Management of Acute Myocardial Infarction During the COVID-19 Pandemic

The worldwide pandemic caused by the novel acute respiratory syndrome coronavirus 2 has resulted in a new and lethal disease termed coronavirus disease-2019 . Although there is an association between cardiovascular disease and COVID-19, the majority of patients who need cardiovascular care for the management of ischemic heart disease may not be infected with this novel coronavirus. The objective of this document is to provide recommendations for a systematic approach for the care of patients with an acute myocardial infarction (AMI) during the COVID-19 pandemic. There is a recognition of two major challenges in providing recommendations for AMI care in the COVID-19 era. Cardiovascular manifestations of COVID-19 are complex with patients presenting with AMI, myocarditis simulating an ST-elevation myocardial infarction (STEMI) presentation, stress cardiomyopathy, non-ischemic cardiomyopathy, coronary spasm, or nonspecific myocardial injury, and the prevalence of COVID-19 disease in the U.S. population remains unknown with risk of asymptomatic spread. This document addresses the care of these patients focusing on 1) the varied clinical presentations; 2) appropriate personal protection equipment (PPE) for health care workers; 3) role of the Emergency Department, Emergency Medical System and the Cardiac Catheterization Laboratory; and 4) Regional STEMI systems of care.During the COVID-19 pandemic, primary PCI remains the standard of care for STEMI patients at PCI capable hospitals when it can be provided in a timely fashion, with an expert team outfitted with PPE in a dedicated CCL room. A fibrinolysis-based strategy may be entertained at non-PCI capable referral hospitals or in specific situations where primary PCI cannot be executed or is not deemed the best option. (J Am Coll Cardiol 2020;76:1375-84)
Patients with cardiovascular disease who develop COVID-19 have a higher risk of mortality [bib_ref] Clinical predictors of mortality due to COVID-19 based on an analysis of..., Ruan [/bib_ref] [bib_ref] Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in..., Wang [/bib_ref] [bib_ref] Cardiovascular implications of fatal outcomes of patients with coronavirus disease 2019 (COVID-19), Guo [/bib_ref] [bib_ref] Impact of coronavirus disease 2019 (COVID-19) outbreak on ST-segment-elevation myocardial infarction care..., Tam [/bib_ref]. However, it is important to emphasize that the majority of patients who need cardiovascular care for the management of ischemic heart disease, peripheral vascular disease, or structural heart disease may not be infected with this novel coronavirus. Furthermore, as we prepare for the care of patients with COVID-19-related illness, we also need to ensure that the overall patient population continues to benefit from the tremendous advancements in cardiovascular care made over the past three decades [bib_ref] From concept to reality: a decade of progress in regional ST-elevation myocardial..., Henry [/bib_ref].
The objective of this document is to provide recommendations for a systematic approach for the care of patients with an acute myocardial infarction (AMI) during the COVID-19 pandemic. It is critical to: 1) inform the public that we can minimize exposure to the coronavirus so they continue to call the emergency medical system (EMS) for acute ischemic heart disease symptoms and therefore get the appropriate level of cardiac care that their presentation warrants; 2) target the use of primary percutaneous coronary intervention (PCI) or fibri- In certain circumstances, a more detailed and confirmatory evaluation in the ED might be required All STEMI patients should initially undergo evaluation in the ED. Patients should be evaluated in the ED prior to CCL activation to ensure appropriate risks are assessed. All patients require the placement of a face mask to prevent droplet contamination of the CCL and environment prior to transport.
CCL staff and physicians should have appropriate PPE for safe performance of the procedure, including gowns, gloves, full face mask, and an N95 respiratory mask. If N95 masks are to be reused between cases by a single HCW, then an additional surgical mask should be worn on top of this mask. The number of HCWs present during the procedure should be limited to only those essential for patient care and procedure support.
Patients with respiratory compromise should be intubated prior to arrival in the CCL if possible. If intubation is required in the CCL, all personnel should have complete PPE and exposures should be minimized to essential team members only. For all procedures at high risk of aerosolization, PAPRs should be considered.
Proper PPE training should be provided and practiced by physicians and CCL staff involved in all cases, and extra consideration should be given to the protection of trainees in high-risk patients and procedures.
Primary PCI should remain the default strategy in patients with clear evidence of a STEMI; if a primary PCI approach is not feasible, a pharmacoinvasive approach may be considered.
During the COVID-19 period, there may be delays in D2B times that result from evaluation and/or management of COVID-19 patients. This can be documented in the medical record and coded in the NCDR CathPCI version 5 as follows: If primary PCI for STEMI, code "Yes" for Seq. #7850 (patient-centered reason for delay in PCI) and selecting "Other" in Seq. #7851 (delay reason). If primary thrombolytic therapy for STEMI, code "Yes" for Seq. #14208 (patient reason for delay in thrombolytic).
Within the CCL, a single negative pressure procedure room with essential supplies only is preferable for the care of known COVID-19 positive or probable patients with a terminal clean after the procedure.

