Patient and Provider Risk in Managing ST-Elevation Myocardial Infarction During the COVID-19 Pandemic: A Decision
Neel M Butala1,2, Nilay K Patel1,2, Jagpreet Chhatwal3,2
1Division of Cardiology (N.B., N.P., E.P., M.A., R.S., A.R., S.E.), Massachusetts General Hospital, Boston.
Insights
Primary percutaneous coronary intervention (PPCI) is generally optimal for ST-segment-elevation myocardial infarction (STEMI) during the COVID-19 pandemic. However, a pharmaco-invasive strategy may be considered for select COVID-19 patients to mitigate provider infection risk.
Area of Science:
- Cardiology
- Infectious Diseases
- Public Health
Background:
- The COVID-19 pandemic created uncertainty regarding optimal ST-segment-elevation myocardial infarction (STEMI) treatment due to occupational exposure risks during primary percutaneous coronary intervention (PPCI).
- Evaluating patient outcomes and provider infection risks associated with different STEMI management strategies during the pandemic was crucial.
Purpose of the Study:
- To quantify the impact of STEMI treatment strategies on patient mortality and healthcare provider infection risk during the COVID-19 pandemic.
- To compare primary percutaneous coronary intervention (PPCI) with the pharmaco-invasive strategy for STEMI management in various clinical scenarios.
Main Methods:
- A decision-analytic framework was employed to model STEMI treatment outcomes.
- Patient mortality and provider infection risks were assessed based on cardiogenic shock, STEMI territory, and COVID-19 status (suspected, presumptive, or known).
Main Results:
- PPCI demonstrated a mortality benefit over the pharmaco-invasive strategy for patients with low COVID-19 suspicion, with minimal provider infection risk (<0.25%).
- In presumptive COVID-19 patients with cardiogenic shock, PPCI significantly reduced 30-day mortality (7.9% absolute decrease) but increased provider infection risk (2.3% absolute increase).
- For non-shock presumptive COVID-19 STEMI cases, PPCI offered a small mortality benefit (0.4%) with a marginal increase in provider infection risk (0.2%), highlighting a trade-off amplified in more severe COVID-19 scenarios.
Conclusions:
- Primary percutaneous coronary intervention (PPCI) remains the standard treatment for most STEMI cases during the COVID-19 pandemic.
- A pharmaco-invasive strategy may be suitable for selected STEMI patients with presumptive COVID-19 and low mortality risk.
- Preventive measures, such as preprocedural intubation, should be considered for high-risk patients undergoing PPCI to minimize provider COVID-19 exposure.
Background:
The optimal treatment strategy for treating ST-segment-elevation myocardial infarction (STEMI) in context of the coronavirus disease 2019 (COVID-19) pandemic is unclear given the potential risk of occupational exposure during primary percutaneous coronary intervention (PPCI). We quantified the impact of different STEMI treatment strategies on patient outcomes and provider risk in context of the COVID-19 pandemic.
Methods:
Using a decision-analytic framework, we evaluated the effect of PPCI versus the pharmaco-invasive strategy for managing STEMI on 30-day patient mortality and individual provider infection risk based on presence of cardiogenic shock, suspected coronary territory, and presence of known or presumptive COVID-19 infection.
Results:
For patients with low suspicion for COVID-19, PPCI had mortality benefit over the pharmaco-invasive strategy, and the risk of cardiac catheterization laboratory provider infection remained very low (<0.25%) across all subgroups. For patients with presumptive COVID-19 with cardiogenic shock, PPCI offered substantial mortality benefit to patients relative to the pharmaco-invasive strategy (7.9% absolute decrease in 30-day mortality), but also greater risk of provider infection (2.3% absolute increase in risk of provider infection). For patients with presumptive COVID-19 with nonanterior STEMI without cardiogenic shock, PPCI offered a 0.4% absolute mortality benefit over the pharmaco-invasive strategy with a 0.2% greater absolute risk of provider infection, and the tradeoff between patient and provider risk with PPCI became more apparent in sensitivity analysis with more severe COVID-19 infections.
Conclusions:
Usual care with PPCI remains the appropriate treatment strategy in the majority of cases presenting with STEMI in the setting of the COVID-19 pandemic. However, utilization of a pharmaco-invasive strategy in selected patients with STEMI with presumptive COVID-19 and low likelihood of mortality from STEMI and use of preventive strategies such as preprocedural intubation in high risk patients when PPCI is the preferred strategy may be reasonable to reduce provider risk of COVID-19 infection.
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