COVID-19-associated myocardial infarction: Difference between revisions

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'''For COVID-19 frequently asked inpatient questions, click [[COVID-19 frequently asked inpatient questions|here]]'''<br>'''For COVID-19 frequently asked outpatient questions, click [[COVID-19 frequently asked outpatient questions|here]]'''<br>
'''For COVID-19 frequently asked inpatient questions, click [[COVID-19 frequently asked inpatient questions|here]]'''<br>'''For COVID-19 frequently asked outpatient questions, click [[COVID-19 frequently asked outpatient questions|here]]'''<br>


{{CMG}}; {{AE}} {{SaraH}}
{{CMG}}; {{AE}} {{Sara.Zand}} {{SaraH}}


{{SK}} [[Novel coronavirus]], [[covid-19]], [[COVID-19]], SARS-CoV-2, Wuhan coronavirus, [[myocardial infarction]], [[MI]], [[Acute coronary syndrome]], [[ACS]], [[STEMI]], [[MSTEMI]]
{{SK}} [[Novel coronavirus]], [[covid-19]], [[COVID-19]], [[SARS-CoV-2]], [[Myocardial Infarction]], [[MI]], [[ST Elevation Myocardial Infarction]], [[STEMI]], [[Non ST Elevation Myocardial Infarction]], [[NSTEMI]]


==Overview==
==Overview==
On March 11, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak as a [[pandemic]]. [[Coronavirus disease 2019]] ([[COVID-19]]) caused by [[severe acute respiratory syndrome coronavirus-2]] ([[SARS-COV-2]]), has affected [[patients]] with [[ST-segment elevation myocardial infarction]] ([[STEMI]]). [[STEMI]] can be the first manifestation of [[covid-19]]. Reported case series addressed the significant reduction of  [[STEMI]] presentation and [[cath lab]] activation rate during  first wane of ″[[pandemic]] period. So, the number of [[out-of hospital]] [[cardiac arrest]] increased due to late presentation of [[STEMI]] in italy. Additionally, there was an increased [[incidence]] of acute thrombotic [[STEMI]] among [[patients]] undergoing [[coronary angiography]] suggestive of increased [[inflammation]] and [[platelet]] activation and direct [[viral]] interaction with [[ACE2]] receptors. However, one-third of [[STEMI]] [[patients]] undergoing [[angiography]] had [[non-obstructive culprit lesion]] indicating of type2 [[myocardial infarction]], [[myocarditis]] secondary to [[SARS-COV-2]] [[infection]], [[SARS-COV-2]] related [[endothelial dysfunction]], or [[cytokine storm]]. [[STEMI]] [[patients]] with confirmed [[COVID-19]]  presented with lower conventional [[risk factors]] and were more likely to present with  deteriotated [[clinical status]] and higher [[killip class]] and progression to [[cardiogenic shock]].
On March 11, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak as a [[pandemic]]. [[Coronavirus disease 2019]] ([[COVID-19]]) has negative effect on [[patients]] with [[ST-segment elevation myocardial infarction]] ([[STEMI]]). [[STEMI]] can be the first manifestation of [[COVID-19]]. Reported case series addressed the significant reduction of  [[STEMI]] presentation and [[cath lab]] activation rate during  first wave of [[pandemic]] period. So, the number of [[out-of hospital]] [[cardiac arrest]] increased due to late presentation of [[STEMI]] in italy. Additionally, there was an increased [[incidence]] of acute thrombotic [[STEMI]] among [[patients]] undergoing [[coronary angiography]] suggestive of increased [[inflammation]] and [[platelet]] activation and direct [[viral]] interaction with [[ACE2]] receptors. However, one-third of [[STEMI]] [[patients]] undergoing [[angiography]] had [[non-obstructive culprit lesion]] indicating of type2 [[myocardial infarction]], [[myocarditis]] secondary to [[SARS-COV-2]] [[infection]], [[SARS-COV-2]] related [[endothelial dysfunction]], or [[cytokine storm]]. [[STEMI]] [[patients]] with confirmed [[COVID-19]]  presented with lower conventional [[risk factors]] and were more likely to present with  deteriotated [[clinical status]] and higher [[killip class]] and progression to [[cardiogenic shock]] as well as higher [[mortality rate]] due to  [[COVID-19]] thrombogenicity and high thrombisis burden in coronary arteries.


