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Clinical Pathway for Management of Suspected or Positive Novel Coronavirus-19 Patients With ST-Segment Elevation Myocardial Infarction
Abstract
Novel coronavirus-19 disease (COVID-19) is an escalating, highly infectious global pandemic that is quickly overwhelming healthcare systems. This has implications on standard cardiac care for ST-elevation myocardial infarctions (STEMIs). In the setting of anticipated resource scarcity in the future, we are forced to reconsider fibrinolytic therapy in our management algorithms. We encourage clinicians to maintain a high level of suspicion for STEMI mimics, such as myopericarditis which is a known, not infrequent, complication of COVID-19 disease. Herein, we present a pathway developed by a multidisciplinary panel of stakeholders at NewYork-Presbyterian/Columbia University Irving Medical Center for the management of STEMI in suspected or confirmed COVID-19 patients.
... The same guidelines apply with consideration of the safety of healthcare professionals (HCP) [87,88]. Primary percutaneous coronary intervention is the ideal decision for STEMI [64,89], and in case of absence of personal protective equipment (PPE), fibrinolytic therapy may be an appropriate option [89,90]. COVID-19 patients with non-ST-segment elevation myocardial infarction (NSTEMI) and who are hemodynamically unstable are managed as STEMI patients. ...
... The same guidelines apply with consideration of the safety of healthcare professionals (HCP) [87,88]. Primary percutaneous coronary intervention is the ideal decision for STEMI [64,89], and in case of absence of personal protective equipment (PPE), fibrinolytic therapy may be an appropriate option [89,90]. COVID-19 patients with non-ST-segment elevation myocardial infarction (NSTEMI) and who are hemodynamically unstable are managed as STEMI patients. ...
Background: Cardiovascular system involvement in coronavirus disease-2019 (COVID-19) has gained great interest in the scientific community. Main body: Several studies reported increased morbidity and mortality among COVID-19 patients who had comor-bidities, especially cardiovascular diseases like hypertension and acute coronary syndrome (ACS). COVID-19 may be associated with cardiovascular complications as arrhythmia, myocarditis, and thromboembolic events. We aimed to illustrate the interactions of COVID-19 disease and the cardiovascular system and the consequences on clinical decision as well as public health. Conclusions: COVID-19 has negative consequences on the cardiovascular system. A high index of suspicion should be present to avoid poor prognosis of those presenting with unusual presentation.
... The same guidelines apply with consideration of the safety of healthcare professionals (HCP) [87,88]. Primary percutaneous coronary intervention is the ideal decision for STEMI [64,89], and in case of absence of personal protective equipment (PPE), fibrinolytic therapy may be an appropriate option [89,90]. COVID-19 patients with non-ST-segment elevation myocardial infarction (NSTEMI) and who are hemodynamically unstable are managed as STEMI patients. ...
... The same guidelines apply with consideration of the safety of healthcare professionals (HCP) [87,88]. Primary percutaneous coronary intervention is the ideal decision for STEMI [64,89], and in case of absence of personal protective equipment (PPE), fibrinolytic therapy may be an appropriate option [89,90]. COVID-19 patients with non-ST-segment elevation myocardial infarction (NSTEMI) and who are hemodynamically unstable are managed as STEMI patients. ...
Background
Cardiovascular system involvement in coronavirus disease-2019 (COVID-19) has gained great interest in the scientific community.
Main body
Several studies reported increased morbidity and mortality among COVID-19 patients who had comorbidities, especially cardiovascular diseases like hypertension and acute coronary syndrome (ACS). COVID-19 may be associated with cardiovascular complications as arrhythmia, myocarditis, and thromboembolic events. We aimed to illustrate the interactions of COVID-19 disease and the cardiovascular system and the consequences on clinical decision as well as public health.
Conclusions
COVID-19 has negative consequences on the cardiovascular system. A high index of suspicion should be present to avoid poor prognosis of those presenting with unusual presentation.
... As for the management of ACS, there is guidance available from multiple specialty societies 134,135 . Although primary percutaneous coronary intervention remains the preferred approach for most patients with ST-segment-elevation MI, fibrinolytic therapy may be appropriate in select patients, especially if personal protective equipment is not available 136 . Additionally, point-of-care echocardiography may be used to assess regional wall-motion abnormalities to guide decisions about cardiac catheterization. ...
... A substantial proportion of patients with severe COVID-19 may show signs of kidney damage. Clinical manifestations and management considerations pertaining to the renal system are presented in Box 3. [134][135][136] General considerations • Utilize non-invasive hemodynamic assessments, and measurement of lactate, troponin, and beta-natriuretic peptide concentrations, with sparing use of routine echocardiography for guidance about fluid resuscitation, vasoactive agents, and mechanical circulatory support • Minimize invasive hemodynamic monitoring, but can consider in select patients with mixed vasodilatory and cardiogenic shock • Consider point-of-care ultrasound to assess regional wall-motion abnormalities to help distinguish type 1 MI from myocarditis • Early catheterization and revascularization is recommended for high-risk patients with NSTEACS (e.g., GRACE score >140) • Consider medical therapy for low-risk patients with NSTEACS, particularly if the suspicion for type 1 MI is low • Monitor and correct electrolyte abnormalities to mitigate arrhythmia risk ...
