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Why Fibrinolytic Therapy for ST-Segment–Elevation Myocardial Infarction in the COVID-19 Pandemic Is Not Your New Best Friend

2020; Lippincott Williams & Wilkins; Volume: 13; Issue: 6 Linguagem: Inglês

10.1161/circoutcomes.120.006885

1941-7705

Ajay J. Kirtane, Sripal Bangalore,

Cardiac Health and Mental Health

HomeCirculation: Cardiovascular Quality and OutcomesVol. 13, No. 6Why Fibrinolytic Therapy for ST-Segment–Elevation Myocardial Infarction in the COVID-19 Pandemic Is Not Your New Best Friend Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessArticle CommentaryPDF/EPUBWhy Fibrinolytic Therapy for ST-Segment–Elevation Myocardial Infarction in the COVID-19 Pandemic Is Not Your New Best Friend Ajay J. Kirtane and Sripal Bangalore Ajay J. KirtaneAjay J. Kirtane Ajay J. Kirtane, MD, SM, 161 Ft Washington Ave, 6th Floor, New York, NY 10032. Email E-mail Address: [email protected] Columbia University Medical Center, NewYork-Presbyterian Hospital, the Cardiovascular Research Foundation, NYU-Langone Medical Center, New York. and Sripal BangaloreSripal Bangalore Columbia University Medical Center, NewYork-Presbyterian Hospital, the Cardiovascular Research Foundation, NYU-Langone Medical Center, New York. Originally published27 Apr 2020https://doi.org/10.1161/CIRCOUTCOMES.120.006885Circulation: Cardiovascular Quality and Outcomes. 2020;13:e006885This article is commented on by the following:ST-Segment–Elevation Myocardial Infarction Care and COVID-19Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: June 2, 2020: Ahead of Print April 27, 2020: Ahead of Print See Article by Bainey et alEditor's Note: In this issue, we publish 2 differing cardiovascular perspectives on how to manage ST-segment–elevation myocardial infarction (STEMI) during the coronavirus disease 2019 (COVID-19) pandemic. COVID-19 has disrupted many processes of care related to emergency cardiac conditions. These perspectives offer 2 opinions understanding that capacity of treating hospitals will continue to evolve and management should change based on it. Placing these side-by-side will allow readers to understand the tradeoffs inherent in such decisions.The coronavirus disease 2019 (COVID-19) pandemic has strained global healthcare systems in ways that simply could not have been imagined just several months ago. Writing from the heart of New York City—the unfortunate new epicenter of this pandemic—we have been confronted with this new reality head-on. As directors of 2 major academic cardiac catheterization laboratories in the city, we both have had to operationalize logistical planning of physician and staff redeployments as well as modification of our respective hospital units including conversion of large portions of the catheterization laboratory into COVID-19 intensive care units to deal with the surge of patients with COVID-19 within the hospital.In the midst of all of these changes has always been the concern of how we could best deal with genuine cardiac emergencies such as acute ST-segment–elevation myocardial infarction (STEMI). Decades of trials have established primary percutaneous coronary intervention (PPCI) as the preferred approach to STEMI.1 Compared with the alternative of fibrinolytic therapy (FT), reperfusion with PPCI is more reliable and durable, and incurs a lower rate of adverse outcomes, resulting in a net clinical benefit to patients as proven through clinical trials demonstrating lower mortality, reinfarction, and bleeding.2 Yet, in the midst of the unique operational challenges posed by the COVID-19 pandemic, there has been a resurgent discussion of FT, with some algorithms even proposing it as a preferred approach.We feel that this approach is misguided for several reasons (Figure). First, FT is an inferior reperfusion alternative to PPCI in patients with STEMI, achieving lower rates of TIMI-3 flow compared with PPCI.3 Moreover, FT is even less likely to be effective in the COVID-19 era because of systemic delays in time to presentation which can lead to older (and more organized) clot.4 Second, because of the high rate of reinfarction, modern implementations of a FT-based approach involve secondary cardiac catheterization, either rescue (in the case