==Historical Perspective==
==Historical Perspective==
*[[COVID-19]] ([[SARS-CoV-2]]) [[outbreak]] initiated and was discovered in December, 2019 in Wuhan, Hubei Province, China.<ref name="pmid32563019">{{cite journal |vauthors=Meng X, Deng Y, Dai Z, Meng Z |title=COVID-19 and anosmia: A review based on up-to-date knowledge |journal=Am J Otolaryngol |volume=41 |issue=5 |pages=102581 |date=June 2020 |pmid=32563019 |pmc=7265845 |doi=10.1016/j.amjoto.2020.102581 |url=}}</ref>
*[[COVID-19]] ([[SARS-CoV-2]]) [[outbreak]] initiated and was discovered in December, 2019 in Wuhan, Hubei Province, China.<ref name="pmid32563019">{{cite journal |vauthors=Meng X, Deng Y, Dai Z, Meng Z |title=COVID-19 and anosmia: A review based on up-to-date knowledge |journal=Am J Otolaryngol |volume=41 |issue=5 |pages=102581 |date=June 2020 |pmid=32563019 |pmc=7265845 |doi=10.1016/j.amjoto.2020.102581 |url=}}</ref>
*On March 11, 2020, the World Health Organization declared the [[COVID-19]] outbreak a [[pandemic]].
*On March 11, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].
*Even before the [[pandemic]] declaration, concerns about the management of Acute Myocardial Infarction in COVID-19 era started to rise and on March 11, 2020, Zeng et al addressed this issue by introducing Protocols From Sichuan Provincial People's Hospital for Acute MI diagnosis and treatment protocol adjustment during COVID-19.<ref name="ZengHuang2020">{{cite journal|last1=Zeng|first1=Jie|last2=Huang|first2=Jianxin|last3=Pan|first3=Lingai|title=How to balance [[acute myocardial infarction]] and [[COVID-19]]: the protocols from Sichuan Provincial People’s Hospital|journal=Intensive Care Medicine|volume=46|issue=6|year=2020|pages=1111–1113|issn=0342-4642|doi=10.1007/s00134-020-05993-9}}</ref>
*Even before the [[pandemic]] declaration, concerns about the management of Acute Myocardial Infarction in COVID-19 era started to rise and on March 11, 2020, Zeng et al addressed this issue by introducing Protocols From Sichuan Provincial People's Hospital for Acute MI diagnosis and treatment protocol adjustment during COVID-19.<ref name="ZengHuang2020">{{cite journal|last1=Zeng|first1=Jie|last2=Huang|first2=Jianxin|last3=Pan|first3=Lingai|title=How to balance [[acute myocardial infarction]] and [[COVID-19]]: the protocols from Sichuan Provincial People’s Hospital|journal=Intensive Care Medicine|volume=46|issue=6|year=2020|pages=1111–1113|issn=0342-4642|doi=10.1007/s00134-020-05993-9}}</ref>
*"Be Prepared" is the title of a paper published on March 15, 2020, discussing the longer time from symptom onset to first medical contact in [[STEMI]] patients due to the [[COVID-19]] [[outbreak]].The call for maximizing acute care resources, maintaining access to services while limiting nosocomial COVID-19 infection was one of the earliest in regards to COVID-19-associated myocardial infarction<ref name="ArdatiMena Lora2020">{{cite journal|last1=Ardati|first1=Amer K.|last2=Mena Lora|first2=Alfredo J.|title=Be Prepared|journal=Circulation: Cardiovascular Quality and Outcomes|volume=13|issue=4|year=2020|issn=1941-7713|doi=10.1161/CIRCOUTCOMES.120.006661}}</ref>
*"Be Prepared" is the title of a paper published on March 15, 2020, discussing the longer time from symptom onset to first medical contact in [[STEMI]] patients due to the [[COVID-19]] [[outbreak]].The call for maximizing acute care resources, maintaining access to services while limiting nosocomial [[COVID-19]] [[infection]] was one of the earliest in regards to [[COVID-19]]-associated [[myocardial infarction]].<ref name="ArdatiMena Lora2020">{{cite journal|last1=Ardati|first1=Amer K.|last2=Mena Lora|first2=Alfredo J.|title=Be Prepared|journal=Circulation: Cardiovascular Quality and Outcomes|volume=13|issue=4|year=2020|issn=1941-7713|doi=10.1161/CIRCOUTCOMES.120.006661}}</ref>
*On Apr 13, 2020, Frankie Tam 'et al.' compared Time Components of STEMI Care Before and After COVID-19 Outbreak<ref name="TamCheung2020">{{cite journal|last1=Tam|first1=Chor-Cheung Frankie|last2=Cheung|first2=Kent-Shek|last3=Lam|first3=Simon|last4=Wong|first4=Anthony|last5=Yung|first5=Arthur|last6=Sze|first6=Michael|last7=Lam|first7=Yui-Ming|last8=Chan|first8=Carmen|last9=Tsang|first9=Tat-Chi|last10=Tsui|first10=Matthew|last11=Tse|first11=Hung-Fat|last12=Siu|first12=Chung-Wah|title=Impact of Coronavirus Disease 2019 (COVID-19) Outbreak on ST-Segment–Elevation Myocardial Infarction Care in Hong Kong, China|journal=Circulation: Cardiovascular Quality and Outcomes|volume=13|issue=4|year=2020|issn=1941-7713|doi=10.1161/CIRCOUTCOMES.120.006631}}</ref>
*On Apr 13, 2020, Frankie Tam 'et al.' compared Time Components of [[STEMI]] Care Before and After COVID-19 Outbreak<ref name="TamCheung2020">{{cite journal|last1=Tam|first1=Chor-Cheung Frankie|last2=Cheung|first2=Kent-Shek|last3=Lam|first3=Simon|last4=Wong|first4=Anthony|last5=Yung|first5=Arthur|last6=Sze|first6=Michael|last7=Lam|first7=Yui-Ming|last8=Chan|first8=Carmen|last9=Tsang|first9=Tat-Chi|last10=Tsui|first10=Matthew|last11=Tse|first11=Hung-Fat|last12=Siu|first12=Chung-Wah|title=Impact of Coronavirus Disease 2019 (COVID-19) Outbreak on ST-Segment–Elevation Myocardial Infarction Care in Hong Kong, China|journal=Circulation: Cardiovascular Quality and Outcomes|volume=13|issue=4|year=2020|issn=1941-7713|doi=10.1161/CIRCOUTCOMES.120.006631}}</ref>
*On March 31, 2020, Kang discussed underlying diseases such as cardiovascular disease as a risk factor developing a serious and severe COVID-19.<ref name="Kang2020">{{cite journal|last1=Kang|first1=Yun-Jung|title=Mortality Rate of Infection With COVID-19 in Korea From the Perspective of Underlying Disease|journal=Disaster Medicine and Public Health Preparedness|year=2020|pages=1–3|issn=1935-7893|doi=10.1017/dmp.2020.60}}</ref>
*On March 31, 2020, Kang discussed underlying [[diseases]] such as [[cardiovascular disease]] as a risk factor developing a serious and severe [[COVID-19]].<ref name="Kang2020">{{cite journal|last1=Kang|first1=Yun-Jung|title=Mortality Rate of Infection With COVID-19 in Korea From the Perspective of Underlying Disease|journal=Disaster Medicine and Public Health Preparedness|year=2020|pages=1–3|issn=1935-7893|doi=10.1017/dmp.2020.60}}</ref>
*On June 9, 2020, Fried et al. discussed 4 cases showing a variety of cardiovascular presentations of COVID-19 and one of the uncertainties as whether or not the staff should proceed to [[coronary angiography]] in response to [[ECG]] changes and positive [[troponin]]<ref name="FriedRamasubbu2020">{{cite journal|last1=Fried|first1=Justin A.|last2=Ramasubbu|first2=Kumudha|last3=Bhatt|first3=Reema|last4=Topkara|first4=Veli K.|last5=Clerkin|first5=Kevin J.|last6=Horn|first6=Evelyn|last7=Rabbani|first7=LeRoy|last8=Brodie|first8=Daniel|last9=Jain|first9=Sneha S.|last10=Kirtane|first10=Ajay J.|last11=Masoumi|first11=Amirali|last12=Takeda|first12=Koji|last13=Kumaraiah|first13=Deepa|last14=Burkhoff|first14=Daniel|last15=Leon|first15=Martin|last16=Schwartz|first16=Allan|last17=Uriel|first17=Nir|last18=Sayer|first18=Gabriel|title=The Variety of Cardiovascular Presentations of COVID-19|journal=Circulation|volume=141|issue=23|year=2020|pages=1930–1936|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.120.047164}}</ref>
*On June 9, 2020, Fried et al. discussed 4 cases showing a variety of [[cardiovascular]] presentations of [[COVID-19]] and one of the uncertainties as whether or not the staff should proceed to [[coronary angiography]] in response to [[ECG]] changes and positive [[troponin]]<ref name="FriedRamasubbu2020">{{cite journal|last1=Fried|first1=Justin A.|last2=Ramasubbu|first2=Kumudha|last3=Bhatt|first3=Reema|last4=Topkara|first4=Veli K.|last5=Clerkin|first5=Kevin J.|last6=Horn|first6=Evelyn|last7=Rabbani|first7=LeRoy|last8=Brodie|first8=Daniel|last9=Jain|first9=Sneha S.|last10=Kirtane|first10=Ajay J.|last11=Masoumi|first11=Amirali|last12=Takeda|first12=Koji|last13=Kumaraiah|first13=Deepa|last14=Burkhoff|first14=Daniel|last15=Leon|first15=Martin|last16=Schwartz|first16=Allan|last17=Uriel|first17=Nir|last18=Sayer|first18=Gabriel|title=The Variety of Cardiovascular Presentations of COVID-19|journal=Circulation|volume=141|issue=23|year=2020|pages=1930–1936|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.120.047164}}</ref>
 