Although COVID-19 is most well known for causing substantial respiratory pathology, it can also result in several extrapulmonary manifestations. These conditions include thrombotic complications, myocardial dysfunction and arrhythmia, acute coronary syndromes, acute kidney injury, gastrointestinal symptoms, hepatocellular injury, hyperglycemia and ketosis, neurologic illnesses, ocular symptoms, and dermatologic complications. Given that ACE2, the entry receptor for the causative coronavirus SARS-CoV-2, is expressed in multiple extrapulmonary tissues, direct viral tissue damage is a plausible mechanism of injury. In addition, endothelial damage and thromboinflammation, dysregulation of immune responses, and maladaptation of ACE2-related pathways might all contribute to these extrapulmonary manifestations of COVID-19. Here we review the extrapulmonary organ-specific pathophysiology, presentations and management considerations for patients with COVID-19 to aid clinicians and scientists in recognizing and monitoring the spectrum of manifestations, and in developing research priorities and therapeutic strategies for all organ systems involved.
... Since the discovery of COVID-19, in Wuhan, China, on December 29th 2019, key questions have been raised on the potential of the relationship between its progression and various clinical and laboratory findings [1]. Dyspnoea, dry cough, weakness, fever, myalgia, and lymphopenia constitute the condition's most common symptom set, while pneumonia manifests in radiologic signs [2]. ...
COVID-19 is a global pandemic viral infection that has affected millions worldwide. Limited data is available on the effect of COVID-19 on hematological parameters in Saudi Arabia. This study is aimed at examining the role of hematological parameters among COVID-19 patients admitted to King Khalid Hospital in Najran, Saudi Arabia. This is a retrospective, hospital-based study of 514 cases who were recruited during August to October 2020. 257 COVID-19 patients formed the study group, and a further 257 negative subjects formed the control group. Anemia was significantly elevated in positive subjects over controls (respectively, 64.2% and 35.8%), with patients 2.5 times more likely to be anemic (p<0:01). Thrombocytopenia was higher in patients over controls (respectively, 62% and 38%), with patients ~1.7 times more likely to be thrombocytopenic (p<0:01). Moreover, leukopenia was significantly higher in patients over controls (respectively, 71% and 29%), with positive subjects ~2.6 times more likely to be leukopenic. Our study results indicate that mild anemia associated with leukopenia may have diagnostic value for COVID-19. Careful assessment of hematological parameters, at baseline and throughout the disease path, will assist physicians in formulating personalized approaches to treatment and promptly offer intensive care to those in greater need.
... Unfortunately, such concerns impair understanding of illness-related issues, leading to other psychosocial challenges such as Depression, Insomnia, and other psychosocial aspects that have not yet been addressed (Gong et al., 2020;Pfefferbaum & North, 2020).The outbreak of COVID 19's infection occurred in China last December 2020 and attracted worldwide attention. The prevalence of severe epidemics, such as Acute Respiratory Syndrome (SARS), Ebola, and Middle East Respiratory Syndrome (MERS), has always been associated with a high prevalence of mental health problems (Huang et al., 2020;Ranard et al., 2020).Compared to other epidemics in the 21st century, COVID-19 is the most serious pandemic characterized by human-to-human transmission, asymptomatic carrier transmission, and high transmission efficiencies (Li et al., 2015).Today, despite technological advances, disorders such as depression, anxiety, and stress are the most common diseases of the present century. The present study investigates the symptoms of insomnia, depression, and anxiety in medical staff (nurses, doctors, and hospital staff) on a case-by-case basis. ...
The article's abstract is not available.
... In LMIS, coronary intervention (CI) is not usually perfor med. Thrombolytics are administered if the patient arrives within the proper time, and if the facility has the resources to do this [9]. If not, the patient is transferred, and precious time is lost. ...
Objective To assess performance measures of attention of STEMI in Coronary Intensive Care Unit in General Hospital Camilo Cienfuegos. Methods Admitted patients with STEMI, from February-April 2020, were compared with patients from similar period from 2015–2019, and patients from January 2019 to January 2020. Primary endpoint were performance measures according to the 2017 AHA / ACC Clinical Performance and Quality Measures for Adults with STEMI document, and secondary endpoint were all-cause in-hospital mortality and major acute coronary events. Results Only 35 patients were admitted from February-April 2020. When comparing with similar periods from recent years, in-hospital death (8.3 % vs. 20 %; p=0.03), major complications (38.7 % vs. 57.1 %; p=0.03), and cardiogenic shock (6.9 % vs. 17.4 %; p=0.04) were significantly higher. When comparing with 2019 and January 2020, in-hospital death (9.6 %; p=0.04), and major complications (35.8 % p=0.03) were significantly higher in February-April 2020; however, there was no difference in prevalence of cardiogenic shock (8 %; p=0.12). Conclusion COVID-19 pandemic had decreased prevalence of STEMI, as well as some performance measures of attention in this center.
... Additionally, all ST elevation myocardial infarction patients are treated with aspirin, P2Y 12 inhibitor, anticoagulation and high-dose statin. 10 It is important to understand the implications of COVID-19 infection on the cardiovascular system, so that timely and effective treatment can be initiated and mortality can be reduced. The present case highlights how myocardial infarction can complicate the COVID 19 systemic illness. ...
Clinicians should be aware of the potential for cardiovascular involvement in COVID-19 infection.
Coronavirus disease-2019 (COVID-19) is a viral illness caused by severe acute respiratory syndrome-coronavirus-2. While it primarily causes a respiratory illness, a number of important cardiovascular implications have been reported. We describe a patient presenting with COVID-19 whose hospital course was complicated by ST elevation myocardial infarction requiring percutaneous coronary intervention. The goal is to help clinicians gain awareness of the possibility of cardiovascular disease in COVID-19 infection, and maintain a high index of suspicion particularly for patients with risk factors or a prior history of cardiovascular disease.
