COVID-19 & Myocardial infarction
COVID-19 & Myocardial infarction
A considerable higher % of ptns may be admitted
with COVID-19 will have an underlying
CAD. Mostly, symptoms related to CAD cannot be observed during admission. It’s possible
that COVID-19 directly &
indirectly may affect CVS system, leading
to acute coronary syndrome (ACS),
myocarditis, and electrical heart illness. Health care providers should make
every effort to persuade ptns to proceed to the necessary evaluation if the
diagnosis of ACS is suspected. On the
other hand, ptns with known/suspected COVID-19,
diagnosis & management of ST-elevation
MI is simulating those without. Occasionally,
it’s advised to liberalize the administration of fibrinolytic
therapy related to percutaneous
coronary procedures. Ptns with known/suspected COVID-19,
diagnosis & management of non-ST-elevation
MI is simulating those without. The
usual management of CAD in ptns with COVID-19 disease is currently not changed EXCEPT:
An elective
revascularization procedures indicative
for relief of Sms is currently delayed.
Hospitalized COVID-19
ptns with stable CAD, routine baseline cardiac troponin
is obtained only by some centers.
Management: The STEMI (ST-elevation MI)
ptns with a documented
COVID-19 infection, should be managed
as in the usual approach of Iry PCI
except that we mask ALL the ptns. If myocarditis appeared more likely than STEMI, A conservative
approach with aspirin + heparin
until Dgx confirmed. In confirmed COVID-19
disease or under investigation with STEMI,
there’re 2 crucial questions:
Ø Does ptn presented with a critical
illness, e.g. OVID-19- respiratory failure
leading them less favorable candidates for the reperfusion procedure? Clinicians
usually asked this Q. prior to re-vascularization in all ptns before to the
pandemic. But, it’s a vital Q. once pandemic developed.
Ø Should the fibrinolytic therapy be administrated more liberally as a therapeutic option
for early reperfusion within a
pandemic episode?
In regard to 1st
Q, the associated risk with reperfusion procedures may
exceed the expected gains in some
ptns, especially if the original competing
illness may be show a poor
outcome. As a fact for all ptns with STEMI,
co-morbidities, infarct size, late referral,
and hemodynamic status must be taken on consideration if reperfusion therapy
has been considered.
In regard to 2nd
Q., and with considering that PCI is generally preferred
to fibrinolytic therapy, some
experts may suggest a more liberality in
fibrinolytic therapy utilization (against the currently recommended)
may be necessitated in particular situations considering resource use and
the possible risk of viral transmission to the health care staffs.
We can partially argue
about the consideration of less viral
exposure to the catheterization staff. It should be emphasized,
however, that fibrinolysis may not reduce
resource utilization during the pandemic
episode as majority of ptns who receive
fibrinolytic
procedures will still in need for coronary
angiography at certain points
during hospitalization, often within 3-24 h. as part of a pharmaco-invasive or rescue strategy for a failed fibrinolysis procedures.
These ptns may need persistent monitoring in an ICU,
thereby utilizing a scarce resource and increasing length of hospitalization.
Moreover, there’re
some ptns who’re more vulnerable to the risk of
bleeding relate to fibrinolysis,
particularly intracranial bleeding,
in case of myocarditis, and some may
not properly evaluate the benefit of myocardial
salvage in the subset of a
competing life-threatening illness. Consequently,
PCI (percutaneous coronary intervention) is
currently preferred as the reperfusion strategy during the pandemic episodes. However, this decision
must be considered in a larger context of the local available resources, in
addition to the ptn factors that include: age,
infarct site, and duration of Sms that affect fibrinolysis efficacy, bleeding risk, and the percentage of myocardial salvage.
When deciding
between primary PCI and fibrinolytic
therapy, factors like clinically significant co-morbidities &
resource limitation should be considered. Ptn with COVID-19 pneumonia & respiratory failure may not
be optimized to reap his benefit of myocardial
reperfusion, on the other hand a ptn with suspected COVID-19
and mild/moderate disease is more likely to reap the benefit of myocardial salvage, and if facilities are available, then reperfusion procedures should
be attempted despite the current risk to providers as well as the utilized resources. Regardless the
initial reperfusion protocol, ALL STEMI
ptns with early ASPRIN, P2Y12 inhibitor, + anticoagulation. High-dose
statin is advised once diagnosis has been established.
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