==Classification==
==Classification==
[[Myocardial infarction]] may be classified according to two sub-types:  
[[Myocardial infarction]] may be classified according to two sub-types:  
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* However,  previous studies showed the increase rate of acute [[MI]] immediately after [[stressful events]] such as [[earthquakes]], or [[terrorist attacks]].<ref name="pmid8552142">{{cite journal |vauthors=Leor J, Poole WK, Kloner RA |title=Sudden cardiac death triggered by an earthquake |journal=N Engl J Med |volume=334 |issue=7 |pages=413–9 |date=February 1996 |pmid=8552142 |doi=10.1056/NEJM199602153340701 |url=}}</ref>  
* However,  previous studies showed the increase rate of acute [[MI]] immediately after [[stressful events]] such as [[earthquakes]], or [[terrorist attacks]].<ref name="pmid8552142">{{cite journal |vauthors=Leor J, Poole WK, Kloner RA |title=Sudden cardiac death triggered by an earthquake |journal=N Engl J Med |volume=334 |issue=7 |pages=413–9 |date=February 1996 |pmid=8552142 |doi=10.1056/NEJM199602153340701 |url=}}</ref>  
* Early clinical features include typical [[chest pain]], [[dyspnea]], [[arrhythmia]], [[hemodynamic collapse]], or [[syncope]].
* Early clinical features include typical [[chest pain]], [[dyspnea]], [[arrhythmia]], [[hemodynamic collapse]], or [[syncope]].
*[[Patients]] with [[MI]] associated [[COVID-19]] experienced longer total [[ischemic]] [[time]], more severe [[condition]] at the time of [[admission]], higher rate of in-hospital advers events. <ref name="pmid34143840">{{cite journal |vauthors=Fardman A, Zahger D, Orvin K, Oren D, Kofman N, Mohsen J, Tsafrir O, Asher E, Rubinshtein R, Jamal J, Efraim R, Halabi M, Shacham Y, Fortis LH, Cohen T, Klempfner R, Segev A, Beigel R, Matetzky S |title=Acute myocardial infarction in the Covid-19 era: Incidence, clinical characteristics and in-hospital outcomes-A multicenter registry |journal=PLoS One |volume=16 |issue=6 |pages=e0253524 |date=2021 |pmid=34143840 |pmc=8213163 |doi=10.1371/journal.pone.0253524 |url=}}</ref>
* [[Patients]] with [[MI]] associated [[COVID-19]] experienced longer total [[ischemic]] [[time]], more severe [[condition]] at the time of [[admission]], higher rate of in-hospital advers events. <ref name="pmid34143840">{{cite journal |vauthors=Fardman A, Zahger D, Orvin K, Oren D, Kofman N, Mohsen J, Tsafrir O, Asher E, Rubinshtein R, Jamal J, Efraim R, Halabi M, Shacham Y, Fortis LH, Cohen T, Klempfner R, Segev A, Beigel R, Matetzky S |title=Acute myocardial infarction in the Covid-19 era: Incidence, clinical characteristics and in-hospital outcomes-A multicenter registry |journal=PLoS One |volume=16 |issue=6 |pages=e0253524 |date=2021 |pmid=34143840 |pmc=8213163 |doi=10.1371/journal.pone.0253524 |url=}}</ref>
* [[STEMI]] [[patients]] with [[COVID-19]] were more likely to develop [[cardiogenic shock]] and were less likey to receive invasive [[coronary angiography]].<ref name="pmid33888249">{{cite journal |vauthors=Garcia S, Dehghani P, Grines C, Davidson L, Nayak KR, Saw J, Waksman R, Blair J, Akshay B, Garberich R, Schmidt C, Ly HQ, Sharkey S, Mercado N, Alfonso CE, Misumida N, Acharya D, Madan M, Hafiz AM, Javed N, Shavadia J, Stone J, Alraies MC, Htun W, Downey W, Bergmark BA, Ebinger J, Alyousef T, Khalili H, Hwang CW, Purow J, Llanos A, McGrath B, Tannenbaum M, Resar J, Bagur R, Cox-Alomar P, Stefanescu Schmidt AC, Cilia LA, Jaffer FA, Gharacholou M, Salinger M, Case B, Kabour A, Dai X, Elkhateeb O, Kobayashi T, Kim HH, Roumia M, Aguirre FV, Rade J, Chong AY, Hall HM, Amlani S, Bagherli A, Patel RAG, Wood DA, Welt FG, Giri J, Mahmud E, Henry TD |title=Initial Findings From the North American COVID-19 Myocardial Infarction Registry |journal=J Am Coll Cardiol |volume=77 |issue=16 |pages=1994–2003 |date=April 2021 |pmid=33888249 |pmc=8054772 |doi=10.1016/j.jacc.2021.02.055 |url=}}</ref>
* [[STEMI]] [[patients]] with [[COVID-19]] were more likely to develop [[cardiogenic shock]] and were less likey to receive invasive [[coronary angiography]].<ref name="pmid33888249">{{cite journal |vauthors=Garcia S, Dehghani P, Grines C, Davidson L, Nayak KR, Saw J, Waksman R, Blair J, Akshay B, Garberich R, Schmidt C, Ly HQ, Sharkey S, Mercado N, Alfonso CE, Misumida N, Acharya D, Madan M, Hafiz AM, Javed N, Shavadia J, Stone J, Alraies MC, Htun W, Downey W, Bergmark BA, Ebinger J, Alyousef T, Khalili H, Hwang CW, Purow J, Llanos A, McGrath B, Tannenbaum M, Resar J, Bagur R, Cox-Alomar P, Stefanescu Schmidt AC, Cilia LA, Jaffer FA, Gharacholou M, Salinger M, Case B, Kabour A, Dai X, Elkhateeb O, Kobayashi T, Kim HH, Roumia M, Aguirre FV, Rade J, Chong AY, Hall HM, Amlani S, Bagherli A, Patel RAG, Wood DA, Welt FG, Giri J, Mahmud E, Henry TD |title=Initial Findings From the North American COVID-19 Myocardial Infarction Registry |journal=J Am Coll Cardiol |volume=77 |issue=16 |pages=1994–2003 |date=April 2021 |pmid=33888249 |pmc=8054772 |doi=10.1016/j.jacc.2021.02.055 |url=}}</ref>
*Ischemic time and [[door to ballon time]] increased in [[patients]] with [[STEMI]] associated [[COVID-19]].<ref name="pmid33339541">{{cite journal |vauthors=De Luca G, Cercek M, Jensen LO, Vavlukis M, Calmac L, Johnson T, Roura I Ferrer G, Ganyukov V, Wojakowski W, von Birgelen C, Versaci F, Ten Berg J, Laine M, Dirksen M, Casella G, Kala P, Díez Gil JL, Becerra V, De Simone C, Carrill X, Scoccia A, Lux A, Kovarnik T, Davlouros P, Gabrielli G, Flores Rios X, Bakraceski N, Levesque S, Guiducci V, Kidawa M, Marinucci L, Zilio F, Galasso G, Fabris E, Menichelli M, Manzo S, Caiazzo G, Moreu J, Sanchis Forés J, Donazzan L, Vignali L, Teles R, Bosa Ojeda F, Lehtola H, Camacho-Freiere S, Kraaijeveld A, Antti Y, Boccalatte M, Martínez-Luengas IL, Scheller B, Alexopoulos D, Uccello G, Faurie B, Gutierrez Barrios A, Wilbert B, Cortese G, Moreno R, Parodi G, Kedhi E, Verdoia M |title=Impact of COVID-19 pandemic and diabetes on mechanical reperfusion in patients with STEMI: insights from the ISACS STEMI COVID 19 Registry |journal=Cardiovasc Diabetol |volume=19 |issue=1 |pages=215 |date=December 2020 |pmid=33339541 |pmc=7747477 |doi=10.1186/s12933-020-01196-0 |url=}}</ref>  
*Ischemic time and [[door to ballon time]] increased in [[patients]] with [[STEMI]] associated [[COVID-19]].<ref name="pmid33339541">{{cite journal |vauthors=De Luca G, Cercek M, Jensen LO, Vavlukis M, Calmac L, Johnson T, Roura I Ferrer G, Ganyukov V, Wojakowski W, von Birgelen C, Versaci F, Ten Berg J, Laine M, Dirksen M, Casella G, Kala P, Díez Gil JL, Becerra V, De Simone C, Carrill X, Scoccia A, Lux A, Kovarnik T, Davlouros P, Gabrielli G, Flores Rios X, Bakraceski N, Levesque S, Guiducci V, Kidawa M, Marinucci L, Zilio F, Galasso G, Fabris E, Menichelli M, Manzo S, Caiazzo G, Moreu J, Sanchis Forés J, Donazzan L, Vignali L, Teles R, Bosa Ojeda F, Lehtola H, Camacho-Freiere S, Kraaijeveld A, Antti Y, Boccalatte M, Martínez-Luengas IL, Scheller B, Alexopoulos D, Uccello G, Faurie B, Gutierrez Barrios A, Wilbert B, Cortese G, Moreno R, Parodi G, Kedhi E, Verdoia M |title=Impact of COVID-19 pandemic and diabetes on mechanical reperfusion in patients with STEMI: insights from the ISACS STEMI COVID 19 Registry |journal=Cardiovasc Diabetol |volume=19 |issue=1 |pages=215 |date=December 2020 |pmid=33339541 |pmc=7747477 |doi=10.1186/s12933-020-01196-0 |url=}}</ref>  
* About 40% of [[STEMI]] [[patients]] in the setting of [[COVID-19]] do not have culprit [[lesion]] in [[coronary angiography]].
* About 40% of [[STEMI]] [[patients]] in the setting of [[COVID-19]] do not have culprit [[lesion]] in [[coronary angiography]].<ref name="pmid32352306">{{cite journal |vauthors=Stefanini GG, Montorfano M, Trabattoni D, Andreini D, Ferrante G, Ancona M, Metra M, Curello S, Maffeo D, Pero G, Cacucci M, Assanelli E, Bellini B, Russo F, Ielasi A, Tespili M, Danzi GB, Vandoni P, Bollati M, Barbieri L, Oreglia J, Lettieri C, Cremonesi A, Carugo S, Reimers B, Condorelli G, Chieffo A |title=ST-Elevation Myocardial Infarction in Patients With COVID-19: Clinical and Angiographic Outcomes |journal=Circulation |volume=141 |issue=25 |pages=2113–2116 |date=June 2020 |pmid=32352306 |pmc=7302062 |doi=10.1161/CIRCULATIONAHA.120.047525 |url=}}</ref>
* The [[clinical feature]] in the setting of non-thrombotic [[STEMI]] may be due to type2 [[myocardial infarction]], [[[[myocarditis]] secondary to [[SARS-COV-2]] [[infection]], [[SARS-COV-2]] related [[endothelial dysfunction]], [[cytokine storm]].
* The [[clinical feature]] in the setting of non-thrombotic [[STEMI]] may be due to type2 [[myocardial infarction]], [[myocarditis]] secondary to [[SARS-COV-2]] [[infection]], [[SARS-COV-2]] related [[endothelial dysfunction]], [[cytokine storm]].
* In [[STEMI]] associated [[COVID-19]], the [[rate]] of [[arterial ]] [[thrombosis]] burden was higher than non-[[covid-19]] [[patients]], so the [[clinical status]] should be established in [[covid-19]] [[patients]].<ref name="pmid32679155">{{cite journal |vauthors=Choudry FA, Hamshere SM, Rathod KS, Akhtar MM, Archbold RA, Guttmann OP, Woldman S, Jain AK, Knight CJ, Baumbach A, Mathur A, Jones DA |title=High Thrombus Burden in Patients With COVID-19 Presenting With ST-Segment Elevation Myocardial Infarction |journal=J Am Coll Cardiol |volume=76 |issue=10 |pages=1168–1176 |date=September 2020 |pmid=32679155 |pmc=7833185 |doi=10.1016/j.jacc.2020.07.022 |url=}}</ref>
* Complications of [[STEMI]] associated [[COVID-19]] are:
*: Higher [[incidence]] of multiple [[thrombotic]] culprit [[lesion]]s
*: Higher [[stent thrombosis]]
*: Higher [[thrombus grade]]
*: Lower rate to [[myocardial blush grade]]
*: Increased use of [[GP2b/3a inhibitors]]
*: Higher [[thrombosis]] aspiration
*: Higher rate of [[pre-hospital]] [[cardiac arrest]]
*: Higher [[admission days]]
*: Lower [[LVEF]], higher [[myocardial damage]] , and [[toponin levels]]
*: Increased [[in-hospital]] [[mortality]]
* Prognosis was generally poor, and the [[mortality rate]] of [[patients]] presented with [[STEMI]] associated [[COVID-19]] was high.  
* Prognosis was generally poor, and the [[mortality rate]] of [[patients]] presented with [[STEMI]] associated [[COVID-19]] was high.  