... Some countries have changed their reperfusion strategy to fibrinolytic therapy [5][6][7], others still follow the guidelines in performing PPCI to all STEMI patients [8][9][10][11]. The delay in seeking medical advice during the lockdown periods, the time needed for screening for COVID-19 infection, and the fear of healthcare providers regarding cross-infection are the main causes behind the change of practice of managing STEMI patients and the fall in PPCI procedures according to some reports [12][13][14][15]. ...
Primary percutaneous coronary intervention (PPCI) is one of the important clinical procedures that have been affected by the COVID-19 pandemic. In this study, we aimed to assess the incidence and impact of COVID-19 on in-hospital clinical outcome of ST elevation myocardial infarction (STEMI) patients managed with PPCI. This observational retrospective study was conducted on consecutive STEMI patients who presented to the International Cardiac Center (ICC) hospital, Alexandria, Egypt between 1 February and 31 October 2020. A group of STEMI patients presented during the same period in 2019 was also assessed (control group) and data was used for comparison. The inclusion criteria were established diagnosis of STEMI requiring PPCI.A total of 634 patients were included in the study. During the COVID-19 period, the number of PPCI procedures was reduced by 25.7% compared with previous year (mean 30.0 ± 4.01 vs. 40.4 ± 5.3 case/month) and the time from first medical contact to Needle (FMC-to-N) was longer (125.0 ± 53.6 vs. 52.6 ± 22.8 min, p = 0.001). Also, during COVID-19, the in-hospital mortality was higher (7.4 vs. 4.6%, p = 0.036) as was the incidence of re-infarction (12.2 vs. 7.7%, p = 0.041) and the need for revascularization (15.9 vs. 10.7%, p = 0.046). The incidence of heart failure, stroke, and bleeding was not different between groups, but hospital stay was longer during COVID-19 (6.85 ± 4.22 vs. 3.5 ± 2.3 day, p = 0.0025). Conclusion: At the ICC, COVID-19 pandemic contributed significantly to the PPCI management of STEMI patients with decreased number and delayed procedures. COVID-19 was also associated with higher in-hospital mortality, rate of re-infarction, need for revascularization, and longer hospital stay.
... If primary PCI is being considered, adequate personal protective equipment and preparedness for the cardiac catheterization lab to handle it must be ensured. 80,81 Increasing incidence of stress cardiomyopathy points to the fact that high index of suspicion should be kept before considering urgent coronary angiography which may put the cardiologist at the risk of nosocomial infection. 62 Point of care echocardiography can be used to assess regional wall motion abnormalities in suspected cases of ACS. ...
Covid‐19 disease can involve any organ system leading to myriad manifestations and complications. Cardiovascular manifestations are being increasingly recognised with the improved understanding of the disease. Acute coronary syndrome, myocarditis, arrhythmias, cardiomyopathy; heart failure and thromboembolic disease have all been described. The elderly and those with prior cardiac diseases are at an increased risk of mortality. Overlapping symptomatology, ability of drugs to cause QTc interval (start of Q wave to the end of T wave) prolongation on electrocardiogram and arrhythmias, potential drug interactions, the need to recognise patients requiring urgent definitive management and provide necessary bedside interventions without increasing the risk of nosocomial spread have made the management challenging. In the background of a pandemic, non‐Covid‐19 cardiac patients are affected by delayed treatment and nosocomial exposure. Triaging using telemedicine and artificial intelligence along with utilization of bedside rapid diagnostic tests to detect Covid‐19 could prove helpful in this aspect.
... It should be assumed that all emergent cases such as myocardial infarction, shock patients and severe symptomatic valvular heart disease patients in need of urgent treatment are already being treated according to locally established protocols (7,8). Waiting patients should be prioritized based on severity of symptoms and other established risk factors. ...
As the world slowly starts to recover from the COVID-19 pandemic, healthcare systems are now thinking about resuming elective cardiovascular procedures, including procedures in the cardiac catheterization laboratories (cath lab). Rebooting cath labs will be an arduous process in part due to limited healthcare resources, new processes and fears stemming from the COVID-19 pandemic. We propose a detailed phased-in approach that considers clinical, patient-centered, and operational strategies to safely and effectively reboot cath lab programs during these unprecedented times. This model balances delivery of essential cardiovascular care while reducing exposure and preserving resources. The guiding principles detailed in this manuscript can be used by cath lab programs when restarting elective interventional procedures.
Increasingly, the vascular system is recognized as a major target of COVID-19 that plays a critical role in dictating clinical outcomes. Vascular dysfunction has been well described in the aftermath of a number of infectious conditions, however, the particularly robust systemic immune response to COVID-19 intensifies this phenomenon. Compounded by a multitude of effects on the complement and RAAS systems, this results in numerous thromboembolic complications in both arterial and venous systems of almost every vascular bed. Interestingly, in a number of these scenarios, the extent of vascular dysfunction does not correlate with systemic disease severity, thus complicating management and indicating the existence of additional pathophysiological mechanisms at work. A better understanding of these mechanisms lays the foundation to devise targeted therapies in an effort to minimize the morbidity and mortality of these complications. In this chapter, we review the current understanding and clinical burden of vascular injury with COVID-19, followed by an overview of the management of these complications. COVID-19 raises unique challenges in delivering optimal medical therapy and a concerted, multidisciplinary approach is essential to optimizing patient outcomes.
