By: Sridevi Pitta, MD, MBA, FSCAI; Jon C. George, MD, FSCAI; John Messenger, MD, FSCAI; Rajesh V. Swaminathan, MD, FSCAI 
Contributors: Jayant Bagai, MD, FSCAI; Faisal Latif, MD, FSCAI

Critically ill patients with COVID-19 can develop myocardial injury and significant cardiac biomarker elevation due to nonischemic causes (i.e., myocarditis) or ischemic causes.^1,2 Management of ST-segment elevation myocardial infarction (STEMI) in patients with COVID-19 is complex and rapidly evolving based on international and domestic experience.³ The purpose of this Tip of the Month is to review current professional societal recommendations for triaging and managing patients with ST elevations during the COVID-19 pandemic, with two case summaries serving as examples.

Case 1: STEMI (Type I Acute Myocardial Infarction [AMI]): A STEMI alert was activated in the field for a 64-year-old female with symptoms of chest pain and worsening dyspnea with an EKG showing anterior ST elevations. The patient was also under investigation for COVID-19 and was pending test results performed at a primary care office for dyspnea and cough. Given the presence of an EKG suggestive of acute left anterior descending (LAD) occlusion and, hence, a high-risk STEMI, emergent cardiac catheterization was performed. Staff wore recommended personal protective equipment (PPE). Coronary angiography showed a mid-LAD occlusion managed successfully with primary PCI (see Figure 1).

Case 2: STEMI (Type II AMI): A 59-year-old female was brought to the emergency department (ED) obtunded and in respiratory distress. There was a high suspicion of COVID-19, so she was intubated in the ED. Her EKG showed anterior ST elevations; a bedside echo showed normal wall motion (see video); and a chest CT scan ruled out acute pulmonary embolism but showed calcifications in the LAD coronary artery. She underwent coronary angiography in a negative-pressure hybrid operating room, which revealed moderate coronary artery disease (CAD) without vessel occlusion (see Figure 2).

Recommendations for the management of suspected STEMI in patients with suspected or known COVID-19 include:

1. Emergent coronary angiography and primary percutaneous coronary intervention (PCI) remain the mainstay of management for patients with a high likelihood of STEMI.
2. Thrombolytic therapy may be considered for non-high-risk MI (examples being inferior wall MI without right ventricular involvement and hypotension) based on the risk/benefit ratio of exposure to cath lab staff and the availability of resources.
3. The recent SCAI/American College of Cardiology (ACC)/American College of Emergency Physicians (ACEP) perspectives on cardiac cath lab procedures during COVID-19 outlines a suggested algorithm ( STEMI COVID-19 Algorithm). A balance between staff exposure and patient benefit needs to be carefully weighed when assessing COVID-19 patients with STEMI.^4,5
4. The presence of classic reciprocal changes on the EKG are a valuable indicator of STEMI, whereas diffuse or atypical patterns of ST elevation, which do not fit the territory of a single vessel, suggest possible myopericarditis.
5. Use of a point-of-care ultrasound (POCUS or bedside cardiac echo) to assess left ventricular wall motion may be helpful in guiding which patients should undergo emergent coronary angiography.
6. Appropriate PPE should be worn for all suspected or known positive patients of COVID-19 (see SCAI’s April Tip of the Month). Patients requiring more than 2-3 liters per minute of inhaled oxygen via nasal canula should be considered for elective intubation by a specialized anesthesia team wearing full PPE, preferably in a negative-pressure room, prior to transfer to the cath lab.⁶

References

1. Kwong JC, Schwartz KL, Campitelli MA. Acute Myocardial Infarction after Laboratory-Confirmed Influenza Infection. N Engl J Med. 2018;378(26):2540-2541.
2. Bonow RO, Fonarow GC, O'Gara PT, Yancy CW. Association of Coronavirus Disease 2019 (COVID-19) With Myocardial Injury and Mortality. JAMA cardiology. 2020.
3. SCAI.http://www.scai.org/press/detail/evolving-pandemic-of-covid-19-interventional-cardi#.Xn_dhEBFyUk. March 2020.
4. Welt FGP, Shah PB, Aronow HD, et al. Catheterization Laboratory Considerations During the Coronavirus (COVID-19) Pandemic: From ACC's Interventional Council and SCAI. J Am Coll Cardiol. May 2020.
5. Mahmud E, Dauerman H, Welt FGP, et al. Management of Acute Myocardial Infarction During the COVID-19 Pandemic: A Consensus Statement from the Society for Cardiovascular Angiography and Interventions (SCAI), American College of Cardiology (ACC), and the American College of Emergency Physicians (ACEP)". Catheter Cardiovasc Interv. 2020 Apr 20. doi: 10.1002/ccd.28946.
6. https://www.cdc.gov/niosh/npptl/topics/respirators/factsheets/respsars.html. The National Personal Protective Technology Laboratory (NPPTL).

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