COVID-19-associated myocardial infarction: Difference between revisions
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==Overview== | ==Overview== | ||
[[COVID-19]] patients with [[cardiovascular]] [[comorbidities]] have higher [[mortality]].Acute [[Myocardial Infarction]] is defined as an acute [[myocardial injury]] with clinical evidence of acute myocardial [[ischemia]] plus rise and/or fall of cardiac [[troponin]] values with at least one value above the 99th percentile upper reference limit and at least one of the following:Symptoms of [[myocardial ischemia]] include new ischemic [[ECG]] changes, development of pathological [[Q waves]], imaging evidence of new loss of viable [[myocardium]] or new regional wall motion abnormality in a pattern consistent with an ischemic [[etiology]]. Identification of a [[coronary]] [[thrombus]] by [[angiography]] or [[autopsy]] (not for type 2 or 3 MI).In a case series with 187 patients who had confirmed COVID-19, 27.8% of patients had a [[myocardial injury]], which caused cardiac dysfunction and [[arrhythmias]]. The result was significantly higher mortality among patients with myocardial injury.It seems to be advisable to [[triage]] patients with [[COVID-19]] based on their underlying [[CVD]] for a more aggressive treatment plan.The mortality during hospitalization was shown to be 7.62% for patients without underlying CVD and normal [[TnT]] levels, 13.33% for those with underlying CVD and normal TnT levels, 37.50% for those without underlying [[Cardiovascular disease|CVD]] but elevated TnT levels, and 69.44% for those with underlying CVD and elevated TnTs. | |||
==Classification== | ==Classification== | ||
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* [[ST Elevation Myocardial Infarction]] (STEMI) | * [[ST Elevation Myocardial Infarction]] (STEMI) | ||
===ST-Elevation Myocardial Infarction (STEMI)=== | ===ST-Elevation Myocardial Infarction (STEMI)=== | ||
A US model from 9 major centers showed a 38% drop in total [[STEMI]] activations during the COVID-19 pandemic. There is a 40% reduction noted in Spain as well. there was also a delay between the first presentation to a medical encounter up to 318 min. This is important since COVID-19 can potentially be a cause of [[STEMI]] through [[microthrombi]], [[cytokine storm]], [[coronary spasm]], or direct [[endothelial injury]].<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> | A US model from 9 major centers showed a 38% drop in total [[STEMI]] activations during the COVID-19 pandemic. There is a 40% reduction noted in Spain as well. there was also a delay between the first presentation to a medical encounter up to 318 min. This is important since COVID-19 can potentially be a cause of [[STEMI]] through [[microthrombi]], [[cytokine storm]], [[coronary spasm]], or direct [[endothelial injury]].<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><ref name="pmid32219356">{{cite journal| author=Guo T, Fan Y, Chen M, Wu X, Zhang L, He T | display-authors=etal| title=Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19). | journal=JAMA Cardiol | year= 2020 | volume= | issue= | pages= | pmid=32219356 | doi=10.1001/jamacardio.2020.1017 | pmc=7101506 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32219356 }} </ref> | ||
*Potential etiologies for the reduction in [[ST elevation myocardial infarction|STEMI]] PPCI activations: | *Potential etiologies for the reduction in [[ST elevation myocardial infarction|STEMI]] PPCI activations: | ||
**avoidance of medical care due to social distancing or concerns of contracting COVID-19 in the hospital | **avoidance of medical care due to social distancing or concerns of contracting COVID-19 in the hospital | ||
| Line 31: | Line 23: | ||
**increased use of pharmacological [[reperfusion]] due to COVID-19 | **increased use of pharmacological [[reperfusion]] due to COVID-19 | ||
It is very important to realize if patients' anxiety is the reason behind decreasing the presentation of [[ST elevation myocardial infarction|STEMI]] to U.S. hospitals.<ref name="pmid32283124">{{cite journal| author=Garcia S, Albaghdadi MS, Meraj PM, Schmidt C, Garberich R, Jaffer FA | display-authors=etal| title=Reduction in ST-Segment Elevation Cardiac Catheterization Laboratory Activations in the United States During COVID-19 Pandemic. | journal=J Am Coll Cardiol | year= 2020 | volume= 75 | issue= 22 | pages= 2871-2872 | pmid=32283124 | doi=10.1016/j.jacc.2020.04.011 | pmc=7151384 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32283124 }} </ref> | It is very important to realize if patients' anxiety is the reason behind decreasing the presentation of [[ST elevation myocardial infarction|STEMI]] to U.S. hospitals.<ref name="pmid32283124">{{cite journal| author=Garcia S, Albaghdadi MS, Meraj PM, Schmidt C, Garberich R, Jaffer FA | display-authors=etal| title=Reduction in ST-Segment Elevation Cardiac Catheterization Laboratory Activations in the United States During COVID-19 Pandemic. | journal=J Am Coll Cardiol | year= 2020 | volume= 75 | issue= 22 | pages= 2871-2872 | pmid=32283124 | doi=10.1016/j.jacc.2020.04.011 | pmc=7151384 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32283124 }} </ref><ref name="pmid30153967">{{cite journal| author=Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA | display-authors=etal| title=Fourth Universal Definition of Myocardial Infarction (2018). | journal=J Am Coll Cardiol | year= 2018 | volume= 72 | issue= 18 | pages= 2231-2264 | pmid=30153967 | doi=10.1016/j.jacc.2018.08.1038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30153967 }} </ref> | ||
*Treatment of [[ST elevation myocardial infarction|STEMI]] & COVID-19: The specific protocols for the treatment have been 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> | *Treatment of [[ST elevation myocardial infarction|STEMI]] & COVID-19: The specific protocols for the treatment have been 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> | ||
Revision as of 13:42, 2 July 2020
For COVID-19 frequently asked inpatient questions, click here
For COVID-19 frequently asked outpatient questions, click here
For COVID-19 natural history, complications and prognosis, click here
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Haddadi, M.D.[2]
Synonyms and keywords: Novel coronavirus, covid-19, COVID-19, SARS-CoV-2, Wuhan coronavirus, myocardial infarction, MI, coronary artery disease, ACS
Overview
COVID-19 patients with cardiovascular comorbidities have higher mortality.Acute Myocardial Infarction is defined as an acute myocardial injury with clinical evidence of acute myocardial ischemia plus rise and/or fall of cardiac troponin values with at least one value above the 99th percentile upper reference limit and at least one of the following:Symptoms of myocardial ischemia include new ischemic ECG changes, development of pathological Q waves, imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in a pattern consistent with an ischemic etiology. Identification of a coronary thrombus by angiography or autopsy (not for type 2 or 3 MI).In a case series with 187 patients who had confirmed COVID-19, 27.8% of patients had a myocardial injury, which caused cardiac dysfunction and arrhythmias. The result was significantly higher mortality among patients with myocardial injury.It seems to be advisable to triage patients with COVID-19 based on their underlying CVD for a more aggressive treatment plan.The mortality during hospitalization was shown to be 7.62% for patients without underlying CVD and normal TnT levels, 13.33% for those with underlying CVD and normal TnT levels, 37.50% for those without underlying CVD but elevated TnT levels, and 69.44% for those with underlying CVD and elevated TnTs.