The current COVID-19 has spread worldwide, the outbreak is altering the usual activity of the catheterization laboratorios and the usual treatment pathways of patients with chronic diseases or emergencies, such as Acute Coronary Syndrome could be disrupted. The involvement of health personnel is a relevant concern, so we created a consensus document of the Costa Rican Association of Cardiology that aims to generate a decision-making workflow to treat this pathology and guarantee adequate and continuous care for ST elevation myocardial infarction during the COVID-19 outbreak.
Purpose of review
Although the respiratory system is the main target of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), it is evident from recent data that other systems, especially cardiovascular and haematological, are also significantly affected. In fact, in severe form, COVID-19 causes a systemic illness with widespread inflammation and cytokine flood, resulting in severe cardiovascular injury. Therefore, we reviewed cardiac injury biomarkers' role in various cardiovascular complications of COVID 19 in recent studies.
Recent findings
Cardiac injury biomarkers were elevated in most of the complicated cases of COVID-19, and their elevation is directly proportional to the worst outcome. Evaluation of cardiac biomarkers with markers of other organ damage gives a more reliable tool for case fatalities and future outcome.
Summary
Significant association of cardiac biomarkers in COVID-19 cases helps disease management and prognosis, especially in severely ill patients.
The ongoing coronavirus disease 2019 pandemic has resulted in additional challenges for systems designed to perform expeditious primary percutaneous coronary intervention for patients presenting with ST-segment-elevation myocardial infarction. There are 2 important considerations: the guideline-recommended time goals were difficult to achieve for many patients in high-income countries even before the pandemic, and there is a steep increase in mortality when primary percutaneous coronary intervention cannot be delivered in a timely fashion. Although the use of fibrinolytic therapy has progressively decreased over the last several decades in high-income countries, in circumstances when delays in timely delivery of primary percutaneous coronary intervention are expected, a modern fibrinolytic-based pharmacoinvasive strategy may need to be considered. The purpose of this review is to systematically discuss the contemporary role of an evidence-based fibrinolytic reperfusion strategy as part of a pharmacoinvasive approach, in the context of the emerging coronavirus disease 2019 pandemic.
Beginning in March 2020, New York City began the fight against coronavirus disease 2019. Health care workers were faced with a disease that led to significant morbidity and mortality with no proven therapies. As hospitals became inundated with patients and underwent rapid expansion of capacity, resources such as drugs, protective and medical equipment, and hospital staff became limited. Pharmacists played a critical role in the management of clinical care and drug delivery during the pandemic. As members of the department of pharmacy within NewYork‐Presbyterian Hospital, we describe our experiences and processes to overcome challenges faced during the pandemic. Strict inventory management through the use of daily usage reports, frequent communication, and minimization of waste was critical for the management of drug shortages. The creation of guidelines, protocols, and restrictions were not only used to mitigate drug shortages, but also helped educate health care providers and guided medication use. Managing technology through setting up new automatic dispensing cabinets to address hospital expansions and modifying the electronic order entry system to include new protocols and drug shortage information were also vital. Additional key pharmacist functions included provision of investigational drug service support and training of pharmacists, prescribers, nurses, and respiratory therapists to educate and standardize medication use. Through implementation of operational and clinical processes, pharmacists managed critical drug inventory and guided patient treatment. As the pandemic continues, pharmacists will remain vital members of the multidisciplinary team dedicated to the fight against the virus. This article is protected by copyright. All rights reserved.
The novel coronavirus disease 2019, otherwise known as COVID-19, is a global pandemic with primary respiratory manifestations in those who are symptomatic. It has spread to more than 187 countries with a rapidly growing number of affected patients. Underlying cardiovascular disease is associated with more severe manifestations of COVID-19 and higher rates of mortality. COVID-19 can have both primary (arrhythmias, myocardial infarction, myocarditis) and secondary (myocardial injury/biomarker elevation, heart failure) cardiac involvement. In severe cases, profound circulatory failure can result. This review discusses the presentation and management of patients with severe cardiac complications of COVID-19 disease, with an emphasis on a "Heart-Lung" team approach in patient management. Furthermore, it focuses on the use of and indications for acute mechanical circulatory support in cardiogenic and/or mixed shock.
The Coronavirus 2019 (COVID-19) pandemic has dramatically altered the delivery of reperfusion therapy for patients with ST-elevation myocardial infarction (STEMI). At this crucial time, it seems prudent to re-evaluate STEMI reperfusion pathways.
Purpose : to perform comparative morphological analysis of causes of dysfunction of epoxy-treated, xenoaortic and xenopericardial, tissues heart valves.
Materials and methods . We included in this study 475 patients with mitral valve disease who have undergone heart valve replacement with tissue valve: (“KemCor”, n=211 [group 1]; “PeriCor”, n=126 [group 2]; and “UniLine”, n=138 [group 3]). Degenerative changes in 26 tissue valves (n=9 “KemCor”, n=11 “PeriCor”, and n=6 “UniLine”) explanted from the mitral position during the repeat replacement were evaluated macroscopically for the presence of calcifications, perforations, leaflet tears and ruptures, pannus, and leaflet fusion to the stent frame. Analysis of survival, freedom from dysfunction and reoperation of the studied tissue heart valves was performed for the period from January 1, 1995 to March 01, 2017.
