Table of Content - Volume 21 Issue 1 - Januray 2022
Clinical study of patients presenting with ST elevation myocardial infarction (STEMI) during period of COVID pandemic
Sunita Arun Borade1*, C N Makhale2, Purvez Grant3, Manisha Dhobe4
1Senior CCU Consultant, 2Senior Cardiologist, 3Chief Cardiologist, 4HOD CCU, Department of Cardiology, Ruby Hall Clinic, Pune, Maharashtra, INDIA. Email: sntbrd24@gmail.com
Abstract Background: Covid pandemic has an unintentional effect on the management of ACS (acute coronary syndrome) and in particular STEMI (ST-elevation myocardial infarction), and high-risk NSTEMI (non ST-elevation myocardial infarction) where time is the most important determinant of the outcome. Present clinical study was aimed to study patients presenting with ST elevation myocardial infarction during period of COVID pandemic, at a tertiary hospital. Material and Methods: Present study was single-center, prospective, observational study, conducted in patients of age > 18 years, either gender, with clinical presentation suggestive of acute myocardial infarction. Results: In present study 145 patients were studied. Majority of them were from 51-60 years age group (40%) followed by > 60 years age group (30.3%). Male patients (82.8%) outnumbered female patients (17.2%) and male to female ratio was 4.8:1. RTPCR report was suggestive of COVID POSITIVE in 17 patients (11.72%). Symptoms observed in majority of patients were chest pain (80%), breathlessness (44.14%), sweating (39.31%) and palpitation (34.48%). 66 patients presented with classical symptom triad of MI (chest pain, breathlessness, sweating). Majority of patients were seen at 4- 8 hours from onset of symptoms (29.66%), followed by at 1- 4 hours from onset of symptoms (20.69%). LVEF > 35% was noted in 53.79% patients. In present study, Anterior Wall MI (61.38%), Inferior Wall MI (22.07%) and Inferior posterior MI (8.97%) were most common types noted. In present study we thrombolysed 103 patients (71.03%). Majority with streptokinase (43.45%) followed by Tenecteplase (24.83%) and Reteplase (2.76%). 35 patients were thrombolysed within 30 minutes. Door to needle time was less than 1 hour in 63.45% patients. Primary PTCA was done in 7 patients. Door to balloon time was < 1 hour and 1-2 hours in 42.85% patients. We used GPIIbIIIa inhibitors in 34.48% patients. (tirofiban- 33.10% and eptifibatide- 1.38%). In present study PTCA was DONE in 101 patients (69.66%). Common findings were single vessel PTCA (34.48%), Multivessel (26.90%), LAD (18.62%), RCA (8.97%), LCX (5.52%). In the present study, common complications noted were heart failure (34.48%), cardiogenic shock (21.38%), malignant arrythmias (VT, V F) (15.17%) and MR (3.45 4 deaths were noted during hospital stay. Majority of patients were discharged in 2-4 days (71.72%). Conclusion: In COVID pandemic, STEMI patients had longer total ischemic time, leading to a more severe disease status on hospital admission, as well as a higher rate of in-hospital adverse events was noted. Keywords: COVID pandemic, STEMI, hospital admission, acute myocardial infarction.
INTRODUCTION Although the health system is overwhelmed with COVID-19 cases across the globe, a change in the hospital admission pattern during the lockdown period has been reported.1 Covid pandemic has an unintentional effect on the management of ACS (acute coronary syndrome) and in particular STEMI (ST-elevation myocardial infarction), and high-risk NSTEMI (non ST-elevation myocardial infarction) where time is the most important determinant of the outcome.2 Early in the COVID-19 outbreak, healthcare professionals began to observe reductions in admissions of patients with myocardial infarction. Various factors, among others the fear of infection with SARSCoV- 2 in the hospital and social isolation measures, have been suggested as possible reasons for this phenomenon.3,4 The incidence rate of STEMI should be relatively stable in the current society or possibly even higher due to increased psychological stress and lack of exercise due to “lockdown policies”.5 Cardiovascular manifestations of COVID-19 are complex with patients presenting with AMI, myocarditis simulating an ST-elevation myocardial infarction (STEMI) presentation, stress cardiomyopathy, non-ischemic cardiomyopathy, coronary spasm, or nonspecific myocardial injury.6 Present clinical study was aimed to study patients presenting with acute myocardial infarction during period of COVID pandemic, at a tertiary hospital.