of failed reperfusion) or routine (to definitively treat the underlying lesion after successful fibrinolysis).5 Thus, in this construct, the theoretical advantage of FT in reducing staff exposure and/or consumption of personal protective equipment is largely negated when the patient undergoes eventual catheterization following FT. Third, the syndrome of COVID-19 myopericarditis is not an uncommon cause of ST-elevation on the ECG.6 Administration of potent FT to a patient with myopericarditis (as opposed to for a thrombotic coronary occlusion) is not only likely to be ineffective but incurs substantial bleeding risk while treating the incorrect pathophysiology. This potential clinical mistreatment is further exacerbated by the fact that ST-segment elevation will typically persist in this setting, necessitating emergent (rescue) cardiac catheterization, unless the operator decides to then medically manage what was initially considered to be a STEMI. Finally, the role of the cardiac catheterization laboratory in STEMI is not solely limited to PPCI. Diagnostic catheterization with coronary angiography accompanied by the judicious use of hemodynamic assessments can be instrumental in not only establishing diagnoses but in prognostication and further stabilization of patients through appropriate titration of medications and/or appropriate hemodynamic support.Download figureDownload PowerPointFigure. Considerations for how limitations of fibrinolytic therapy use in patients with ST-segment–elevation myocardial infarction (STEMI) may apply in patients with coronavirus disease 2019 (COVID-19) with ST-elevation on their ECG. CAD indicates coronary artery disease; PPCI, primary percutaneous coronary intervention; and TIMI, thrombolysis in myocardial infarction.The 2 most compelling reasons to advocate for a strategy of FT for STEMI in the COVID-19 era relate to reducing staff exposure/resources as well as in overcoming delays to reperfusion. It is our opinion that the solution to the former problem is easily overcome by appropriate procurement and use of full personal protective equipment for all STEMI cases. Further, delays to reperfusion even in the COVID-19 era are more pronounced between symptom onset to diagnosis (which already disfavors FT) than from diagnosis to reperfusion through PPCI. Decades of clinical trials have clearly shown inferiority of FT over PPCI especially when treatment delays are greater. Excepting scenarios of impeded or delayed transfer from hospitals without on-site catheterization facilities, it is unlikely that this relationship would change in an infectious disease pandemic. Whether FT is useful to target systemic micro-thrombi associated with COVID-19 remains to be proven. Until that time, PPCI remains the best treatment option for suspected STEMI, taking full precautions to minimize risks of exposure for the cardiac catheterization staff.DisclosuresDr Kirtane reports institutional funding to Columbia University and/or Cardiovascular Research Foundation from Medtronic, Boston Scientific, Abbott Vascular, Abiomed, CSI, CathWorks, Siemens, Philips, ReCor Medical. In addition to research grants, institutional funding includes fees paid to Columbia University and/or Cardiovascular Research Foundation for speaking engagements and/or consulting; no speaking/consulting fees were personally received. Personal: Travel Expenses/Meals from Medtronic, Boston Scientific, Abbott Vascular, Abiomed, CSI, CathWorks, Siemens, Philips, ReCor Medical, Chiesi, OpSens, Zoll, and Regeneron. Dr Bangalore reports research grants from Abbott Vascular, NHLBI and being on the advisory board for Abbott Vascular, Pfizer, Amgen, and Biotronik.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Ajay J. Kirtane, MD, SM, 161 Ft Washington Ave, 6th Floor, New York, NY 10032. Email akirtane@columbia.eduReferences1. 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Comparison of primary percutaneous coronary intervention and fibrinolytic therapy in ST-segment-elevation myocardial infarction: bayesian hierarchical meta-analyses of randomized controlled trials and observational studies.Circulation. 