COVID-19: Confirmed Infection Plus STEMI Associated With High Risk for Death, Stroke, Recurrent MI

The NACMI (North American COVID-19 and STEMI) registry is intended to describe demographic characteristics, management strategies, and outcomes of COVID-19 patients with STEMI.

People with confirmed COVID-19 and ST-segment elevated myocardial infarction (STEMI) should be viewed as part of a high-risk group of patients, and further study is needed to understand the high mortality in this patient population, according to research published in the Journal of the American College of Cardiology.  

Current data indicate that people with cardiovascular disease have a higher risk of contracting more severe forms of COVID-19, with research showing a 20% to 30% prevalence of myocardial injury — evidenced by either biomarkers of cardiac damage or cardiac magnetic resonance — in people hospitalized with COVID-19 infections. Despite these data, though, management of these patients is controversial.

To address these knowledge gaps, a cohort of researchers from the Society for Cardiovascular Angiography and Interventions (SCAI), the Canadian Association of Interventional Cardiologists, and the American College of Cardiology Interventional Council joined together to create the North American COVID-19 Myocardial Infarction (NACMI) registry. The goal of this registry is to provide “real-time clinical, management, and outcome data on STEMI patients” throughout the U.S. and Canada.

NACMI is a prospective, multicenter, observational, investigator-initiated registry of hospitalized patients with STEMI with either confirmed or suspected COVID-19. Patients were enrolled between January 1 and December 6, 2020. Primary endpoint was a composite of in-hospital death, stroke, recurrent MI, or unplanned revascularization.

The total patient cohort included 230 patients with confirmed COVID-19 (COVID+) and 495 patients with suspected COVID-19, as well as 460 age- and sex-matched control patients (71% men, aged 56 to 75 years). Patients in the COVID+ group were primarily Hispanic, Black, or Asian (23%, 24%, and 6%, respectively).

Within the COVID+ group, 78% underwent angiography; 71% of these patients received primary percutaneous coronary intervention (PPCI). Other reperfusion strategies included facilitated or rescue PCI (4%), thrombolytic therapy (3%), and coronary artery bypass graft surgery (2%). Twenty percent of those who underwent angiography received medical management alone without reperfusion. Comparatively, patients in the control group were more likely to receive PPCI (93%) and less likely to receive medical management alone (2%).

In total, 106 people in the COVID+ group and 347 in the suspected COVID group received PPCI and had available treatment time data. Researchers noted “only slightly longer” door-to-balloon times in the COVID+ and suspected COVID groups relative to the control group (median, 79 and 77 minutes vs 66 minutes).

Ultimately, 36% and 13% in the COVID+ and suspected COVID groups, respectively, met the primary endpoint, compared with only 5% of patients in the control group. This difference, according to researchers, was “driven primarily by increased in-hospital mortality.”

Within the COVID+ group, mortality was higher among patients who did not undergo coronary angiography vs those who did (48% vs 28%).

Study limitations include a lack of important subgroup analyses that still need to be conducted, the lack of prehospital data on total ischemic and transfer times for patients who presented at a non-PPCI hospital, and an inability to accurately estimate door-to-balloon time due to atypical presentations in the setting of a COVID-19 infection. Researchers also noted that they “could not rule out delayed symptom-hospital presentation as a contributor to worse outcomes.”

“COVID+ patients with STEMI represent a high-risk group of patients with unique demographic and clinical characteristics,” the researchers concluded. “Timely PPCI is feasible and remains the predominant reperfusion strategy, supporting current recommendations.”

Disclosure: This clinical trial was supported by Medtronic and Abbott Vascular. Please see the original reference for a full list of authors’ disclosures.


Garcia S, Dehghani P, Grines C, et al; the Society for Cardiac Angiography and Interventions, the Canadian Association of Interventional Cardiology, and the American College of Cardiology Interventional Council. Initial findings from the North American COVID-19 Myocardial Infarction registry. J Am Coll Cardiol. 2021;77(16):1994-2003.