* Table  bellow shown the reported cases [[TIMI  flow]] zero or no-reflow in [[patients]] with [[STEMI]] associated [[COVID-19]] undergoing [[percutaneous coronary intervention]].   
* Table  bellow shown the reported cases of [[TIMI  flow]] zero or no-reflow in [[patients]] with [[thrombotic]] [[STEMI]] associated [[COVID-19]] undergoing [[percutaneous coronary intervention]].   
{| style="border: 2px solid #4479BA; align="left"
{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Age, sex}}
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Age, sex}}
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| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Hypertension]], [[diabetes mellitus]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Hypertension]], [[diabetes mellitus]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | New [[chest pain]], [[shortness of breath]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | New [[chest pain]], [[shortness of breath]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Troponin]]=
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | High levels of  [[troponin]], [[CRP]], [[D-dimer]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 8 weeks
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 7 days
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | None
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Sinus bradycardia]], [[complete heart block]], [[inferior STelevation]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Mild
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Mild
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[STEMI]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Inferior [[STEMI]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[LAD]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 100% [[RCA]] stenosis, moderate [[LAD]] stenosis, NO visible edge dissection in [[IVUS]]  
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Conservative, dual [[antiplatelet]], [[betablocker]], [[ACE inhibitor]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[ASA]], [[ticagrelor]], [[heparin]], [[eptifibatide ]], [[PCI]] of [[RCA]], [[ballon angioplasty]], [[thrombectomy]], [[vasodilation]], [[IABP]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Survived
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Cardiogenic shock]] after [[PCI]] despite patency of [[stent]] or no evidence of edge dissection in [[IVUS]], expired due to persistent [[microvascular thrombosis]]
|-
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 40 years, [[male]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 74 years, [[female]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | None
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Hypertension]], [[diabetes mellitus]], [[hyperlipidemia]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Fever]], [[cough]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Shortness of breath]], [[fever]], [[myalgia]], [[hypoxic]] [[respiratory failure]], new onset [[chest pain]] 5 days after admission
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Not reported
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | High levels of [[troponin]], [[CRP]], [[ferritin]], [[D-dimer]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 7 days after [[ECMO]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 8 days
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Cardiogenic shock]], [[severe respiratory distress syndrome]], [[cardiac thrombosis]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |  
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[lung]] infiltration
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[lung]] infiltration
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[NSTEMI]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Antrolateral STEMI]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[LAD]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 100% distal [[LAD]] [[lesion]],
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Conservative
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[ASA]], [[clopidogrel]], [[enoxaparin]], [[intubation]], [[urgent catheterization]], [[thrombectomy]], [[PCI]] of [[LAD]] lesion, [[ballon angioplasty]], [[stent placement]], no achieved [[distal flow]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Survived
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Expired due to [[sepsis]] and [[respiratory failure]]
|-
|-
|}
|}
*In a study done among 28 patients with COVID-19, [[STEMI]] was the first presentation of the COVID-19 infection in 24 cases.
*Typical [[chest pain]] in the presence/absence of [[dyspnea]] was the most common [[symptom]]. [[Dyspnea]] without [[chest pain]] was the second common [[symptoms]] among the cases.
* 11 out of 28 (39.3%) patients died during their hospitalization course.
*According to a recent [[systematic review]] and [[meta-analysis]],[[acute cardiac injury]] with [[troponin]] levels greater than 28 pg/ml was detected in 12.4% of confirmed [[COVID-19]] patients.''<ref name="NasiriHaddadi2020">{{cite journal|last1=Nasiri|first1=Mohammad Javad|last2=Haddadi|first2=Sara|last3=Tahvildari|first3=Azin|last4=Farsi|first4=Yeganeh|last5=Arbabi|first5=Mahta|last6=Hasanzadeh|first6=Saba|last7=Jamshidi|first7=Parnian|last8=Murthi|first8=Mukunthan|last9=Mirsaeidi|first9=Mehdi|year=2020|doi=10.1101/2020.03.24.20042903}}</ref>''


==Diagnosis==
==Diagnosis==
Line 161: Line 160:


*Considering the [[diagnostic criteria]], it is not difficult to differentiate [[STEMI]] from other causes of [[chest pain]] or equivalent anginal symptoms. However, during [[COVID-19]] [[pandemic]] other causes of [[myocardial injury|COVID-19-associated myocardial injury]] such as [[stress cardiomyopathy|COVID-19-associated stress cardiomyopathy]] or [[myocarditis|COVID-19-associated myocarditis]] should be the top of the differential diagnosis list.
*Considering the [[diagnostic criteria]], it is not difficult to differentiate [[STEMI]] from other causes of [[chest pain]] or equivalent anginal symptoms. However, during [[COVID-19]] [[pandemic]] other causes of [[myocardial injury|COVID-19-associated myocardial injury]] such as [[stress cardiomyopathy|COVID-19-associated stress cardiomyopathy]] or [[myocarditis|COVID-19-associated myocarditis]] should be the top of the differential diagnosis list.
*[[EKG]] criteria are not specific and may also be present in other [[myocardial injury|COVID-19-associated myocardial injury]] conditions associated with COVID-19.
*[[EKG]] criteria are not specific and may also be present in other [[myocardial injury|COVID-19-associated myocardial injury]] conditions associated with [[COVID-19]].
*Although elevated [[troponin]] is also a non-specific finding, for patients with a high troponin level and suspected [[STEMI]], [[echocardiography]] is not generally performed due to the emergent need for [[angiography]].  
*Although elevated [[troponin]] is also a non-specific finding, for [[patients]] with a high troponin level and suspected [[STEMI]], [[echocardiography]] is not generally performed due to the emergent need for [[angiography]].  
*For critically ill patients due to COVID-19, the decision to perform angiography or [[reperfusion]] should be done on a case by case basis.<ref name="UpToDate">{{cite website| author= Duane S Pinto| display-authors=etal| title=Coronavirus disease 2019 (COVID-19): Myocardial infarction and other coronary artery disease issues (2020). | year= May 2020 | url=https:https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19-myocardial-infarction-and-other-coronary-artery-disease-issues }} </ref>
*For critically ill patients due to [[COVID-19]], the decision to perform angiography or [[reperfusion]] should be done on a case by case basis.