MATERIAL AND METHODS Present study was single-center, prospective, observational study, conducted in the emergency room, OPDs, wards, CCU of Ruby Hall Clinic, Pune, India, a tertiary care hospital. Study duration was of 10 months (March 2020 to December 2020). Study was approved by the institutional ethical committee. Inclusion criteria: Patients of age > 18 years, either gender, with clinical presentation suggestive of acute myocardial infarction, later confirmed if any two out of three of the following criteria were present: 1. Electrocardiogram (ECG) evidence of ST elevation myocardial infarction. 2. Ischemic chest pain for at least 10 min. 3. Rise of the cardiac biomarker troponin. Exclusion criteria: Patients with evolved myocardial infarction, non ST elevation MI. Written informed consent was obtained from the participants prior to inclusion. Complete history, clinical examination, investigations and other workup of STEMI patients was done on admission. On admission COVID swab was sent for RTPCR, till patients were managed in an isolation ward. Coronary angiography was performed whenever required to assess the number and type of vessels which were involved. Further necessary management was done in all cases. Follow up was kept for 3 months from discharge. Collected data was entered in Microsoft excel sheet and analysed accordingly.
RESULTS In the present study 145 patients were studied. Majority of them were from the 51-60 years age group (40%) followed by > 60 years age group (30.3%). Male patients (82.8%) outnumbered female patients (17.2%) and male to female ratio was 4.8:1. RTPCR report was suggestive of COVID POSITIVE in 17 patients (11.72%). Comorbidities noted in study patients were diabetes mellitus and hypertension (40%), diabetes mellitus (12.41%), hypertension (3.45%) and old cerebrovascular accidents (2.76%), (38%) patients with no hypertension, diabetes mellitus, OR previous medical history.
Table 1: General characteristics
In the present study, symptoms observed in the majority of patients were chest pain (80%), breathlessness (44.14%), sweating (39.31%) and palpitation (34.48%). 66 patients presented with a classical symptom triad of MI (chest pain, breathlessness, sweating). Majority of patients were seen at 4- 8 hours from onset of symptoms (29.66%), followed by at 1- 4 hours from onset of symptoms (20.69%). LVEF > 35% was noted in 53.79% patients.
In the present study, Anterior Wall MI (61.38%), Inferior Wall MI (22.07%) and Inferior posterior MI (8.97%) were the most common types noted.
Table 3: Distribution of myocardial infarction (MI)
In the present study we thrombolysed 103 patients (71.03%). Majority with streptokinase (43.45%) followed by Tenecteplase (24.83%) and Reteplase (2.76%). 35 patients were thrombolysed within 30 minutes. Door to needle time was less than 1 hour in 63.45% patients. Primary PTCA was done in 7 patients. Door to balloon time was < 1 hour and 1-2 hours in 42.85% patients We used GPIIbIIIa inhibitors in 34.48% patients. (tirofiban- 33.10% and eptifibatide- 1.38%). In present study PTCA was DONE in 101 patients (69.66%). Common findings were single vessel PTCA (34.48%), Multivessel (26.90%), LAD (18.62%), RCA (8.97%), LCX (5.52%). Left Main (4.83%)
Table 4: Treatment provided
In the present study, common complications noted were heart failure (34.48%), cardiogenic shock (21.38%), malignant arrhythmias (VT,V F) (15.17%) and MR (3.45%). Cardiogenic shock patients were managed on single inotrope support (51%), multiple inotropic support (48%) and inotropes + IABP (12%). 4 (2.76%) deaths were noted during hospital stay.
Table 5: Complications
Majority of patients were discharged in 2-4 days (71.72%).
