating a ST-elevation MI presentation (STEMI), stress cardiomyopathy, non-ischemic cardiomyopathy, coronary spasm, or nonspecific myocardial injury. Add to this the fact that the prevalence of COVID-19 disease in the US population remains unknown due to limited testing despite a presumed risk of asymptomatic spread, and “a balance must be struck in identifying appropriate patients for invasive approaches to AMI regardless of their COVID-19 status, and maintaining the safety of healthcare workers who might be exposed to the disease…”

PCI should remain the standard of care for individuals with definite STEMI who can be treated within 90 minutes of first medical contact. With this as a primary strategy, however, pre-catheterization laboratory assessments may take longer because of the need for COVID-19 assessment and possible respiratory management and door-to-balloon time will likely exceed 90 minutes during this period. Since about 50% of patients who undergo fibrinolysis will require rescue PCI, primary PCI should be attempted when possible.

However, the authors acknowledge that in some patients with COVID-19 and STEMI, PCI may not be appropriate and may be futile. “In COVID- 19 confirmed patients with severe pulmonary decompensation (adult respiratory distress syndrome) or pneumonia who are intubated in the ICU and felt to have an excessively high mortality, consideration for compassionate medical care may be appropriate,” said Mahmud et al.

For NSTEMI patients, in the absence of hemodynamic instability or ongoing ischemic symptoms, those who are COVID-19 positive or probable can be optimally managed with an initial medical stabilization strategy.

It is imperative that all catheterization laboratory personnel and clinicians wear appropriate personal protective equipment (PPE) for all invasive procedures during this pandemic. As well, the authors suggest that regional STEMI care networks revise their suggested algorithms to accommodate for local circumstances “to ensure that EMS and referral hospital teams are facile with a balanced and standardized approach towards STEMI care during the COVID-19 pandemic.”

And finally, it is critical to inform the public of that all possible precautions are being taken to minimize exposure to the coronavirus and that plans are in place to provide continued treatment of AMI “so they continue to call the Emergency Medical System (EMS) for acute ischemic heart disease symptoms and therefore get the appropriate level of cardiac care that their presentation warrants,” said Mahmud et al.

References

Mahmud E, Dauerman HL, Welt FGP, et al. Management of acute myocardial infarction during COVID-19 pandemic. J Am Coll Cardiol. 2020; April 24.