Results: Pannus overgrowth on the stent struts with extension onto the leaflets was seen on 53.8% of explanted tissue valves. “KemCor” and “PeriCor” tissue valves demonstrated over 70% rate of adhesion formation at the commissure, and in 93% of these cases there were leaflet ruptures at the commissure. Signs of calcification of different grades had 57.6% of specimens. Over 50% of “PeriCor” and “UniLine” tissue valve specimens had calcification at the stent frame. Calcified pannus was noted in 35% of all studied tissue heart valves. Interestingly, dysfunction in 53.3% of the studied tissue heart valves with detected calcification was not associated with calcific deposits. The 6-year actuarial survival for groups I, II and III was 73.5, 66.1 and 87.6%, respectively (group I vs. group II, p=0.6; group II vs. group III - p<0.05; group I vs. group III - p<0.05). The actuarial freedom from reoperation was 81.9%, 75.0% and 94.2%, respectively (p I-II >0.05; p II-III <0.05; p I-III <0.05). The actuarial freedom from dysfunction was 79.6%, 75.0%, and 94.2%, respectively (p I-II >0.05; p II-III <0.05; p I-III <0.05).
Conclusion. The structure of dysfunctions of the studied tissue heart valves was represented by primary tissue failure, calcification and pannus growth. Specific design of the “UniLine” valve allowed to prevent the formation of adhesions between leaflets and the frame in the commissure buttress area, and as a result leaflet rupture from the stent struts. Xenopericardial “UniLine” tissue valves turned out to be superior to xenoaortic “KemCor” and “PeriCor” tissue valves in terms of survival, freedom from reoperations and dysfunction within the 6-year follow-up.
Background:
The efficacy of ticagrelor in the long-term post-ST-segment elevation myocardial infarction (STEMI) treated with fibrinolytic therapy remains uncertain.
Objectives:
The purpose of this study was to evaluate the efficacy of ticagrelor when compared with clopidogrel in STEMI patients treated with fibrinolytic therapy.
Methods:
This international, multicenter, randomized, open-label with blinded endpoint adjudication trial enrolled 3,799 patients (age <75 years) with STEMI receiving fibrinolytic therapy. Patients were randomized to ticagrelor (180-mg loading dose, 90 mg twice daily thereafter) or clopidogrel (300- to 600-mg loading dose, 75 mg daily thereafter). The key outcomes were cardiovascular mortality, myocardial infarction, or stroke, and the same composite outcome with the addition of severe recurrent ischemia, transient ischemic attack, or other arterial thrombotic events at 12 months.
Results:
The combined outcome of cardiovascular mortality, myocardial infarction, or stroke occurred in 129 of 1,913 patients (6.7%) receiving ticagrelor and in 137 of 1,886 patients (7.3%) receiving clopidogrel (hazard ratio: 0.93; 95% confidence interval: 0.73 to 1.18; p = 0.53). The composite of cardiovascular mortality, myocardial infarction, stroke, severe recurrent ischemia, transient ischemic attack, or other arterial thrombotic events occurred in 153 of 1,913 patients (8.0%) treated with ticagrelor and in 171 of 1,886 patients (9.1%) receiving clopidogrel (hazard ratio: 0.88; 95% confidence interval: 0.71 to 1.09; p = 0.25). The rates of major, fatal, and intracranial bleeding were similar between the ticagrelor and clopidogrel groups.
Conclusion:
Among patients age <75 years with STEMI, administration of ticagrelor after fibrinolytic therapy did not significantly reduce the frequency of cardiovascular events when compared with clopidogrel. (Ticagrelor in Patients With ST Elevation Myocardial Infarction Treated With Pharmacological Thrombolysis [TREAT]; NCT02298088).
The Middle East respiratory syndrome (MERS) coronavirus has caused recurrent outbreaks in the Arabian Peninsula since 2012. Although MERS has low overall human-to-human transmission potential, there is occasional amplification in the healthcare setting, a pattern reminiscent of the dynamics of the severe acute respiratory syndrome (SARS) outbreaks in 2003. Here we provide a head-to-head comparison of exposure patterns and transmission dynamics of large hospital clusters of MERS and SARS, including the most recent South Korean outbreak of MERS in 2015.
To assess the unexpected nature of the recent South Korean nosocomial outbreak of MERS and estimate the probability of future large hospital clusters, we compared exposure and transmission patterns for previously reported hospital clusters of MERS and SARS, based on individual-level data and transmission tree information. We carried out simulations of nosocomial outbreaks of MERS and SARS using branching process models rooted in transmission tree data, and inferred the probability and characteristics of large outbreaks.
A significant fraction of MERS cases were linked to the healthcare setting, ranging from 43.5 % for the nosocomial outbreak in Jeddah, Saudi Arabia, in 2014 to 100 % for both the outbreak in Al-Hasa, Saudi Arabia, in 2013 and the outbreak in South Korea in 2015. Both MERS and SARS nosocomial outbreaks are characterized by early nosocomial super-spreading events, with the reproduction number dropping below 1 within three to five disease generations. There was a systematic difference in the exposure patterns of MERS and SARS: a majority of MERS cases occurred among patients who sought care in the same facilities as the index case, whereas there was a greater concentration of SARS cases among healthcare workers throughout the outbreak. Exposure patterns differed slightly by disease generation, however, especially for SARS. Moreover, the distributions of secondary cases per single primary case varied highly across individual hospital outbreaks (Kruskal-Wallis test; P < 0.0001), with significantly higher transmission heterogeneity in the distribution of secondary cases for MERS than SARS. Simulations indicate a 2-fold higher probability of occurrence of large outbreaks (>100 cases) for SARS than MERS (2 % versus 1 %); however, owing to higher transmission heterogeneity, the largest outbreaks of MERS are characterized by sharper incidence peaks. The probability of occurrence of MERS outbreaks larger than the South Korean cluster (n = 186) is of the order of 1 %.
