In the Journal of American College of Cardiology, Ehtisham Mahmud (University of California, San Diego, Sulpizio Cardiovascular Center, La Jolla, USA) and others outline, in a consensus statement, recommendations for managing acute myocardial infarction during the COVID-19 pandemic. The statement is on behalf the Society for Cardiovascular Angiography and Interventions (SCAI), the American College of Cardiology (ACC), and the American College of Emergency Physicians.
Mahmud et al write that that there are “two major challenges” to treating acute myocardial infarctions during the current pandemic. The first, they add, is that cardiovascular manifestations of COVID-19 are “complex”, “with patients presenting with acute myocardial infarction, myocarditis simulating ST-segment elevation myocardial infarction presentation, stress cardiomyopathy, coronary spasm, and non-specific cardiac injury”. The second challenge is that prevalence of COVID-19 in the USA is unknown as is the risk of asymptomatic spread.
The aim of the statement, therefore, was to review these challenges by focusing the varied clinical presentations, the need for personal protective equipment for healthcare workers, the role of the emergency department, emergency medical systems and cath labs, and regional ST-segment elevation myocardial infarction (STEMI) systems of care.
A key recommendation is that primary percutaneous coronary intervention (PCI) “remains the standard of care” for patients with confirmed STEMI at PCI capable hospitals. However, this is with the caveats that PCI can be performed “in a timely fashion” in a dedicated cath lab with an “expert team outfitted in personal protective equipment”. Mahmud et al state that a fibrinolysis-strategy “may be entertained” at non-PCI capable referral hospitals “or in specific situations where primary PCI cannot be executed or deemed the best option”.
However, prior to choosing a reperfusion strategy, the authors state a “broad differential diagnosis for ST elevations” should be considered in the emergency department given “patients with COVID-19 are inherently complex”. “In the absence of haemodynamic instability or ongoing ischaemic symptoms, NSTEMI patients who are COVID-19 positive or probably are optimally managed with an initial medical stabilisation strategy,” they say. Furthermore, Mahmud et al comment that appropriate personal protective equipment is used for all invasive procedures and that COVID-19 testing is “expeditiously disseminated” to all hospitals involved in the care of patients with an acute myocardial infarction”.