CME INDIA Presentation by Admin.

It is well known that the COVID-19 outbreak led to a substantial drop in the number of admitted STEMI cases as well as delays in patients’ access to care. The proportion of patients undergoing primary PCI decreased. It was expected that number of thrombolysis would increase, but the proportion of patients receiving effective reperfusion therapy remained stable. The outbreak led to be associated with moderately increased in-hospital mortality and in-hospital heart failure.

At this time, when we are in community transmission phase, lots of issues are related to Acute Myocardial Infarction.

CME INDIA presents two scenarios and discusses the ways ahead.

Inputs from, Dr Deepak Gupta, DM, Card., Ranchi; Dr Varun Kumar, DM, Card., Ranchi and Dr Satish Kumar, CSI-President, Jharkhand.

Scenario 1:

Acute Myocardial Infarction ECG

Dr Varun Kumar, DM, Card., Ranchi: 50 yr old male with evolving ALMI. Chest pain of 2 hrs duration. In Echo LAD territory akinetic with LVEF of 25-30%. Thrombolysed with Tenecteplase considering COVID constraints…

Acute Myocardial Infarction ECG

Dr Varun, DM Card, Orchid, Ranchi: Failed thrombolysis with persistence of chest pain & pt went into shock BP 60/40… started on Norad… What to do?

I decided to go for rescue angioplasty without COVID test…

Acute Myocardial Infarction Angioplasty

CAG showed mid LAD total occlusion…

Acute Myocardial Infarction Angioplasty

Did rescue angioplasty by radial approach, though I remained very much apprehensive due to the risk of bleeding as it is done just 3 hrs after thrombolysis, but everything went well & patient doing well now.

Acute Myocardial Infarction ECG

Post PTCA ECG. Just felt good that I saved a heart on World Heart Day. 🤗

Scenario 2:

Acute Myocardial Infarction ECG

Dr Deepak Gupta, DM, Card., Pulse Hospital, Ranchi: This patient came just now in my PCI center. Unbearable pain for 2 hrs. COVID status not known. What should be done?  Systolic BP 90 mmHg. Clearly Acute MI. No doubt. Question is, If COVID status is not known should go for primary PCI  or Thrombolysis?

Dr N K Singh: Is RAT test available to you?

Dr Deepak Gupta, DM, Card Pulse Hosp., Ranchi: We don’t believe in RAT.

Dr Binay Kr Misra, Ranchi: RAT positive is true positive. If yes, go ahead with PPE.

Dr N K Singh: If positive…Then clear, but if negative… Case still could be COVID. Indicating – RAT negative results are unreliable; the Health Ministry has directed all states and UTs to re-test such patients.

Dr D P Khaitan, Gaya: Age of the patient? Any CAD risk factor?

Dr Deepak Gupta: 80 yr.

Dr D P Khaitan, Gaya: Findings suggestive of Acute LAD involvement proximal to diagonal branch (Leads I, aVL, V2 -6 involvement with ST elevation) with high anterior hemiblock block (axix -75)/ possibly? RBBB with Sinus Bradycardia(54/mt). I do agree with Dr Deepak Gupta – clearly acute MI. Very remote possibility of MI mimic due to COVID. But COVID status should be known. I would prefer PCI.

Dr Ranjeet Kumar, Ramgarh: Thrombolysis with TNK. Ideally PCI.

Dr Satish Kumar, CSI-President, Jharkhand, Bokaro: Consider all the patients positive unless proved otherwise and take all possible precautions and PPEs for all staffs is mandatory.

See, this viral disease is going to stay for some time to come. We are getting news of a wave of re-infections with mutated strains. In such a scenario, we have to deal with various emergencies and one cannot deny the appropriate therapy.

Nevertheless, the safety of the saviour is also of utmost importance.

In a nutshell, we have to consider the gravity of the situation, the probability of the patient having been infected and infectious among many things.

Finally, the decision of the clinician should have precedence over everything.

Acute Myocardial Infarction ECG

Dr Deepak Gupta: ECG After 15 mins of Thrombolysis with 40 mg tenecteplase in ER. No pain now. Sytolic BP 130. Many patients turned COVID positive after intervention. So be careful. Will do angio after RTPCR test.

Dr D P Khaitan, Gaya: Under circumstances rightly done.

Acute Myocardial Infarction ECG

ECG almost 1 hr post thrombolysis.

Acute Myocardial Infarction Angioplasty

Acute Myocardial Infarction Angioplasty
Post Plasty (Done after rtPCR came negative). Significant residual lesion in LAD after septal branch. LCX and RCA was normal.

