Presenter: Dr. Payam Dehghani

The NACMI registry was created under the guidance of three North American cardiovascular associations – SCAI, the Canadian Association of Interventional Cardiologists, and the American College of Cardiology Interventional Council – in response to evidence that cardiovascular disease patients are more susceptible to severe forms of the infection(1). The registry currently includes patients over 18 years of age with STEMI or new left bundle branch block who were confirmed to be COVID-19-positive (n=301), those with suspected infection, known as “persons under investigation” or PUI – who eventually turned out to be negative for COVID-19 (n=604) – and a control group of 602 STEMI patients treated prior to the pandemic (between 2015 and 2019) who were age- and sex-matched to the COVID-19-positive group in a 2:1 ratio.

According to the update presented by Payam Dehghani, MD, University of Saskatchewan, the primary composite outcome (in-hospital death, stroke, recurrent myocardial infarction [MI], or repeat unplanned revascularization) occurred in 36% of the COVID-19-positive group, versus 13% of PUI and 5% of control patients (p<0.001 relative to controls)(2). Furthermore, the majority of this composite was driven by high mortality in these patients.

“Most of this in-hospital outcome is driven significantly with mortality,” he added. “Not unexpectedly, (COVID-19 patients had) higher longer ICU stays, and much longer total length of stay.”

Dehghani noted that a higher proportion of the COVID-19-positive patients were dyspneic (51% with dyspnea on presentation vs. 35% in the PUI group; p<0.001) and had radiographic infiltrates (45% of COVID-19-positive group vs. 16% of PUI; p<0.001), but that fewer of the COVID-19 group had chest pain on presentation (53% vs. 80%; p<0.001). The findings thus far also point to inequalities in outcomes between different ethnic groups, with COVID-19-positive patients more likely to have a “minority ethnicity” (p<0.001). In the COVID-19-positive cohort, 55% of patients were non-Caucasian, compared to 25% in PUI (p<0.001).

“We have never seen a cohort of MIs where 55% were non-Caucasian,” said Dehghani. He added that 44% of those with COVID-19 were diabetic, compared to just 33% of those in the PUI group (p<0.001). 

The current study also gave updates on perfusion strategy, a matter that has been controversial during the pandemic.   As with many other healthcare services, timely access to primary PCI has been impacted during the COVID-19 pandemic. Authors of a previous NACMI results report, led by Santiago Garcia, MD, from the Minneapolis Heart Institute Foundation, said that one strategy has been to shift to pharmacological reperfusion to avoid delays, protect resources and essential healthcare workers(3). Publications from China and Europe previously cited the importance of thrombolytic drugs in reperfusion, Dehghani said, but he stressed that the American College of Cardiology guidelines suggest “that is probably not a good idea. You can see that reflected in the way patients were being treated, less than 3% of COVID-positive were given thrombolytics – primary PCI was the dominant reperfusion modality.” 

Among the COVID-19-positive patients who received angiography, 71% received primary PCI and 23% had no culprit vessels identified on angiography (both p<0.001 relative to controls). Nevertheless, in the current study, Dehghani and colleagues reported that the COVID-19-positive patients were more likely to undergo medical therapy as the primary perfusion therapy (p<0.001 relative to PUI). This had to do with “how sick this patient population is and how they had significant comorbidities, including intubation and respiratory illness,” said Dehghani. He added that 1 in 5 of the COVID-19-positive patients who underwent angiography had no culprit vessel identified. “Of the patients who have culprit disease, PCI was similar in success rate to both groups and fairly comparable to pre-pandemic numbers,” he said. Although his presentation did not include exact door-to-balloon times, he said more than 70% come in under the 90-minute range. 

Dehghani went on to reiterate conclusions from the previous analysis that primary PCI is “common, it’s feasible, and it’s associated with reduced mortality. This is in keeping with our current guidelines.” Recruitment is ongoing in the NACMI registry, and the researchers are keen to ask a significant number of additional questions to aid in identifying additional patterns.

All Authors: Giorgio A. Medranda, MD; Brian C. Case, MD; Jason P. Wermers, BS, Natalie Morrison, BA (Hons); and Ron Waksman, MD, MSCAI. 

