Timely primary percutaneous coronary intervention (PCI) should remain first line treatment for patients presenting to the emergency department (ED) with acute ST-segment elevation myocardial infarction (STEMI) during the coronavirus disease 2019 (COVID-19) pandemic, according to a joint statement published in the Journal of the American College of Cardiology.
A relationship between COVID-19 and cardiovascular events, both in terms of secondary complications and primary CV presentations, currently, has been established. However, a significant proportion of patients with ischemic heart disease and acute myocardial infarction (AMI) may not be infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that causes COVID-19.
The authors of this consensus statement from the Society for Cardiovascular Angiography and Interventions, the American College of Cardiology, and the American College of Emergency Physicians sought to provide guidelines and recommendations on how to systematically and safely approach patient care for individuals experiencing AMI during the pandemic.
They acknowledged 2 key challenges: the true COVID-19 prevalence in the United States remains unclear, with considerable risk of asymptomatic transmission within the population; and CV presentations of COVID-19 are complex and diverse, with conditions that include AMI, coronary spasm, nonischemic cardiomyopathy, stress cardiomyopathy, nonspecific myocardial injury, and myocarditis that mimics STEMI. These challenges require to balance between appropriate AMI intervention (eg, with PCI), irrespective of the patient’s COVID-19 status, and the protection of healthcare workers (with personal protective equipment [PPE] and virus spread minimization strategies).
Patient care requires proper utilization of PPE by healthcare workers, considerations of regional STEMI care systems, clinical presentation variability, and the separate but interdependent roles of the ED, cardiac catherization laboratory, and Emergency Medical System.
Additional recommendations include the importance for ED physicians to consider a broad differential diagnosis before selecting a reperfusion treatment, rapid COVID-19 testing of patients presenting with AMI, and the need for regional centers to revise algorithms based on local environments to ensure continued standardization of care for AMI during the pandemic.
“Clinicians should recognize that patients with COVID-19 are inherently complex,” noted the authors. “It is critical to inform the public that we can minimize exposure to the coronavirus so they continue to call the Emergency Medical System for acute ischemic heart disease symptoms and therefore get the appropriate level of cardiac care that their presentation warrants.”
Mahmud E, Dauerman HL, Welt FG, et al. Management of acute myocardial infarction during the COVID-19 pandemic. J Am Coll Cardiol. April 2020. doi:10.1016/j.jacc.2020.04.039