COVID-19 and 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 1^st 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 2^nd 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.