Classification
Myocardial infarction may be classified according to two subtypes:
- Non ST Elevation Myocardial Infarction (non-STEMI)
- ST Elevation Myocardial Infarction (STEMI)
ST-Elevation Myocardial Infarction (STEMI)
A US model from 9 major centers showed a 38% drop in total STEMI activations during the COVID-19 pandemic. There is a 40% reduction noted in Spain as well. there was also a delay between the first presentation to a medical encounter up to 318 min. This is important since COVID-19 can potentially be a cause of STEMI through microthrombi, cytokine storm, coronary spasm, or direct endothelial injury.[1][2]
- Potential etiologies for the reduction in STEMI PPCI activations:
- avoidance of medical care due to social distancing or concerns of contracting COVID-19 in the hospital
- STEMI misdiagnosis
- increased use of pharmacological reperfusion due to COVID-19
It is very important to realize if patients' anxiety is the reason behind decreasing the presentation of STEMI to U.S. hospitals.[3][4]
- Treatment of STEMI & COVID-19: The specific protocols for the treatment have been 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.[1]
Pathophysiology
The mechanism of COVID-19 cardiovascular injury has not been fully understood and is likely multifactorial.
- SARS-CoV-2 virus attaches to ACE2 protein for ligand binding before entering the cell via receptor-mediated endocytosis.
- Based on single-cell RNA sequencing more than 7.5% of myocardial cells have positive ACE2 expression. This protein can mediate the entry of SARS-CoV-2 and result in direct cardiotoxicity.
- The cytokine release caused by the virus may lead to vascular inflammation, plaque instability, myocardial inflammation, a hypercoagulable state, or direct myocardial suppression.
Pathological changes:
- In the level of cardiac tissue: minimal change to interstitial inflammatory infiltration and myocyte necrosis
- In the level of vasculature: micro-thrombosis and vascular inflammation[5]
Causes
According to the Fourth Universal Definition of MI, there are two clinical classifications of the disease based on the causes:
- Type 1: MI caused by acute atherothrombotic CAD precipitated by atherosclerotic plaque disruption (rupture or erosion).
- Type 2: MI due to a mismatch between oxygen demand and supply
Most of the MIs associated with COVID-19 are type 2 indicating the causes to be the primary infection, hemodynamic disturbance, or respiratory deterioration.[4] [6]
Differentiating Myocardial infarction from other Diseases
Differentiating ST Elevation Myocardial Infarction from other Diseases
Differentiating Unstable Angina/Non-ST Elevation Myocardial Infarction from other Disorders
Epidemiology and Demographics
- Hospitalized patients with COVID-19 and Cardiovascular disease seem to be more prevalent in both the USA and China. [5]
- Studies have shown reduction of incidence and hospitalization of acute MI during COVID-19 Pandemic.[7][3][8][9]
- A study in Italy showed up to a 49.4 percent reduction in admissions for acute MI to coronary care units from March 12th to 19th in 2020 compared to the equivalent time in 2019. [7]
Risk Factors
Diagnosis
History and Symptoms
- Substernal chest pain
- Occurs at rest or exertion
- Radiation to neck, jaw, left shoulder and left arm
- Aggravated by physical activity and emotional stress
- Relieved by rest, nitroglycerin or both
- Chest discomfort described crushing, squeezing, burning, choking, tightness or aching
- Dyspnea
- Diaphoresis
- Nausea and vomiting
- Fatigue
- Syncope[10]
Laboratory Findings
Treatment
In patients with ACS, and COVID-19, treatment should follow the guidelines of the updated Society for Cardiovascular Angiography and Interventions.[5] [11]
References
- ↑ 1.0 1.1 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). - ↑ 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). - ↑ 3.0 3.1 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). - ↑ 4.0 4.1 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.
- ↑ 5.0 5.1 5.2 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). - ↑ Template:Cite website
- ↑ 7.0 7.1 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). - ↑ 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). - ↑ 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). - ↑ 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
- ↑ 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).