NACMI registry IDs key traits, risks in patients with COVID-19 and ST-elevation

Patients with ST-elevation and COVID-19 have different characteristics than those without COVID-19, and may have a higher risk of in-hospital mortality and stroke, according to initial results of the NACMI* registry study presented at TCT Connect 2020.

The NACMI registry comprised adults who tested positive or were under investigation for suspected COVID-19, with ST-segment elevation or new-onset left bundle branch block (LBBB) as per 12-lead ECG, and clinical signs of myocardial ischaemia.

As of October 4, 2020, the database included 594 patients from 64 sites, of whom 171 were confirmed COVID-19-positive and 423 who tested negative following investigation (PUI). They were compared with a historical comparator group comprising a propensity-matched cohort of patients from the Midwest STEMI Consortium (MSC).

There were no significant differences in age or sex between the groups, though there were significant differences in ethnicity. The COVID-19-positive group had more patients with diabetes than the PUI (44 percent vs 33 percent; p=0.015) and MSC groups (20 percent; p<0.001). [TCT Connect 2020, Late-Breaking Clinical Science Session I]

Pre-PCI** cardiac arrest incidence was comparable across groups (12, 17, and 11 percent of the COVID-19-positive, PUI, and MSC groups, respectively). However, cardiogenic shock was more common in the COVID-19-positive vs PUI group (20 percent vs 14 percent; p=0.074) or MSC group (5 percent; p<0.001). Ejection fraction was lower in the COVID-19-positive and PUI groups (45 for both) vs the MSC group (50).

Infiltrates on chest X-ray were more common in the COVID-19-positive vs PUI group (49 percent vs 17 percent), as was dyspnoea (58 percent vs 38 percent), while chest pain was less common (53 percent vs 78 percent; p<0.001 for all).

Twenty-one percent of COVID-19-positive patients did not undergo angiography compared with 5 percent in the PUI group (p<0.001) and 0 in the MSC group. Primary PCI rates were 71, 80, and 81 percent, respectively, while thrombolytics were given in 6, 2, and 3 percent, respectively. Door-to-balloon (D2B) time was also comparable between groups (median 80, 78, and 86 minutes, respectively).

In-hospital mortality was significantly higher among COVID-19-positive patients compared with PUI (32 percent vs 12 percent) or the MSC cohort (6 percent; p<0.001 for both).

Duration of hospitalization was also longer in the COVID-19-positive (median 6 days) compared with the PUI and the MSC groups (median 3 days for both; p<0.001 for both), as was length of intensive care unit stay (median 4 vs 2 days for COVID-19-positive vs PUI groups, respectively; p<0.001).

The incidence of in-hospital stroke was also higher among COVID-19-positive patients compared with the MSC (3.4 percent vs 0.6 percent; p=0.039) or PUI groups (2 percent; nonsignificant).

“COVID-19-positive patients with ST-elevation represent a unique and high-risk patient population,” presented Dr Timothy Henry from The Christ Hospital, Cincinnati, Ohio, US.

Five previous studies, comprising in total 174 patients, have shown that patients with COVID-19 who have ST-elevation more frequently present in hospital, have more thrombotic lesions and more frequently without a culprit, and are at higher mortality risk. Furthermore, there is considerable controversy regarding the appropriate management of these patients, said Henry.

The present analysis showed that primary PCI is preferable and feasible in COVID-19-positive patients with D2B times similar to PUI or COVID-19-negative patients. This supports the current COVID-19-specific STEMI guidelines produced by SCAI/ACC/AHA***, he said.

Henry noted that the mortality rate was only about 12–13 percent among those who underwent PCI but was higher among patients who did not undergo angiography, though these are early results and more research is warranted.