===History and Symptoms===
===History and Symptoms===
Line 170: Line 169:
:*[[Chest pain|Substernal chest pain]]
:*[[Chest pain|Substernal chest pain]]
:*Occurs at rest or [[exertion]]
:*Occurs at rest or [[exertion]]
:*Radiation to neck, jaw, left shoulder and left arm
:*Radiation to [[neck]], []jaw]], left []shoulder]] and left [[arm]]
:*Aggravated by physical activity and emotional stress
:*Aggravated by [[physical activity]] and []emotional stress]]
:*Relieved by rest, [[nitroglycerin]] or both
:*Relieved by [[rest]], [[nitroglycerin]] or both
*Chest discomfort described crushing, squeezing, burning, choking, tightness or aching
*[[Chest discomfort]] described [[crushing]], [[squeezing]], [[burning]], [[choking]], [[tightness]], or [[aching]]
*[[Dyspnea]]
*[[Dyspnea]]
*[[Diaphoresis]]
*[[Diaphoresis]]
Line 187: Line 186:


===Laboratory Findings===
===Laboratory Findings===
Elevated cardiac [[Troponin]] levels have been detected in 10%-30% of COVID-19 patients and studies have shown an association between mortality and higher troponin in COVID-19. However, the clinical value of [[troponin]] to assess suspected [[ACS]] based on clinical presentation has not been established. <ref name="pmid32171076">{{cite journal| author=Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z | display-authors=etal| title=Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. | journal=Lancet | year= 2020 | volume= 395 | issue= 10229 | pages= 1054-1062 | pmid=32171076 | doi=10.1016/S0140-6736(20)30566-3 | pmc=7270627 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32171076  }} </ref>
*Laboratory finding in [[patients]] with [[STEMI]] associated [[COVID-19]] showed  increase levels of [[inflammatory markers]] including  [[lymphopnea]], [[D-dimer]], [[C- reactive protein]] as well as increased [[troponin]] and [[CK-MB]] levels.
*For COVID-19 laboratory findings please[[COVID-19 laboratory findings| click here]]
* Higher [[D-dimer]] level in [[COVID-19]] [[patients]] with [[STEMI]] was correlated  with [[thrombus]] grade, [[myocardial blush grade]], need for higher dose of [[heparin]] during primary [[PCI]].
*For non ST elevation myocardial infarction biomarkers please[[Unstable angina / non ST elevation myocardial infarction biomarkers| click here]]
*For ST elevation myocardial infarction laboratory findings please[[ST elevation myocardial infarction laboratory findings| click here]]


===Electrocardiogram===
===Electrocardiogram===
Line 238: Line 235:


*Treatment of [[ST elevation myocardial infarction|STEMI]] and COVID-19:  
*Treatment of [[ST elevation myocardial infarction|STEMI]] and COVID-19:  
**The specific protocols for the treatment are evolving. Early recommendations showed intravenous [[thrombolysis]] as first-line therapy for [[STEMI]] patients with confirmed COVID-19 since most hospitals do not have protected cardiac [[catheterization]] labs.<ref name="pmid32550258">{{cite journal| author=Ullah W, Sattar Y, Saeed R, Ahmad A, Boigon MI, Haas DC | display-authors=etal| title=As the COVID-19 pandemic drags on, where have all the STEMIs gone? | journal=Int J Cardiol Heart Vasc | year= 2020 | volume= 29 | issue=  | pages= 100550 | pmid=32550258 | doi=10.1016/j.ijcha.2020.100550 | pmc=7261452 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32550258  }} </ref>
** [[ Intravenous]] [[thrombolysis]] as first-line therapy for [[STEMI]] patients with confirmed COVID-19 since most hospitals do not have protected cardiac [[catheterization]] labs.<ref name="pmid32550258">{{cite journal| author=Ullah W, Sattar Y, Saeed R, Ahmad A, Boigon MI, Haas DC | display-authors=etal| title=As the COVID-19 pandemic drags on, where have all the STEMIs gone? | journal=Int J Cardiol Heart Vasc | year= 2020 | volume= 29 | issue=  | pages= 100550 | pmid=32550258 | doi=10.1016/j.ijcha.2020.100550 | pmc=7261452 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32550258  }} </ref>
**According to the latest European Society of Cardiology (ESC) guidance for the management of cardiac complications related to COVID-19, if STEMI is diagnosed timely primary percutaneous intervention should be performed, irrespective of COVID-19 diagnosis. Fibrinolysis should be the first treatment choice when percutaneous intervention is not feasible within 12 hours of symptom onset.
**According to the latest European Society of Cardiology (ESC) guidance for the management of cardiac complications related to [[COVID-19]], if [[STEMI]] is diagnosed timely primary percutaneous intervention should be performed, irrespective of COVID-19 diagnosis. [[Fibrinolysis]] should be the first treatment choice when percutaneous intervention is not feasible within 12 hours of symptom onset.
*Treatment of non-ST-STEMI, should be based on risk stratification:
*Treatment of [[NSTEMI]] should be based on risk stratification:
**High-risk cases: immediate invasive strategy, SARS-CoV-2 testing should be delayed.
**High-risk cases: immediate [[invasive strategy]]
**Intermediate/low-risk cases: non-invasive strategies such as [[coronary]] [[CT-angiography]] with regular follow-ups should be the treatment of choice.<ref name="MontoneIannaccone2020">{{cite journal|last1=Montone|first1=Rocco A|last2=Iannaccone|first2=Giulia|last3=Meucci|first3=Maria Chiara|last4=Gurgoglione|first4=Filippo|last5=Niccoli|first5=Giampaolo|title=Myocardial and Microvascular Injury Due to Coronavirus Disease 2019|journal=European Cardiology Review|volume=15|year=2020|issn=17583764|doi=10.15420/ecr.2020.22}}</ref>
**Intermediate/low-risk cases: non-invasive strategies such as [[coronary]] [[CT-angiography]] with regular follow-ups should be the treatment of choice.<ref name="MontoneIannaccone2020">{{cite journal|last1=Montone|first1=Rocco A|last2=Iannaccone|first2=Giulia|last3=Meucci|first3=Maria Chiara|last4=Gurgoglione|first4=Filippo|last5=Niccoli|first5=Giampaolo|title=Myocardial and Microvascular Injury Due to Coronavirus Disease 2019|journal=European Cardiology Review|volume=15|year=2020|issn=17583764|doi=10.15420/ecr.2020.22}}</ref>


===Primary Prevention===
===Primary Prevention===
*There are no available [[vaccines]] against [[COVID-19]] and studies are going on for finding an effective [[vaccine]].<br>
*Effective measure for [[primary prevention]] of [[MI]] associated [[COVID-19]] is [[vaccination]].
*Other [[primary prevention]] strategies include measures to reduce the occurrence of [[myocardial injury]] among COVID-19 patients. Recent studies have suggested the use of medications improving [[microcirculation]], especially for the high-risk group such as males, smokers, diabetic patients, and patients with established cardiovascular disease comorbidities.<ref name="MontoneIannaccone2020">{{cite journal|last1=Montone|first1=Rocco A|last2=Iannaccone|first2=Giulia|last3=Meucci|first3=Maria Chiara|last4=Gurgoglione|first4=Filippo|last5=Niccoli|first5=Giampaolo|title=Myocardial and Microvascular Injury Due to Coronavirus Disease 2019|journal=European Cardiology Review|volume=15|year=2020|issn=17583764|doi=10.15420/ecr.2020.22}}</ref><br>
*Other [[primary prevention]] strategies include measures to reduce the occurrence of [[myocardial injury]] among [[COVID-19]] [[patients]]. Recent studies have suggested the use of medications improving [[microcirculation]], especially for the high-risk group such as [[males]], [[smokers]], [[diabetic]] [[patients]], and [[patients]] with established [[cardiovascular]] disease [[comorbidities]].<ref name="MontoneIannaccone2020">{{cite journal|last1=Montone|first1=Rocco A|last2=Iannaccone|first2=Giulia|last3=Meucci|first3=Maria Chiara|last4=Gurgoglione|first4=Filippo|last5=Niccoli|first5=Giampaolo|title=Myocardial and Microvascular Injury Due to Coronavirus Disease 2019|journal=European Cardiology Review|volume=15|year=2020|issn=17583764|doi=10.15420/ecr.2020.22}}</ref><br>
**For Risk factors associated with COVID-19 please [[COVID-19 risk factors|click here]]
**For Risk factors associated with COVID-19 please [[COVID-19 risk factors|click here]]