Our study suggests that the South Korean outbreak followed a similar progression to previously described hospital clusters involving coronaviruses, with early super-spreading events generating a disproportionately large number of secondary infections, and the transmission potential diminishing greatly in subsequent generations. Differences in relative exposure patterns and transmission heterogeneity of MERS and SARS could point to changes in hospital practices since 2003 or differences in transmission mechanisms of these coronaviruses.
Patient: Male, 58 Final Diagnosis: Myopericarditis Symptoms: Retrosternal thoracic pain Medication: - Clinical Procedure: MRI Specialty: Cardiology.
Challenging differential diagnosis.
Patients with acute cardiac symptoms, elevated cardiac troponin, and culprit-free angiograms are a consistent proportion of patients admitted with presumed acute coronary syndromes (ACS). Current literature on this population of patients justifies the diagnostic importance of cardiovascular magnetic resonance (CMR) imaging.
This report describes the case of a 58-year-old cyclist in which CMR allowed us to perform a diagnosis of myopericarditis mimicking acute STEMI against other evidence. There are several such reports in literature because the clinical presentation of myocarditis is quite variable.
This case report emphasizes the importance of cardiovascular magnetic resonance imaging in the differential diagnosis of the etiology of acute coronary syndromes. This is especially important because the signs and symptoms presented are ambiguous and equivalent to those of other diseases, such as myopericarditis, which affects mainly young athletes but also middle-aged athletes.
For the treatment of myocardial infarction with ST-segment elevation, primary angioplasty is considered superior to fibrinolysis for patients who are admitted to hospitals with angioplasty facilities. Whether this benefit is maintained for patients who require transportation from a community hospital to a center where invasive treatment is available is uncertain.
We randomly assigned 1572 patients with acute myocardial infarction to treatment with angioplasty or accelerated treatment with intravenous alteplase; 1129 patients were enrolled at 24 referral hospitals and 443 patients at 5 invasive-treatment centers. The primary study end point was a composite of death, clinical evidence of reinfarction, or disabling stroke at 30 days.
Among patients who underwent randomization at referral hospitals, the primary end point was reached in 8.5 percent of the patients in the angioplasty group, as compared with 14.2 percent of those in the fibrinolysis group (P=0.002). The results were similar among patients who were enrolled at invasive-treatment centers: 6.7 percent of the patients in the angioplasty group reached the primary end point, as compared with 12.3 percent in the fibrinolysis group (P=0.05). Among all patients, the better outcome after angioplasty was driven primarily by a reduction in the rate of reinfarction (1.6 percent in the angioplasty group vs. 6.3 percent in the fibrinolysis group, P<0.001); no significant differences were observed in the rate of death (6.6 percent vs. 7.8 percent, P=0.35) or the rate of stroke (1.1 percent vs. 2.0 percent, P=0.15). Ninety-six percent of patients were transferred from referral hospitals to an invasive-treatment center within two hours.
A strategy for reperfusion involving the transfer of patients to an invasive-treatment center for primary angioplasty is superior to on-site fibrinolysis, provided that the transfer takes two hours or less.
The novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is highly infectious, carries significant morbidity and mortality, and has rapidly resulted in strained health care system and hospital resources. In addition to patient-related care concerns in infected individuals, focus must also relate to diminishing community spread, protection of staff, case selection, and concentration of resources. The current document based on available data and consensus opinion addresses appropriate catheterization laboratory preparedness for treating these patients, including procedure-room readiness to minimize external contamination, safe donning and doffing of personal protective equipment (PPE) to eliminate risk to staff, and staffing algorithms to minimize exposure and maximize team availability. Case selection and management of both emergent and urgent procedures are discussed in detail, including procedures that may be safely deferred or performed bedside.
Clinical pathways reinforce best practices and help healthcare institutions standardize care delivery. The NewYork-Presbyterian/Columbia University Irving Medical Center has used such a pathway for the management of patients with chest pain and acute coronary syndromes for almost 2 decades. A multidisciplinary panel of stakeholders serially updates the algorithm according to new data and recently published guidelines. Herein, we present the 2019 version of the clinical pathway. We explain the rationale for changes to the algorithm and describe our experience expanding the pathway to all the 8 affiliated institutions within the NewYork Presbyterian healthcare system.
Middle East respiratory syndrome-coronavirus (MERS-CoV) resembles a severe form of community-acquired pneumonia initially reported in Saudi Arabia in 2012. The MERS-CoV epidemic poses a big challenge because of its high mortality. In January 2015, a patient who was potentially incubating MERS-CoV arrived from the emergency department of another hospital and was admitted with acute coronary syndrome. This resulted in an outbreak in the cardiac surgery ward that caused the deaths of 5 of 6 patients who had undergone cardiac operations.
Pericarditis and myocarditis are characterised by electrocardiographic changes and elevated cardiac enzymes, respectively, and patients with perimyocarditis often complain of chest discomfort. These findings are nonspecific and often lead to diagnostic difficulties, as ST-elevation myocardial infarction commonly presents in a similar fashion. Clinical differentiation between perimyocarditis and myocardial infarction are especially important because adverse side effects can occur if reperfusion therapy is administered for a patient with acute pericarditis or if a diagnosis of acute myocardial infarction is missed. We herein describe a case of perimyocarditis with ST elevation and raised cardiac markers, which led to two emergency coronary angiographies that were subsequently found to be normal. We include the three serial electrocardiographies (ECGs) performed to show the characteristic features of perimyocarditis and further discuss the importance of identifying typical and atypical ECG features of pericarditis.