CSI Recommendations (Edited)

  • Current non-availability of a rapid nucleic acid test for SARS-CoV-2 infection does not permit rapid discrimination of patients COVID-19 status (COVID-19 positive or negative). Even when available this testing will also cause some delay in providing reperfusion. Presently there are limited number of centres for testing for SARS-CoV-2 and test results are available only after 24–72 h. Available RAT kits are not reliable to a large extent.
  • At the present stage in COVID-19 epidemic, it is imperative to screen every patient. The respiratory status of the patient should be assessed and classified. For instance, the risk-benefit ratio of primary PCI may be limited in patients with severe pneumonia.
  • Patients presenting with Acute MI could be classified into 3 groups:
    • Confirmed COVID-19 patient (Group A): This would include patients with a positive COVID 19 test result. Currently, such patients are rare in the community in India, but their numbers may grow with increased testing and community spread.
    • Suspected COVID-19 patient (Group B): When the epidemic is in the community stage, many patients will belong to this group even if they have no respiratory symptoms. Rapid testing will permit quick classification of these patients.
    • Patient with Low clinical probability of being a COVID-19 patient/Confirmed non-COVID-19 patient (Group C): This would include a patient with no symptoms suggestive of influenza and no history of travel/contact with a COVID-19 patient or a patient whose COVID 19 test is negative.
  • For the confirmed or suspected COVID-19 patient with ST elevation myocardial infarction (STEMI) presenting within 12 h, primary PCI should be preferred if performed with the necessary precautions and preparedness
  • Thrombolysis is the prudent option as PCI may not be feasible due to the prevailing logistic problems in performing timely PCI, especially if the patient is hemodynamically stable.
  • Clinical judgement is important in diagnosing myocardial infarction as myocarditis may masquerade as myocardial infarction. If the patient is hemodynamically unstable, primary PCI would be an ideal option, especially if the COVID-19 pneumonia (respiratory status) is assessed as mild to moderate.
  • However, if primary PCI may not be feasible due to the prevailing logistic problems, thrombolysis should still be tried even if patient is unstable with a plan for rescue PCI.
  • PCI would also be a desirable option for failed thrombolysis (Rescue PCI) or for a delayed presentation beyond 12 h, especially if pneumonia is mild to moderate and appropriate PPE is available.
  • Primary PCI should be preferably performed in an isolated catheterization laboratory with minimum trained personnel to reduce nosocomial spread. It should not be performed if adequate PPE are not available.
  • For the stable NSTEMI patient, coronary angiography and or PCI should be preferably deferred until a COVID-19 negative test has been obtained.
  • For the confirmed or suspected COVID-19 patient, thrombolysis should be given in an isolation room/area within the designated ICCU as per institutional protocol.
  • In small towns and villages and at the spokes in a hub and spoke model of STEMI care, thrombolysis should be the preferred reperfusion strategy
  • Indian Heart J. 2020 Mar-Apr; 72(2): 70–74.
  • Published online 2020 May 6. doi: 10.1016/j.ihj.2020.04.009

CME INDIA Learning Points:

  • There is no single solution for all invasive services and networks in the COVID-19 pandemic, and there will be a variation of the restrictions according to the stage of the crisis.
  • Whenever there is a high suspicion of asymptomatic COVID-19 positive patients in the community, the risk to benefit ratio of primary PCI vs lytic therapy to both the patient as well as hospital personnel will have to be assessed. If hospitals are overwhelmed with COVID-19 patients, the feasibility of timely primary PCI will be a challenge and situation should be dealt in accordance with available resources. Protection of health care workers is paramount so that workforce is not depleted and is available as the pandemic evolves.
  • Even during the COVID-19 pandemic, primary percutaneous intervention (PCI) remains the standard of care for ST-elevation myocardial infarction (STEMI) patients at PCI capable hospitals with an expert team equipped with Personal protection equipment (PPE) in a dedicated COVID Cath lab providing timely care.
  • A fibrinolysis-based strategy is suitable at non-PCI capable referral hospitals or in specific situations where primary PCI cannot be executed or is not deemed the best option.
  • Poor candidates for FT include delayed presentations, large infarcts, hemodynamic or electrical instability, patients with cardiogenic shock or FT contraindications should be considered for PPCI where feasible.
  • A dedicated COVID-19 Cath laboratory is ideal. “Negatively pressured” Cath laboratory is desirable else understanding of the air conditioning system is important as this may expose other parts of the hospital with a single procedure.
  • PPE kits including gown, gloves, goggles (or shields), and an N95 mask is must. The use of powered air purifying respirator systems may also be reasonable. Minimum number of personnel should be in the room at the time of intubation/extubation.
  • The COVID-19 pandemic should not compromise timely reperfusion of STEMI patients. In line with current guidelines, reperfusion therapy remains indicated in patients with symptoms of ischaemia of <12 h duration and persistent ST-segment elevation in at least two contiguous ECG leads.

CME INDIA Tail Piece:

  • All STEMI patients should be managed as COVID-19 positive.
  • Primary PCI is first-line therapy if it can be performed in a timely fashion – 120 min from symptom onset.
  • Fibrinolysis if not contraindicated can be considered when the delay is longer.
  • Complete revascularization to be considered if indicated and appropriate.
  • Left ventricular angiogram instead of echo to evaluate left ventricular function.
  • Very high risk NSTE-ACS should be managed similarly to STEMI.
  • High risk NSTE-ACS should be tested before coronary angiography.
  • Intermediate risk NSTE-ACS could be evaluated non-invasively, if feasible with CCTA.
  • Consider adding CCTA protocol to thorax CT scan performed in COVID 19 patients.
  • Myocardial injury, as quantified by cardiac troponin T/I concentrations, may occur in COVID-19 infections as in other pneumonias. The level of cardiac troponins correlates with disease severity and also seems to have a prognostic value.
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