===Secondary Prevention===
===Secondary Prevention===
*There are no established measures for the secondary prevention of COVID-19-associated myocardial infarction.
*There are no established measures for the [[secondary prevention]] of [[COVID-19]]-associated [[myocardial infarction]].
*For ST-elevation myocardial infarction secondary prevention please [[ST elevation myocardial infarction secondary prevention| click here]]
*For ST-elevation myocardial infarction secondary prevention please [[ST elevation myocardial infarction secondary prevention| click here]]


Latest revision as of 11:05, 10 November 2021

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Main article:COVID-19
For COVID-19 frequently asked inpatient questions, click here
For COVID-19 frequently asked outpatient questions, click here

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Sara Haddadi, M.D.[3]

Synonyms and keywords: Novel coronavirus, covid-19, COVID-19, SARS-CoV-2, Myocardial Infarction, MI, ST Elevation Myocardial Infarction, STEMI, Non ST Elevation Myocardial Infarction, NSTEMI

Overview

On March 11, 2020, the World Health Organization declared the COVID-19 outbreak as a pandemic. Coronavirus disease 2019 (COVID-19) has negative effect on patients with ST-segment elevation myocardial infarction (STEMI). STEMI can be the first manifestation of COVID-19. Reported case series addressed the significant reduction of STEMI presentation and cath lab activation rate during first wave of pandemic period. So, the number of out-of hospital cardiac arrest increased due to late presentation of STEMI in italy. Additionally, there was an increased incidence of acute thrombotic STEMI among patients undergoing coronary angiography suggestive of increased inflammation and platelet activation and direct viral interaction with ACE2 receptors. However, one-third of STEMI patients undergoing angiography had non-obstructive culprit lesion indicating of type2 myocardial infarction, myocarditis secondary to SARS-COV-2 infection, SARS-COV-2 related endothelial dysfunction, or cytokine storm. STEMI patients with confirmed COVID-19 presented with lower conventional risk factors and were more likely to present with deteriotated clinical status and higher killip class and progression to cardiogenic shock as well as higher mortality rate due to COVID-19 thrombogenicity and high thrombisis burden in coronary arteries.

Historical Perspective

  • COVID-19 (SARS-CoV-2) outbreak initiated and was discovered in December, 2019 in Wuhan, Hubei Province, China.[1]
  • On March 11, 2020, the World Health Organization declared the COVID-19 outbreak a pandemic.
  • Even before the pandemic declaration, concerns about the management of Acute Myocardial Infarction in COVID-19 era started to rise and on March 11, 2020, Zeng et al addressed this issue by introducing Protocols From Sichuan Provincial People's Hospital for Acute MI diagnosis and treatment protocol adjustment during COVID-19.[2]
  • "Be Prepared" is the title of a paper published on March 15, 2020, discussing the longer time from symptom onset to first medical contact in STEMI patients due to the COVID-19 outbreak.The call for maximizing acute care resources, maintaining access to services while limiting nosocomial COVID-19 infection was one of the earliest in regards to COVID-19-associated myocardial infarction.[3]
  • On Apr 13, 2020, Frankie Tam 'et al.' compared Time Components of STEMI Care Before and After COVID-19 Outbreak[4]
  • On March 31, 2020, Kang discussed underlying diseases such as cardiovascular disease as a risk factor developing a serious and severe COVID-19.[5]
  • On June 9, 2020, Fried et al. discussed 4 cases showing a variety of cardiovascular presentations of COVID-19 and one of the uncertainties as whether or not the staff should proceed to coronary angiography in response to ECG changes and positive troponin[6]

Classification

Myocardial infarction may be classified according to two sub-types:

Pathophysiology

The mechanism of COVID-19 myocardial infarction is not fully understood and is likely multi-factorial.

Pathological changes:

Causes

According to the Fourth Universal Definition of MI, there are two clinical classifications of the disease based on the causes:

Most of the MIs associated with COVID-19 are type 2 indicating the cause to be the primary infection, hemodynamic disturbance, or respiratory deterioration.[11] [8]

Differentiating Myocardial infarction from other Diseases

  • For further information about the differential diagnosis, click here.
  • To view the differential diagnosis of COVID-19, click here.

Epidemiology and Demographics

  • The exact incidence of STEMI associated COVID-19 is not fully understood yet. However, during the first wave of pandemic, the number of hospitalized STEMI patients decreased in comparison with the parallel year.[12][13][14][15]
    • A study in Italy showed up to a 49.4% reduction in admissions for acute MI to coronary care units from March 12th to 19th in 2020 compared to the equivalent time in 2019. [12]

Age

Gender

Race

Risk Factors

Common risk factors in the development of acute coronary syndrome including STEMI and non-STEMI are listed below:[17]

For Risk factors associated with COVID-19 please click here

Screening

Due to the higher mortality of patients with COVID-19 and cardiovascular comorbidities, it advisable to triage patients with COVID-19 based on their underlying CVD for a more aggressive treatment plan.[18]

Natural History, Complications and Prognosis

Age, sex Cardiovascular history Symptoms Laboratory findings Timing according to covid-19 infection Concomitant covid-19 complications Covid-19 severity Diagnosis Vessle Treatment Outcome
65 years, male Hypertension, diabetes mellitus New chest pain, shortness of breath High levels of troponin, CRP, D-dimer 7 days Sinus bradycardia, complete heart block, inferior STelevation Mild Inferior STEMI 100% RCA stenosis, moderate LAD stenosis, NO visible edge dissection in IVUS ASA, ticagrelor, heparin, eptifibatide , PCI of RCA, ballon angioplasty, thrombectomy, vasodilation, IABP Cardiogenic shock after PCI despite patency of stent or no evidence of edge dissection in IVUS, expired due to persistent microvascular thrombosis
74 years, female Hypertension, diabetes mellitus, hyperlipidemia Shortness of breath, fever, myalgia, hypoxic respiratory failure, new onset chest pain 5 days after admission High levels of troponin, CRP, ferritin, D-dimer 8 days Severe lung infiltration Antrolateral STEMI 100% distal LAD lesion, ASA, clopidogrel, enoxaparin, intubation, urgent catheterization, thrombectomy, PCI of LAD lesion, ballon angioplasty, stent placement, no achieved distal flow Expired due to sepsis and respiratory failure

Diagnosis

Diagnostic Study of Choice


History and Symptoms

There are no specific symptoms associated with COVID-19-associated-Myocardial infarction. Common symptoms in patients with acute MI is listed below:[27]

For non-ST elevation myocardial infarction history and symptoms please click here
For ST elevation myocardial infarction history and symptoms please click here

Physical Examination

  • For non-ST elevation myocardial infarction physical examination please click here
  • For STEMI physical examination please click here

Laboratory Findings

Electrocardiogram

There are no specific ECG findings associated with both COVID-19 and Myocardial infarction.

  • For non-ST-elevation myocardial infarction electrocardiogram please click here
  • For ST-elevation myocardial infarction electrocardiogram please click here
  • For COVID-19 electrocardiogram findings please click here

X-ray

There are no specific X-ray findings associated with both COVID-19 and Myocardial infarction.

  • For X-ray findings in COVID-19 please click here
  • For X-ray findings in Myocardial Infarction please click here

Echocardiography

  • In a study done among 28 patients with COVID-19 with STEMI, the following echocardiographic findings were reported:[19]
    • Localized wall motion abnormalities
    • Diffuse hypokinesia  
    • Left ventricular ejection fraction was lower than 50% in about 61% of the individuals.