Background:
It is not known whether prehospital fibrinolysis, coupled with timely coronary angiography, provides a clinical outcome similar to that with primary percutaneous coronary intervention (PCI) early after acute ST-segment elevation myocardial infarction (STEMI).
Methods:
Among 1892 patients with STEMI who presented within 3 hours after symptom onset and who were unable to undergo primary PCI within 1 hour, patients were randomly assigned to undergo either primary PCI or fibrinolytic therapy with bolus tenecteplase (amended to half dose in patients ≥75 years of age), clopidogrel, and enoxaparin before transport to a PCI-capable hospital. Emergency coronary angiography was performed if fibrinolysis failed; otherwise, angiography was performed 6 to 24 hours after randomization. The primary end point was a composite of death, shock, congestive heart failure, or reinfarction up to 30 days.
Results:
The primary end point occurred in 116 of 939 patients (12.4%) in the fibrinolysis group and in 135 of 943 patients (14.3%) in the primary PCI group (relative risk in the fibrinolysis group, 0.86; 95% confidence interval, 0.68 to 1.09; P=0.21). Emergency angiography was required in 36.3% of patients in the fibrinolysis group, whereas the remainder of patients underwent angiography at a median of 17 hours after randomization. More intracranial hemorrhages occurred in the fibrinolysis group than in the primary PCI group (1.0% vs. 0.2%, P=0.04; after protocol amendment, 0.5% vs. 0.3%, P=0.45). The rates of nonintracranial bleeding were similar in the two groups.
Conclusions:
Prehospital fibrinolysis with timely coronary angiography resulted in effective reperfusion in patients with early STEMI who could not undergo primary PCI within 1 hour after the first medical contact. However, fibrinolysis was associated with a slightly increased risk of intracranial bleeding. (Funded by Boehringer Ingelheim; ClinicalTrials.gov number, NCT00623623.).
Jeffrey L. Anderson, MD, FACC, FAHA, Chair; Alice K. Jacobs, MD, FACC, FAHA, Immediate Past Chair; Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect; Nancy M. Albert, PhD, CCNS, CCRN, FAHA; Ralph G. Brindis, MD, MPH, MACC; Mark A. Creager, MD, FACC, FAHA; David DeMets, PhD; Robert A. Guyton, MD,
The 12-lead electrocardiogram (ECG) remains the cornerstone of prompt diagnosis of STEMI; Furthermore, the 12-lead ECG provides the primary indication for emergent reperfuison therapy in the STEMI patient. In certain cases, a patient's ECG can resemble STEMI yet manifest ST-segment elevation from a non-coronary-based syndrome; these entities are termed the STEMI mimics and include benign early repolarization, acute pericarditis, and left ventricular aneurysm, to name only a few. In other situations, the patient's ECG makes it difficult or impossible to determine whether STEMI is present, the so-called STEMI confounders and include left bundle branch block pattern, left ventricular hypertrophypattern, and the ventricular paced pattern. The goal with STEMI mimics and confounders is to maximize rapid, accurate diagnosis while avoiding delays in treatment of alternative causes of ST-segment elevation.
Deviation of the PR segment is a common but often ignored ECG finding in acute myopericarditis, but seems to be rare in the acute phase of ST elevation myocardial infarction (STEMI). Since rapid bedside differential diagnosis of acute myopericarditis and STEMI is essential, we decided to assess the diagnostic power of PR depressions in patients presenting with ST elevations in the emergency room.
Thirty-four consecutive patients with acute myopericarditis and 46 STEMI patients presenting with ST elevations fulfilling the criteria for STEMI were included. The first ECG recorded in the emergency room was analyzed with a focus on the PR segment. The diagnoses of myopericarditis and STEMI were ascertained with clinical follow-up together with rise in troponin levels, and in the STEMI patients also with coronary angiography.
In myopericarditis, the most common location for PR depression was lead II (55.9%), while this ECG finding least likely appeared in lead aVL (2.9%). PR depression in any lead had a high sensitivity (88.2%), but fairly low specificity (78.3%) for myopericarditis. The combination of PR depressions in both precordial and limb leads had the most favorable predictive power to differentiate myopericarditis from STEMI (positive 96.7% and negative power 90%).
Our present observations show that PR segment analysis is a powerful tool in the differential diagnosis of myopericarditis and STEMI. This simple information should be added to the diagnostic workup of patients presenting with ST elevations.
Objectives:
We sought to directly compare primary stenting with accelerated tissue plasminogen activator (t-PA) in patients presenting with acute ST-elevation myocardial infarction (AMI).
Background:
Thrombolysis remains the standard therapy for AMI. However, at some institutions primary angioplasty is favored. Randomized trials have shown that primary angioplasty is equal or superior to thrombolysis, while recent studies demonstrate that stent implantation improves the results of primary angioplasty.
Methods:
Patients presenting with AMI were randomly assigned to primary stenting (n = 62) or accelerated t-PA (n = 61). The primary end point was the composite of death, reinfarction, stroke or repeat target vessel revascularization (TVR) for ischemia at six months.
