Cardio Groups Offer AMI Guidance for COVID-19

By: EMSWORLD

Among other impacts, the COVID-19 pandemic has complicated the care of MI patients. Non-STEMI catheterizations have been delayed, and even STEMIs in some locations (e.g., China) have been increasingly treated with thrombolytics alone.

Now some guidance from top cardiology groups may make decisions easier for emergency care systems. They say STEMI patients should still go to cath labs, but not directly, and offers some other modifications.

The statement, from the American College of Cardiology (ACC), American College of Emergency Physicians (ACEP), and Society for Cardiovascular Angiography and Interventions (SCAI), appeared in the Journal of the American College of Cardiology.

For EMS, “direct transport of the patient to the CCL is not felt to be prudent at this time.” Instead, urge the authors—led by Ehtisham Mahmud, MD, chief of cardiovascular medicine at UC San Diego—have all STEMI patients initially assessed in any appropriate ED to ensure the right diagnosis and care plan. Notify the attending interventional cardiologist but do not activate the STEMI team until the plan is confirmed.

The cardiovascular manifestations of COVID-19 can be complex, the authors note. Patients may present with AMI, myocarditis mimicking a STEMI, stress cardiomyopathy, nonischemic cardiomyopathy, coronary spasm, or nonspecific myocardial injury. Timely PCI is still the standard of care for STEMI patients, with fibrinolysis acceptable where it’s not possible, but asymptomatic cases and testing delays have made it difficult to know which patients might be infected with SARS-CoV-2.

Under the new guidelines, PCI is still appropriate for STEMI patients who present to primary PCI centers, but with some caveats. First, there may be delays in cath lab transfers for COVID-19 status assessment and treatment such as respiratory support. Rapid testing should be routinely implemented for STEMI patients, they urge. Fibrinolysis is less effective and often requires rescue PCI anyway. Possible STEMI patients should receive a noninvasive ED evaluation to inform a decision by the ED physician and interventional cardiologist regarding CCL activation.

At referral hospitals STEMI patients should get initial fibrinolysis followed by consideration of transfer to a PCI center. Such transfers were routine before the pandemic, but COVID status now must be accounted for. Fibrinolysis within 30 minutes of STEMI diagnosis may be preferable, provided a true STEMI is likely and time to reperfusion will be lengthy.

Resuscitated out-of-hospital cardiac arrest patients are the highest-risk subgroup of AMI patients. They should be selectively considered for CCL activation in the presence of persistent ST-elevation and a concomitant wall motion abnormality. OHCA patients without ST-elevation generally should not receive a routine early invasive approach.

COVID-positive or -probable patients with NSTEMI presentations should be managed medically and only taken for urgent coronary angiography and possible PCI with high-risk clinical features or hemodynamic instability. And overall, any patient requiring emergent activation of the CCL should be treated as COVID-possible.

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