Table 6: Duration of stay
DISCUSSION It has also been observed that COVID-19 infection is more likely to have poor prognosis and increased mortality in patients with advancing age, co-morbidities like obesity, chronic obstructive pulmonary disease, diabetes mellitus, hypertension, coronary artery and cerebrovascular diseases.7 Recent reports suggest that presentation of COVID-19 infection mimicking ST-elevation myocardial infarction (STEMI) with an elevation of cardiac biomarkers, electrocardiographic and echocardiographic abnormalities is highly prevalent, and is associated with more severe disease and worse prognosis.8 This overlapping atypical presentation of COVID-19 with STEMI has compounded the management of the infected patients and has overstretched the healthcare resources, and in some instances fatally exposed the medical personnel such as cardiologists to this contagion. Geevar Z et al.,9 conducted a two-timepoint cross-sectional study involving 187 hospitals across India, among 41,832 consecutive adults with AMI. The weekly average decrease in AMI admissions in 2020 correlated negatively with the number of COVID cases, but strongly correlated with the stringency of the lockdown index. On a multilevel logistic regression, admissions were lower in 2020 with older age categories, tier 1 cities, and centers with high patient volume. Adjusted utilization rate of coronary angiography, and percutaneous coronary intervention decreased by 11.3%, and 5.9% respectively. Similar findings were noted in the present study. Baumhardt M et al.,10 conducted a systematic literature review and meta-analysis of studies reporting 81,163 patients with STEMI and/or NSTEMI during lockdown episodes. They found that the number of hospital admissions of patients with myocardial infarction was significantly lower during the lockdown than before the pandemic (incidence rate ratio [IRR] = 0.516 [0.403; 0.660], I2 = 98%). This was true both for patients with STEMI (IRR = 0.620 [0.514; 0.746], I2 = 96%) and for patients with NSTEMI (IRR = 0.454 [0.354; 0.584], I2 = 96%). However, no significant difference in the time from hospital admission to cardiac catheterization, or in mortality, in relation to the time from symptom onset to first medical contact was noted. Lockdown due to COVID-19 was associated with a marked decline in the number of hospital admissions of patients with myocardial infarction. As no significant effect on delay times or mortality was observed, it seems that timely medical care continued to be delivered. Fardman A et al.,11 studied a cohort comprising 1466 consecutive acute MI patients, of whom 774 (53%) were hospitalized during the Covid-19 outbreak. Overall, 841 patients were diagnosed with STEMI: 424 (50.4%) during the Covid-19 era and 417 (49.6%) during the parallel period in 2018. Although STEMI patients admitted during the Covid-19 period had fewer comorbidities, they presented with a higher Killip class (p value = .03). Hospitalization during the Covid-19 era was independently associated with an increased risk of the combined endpoint in the multivariable regression model (OR 1.65, 95% CI 1.03–2.68, p value = .04). Furthermore, the rate of mechanical complications was four times higher during the Covid-19 era (95% CI 1.42–14.8, p-value = .02). However, in-hospital mortality remained unchanged (OR 1.73, 95% CI 0.81–3.78, p-value = .16). STEMI patients admitted during the first wave of Covid-19 outbreak, experienced longer total ischemic time, which was translated into a more severe disease status upon hospital admission, and a higher rate of in-hospital adverse events, compared with parallel period. Similar findings were noted in the present study. Timely reperfusion therapy is critical for STEMI patients because a short ischemia time is associated with better clinical outcomes and lower acute and long-term mortality. The COVID-19 pandemic placed the management of STEMI patients in a difficult situation due to the need to balance timely reperfusion therapy and maintaining strict infection control practices.12,13,14 In the present study, CABG advised for 10 patients - 8 underwent CABG, All patients were discharged on dual antiplatelet (aspirin / clopidogrel/ticagrelor/prasugrel) and high dose statin. Out of 67 LVF patients, 34 patients discharged on dapagliflozin and anti failure treatment. On follow up repeat episodes of chest pain (4.14%), breathlessness (1.38%), palpitation (2.76%) were noted. Re-hospitalization was required in 8 (5.52%) cases, out of which 1 underwent CAG, 3 underwent PTCA and 1 underwent CABG. In the follow up period mortality was noted in 6 cases. During the COVID-19 pandemic, primary PCI remains the standard of care for STEMI patients at PCI capable hospitals when it can be provided in a timely fashion, with an expert team outfitted with PPE in a dedicated CCL room. A fibrinolysis-based strategy may be entertained at non-PCI capable referral hospitals or in specific situations where primary PCI cannot be executed or is not deemed the best option.6 Considering an estimated 3 million STEMI per year in India, a 35% reduction in India during the pandemic, would translate to a staggering 1 million less STEMI admissions alone in a year. This would result in increased cardiac arrests in the community, more patients with LV dysfunction and heart failure presenting later, and lack of secondary prevention measures for a vast majority with AMI. With an average age of AMI of 58-years, the health and economic consequences would be staggering for an emerging economy.15 Telemedicine, which is used to deliver health care services using information or communication technology, provides an opportunity to carry out the evaluation, diagnosis, and even monitor the patients after discharge when social distancing is needed.16 CONCLUSION In COVID pandemic, STEMI patients had longer total ischemic time, leading to a more severe disease status on hospital admission, as well as a higher rate of in-hospital adverse events was noted. Early medical help is required to prevent mortality from these life-threatening events along with, promotion of tele or virtual health consultation is required during such crises.
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