References

1. Payam Dehghani, MD, FSCAI; Laura J. Davidson, MD, MS, FSCAI; Cindy L. Grines, MD, MSCAI; Keshav Nayak, MD, FSCAI; Jacqueline Saw, MD, FSCAI; Prashant Kaul, MD, FSCAI; Bagai Akshay MD, MHS; Ross Garberich, MS, MBS; Christian Schmidt, MS; Hung Q. Ly, MD, SM; Jay Giri, MD, MPH, FSCAI; Perwaiz Meraj, MD, FSCAI; Binita Shah, MD, FSCAI; Santiago Garcia, MD, FSCAI; Scott Sharkey, MD; David A. Wood, MD, FSCAI; Frederick G. Welt, MD, MSc, FSCAI; Ehtisham Mahmud, MD, MSCAI; Timothy D. Henry, MD, MSCAI. North American COVID-19 ST-Segment-Elevation Myocardial Infarction (NACMI) registry: Rationale, design, and implications. Am Heart J 2020;227:11-18.
2. Update on the North American COVID-19 Myocardian Infarcation (NACMI) Registry
3. Santiago Garcia, MD, FSCAI; Payam Dehghani, MD, FSCAI; Cindy Grines, MD, MSCAI; Laura J. Davidson, MD, MS, FSCAI; Keshav R. Nayak, MD, FSCAI; Jacqueline Saw, MD, FSCAI; Ron Waksman, MD, MSCAI; John Blair, MD; Bagai Akshay, MD, MHS; Ross Garberich, MS, MBS; Christian Schmidt, MS; Hung Q. Ly, MD, SM; Scott Sharkey, MD; Nestor Mercado,MD, PhD, FESC, FSCAI; Carlos E. Alfonso, MD, FSCAI; Naoki Misumida, MD, FSCAI; Deepak Acharya, MD, MSPH; Mina Madan, MD, MHS, FSCAI; Abdul Moiz Hafiz, MD, FSCAI; Nosheen Javed, MD; Jay Shavadia, MBChB; Jay Stone, MD, FSCAI, M. Chadi Alraies, MD, MPH; Wah Htun, MD,FSCAI; William Downey, MD, FSCAI; Brian A, Bergmark, MD, FSCAI; Joseph Ebinger, MD; Tareq Alyousef, MD; Housman Khalili, MD, FSCAI; Chao-Wei Hwang, MD, PhD, FSCAI; Joshua Purow, MD; Alexander Llanso, MD; Brent McGrath, MD, PhD, MSc, FSCAI; Mark Tannenbaum, MD; Jon Resar, MD, FSCAI; Rodrigo Bagur, MD, PhD; Pedro Cox-Alomar, MD, MPH, FSCAI; Ada C. Stenfanescu Schmidt, MD, MSc;  Lindsey A. Cilia, MD; Farouc A, Jaffer, MD, PhD, FSCAI; Michael Gharacholou, MD, MSc, FSCAI; Michael Salinger, MD, FSCAI; Brian Case, MD; Ameer Kabour, MD; Xuming Dai, MD PhD, FSCAI; Osama Elkhateeb, MD; Taisei Kobayashi, MD, LCDR, USNR; Hahn-Ho Kim, ON; Mazen Roumia, MD, FSCAI; Frank V. Aquirre, MD; Jeffrey J. Rade, MD; Aun-Yeong Chong, MD; Hurst M. Hall, MD; Shy Amiani, MD; Alireza Bagherli, MD; Rajan A.G. Patel, MD, FSCAI; David, A. Wood, MD, FSCAI; Fredrick G. Welt, MD, MSc, FSCAI; Jay Giri, MD, MPH, FSCAI; Ehtisham Mahmud, MD, MSCAI; Timothy D, Henry, MD, MSCAI and on behalf of the Society for Cardian Angiography and Interventions, the Canadian Association of Interventional Cardiology, and the American College of Cardiology Interventional Council. Initial Findings From the North American COVID-19 Myocardial Infarction Registry. AM Coll Cardiol 2021;77:1994-2003