CT scan

  • There are no specific CT scan findings related to COVID-19-associated myocardial infarction.

MRI

  • There are no MRI findings related to COVID-19-associated myocardial infarction.

Other Imaging Studies

Coronary Angiography

  • In one study done among patients with COVID-19 with STEMI, coronary angiography failed to reveal any culprit lesion in about 40% of the patients. However, in the remaining patients, coronary angiography was able to localize a lesion.[19]


Other Diagnostic Studies

  • There are no specific other diagnostic studies related to COVID-19-associated myocardial infarction.

Treatment

Medical Therapy

In patients with ACS and COVID-19, treatment should follow the guidelines of the updated Society for Cardiovascular Angiography and Interventions.[10] [28]

  • Treatment of STEMI and COVID-19:
    • Intravenous thrombolysis as first-line therapy for STEMI patients with confirmed COVID-19 since most hospitals do not have protected cardiac catheterization labs.[29]
    • According to the latest European Society of Cardiology (ESC) guidance for the management of cardiac complications related to COVID-19, if STEMI is diagnosed timely primary percutaneous intervention should be performed, irrespective of COVID-19 diagnosis. Fibrinolysis should be the first treatment choice when percutaneous intervention is not feasible within 12 hours of symptom onset.
  • Treatment of NSTEMI should be based on risk stratification:

