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Primary percutaneous coronary intervention (PCI) was feasible for treating COVID-19 patients with ST-segment elevation MI (STEMI), though prognosis is variable, according to a study from the NACMI registry.

COVID-positive STEMI patients had a 36% risk of the primary outcome of a composite of in-hospital death, stroke, recurrent MI, or repeat unplanned revascularization. This was significantly higher than both the 13% risk observed in patients suspected of infection without testing positive, and the 5% risk among matched controls (P<0.001 for both), reported a group led by Santiago Garcia, MD, of the Minneapolis Heart Institute Foundation in Minnesota.

The elevated risk was driven primarily by differences in in-hospital mortality (33% vs 11% vs 4%, respectively) and stroke (3% vs 2% vs 0%), they noted in the .

NACMI (North American COVID-19 and STEMI) is a multicenter registry created under the guidance of the Society for Cardiac Angiography and Interventions, the Canadian Association of Interventional Cardiology, and the American College of Cardiology.

At the time of the analysis in December 2020, there were 230 STEMI patients with confirmed COVID infection and 495 with suspected infection, who were matched for age and sex with 460 STEMI patients from the pre-pandemic era (2015-2019).

Garcia's group reported that COVID-positive patients were more likely to be of an ethnic minority (23% Hispanic, 24% Black) and had a high prevalence of diabetes (46%).

"This finding may imply that STEMI care in the presence of COVID-19 may disproportionally affect minority groups and that future focus of care should be directed to a double challenge: addressing unique aspects of STEMI with COVID-19 and economic and social issues associated with STEMI in minority populations," wrote Ran Kornowski, MD, and Katia Orvin, MD, both of Rabin Medical Center and Tel Aviv University in Israel, in an .

COVID patients with STEMI also tended to present with atypical symptoms, such as dyspnea (54%), pulmonary infiltrates on chest x-ray film (46%), and high-risk conditions like cardiogenic shock (18%).

However, this group was significantly less likely than the other STEMI groups to receive invasive angiography (78% vs 96% in those with suspected COVID vs 100% in controls; all P<0.001).

When COVID-positive patients did receive angiography, primary PCI remained the dominant revascularization modality, accounting for 71% of cases. Yet this was still lower than the pre-COVID controls receiving PCI in 93% of cases.

Delays to primary PCI were limited, but nevertheless significant, during the pandemic: median door-to-balloon times were 79 minutes in those with confirmed COVID, 77 minutes in those with suspected COVID, and 66 minutes in controls.

"In line with current guidelines, patients with suspected STEMI should be managed with primary PCI without delay while the safety of health care providers is ensured. In this case, primary PCI should be performed routinely even if the patient is presumed to have COVID-19, because primary PCI should not be postponed," Kornowski and Orvin wrote.

"Confirmation of SARS-CoV-2 infection should not delay urgent decision management concerning reperfusion strategy," they noted.

Garcia and colleagues said that important analyses from NACMI remain to be conducted.

"Previous studies have revealed high thrombus burden in patients with COVID-19 presenting with STEMI. A planned, independent angiographic core lab analysis will shed light on this important issue, which may have therapeutic implications," they wrote.

A limitation of the registry is the lack of pre-hospital data regarding total ischemic and transfer times for patients first presenting to non-PCI centers.

"Because the NACMI is an ongoing registry, it would be interesting to observe the temporal trends related to demographics, management strategies, and outcomes of STEMI patients with confirmed or suspected COVID-19 diagnosis. Global efforts should be made to optimize STEMI management among all patients in need of primary PCI during the COVID-19 period," Kornowski and Orvin concluded.

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