Management of acute MI during COVID-19 outbreak: New recommendations
The outbreak of coronavirus disease 2019 (COVID-19) has become a global challenge and a public health emergency of international concern. Meanwhile, it is a herculean task to balance cardiovascular emergency patients and COVID-19 control. For acute myocardial infarction (AMI) patients with COVID-19, a safe and efficient medical environment should be ensured in parallel with effective reperfusion therapy.
Unfortunately, most medical centers do not have professionally protected cardiac catheterization rooms and cardiac care units (CCUs) for respiratory infectious diseases. Under these circumstances, the prevention of COVID-19 needs the coordination of all departments to ensure a smooth workflow. The hospital administrators and the collaboration of multidisciplinary teams including the cardiology department, emergency department, infections department, pneumology department, radiology department, and the medical laboratory department are required for proper management of such cases.
Peking Union Medical College Hospital first proposed the following medical recommendations in China based on real-world experiences in AMI management during the COVID-19 outbreak. All the recommendations are in strict accordance with the COVID-19 prevention principles of the World Health Organization and the regulations from each national health authorities. The guideline has been published in the European Heart Journal.
Management of suspected STEMI patients with the potential risk of COVID-19 infection
Main recommendations are-
For STEMI patients with confirmed COVID-19, strict isolation should start immediately, and thrombolytic contraindications should be evaluated. Patients with thrombolytic contraindications should be transferred to the local designated infectious medical institution immediately for further treatment through the first-aid transport mode designated by the government. Patients without thrombolytic contraindications should first start intravenous thrombolysis and then transfer to the local designated medical institution of infectious disease for further treatment.
For STEMI patients with suspected COVID-19 (defined as fever, respiratory symptoms, and/or epidemiological linkage to other COVID-19 cases or areas with cluster transmission), the emergency should be protected strictly according to the standard of the fever clinic. Routine blood examination, C-reactive protein, pharyngeal swab/sputum specimen/blood sample for detection of novel coronavirus nucleic acid, and chest computed tomography (CT) examination should be performed for COVID-19 confirmation. Considering the fact that most medical centers do not have professional protected interventional catheterization rooms, and the conflict between the time required for novel coronavirus nucleic acid detection and early reperfusion for AMI, it is recommended to start emergency intravenous thrombolysis for STEMI patients if COVID-19 cannot be excluded in a short time. Cardiologists should be contacted for the indications and contraindications, and myocardial reperfusion therapy should be initiated within 30 min. If COVID-19 was diagnosed after intravenous thrombolysis, patients should be transferred to the designated infectious medical institution for further treatment. If COVID-19 and other infectious diseases were excluded after intravenous thrombolysis, patients could be transferred to the CCU. Remedial coronary interventional therapy or intensive medical treatment could be considered depending on the status of the patient's coronary artery. Special circumstances: if COVID-19 could be excluded by the expert group within ≤1 h, and the possibility of having COVID-19 was clinically small, cardiologists should evaluate the following two schemes:
Monitor closely, conduct emergency coronary intervention immediately after the elimination of COVID-19.
Proceed with onsite thrombolysis, make the treatment decision after comprehensive consideration of the benefit to risk ratio. During thrombolysis, review electrocardiogram, bedside echocardiography, and chest radiography. After thrombolysis, check the recanalization status of myocardial perfusion and perform chest CT immediately.
For STEMI patients with low risk of COVID-19 (defined as no fever, respiratory symptoms, and epidemiological exposure to other COVID-19 cases or areas with cluster transmission), routine blood examination, electrocardiogram, chest CT, myocardial injury biomarkers, and/or bedside echocardiography should be done immediately. Bedside chest radiography can be considered an alternative to chest CT for patients with movement disorders or uncontrollable factors. Specialists in infectious diseases should be consulted urgently for the necessity of sending pharyngeal swab/sputum specimens/blood samples for the further exclusion of novel coronavirus nucleic acid.
If the infectious disease specialists consider it unnecessary to send biological samples, patients should be transferred immediately to the cardiac catheterization room for emergency coronary interventional therapy or transferred to the CCU after intravenous thrombolysis.
If the infectious disease specialists consider it indispensable to send biological samples for nucleic acid detection and patients have no contraindications for thrombolysis, thrombolysis should be conducted immediately in the emergency room. Pharyngeal swab/sputum specimen/blood sample for the novel coronavirus nucleic acid detection should be sent after the start of thrombolysis. After thrombolysis, patients should be considered for transfer to the designated infectious medical institution or CCU. If the patient had thrombolytic contraindications, the result of nucleic acid detection of COVID-19 should be waited for. Patients excluded from COVID-19 should be transferred immediately to the cardiac catheterization room for emergency coronary interventional therapy, and patients diagnosed with COVID-19 should be transferred to the local designated medical institution for infectious diseases.
Management of suspected unstable angina (UA)/NSTEMI patients with the potential risk of COVID-19 infection.
Thrombolytic therapy in NSTEMI patients has no clinical benefit. Treatment strategies should be determined based on the risk stratification of coronary artery diseases. Therefore, it is necessary to evaluate the existence of COVID-19 as soon as possible.
Main recommendations are-
Confirmed patients with COVID-19 should be transferred to the designated medical institution immediately for further treatment.
For NSTEMI patients who are suspected to have or are unable to be excluded from COVID-19, the following principles should be followed.
Consult specialists on infectious diseases or respiratory physicians from designated medical institutions to confirm COVID-19 as soon as possible. Chest CT and novel coronavirus nucleic acid detection should be performed immediately for suspected cases.
If COVID-19 can be excluded by the infectious disease specialist according to chest CT, it is recommended to choose a treatment strategy according to the risk stratification of NSTE-ACS: intervention or medication.
If COVID-19 cannot be excluded by chest CT, routine medical treatment of NSTEMI should be given and risk stratification should be conducted while waiting for the results of nucleic acid detection. For patients with low or middle risk, routine medical therapy including oxygen inhalation, coronary artery dilatation, and antithrombotic treatment should be given in the emergency room. Blood oxygen saturation and other clinical data should be monitored closely for the prevention of malignant arrhythmia. For patients with high or extremely high risk, especially those with hemodynamic instability and strong indications for immediate interventional treatment, the high-level infection control panel should be started, and two or more specialists should co-determine the risk of COVID-19. If the risk of COVID-19 is considered high, patients should be transferred to the local designated medical institution for interventional treatment and enhanced supportive treatment.
While waiting for the confirmation of COVID-19, efforts should be made to identify the patient's etiology. If a viral infection was a contributing factor or cause of myocardial injury, type 2 myocardial infarction should be diagnosed. The treatment strategy of type 2 myocardial infarction should be mainly based on primary diseases. Therefore, CT coronary artery scan should be completed at the same time as a chest CT examination for better determination of treatment strategy. In addition, risk factors of acute pulmonary embolism, such as orthopedic surgery, tumor, and deep vein thrombosis, should be investigated. Blood oxygen saturation, D-dimer, and ultrasound for thrombosis in lower limb deep veins should be performed to exclude acute pulmonary embolism. When necessary, CT pulmonary angiography could be completed at the same time as a chest CT. Clinicians need to be on high alert for misdiagnosis between pulmonary infarction induced by acute pulmonary embolism and COVID-19. Clinicians should also strengthen their vigilance of chest pains caused by aortic dissection or acute myocarditis.
For NSTEMI patients excluded from COVID-19, early or time-limited intervention strategies should be selected immediately according to the risk stratification of NSTE-ACS. Patients should be enrolled in the CCU for further intensive medical therapy including oxygen inhalation, coronary artery dilatation, and antithrombotic treatment.
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