STEMI Outcomes Worsened at Height of COVID-19 in China

As seen in other parts of the world, the number of STEMIs dropped as the COVID-19 outbreak raged in China, particularly in the province of Hubei, where case numbers swelled following the emergence of SARS-CoV-2 in Wuhan. At the same time, in-hospital STEMI outcomes deteriorated.

There was a 26% decline in the number of hospitalized STEMIs across Chinese chest pain centers from the end of December to February 20, 2020, but the fall was 62% in Hubei province, according to researchers led by Dingcheng Xiang, MD (General Hospital of Southern Theatre Command of PLA, Guangzhou, China), and Xin Xiang, PhD (Harvard University, Cambridge, MA).

Midway through that period, the STEMI treatment protocol was modified to recommend thrombolysis—not primary PCI—as “the preferred reperfusion strategy for patients with unconfirmed COVID-19 status in areas affected by the outbreak to ensure timely reperfusion and prevent nosocomial infection,” they say. In the 4 weeks after that change was made, rates of in-hospital mortality and heart failure among STEMI patients rose, with the largest increases seen in Hubei.

The findings, published online August 19, 2020, ahead of print in the Journal of the American College of Cardiology, “provide much needed empirical evidence for healthcare professionals searching for a balance between optimizing timely treatment for STEMI patients and protecting healthcare workers and vulnerable cardiovascular patients from the risk of nosocomial COVID-19 infection,” the investigators write.

“Despite the inevitable delays in treatment time line due to mandatory infection-control procedures and changes in reperfusion strategies during the outbreak, the proportion of patients receiving effective reperfusion remained stable,” they note.

Chinese Chest Pain Center Database

The COVID-19 pandemic has had far-reaching effects on the delivery of medical care, with clinicians and researchers seeking ways to maintain good patient outcomes while protecting healthcare workers. When it comes to STEMI, some experts have recommended continuing with a focus on providing primary PCI in a timely fashion whenever possible, whereas others have recommended increased use of thrombolytic treatment.

In the current study, the researchers assessed the impact of the modified STEMI treatment protocol placing a greater emphasis on thrombolytic therapy that was adopted on January 23, 2020, the day the Chinese government announced that Wuhan would be going into lockdown to control the spread of COVID-19. They analyzed data on 28,189 STEMI patients admitted to 1,372 chest pain centers across China between December 27, 2019, and February 20, 2020—that includes the 4-week periods before and after the modified protocol was issued.

Consistent with that protocol, the percentage of patients undergoing primary PCI declined and the proportion receiving thrombolytic therapy increased over time. In Hubei, a halving in the use of primary PCI was accompanied by a marked spike in use of thrombolysis. That pattern was seen outside of Hubei as well, but the shifts were less dramatic. Overall, the COVID-19 outbreak was associated with a lower likelihood of primary PCI (OR 0.76; 95% CI 0.71-0.81) and greater odds of thrombolysis (OR 1.66; 95% CI 1.50-1.84).

The percentage of patients who received timely reperfusion with primary PCI or thrombolysis declined across the country, with an average delay of roughly 20 minutes in Hubei and 5 minutes elsewhere. However, the odds of receiving effective reperfusion—defined as successful thrombolysis or TIMI grade 3 flow after primary PCI—remained consistent over the study period.

Along with the treatment delays, in-hospital outcomes worsened. In Hubei, mortality increased from 4.6% to 7.3% and heart failure bumped up from 14.2% to 18.4%. There were smaller changes in other provinces. Rates of in-hospital hemorrhage did not significantly change after adoption of the modified treatment protocol.

Primary PCI as the Preferred Treatment

That last finding was surprising because a shift toward greater use of thrombolytic therapy versus primary PCI would be expected to be accompanied by more bleeding events, as seen in prior studies, commented Lauren Ranard, MD, who wrote an accompanying editorial with Sahil Parikh, MD, and Ajay Kirtane, MD (all from NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY). That suggests that bleeding was potentially under-reported in this database.

“Despite the low number of bleeding events seen in this study, we still should favor primary PCI given the research over the past few months showing that there are many STEMI mimickers with COVID,” Ranard told TCTMD, pointing out that giving fibrinolytic therapy to patients without an obstructed artery can be associated with adverse outcomes. “Given those STEMI mimickers, perhaps point-of-care ultrasound should be used to see if there’s any corresponding wall-motion abnormality or further evaluation before giving lytic therapy.”

Ranard said this study “overall did show consistencies with prior published research that shows that during COVID there’s less-timely reperfusion—that has been seen with the STEMIs—and it’s also consistent with other prior studies that have shown that there’s increase in in-hospital heart failure related to these less-timely reperfusions.”

To TCTMD, Kirtane pointed out that historically many STEMI patients in China were not getting reperfused at all, and that there have been efforts in recent years to increase reperfusion rates. This data set indicates those initiatives have been effective, but the potential differences between US and Chinese practice might influence interpretation of the results, he indicated. “The specific challenge here is that extrapolating that data to US practice might be difficult given the fact that we have generally higher rates of reperfusion as a whole.”