A comprehensive protocol-based triaging and decision making at the point of care in patients with COVID-19 presenting with acute myocardial injury is necessary to reduce provider anxiety and confusion, offer a pathway for streamlined management of these challenging patients, while simultaneously minimizing the exposure of medical personnel to this highly contagious virus, according to a report published in Atherosclerosis.

COVID-19 has forced the healthcare system to reconsider its approach to even the most basic practices. Recent reports show that acute myocardial injury and subsequent troponin and/or ST-segment elevation are common findings and risk predictors among patients with COVID-19.

Consequently, a comprehensive protocol which incorporates recommendations by the American College of Cardiology and the Society for Cardiovascular Angiography and Interventions for the management of acute coronary syndromes in patients with COVID-19, was developed.

Patients with suspected and confirmed COVID-19 and acute myocardial injury are treated similarly. Whenever possible, the cardiovascular team does the initial evaluation and triaging through teleconsult. Patients with definite or probable regional wall motion abnormalities in a coronary distribution are treated as myocardial infarction, and those with wall motion abnormalities outside of a coronary artery distribution are considered as noncoronary myocardial injury.


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Type 2 myocardial infarction  and stable non-ST-elevation myocardial infarction are treated conservatively, and patients with unstable non-ST-elevation myocardial infarction are treated with an early invasive strategy, on condition that that the benefit from revascularization surpasses the risk for respiratory failure, adverse outcomes and COVID-19 exposure.

For ST-elevation myocardial infarction, the reperfusion approach is grounded on patient’s clinical, electrical, and hemodynamic stability, bleeding risk, time delays, and severity of pneumonia. Rescue percutaneous coronary intervention may be an option if thrombolysis fails, after taking into account the patient’s respiratory status and prognosis. Thrombolysis should be considered only in patients with high likelihood for ST-elevation myocardial infarction.

“Institutions caring for [patients with] COVID-19 would benefit from a heart team-like approach – developing a combined cardiology/critical care team that meets daily to optimize diagnostic and therapeutic strategies,” concluded the study authors.

Reference

Chatzizisis YS, Gajanan G, Bhatt DL, Dangas G, Porter T. Management of acute myocardial injury in patients with confirmed or suspected COVID-19 (published online June 11, 2020). Atherosclerosis. doi.org/10.1016/j.atherosclerosis.2020.06.008