2009; 119:3101–3109. doi: 10.1161/CIRCULATIONAHA.108.793745LinkGoogle Scholar3. GUSTO Investigators. An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction.New Eng J Med. 1993; 329:673–682. doi: 10.1056/NEJM199309023291001CrossrefMedlineGoogle Scholar4. Boersma E, Maas AC, Deckers JW, Simoons ML. Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour.Lancet. 1996; 348:771–775. doi: 10.1016/S0140-6736(96)02514-7CrossrefMedlineGoogle Scholar5. Armstrong PW, Fu Y, Chang WC, Topol EJ, Granger CB, Betriu A, Van de Werf F, Lee KL, Califf RM. Acute coronary syndromes in the GUSTO-IIb trial: prognostic insights and impact of recurrent ischemia. The GUSTO-IIb Investigators.Circulation. 1998; 98:1860–1868. doi: 10.1161/01.cir.98.18.1860LinkGoogle Scholar6. Bangalore S, Sharma A, Slotwiner A, Yatskar L, Harari R, Shah B, Ibrahim H, Friedman GH, Thompson CR, Alviar C, Chadow H, Fishman G, Reynolds HR, Keller N, Hochman JS. St-segment elevation in patients with covid-19 — a case series [published online ahead of print April 17, 2020].New Eng J Med. 2020;NEJMc2009020. doi:10.1056/NEJMc2009020CrossrefGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Li K, Zhang B, Zheng B, Zhang Y and Huo Y (2022) Reperfusion Strategy of ST-Elevation Myocardial Infarction: A Meta-Analysis of Primary Percutaneous Coronary Intervention and Pharmaco-Invasive Therapy, Frontiers in Cardiovascular Medicine, 10.3389/fcvm.2022.813325, 9 Maleki M, Norouzi Z and Maleki A (2022) COVID-19 Infection: A Novel Fatal Pandemic of the World in 2020 Practical Cardiology, 10.1016/B978-0-323-80915-3.00003-X, (731-735), . Vemmou E, Nikolakopoulos I, Brilakis E, Dehghani P and Garcia S (2021) Case Selection During the COVID-19 Pandemic: Who Should Go to the Cardiac Catheterization Laboratory?, Current Treatment Options in Cardiovascular Medicine, 10.1007/s11936-020-00892-0, 23:4, Online publication date: 1-Apr-2021. Firouzi A, Baay M, Mazayanimonfared A, Pouraliakbar H, Sadeghipour P, Noohi F, Maleki M, Peighambari M, Kiavar M, Abdi S, Maadani M, Shakerian F, Zahedmehr A, Kiani R, Alemzadeh-Ansari M, Rashidinejad A and Hosseini Z (2020) Effects of the COVID-19 Pandemic on the Management of Patients With ST-elevation Myocardial Infarction in a Tertiary Cardiovascular Center, Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine, 10.1097/HPC.0000000000000228, 20:1, (53-55), Online publication date: 1-Mar-2021. Nan J, Meng S, Hu H, Jia R and Jin Z (2021) Fibrinolysis Therapy Combined with Deferred PCI versus Primary Angioplasty for STEMI Patients During the COVID-19 Pandemic: Preliminary Results from a Single Center, International Journal of General Medicine, 10.2147/IJGM.S292901, Volume 14, (201-209) Citro R, Pontone G, Bellino M, Silverio A, Iuliano G, Baggiano A, Manka R, Iesu S, Vecchione C, Asch F, Ghadri J and Templin C (2021) Role of multimodality imaging in evaluation of cardiovascular involvement in COVID-19, Trends in Cardiovascular Medicine, 10.1016/j.tcm.2020.10.001, 31:1, (8-16), Online publication date: 1-Jan-2021. Butala N, Patel N, Chhatwal J, Vahdat V, Pomerantsev E, Albaghdadi M, Sakhuja R, Rosenzweig A and Elmariah S (2020) Patient and Provider Risk in Managing ST-Elevation Myocardial Infarction During the COVID-19 Pandemic, Circulation: Cardiovascular Interventions, 13:11, Online publication date: 1-Nov-2020.Engel Gonzalez P, Omar W, Patel K, de Lemos J, Bavry A, Koshy T, Mullasari A, Alexander T, Banerjee S and Kumbhani D (2020) Fibrinolytic Strategy for ST-Segment–Elevation Myocardial Infarction, Circulation: Cardiovascular Interventions, 13:9, Online publication date: 1-Sep-2020. Ranard L, Parikh S and Kirtane A (2020) COVID-19–Specific Strategies for the Treatment of ST-Segment Elevation Myocardial Infarction in China, Journal of the American College of Cardiology, 10.1016/j.jacc.2020.07.054, 76:11, (1325-1327), Online publication date: 1-Sep-2020. Related articlesST-Segment–Elevation Myocardial Infarction Care and COVID-19Kevin R. Bainey, et al. Circulation: Cardiovascular Quality and Outcomes. 2020;13 June 2020Vol 13, Issue 6 Advertisement Article InformationMetrics © 2020 American Heart Association, Inc.https://doi.org/10.1161/CIRCOUTCOMES.120.006885PMID: 32339025 Originally publishedApril 27, 2020 KeywordsCOVID-19emergenciespandemicpercutaneous coronary interventionPDF download Advertisement SubjectsEthics and PolicyQuality and Outcomes