Results:
The primary end point was significantly reduced in the stent group compared with the accelerated t-PA group, 24.2% versus 55.7% (p < 0.001). The event rates for other outcomes in the stent group versus the t-PA group were as follows: mortality: 4.8% versus 3.3% (p = 1.00); reinfarction: 6.5% versus 16.4% (p = 0.096); stroke: 1.6% versus 4.9% (p = 0.36); recurrent unstable ischemia: 9.7% versus 26.2% (p = 0.03) and repeat TVR for ischemia: 14.5% versus 49.2% (p < 0.001). The median length of the initial hospitalization was four days in the stent group and seven days in the t-PA group (p < 0.001).
Conclusions:
Compared with accelerated t-PA, primary stenting reduces death, reinfarction, stroke or repeat TVR for ischemia. In centers where facilities and experienced interventionists are available, primary stenting offers an attractive alternative to thrombolysis.
To determine the relative prognostic significance of location (anterior or inferior) and type (Q wave or non-Q wave) of infarction, the hospital course and follow-up outcome (mean duration 30.8 months) of 471 patients with a first infarction were analyzed. Analyses were performed grouping the patients according to infarct location (anterior, n = 253; inferior, n = 218), infarct type (Q wave, n = 323; non-Q wave, n = 148), and both location and type (inferior non-Q wave, n = 85; inferior Q wave, n = 133; anterior non-Q wave, n = 63; and anterior Q wave, n = 190).
Fibrinolytic treatment for ST-elevation myocardial infarction is associated with increased bleeding risk but is still widely used world wide, mainly because of limited access to primary PCI.
To analyse contemporary fibrinolytic treatment patterns, in-hospital bleeding risk and prognosis during 2001 to 2006 in unselected Swedish patients.
The RIKS-HIA registry covers almost all Swedish patients treated for acute coronary syndromes. Major in-hospital bleeding was defined as lethal or intracranial bleeding or bleeding requiring surgery or blood transfusion. Survival status of the 15 373 patients was obtained from the National Cause of Death Register. The number of patients receiving fibrinolysis as reperfusion therapy decreased from 4336 patients in 2001 to 733 in 2006. Cases of major in-hospital bleeding increased from 1.2% (including 0.7% lethal or intracranial) in 2001 to 4.0% (1.1%) in 2006, p<0.001. Higher age, female gender, hypertension, kidney failure, clopidogrel treatment before admission, pre-hospital administration of fibrinolysis and fibrin-specific fibrinolytic agents were identified as predictors for bleeding. Major in-hospital bleeding was the strongest predictor of adverse prognosis with a more than threefold increase in 1-year mortality.
During 2001 to 2006 the use of fibrinolytic treatment markedly decreased while the incidence of major bleeding complications more than doubled. The latter might in part be explained by increasing use concomitant antiplatelet therapy, pre-hospital treatment and fibrin-specific fibrinolytic agents. Future close monitoring of bleeding complications is warranted, especially when considering the increased use of various combinations of antithrombotic drugs in conjunction with fibrinolysis and the great impact of bleeding on long-term mortality.
Many trials have been done to compare primary percutaneous transluminal coronary angioplasty (PTCA) with thrombolytic therapy for acute ST-segment elevation myocardial infarction (AMI). Our aim was to look at the combined results of these trials and to ascertain which reperfusion therapy is most effective.
We did a search of published work and identified 23 trials, which together randomly assigned 7739 thrombolytic-eligible patients with ST-segment elevation AMI to primary PTCA (n=3872) or thrombolytic therapy (n=3867). Streptokinase was used in eight trials (n=1837), and fibrin-specific agents in 15 (n=5902). Most patients who received thrombolytic therapy (76%, n=2939) received a fibrin-specific agent. Stents were used in 12 trials, and platelet glycoprotein IIb/IIIa inhibitors were used in eight. We identified short-term and long-term clinical outcomes of death, non-fatal reinfarction, and stroke, and did subgroup analyses to assess the effect of type of thrombolytic agent used and the strategy of emergent hospital transfer for primary PTCA. All analyses were done with and without inclusion of the SHOCK trial data.
Primary PTCA was better than thrombolytic therapy at reducing overall short-term death (7% [n=270] vs 9% [360]; p=0.0002), death excluding the SHOCK trial data (5% [199] vs 7% [276]; p=0.0003), non-fatal reinfarction (3% [80] vs 7% [222]; p<0.0001), stroke (1% [30] vs 2% [64]; p=0.0004), and the combined endpoint of death, non-fatal reinfarction, and stroke (8% [253] vs 14% [442]; p<0.0001). The results seen with primary PTCA remained better than those seen with thrombolytic therapy during long-term follow-up, and were independent of both the type of thrombolytic agent used, and whether or not the patient was transferred for primary PTCA.
Primary PTCA is more effective than thrombolytic therapy for the treatment of ST-segment elevation AMI.
Severe acute respiratory syndrome (SARS) is a highly contagious disease that has led to large hospital and community outbreaks, necessitating stringent infection control in its management. Among 90 SARS patients in our institution in the 2003 outbreak, 2 underwent cardiac catheterization. We report the personal respiratory protection and environmental control measures implemented to minimize the risk of droplets spread during these procedures, including re-engineering of the ventilation system of the cardiac catheterization laboratory (CCL). The report highlights the importance of collaboration of CCL personnel with relevant hospital engineering and management teams to develop a contingency infection control plan to prepare for future outbreaks of SARS or other epidemics.
An interactive web-based dashboard to track COVID-19 in real time [published online ahead of print February 9, 2020].
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