The Novel Coronavirus 2019 (SARS-CoV-2), was first discovered in Wuhan, China at the end of 2019. A public health emergency of international concern was declared in January 2020 and on March 11th, 2020, the outbreak was declared a global pandemic. Better known as COVID19, it has affected each and every one of us as we care for our patients during this difficult time.
There has been much confusion about how to best treat patients with acute myocardial infarctions. Practicing emergency medicine in the COVID19 era is complex due to the necessity of of airborne and droplet precautions. To help guide us, the American College of Cardiology (ACC), American College of Emergency Physicians (ACEP), and the Society for Cardiovascular Angiography and Interventions (SCAI) produced a joint position statement on the treatment of acute myocardial infarctions during the COVID19 pandemic. Here is our summary:
Mahmud E, Dauerman HL, Welt FGP, Messenger JC, Rao SV, Grines C, Mattu A, Kirtane AJ, Jauhar R, Meraj P, Rokos IC, Rumsfeld JS, Henry TD. Management of Acute Myocardial Infarction During the COVID-19 Pandemic. Journal of the American College of Cardiology. 2020 Apr. DOI: 10.1016/j.jacc.2020.04.039.
Joint position statement endorsed by the American College of Cardiology (ACC), American College of Emergency Physicians (ACEP), and the Society for Cardiovascular Angiography and Interventions (SCAI).
COVID is here, the USA has the most number of cases
COVID poses a higher risk of mortality for patients with cardiovascular disease
Not all STEMIs have COVID, so we should continue to treat STEMIs by meeting appropriate standards of care
There is a paucity of data; much of the guidelines are from observational studies from China and Europe.
Patients presenting with STEMI to primary PCI center (THAT'S US AT ST. VINCENT) > FOR DEFINITE STEMI - ED evaluation should be focused and patients should be transferred to cath lab ASAP to perform PCI. - Until we can establish prevalence of the disease in the general population, all patients with suspected STEMI should be considered COVID possible. - Additional time may be taken to identify STEMI (bedside echo, etc), assess for COVID status, or stabilize critically ill. - Routinely use COVID testing to better characterize diagnosis and risk, and optimize treatment and placement in hospital. - If patient is in cath lab, any high grade disease in a non-infarct related artery should be treated to minimize chance of needing repeat cath lab visit. - Some patients may have STEMI-mimickers; PCI centers should monitor the ability to provide timely PCI based on availability of staff/PPE, additional testing, and management of cleaning of the cath lab. > Possible STEMI - Additional noninvasive evaluation in the ED is recommended, focusing on: * further risk stratification of COVID status * further evaluation of the diagnosis specifically assessing the potential for coronary thrombotic occlusion vs other pathologies (POCUS, serial ECGs, troponins, CT coronary angiography, etc.) - Patients with hemodynamic instability might still require an invasive evaluation in the cath lab to make a definitive diagnosis and provide necessary hemodynamic assessment and support (eg. impella) > Futile Prognosis - Patients in COVID19 confirmed patients with severe pulmonary decompensation or pneumonia who are intubated in the ICU have excessively high mortality; consider compassionate medical care.
Patients presenting with STEMI to referral hospitals (non-PCI capable) - Primary PCI is standard of care for patients transferred rapidly from non-PCI centers (within 120 minutes of first medical contact at referral hospital). - If rapid PCI is not possible (within 120 minutes), then give initial fibrinolysis (within 30 minutes of diagnosis) followed by consideration of transfer to PCI center - Patients with STEMI and established COVID should be transferred for rescue PCI when necessary, provided the diagnosis of true STEMI is highly likely (discuss with cardiology)
Out of hospital cardiac arrest (OHCA) and/or cardiogenic shock - OHCA and cardiogenic shock patients should be resuscitated and selectively considered for cath lab based on persistent STEMI and concomitant wall motion abnormality on echo. - OHCA without STEMI should not receive routine early invasive approach, unless hemodynamic instability ensues, coronary occlusion is high on ddx, and multidisciplinary team concurs. - Appropriate PPE is required regardless of COVID status during resuscitation. - For known COVID positive or probable patients, consider bedside application of mechanical circulatory support devices or VV-ECMO for severe pulmonary decompensation and failure to oxygenate.
Patients with NSTEMI - Elevated troponin test is a poor prognostic marker in the COVID positive patient group. - COVID positive and probable patients with NSTEMI should be medically managed and taken for urgent coronary angiography and PCI in the presence of high-risk clinical features (GRACE score>140) or hemodynamic instability.
PPE - PPE FOR EVERYONE! - PAPR for endotracheal intubation/extubation - Minimum number of people in the room during intubation/extubation and invasive cardiovascular procedures
ED and EMS Collaboration - Low threshold for EMS personnel to wear PPE - Liberal use of ECGs in ED and prehospital - "Direct transport of the patient to the cath lab is not felt to be prudent at this time" - Initial assessment of all STEMI patients in the ED to ensure correct diagnosis and care plan, EVEN TRANSFERS TO CATH LAB SHOULD STOP IN THE ED OR ICU FOR RE-SCREENING OPPORTUNITY
Regional STEMI Systems of Care - Consider immediate adjustments/updates to protocols that maximize treatment while protecting the safety of patients and providers
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