August 19, 2020
Study From China Evaluates Prognosis for STEMI Patients During COVID-19 Pandemic
August 19, 2020—The American College of Cardiology (ACC) announced the publication of a study showing that the risk of in-hospital death and in-hospital heart failure increased for patients with ST-segment elevation myocardial infarction (STEMI) in China during the COVID-19 pandemic. Hospitals also experienced a decline in the number of heart attack patients seeking treatments, as well as delays in time to treatment and changes in treatment protocols.
The study, “Management and Outcomes of Patients With STEMI During the COVID-19 Pandemic in China,” by Dingcheng Xiang, MD, et al, is available online ahead of print in Journal of the American College of Cardiology (JACC).
Dr. Xiang, who is a cardiologist in the Department of Cardiology at General Hospital of Southern Theater Command of People’s Liberation Army in Guangzhou, China, commented in the ACC press release, “Our findings provide much needed empirical evidence for health care professionals searching for a balance between optimizing timely treatment for STEMI patients and protecting health care workers and vulnerable cardiovascular patients from the risk of COVID-19 infection.” Dr. Xiang advised, “Despite the inevitable delays in treatment timeline due to mandatory infection control procedures and changes in reperfusion strategies during the outbreak, the proportion of patients receiving effective reperfusion remained stable.”
The ACC announcement noted that at the start of the COVID-19 outbreak on January 23, 2020, China Chest Pain Center’s Executive Committee recommended prioritizing thrombolytic treatment for most patients with unconfirmed COVID-19 status in areas affected by the outbreak to ensure timely reperfusion therapy for patients and control in-hospital infection.
As the pandemic developed, experts in Iran, Palestine, and Jordan recommended similar protocols, while those in the United States, Italy, Australia, and New Zealand have recommended continuing with existing percutaneous coronary intervention (PCI) protocols except in special circumstances.
In the study, investigators evaluated the impact of the COVID-19 outbreak and China Chest Pain Center’s modified STEMI protocol on the treatment and prognosis of patients with STEMI in China. Data were reviewed from 28,189 STEMI patients admitted to 1,372 Chest Pain Centers between December 27, 2019, and February 20, 2020. A total of 25,150 (89.2%) of patients met the inclusion criteria.
According to ACC, the investigators reported in JACC that there was approximately a 26% drop in weekly hospitalized STEMI cases during the outbreak nationwide and a 62% drop in Hubei province, which was the epicenter of the outbreak in China. This suggests that patients with STEMI were less likely to access care during the outbreak, which is similar to trends seen worldwide.
Consistent with new protocols, the percentage of primary PCI dropped by half, while the percentage of thrombolysis increased fourfold in Hubei province. In other less affected provinces, there were slight decreases in the percentage of primary PCI and slight increases in the percentage of thrombolysis.
Despite these changes, the percentage of STEMI patients receiving timely reperfusion therapy during the outbreak dropped from 59.4% to 51.6% in Hubei province during the COVID-19 outbreak and from 65.1% to 60.1% in other provinces.
The investigators also found that the COVID-19 outbreak delayed primary PCI for approximately 21 minutes in Hubei province and about 4 minutes in other provinces. The delay for thrombolytic treatment was approximately 23 minutes in Hubei province and approximately 5 minutes in other provinces.
The rate of in-hospital mortality increased from 4.6% to 7.3% and the rate of in-hospital heart failure increased from 14.2% to 18.4% in Hubei province during the outbreak period. Other provinces saw smaller increases of 4% to 4.7% for in-hospital mortality and 13.2% to 14% for in-hospital heart failure. There did not appear to be differences in in-hospital hemorrhage.
In the press release, ACC noted limitations of the study. These include that because there was little time between the start of China’s response to the COVID-19 outbreak and the release of the modified STEMI protocol, the observational study cannot fully dissociate the effects of the modified protocol from the other aspects of the COVID-19 outbreak that contribute to the deterioration of STEMI patient prognosis.
Additionally, investigators were unable to assess the extent to which the modified protocol protected health care workers and other vulnerable cardiovascular patients from COVID-19 infection because of the lack of complete data on nosocomial infection. However, the investigators suggest the protocol was likely effective in this regard.
In a related editorial commentary published online in JACC, Lauren S. Ranard, MD, et al stated that PCI should remain the preferred method of revascularization for STEMI patients, irrespective of COVID-19, especially in areas with adequate personal protective equipment and timely access to PCI. Dr. Ranard et al also noted that bleeding risk might be higher than the study suggests. The authors are cardiologists at Columbia University Irving Medical Center/New York-Presbyterian Hospital in New York, New York.
“Widespread adaptation of [thrombolysis] as the preferred reperfusion approach may unnecessarily expose many patients to bleeding risk,” stated Dr. Ranard in the ACC press release. “The low total number of patients with bleeding events in this report, despite increasing adoption of [thrombolysis], suggests potential underreporting of these outcomes, which are not readily ascertained as outcomes such as overall mortality. However, this study has added to the growing evidence base that COVID-19 epicenters have had a decline in hospitalized STEMI cases, in conjunction with increases in time to reperfusion. Despite a protocol-based recommendation to change to a strategy of [thrombolysis] to attempt to reduce these delays in reperfusion, increases in mortality and heart failure were still observed. The old adage of ‘time is muscle’ therefore remains true, pandemic or not.”