Primary Prevention

Secondary Prevention

References

  1. ↑ Meng X, Deng Y, Dai Z, Meng Z (June 2020). "COVID-19 and anosmia: A review based on up-to-date knowledge". Am J Otolaryngol. 41 (5): 102581. doi:10.1016/j.amjoto.2020.102581. PMC 7265845 Check |pmc= value (help). PMID 32563019 Check |pmid= value (help).
  2. ↑ Zeng, Jie; Huang, Jianxin; Pan, Lingai (2020). "How to balance acute myocardial infarction and COVID-19: the protocols from Sichuan Provincial People’s Hospital". Intensive Care Medicine. 46 (6): 1111–1113. doi:10.1007/s00134-020-05993-9. ISSN 0342-4642.
  3. ↑ Ardati, Amer K.; Mena Lora, Alfredo J. (2020). "Be Prepared". Circulation: Cardiovascular Quality and Outcomes. 13 (4). doi:10.1161/CIRCOUTCOMES.120.006661. ISSN 1941-7713.
  4. ↑ Tam, Chor-Cheung Frankie; Cheung, Kent-Shek; Lam, Simon; Wong, Anthony; Yung, Arthur; Sze, Michael; Lam, Yui-Ming; Chan, Carmen; Tsang, Tat-Chi; Tsui, Matthew; Tse, Hung-Fat; Siu, Chung-Wah (2020). "Impact of Coronavirus Disease 2019 (COVID-19) Outbreak on ST-Segment–Elevation Myocardial Infarction Care in Hong Kong, China". Circulation: Cardiovascular Quality and Outcomes. 13 (4). doi:10.1161/CIRCOUTCOMES.120.006631. ISSN 1941-7713.
  5. ↑ Kang, Yun-Jung (2020). "Mortality Rate of Infection With COVID-19 in Korea From the Perspective of Underlying Disease". Disaster Medicine and Public Health Preparedness: 1–3. doi:10.1017/dmp.2020.60. ISSN 1935-7893.
  6. ↑ Fried, Justin A.; Ramasubbu, Kumudha; Bhatt, Reema; Topkara, Veli K.; Clerkin, Kevin J.; Horn, Evelyn; Rabbani, LeRoy; Brodie, Daniel; Jain, Sneha S.; Kirtane, Ajay J.; Masoumi, Amirali; Takeda, Koji; Kumaraiah, Deepa; Burkhoff, Daniel; Leon, Martin; Schwartz, Allan; Uriel, Nir; Sayer, Gabriel (2020). "The Variety of Cardiovascular Presentations of COVID-19". Circulation. 141 (23): 1930–1936. doi:10.1161/CIRCULATIONAHA.120.047164. ISSN 0009-7322.
  7. ↑ Bansal, Manish (2020). "Cardiovascular disease and COVID-19". Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 14 (3): 247–250. doi:10.1016/j.dsx.2020.03.013. ISSN 1871-4021.
  8. ↑ 8.0 8.1 8.2 8.3 Montone, Rocco A; Iannaccone, Giulia; Meucci, Maria Chiara; Gurgoglione, Filippo; Niccoli, Giampaolo (2020). "Myocardial and Microvascular Injury Due to Coronavirus Disease 2019". European Cardiology Review. 15. doi:10.15420/ecr.2020.22. ISSN 1758-3764.
  9. ↑ Xiong, Chenglong; Feng, Yi; Chen, Mingquan; Li, Xiangjie; Chen, Liang (2020). "The ACE2 expression in human heart indicates new potential mechanism of heart injury among patients infected with SARS-CoV-2". Cardiovascular Research. 116 (6): 1097–1100. doi:10.1093/cvr/cvaa078. ISSN 0008-6363.
  10. ↑ 10.0 10.1 Kang Y, Chen T, Mui D, Ferrari V, Jagasia D, Scherrer-Crosbie M; et al. (2020). "Cardiovascular manifestations and treatment considerations in covid-19". Heart. doi:10.1136/heartjnl-2020-317056. PMC 7211105 Check |pmc= value (help). PMID 32354800 Check |pmid= value (help).
  11. ↑ 11.0 11.1 Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA; et al. (2018). "Fourth Universal Definition of Myocardial Infarction (2018)". J Am Coll Cardiol. 72 (18): 2231–2264. doi:10.1016/j.jacc.2018.08.1038. PMID 30153967.
  12. ↑ 12.0 12.1 De Rosa S, Spaccarotella C, Basso C, Calabrò MP, Curcio A, Filardi PP; et al. (2020). "Reduction of hospitalizations for myocardial infarction in Italy in the COVID-19 era". Eur Heart J. 41 (22): 2083–2088. doi:10.1093/eurheartj/ehaa409. PMC 7239145 Check |pmc= value (help). PMID 32412631 Check |pmid= value (help).
  13. ↑ Garcia S, Albaghdadi MS, Meraj PM, Schmidt C, Garberich R, Jaffer FA; et al. (2020). "Reduction in ST-Segment Elevation Cardiac Catheterization Laboratory Activations in the United States During COVID-19 Pandemic". J Am Coll Cardiol. 75 (22): 2871–2872. doi:10.1016/j.jacc.2020.04.011. PMC 7151384 Check |pmc= value (help). PMID 32283124 Check |pmid= value (help).
  14. ↑ Solomon MD, McNulty EJ, Rana JS, Leong TK, Lee C, Sung SH; et al. (2020). "The Covid-19 Pandemic and the Incidence of Acute Myocardial Infarction". N Engl J Med. doi:10.1056/NEJMc2015630. PMID 32427432 Check |pmid= value (help).
  15. ↑ De Filippo O, D'Ascenzo F, Angelini F, Bocchino PP, Conrotto F, Saglietto A; et al. (2020). "Reduced Rate of Hospital Admissions for ACS during Covid-19 Outbreak in Northern Italy". N Engl J Med. doi:10.1056/NEJMc2009166. PMC 7224608 Check |pmc= value (help). PMID 32343497 Check |pmid= value (help).
  16. ↑ 16.0 16.1 Garcia S, Dehghani P, Grines C, Davidson L, Nayak KR, Saw J, Waksman R, Blair J, Akshay B, Garberich R, Schmidt C, Ly HQ, Sharkey S, Mercado N, Alfonso CE, Misumida N, Acharya D, Madan M, Hafiz AM, Javed N, Shavadia J, Stone J, Alraies MC, Htun W, Downey W, Bergmark BA, Ebinger J, Alyousef T, Khalili H, Hwang CW, Purow J, Llanos A, McGrath B, Tannenbaum M, Resar J, Bagur R, Cox-Alomar P, Stefanescu Schmidt AC, Cilia LA, Jaffer FA, Gharacholou M, Salinger M, Case B, Kabour A, Dai X, Elkhateeb O, Kobayashi T, Kim HH, Roumia M, Aguirre FV, Rade J, Chong AY, Hall HM, Amlani S, Bagherli A, Patel R, Wood DA, Welt FG, Giri J, Mahmud E, Henry TD (April 2021). "Initial Findings From the North American COVID-19 Myocardial Infarction Registry". J Am Coll Cardiol. 77 (16): 1994–2003. doi:10.1016/j.jacc.2021.02.055. PMC 8054772 Check |pmc= value (help). PMID 33888249 Check |pmid= value (help). Vancouver style error: initials (help)
  17. ↑ Fuster V, Badimon L, Cohen M, Ambrose JA, Badimon JJ, Chesebro J (1988). "Insights into the pathogenesis of acute ischemic syndromes". Circulation. 77 (6): 1213–20. PMID 3286036.
  18. ↑ Guo T, Fan Y, Chen M, Wu X, Zhang L, He T; et al. (2020). "Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19)". JAMA Cardiol. doi:10.1001/jamacardio.2020.1017. PMC 7101506 Check |pmc= value (help). PMID 32219356 Check |pmid= value (help).
  19. ↑ 19.0 19.1 19.2 Stefanini, Giulio G.; Montorfano, Matteo; Trabattoni, Daniela; Andreini, Daniele; Ferrante, Giuseppe; Ancona, Marco; Metra, Marco; Curello, Salvatore; Maffeo, Diego; Pero, Gaetano; Cacucci, Michele; Assanelli, Emilio; Bellini, Barbara; Russo, Filippo; Ielasi, Alfonso; Tespili, Maurizio; Danzi, Gian Battista; Vandoni, Pietro; Bollati, Mario; Barbieri, Lucia; Oreglia, Jacopo; Lettieri, Corrado; Cremonesi, Alberto; Carugo, Stefano; Reimers, Bernhard; Condorelli, Gianluigi; Chieffo, Alaide (2020). "ST-Elevation Myocardial Infarction in Patients With COVID-19". Circulation. 141 (25): 2113–2116. doi:10.1161/CIRCULATIONAHA.120.047525. ISSN 0009-7322.
  20. ↑ Metzler B, Siostrzonek P, Binder RK, Bauer A, Reinstadler SJ (May 2020). "Decline of acute coronary syndrome admissions in Austria since the outbreak of COVID-19: the pandemic response causes cardiac collateral damage". Eur Heart J. 41 (19): 1852–1853. doi:10.1093/eurheartj/ehaa314. PMC 7184486 Check |pmc= value (help). PMID 32297932 Check |pmid= value (help).
  21. ↑ Mafham MM, Spata E, Goldacre R, Gair D, Curnow P, Bray M, Hollings S, Roebuck C, Gale CP, Mamas MA, Deanfield JE, de Belder MA, Luescher TF, Denwood T, Landray MJ, Emberson JR, Collins R, Morris E, Casadei B, Baigent C (August 2020). "COVID-19 pandemic and admission rates for and management of acute coronary syndromes in England". Lancet. 396 (10248): 381–389. doi:10.1016/S0140-6736(20)31356-8. PMC 7429983 Check |pmc= value (help). PMID 32679111 Check |pmid= value (help). Vancouver style error: initials (help)
  22. ↑ Leor J, Poole WK, Kloner RA (February 1996). "Sudden cardiac death triggered by an earthquake". N Engl J Med. 334 (7): 413–9. doi:10.1056/NEJM199602153340701. PMID 8552142.
  23. ↑ Fardman A, Zahger D, Orvin K, Oren D, Kofman N, Mohsen J, Tsafrir O, Asher E, Rubinshtein R, Jamal J, Efraim R, Halabi M, Shacham Y, Fortis LH, Cohen T, Klempfner R, Segev A, Beigel R, Matetzky S (2021). "Acute myocardial infarction in the Covid-19 era: Incidence, clinical characteristics and in-hospital outcomes-A multicenter registry". PLoS One. 16 (6): e0253524. doi:10.1371/journal.pone.0253524. PMC 8213163 Check |pmc= value (help). PMID 34143840 Check |pmid= value (help).
  24. ↑ De Luca G, Cercek M, Jensen LO, Vavlukis M, Calmac L, Johnson T, Roura I Ferrer G, Ganyukov V, Wojakowski W, von Birgelen C, Versaci F, Ten Berg J, Laine M, Dirksen M, Casella G, Kala P, Díez Gil JL, Becerra V, De Simone C, Carrill X, Scoccia A, Lux A, Kovarnik T, Davlouros P, Gabrielli G, Flores Rios X, Bakraceski N, Levesque S, Guiducci V, Kidawa M, Marinucci L, Zilio F, Galasso G, Fabris E, Menichelli M, Manzo S, Caiazzo G, Moreu J, Sanchis Forés J, Donazzan L, Vignali L, Teles R, Bosa Ojeda F, Lehtola H, Camacho-Freiere S, Kraaijeveld A, Antti Y, Boccalatte M, Martínez-Luengas IL, Scheller B, Alexopoulos D, Uccello G, Faurie B, Gutierrez Barrios A, Wilbert B, Cortese G, Moreno R, Parodi G, Kedhi E, Verdoia M (December 2020). "Impact of COVID-19 pandemic and diabetes on mechanical reperfusion in patients with STEMI: insights from the ISACS STEMI COVID 19 Registry". Cardiovasc Diabetol. 19 (1): 215. doi:10.1186/s12933-020-01196-0. PMC 7747477 Check |pmc= value (help). PMID 33339541 Check |pmid= value (help). Vancouver style error: missing comma (help)
  25. ↑ Stefanini GG, Montorfano M, Trabattoni D, Andreini D, Ferrante G, Ancona M, Metra M, Curello S, Maffeo D, Pero G, Cacucci M, Assanelli E, Bellini B, Russo F, Ielasi A, Tespili M, Danzi GB, Vandoni P, Bollati M, Barbieri L, Oreglia J, Lettieri C, Cremonesi A, Carugo S, Reimers B, Condorelli G, Chieffo A (June 2020). "ST-Elevation Myocardial Infarction in Patients With COVID-19: Clinical and Angiographic Outcomes". Circulation. 141 (25): 2113–2116. doi:10.1161/CIRCULATIONAHA.120.047525. PMC 7302062 Check |pmc= value (help). PMID 32352306 Check |pmid= value (help).
  26. ↑ Choudry FA, Hamshere SM, Rathod KS, Akhtar MM, Archbold RA, Guttmann OP, Woldman S, Jain AK, Knight CJ, Baumbach A, Mathur A, Jones DA (September 2020). "High Thrombus Burden in Patients With COVID-19 Presenting With ST-Segment Elevation Myocardial Infarction". J Am Coll Cardiol. 76 (10): 1168–1176. doi:10.1016/j.jacc.2020.07.022. PMC 7833185 Check |pmc= value (help). PMID 32679155 Check |pmid= value (help).
  27. ↑ 27.0 27.1 Abidov A, Rozanski A, Hachamovitch R, Hayes SW, Aboul-Enein F, Cohen I; et al. (2005). "Prognostic significance of dyspnea in patients referred for cardiac stress testing". N Engl J Med. 353 (18): 1889–98. doi:10.1056/NEJMoa042741. PMID 16267320. Review in: Evid Based Med. 2006 Jun;11(3):91
  28. ↑ Szerlip M, Anwaruddin S, Aronow HD, Cohen MG, Daniels MJ, Dehghani P; et al. (2020). "Considerations for cardiac catheterization laboratory procedures during the COVID-19 pandemic perspectives from the Society for Cardiovascular Angiography and Interventions Emerging Leader Mentorship (SCAI ELM) Members and Graduates". Catheter Cardiovasc Interv. doi:10.1002/ccd.28887. PMID 32212409 Check |pmid= value (help).
  29. ↑ Ullah W, Sattar Y, Saeed R, Ahmad A, Boigon MI, Haas DC; et al. (2020). "As the COVID-19 pandemic drags on, where have all the STEMIs gone?". Int J Cardiol Heart Vasc. 29: 100550. doi:10.1016/j.ijcha.2020.100550. PMC 7261452 Check |pmc= value (help). PMID 32550258 Check |pmid= value (help).


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