## Positive/probable
Patients diagnosed as a field STEMI by the emergency medical system personnel need to be evaluated in the emergency department to assess their COVID-19 status and confirm the diagnosis of an STEMI. Individual patient-level decision making can be pursued as outlined in . The decision to proceed with an initial fibrinolysis or direct transfer to a PCI center is multifactorial, and it will likely vary in different regions.
The treatment decision also depends on whether the patient is COVID-19 positive or probable and should be made between the referral hospital physician and PCI center physician. On transfer of a patient with an STEMI from a referral hospital to a PCI center, the patient should and staff potentially exposed during invasive cardiovascular procedures; this may include limiting the involvement of trainees in high-risk procedures and patients.

## Ed and ems collaboration
The ED is the place of initial medical contact for the majority of patients with STEMI in the United States.
For the past two decades, the priority in emergency medicine in caring for these patients has been to rapidly diagnose STEMI and aim for urgent reperfusion. However, as mentioned previously, the elec- . The attending interventional cardiologist should be notified, but without activation of the entire STEMI team until the plan for CCL activation is confirmed. .

## Regional stemi systems of care
These recommendations will need to be adapted to each regional system's PCI centers, STEMI referral hospitals, and EMS system and need to be communicated clearly between cardiology and emergency medicine providers within each hospital. As the COVID-19 pandemic grows or recedes, this algorithm will need to be updated and adapted but will eventually return to the principles of simplicity and efficiency previously outlined in the STEMI accelerator program and the ACC/AHA guidelines [bib_ref] From concept to reality: a decade of progress in regional ST-elevation myocardial..., Henry [/bib_ref] [bib_ref] Regional systems of care demonstration project: American Heart Association Mission: lifeline STEMI..., Jollis [/bib_ref]. For now, each system must recognize the competing and equally important principles of: a) timely reperfusion of STEMI patients; b) safe regional transport and treatment of potentially high-risk patients; and c) additional emphasis on protection and safety of all health care personnel.

# Conclusions
[fig] F u t i: l e p r o g n o s i s . We note that not all COVID-19 patients with ST elevation with/without an acute coronary occlusion will benefit from any reperfusion strategy or advanced mechanical support. In COVID-19 confirmed patients with severe pulmonary [/fig]
[table] TABLE 1: Summary of Recommendations for the Care of Patients With Acute Myocardial Infarction During the COVID-19 Pandemic [/table]
[table] TABLE 2: STEMI Regional Systems of CareSystem-wide: emergency medical services, STEMI referral hospitals, and PCI centers Each regional STEMI system should update their system of care immediately to maximize patient and provider safety including adequate PPE during transport and procedures for STEMI patients who are COVID-19 positive or probable. First medical contact to reperfusion time remains of paramount importance and should not substantially delay primary PCI for STEMI patients. Additional time at the primary PCI center ED or ICU may be a necessary delay required for confirmation of COVID-19 and STEMI status prior to transfer to the CCL. STEMI patients with cardiogenic shock and/or resuscitated cardiac arrest should still be prioritized for a primary PCI approach. If timely PCI is not possible or team/room/PPE not available, a pharmacoinvasive strategy may be considered. It is critical to ensure PPE and rapid sterilization procedures are prioritized throughout the entire system of care and that communication occurs among transfer hospital, EMS, ED, and CCL providers regarding COVID-19 status.Emergency medical services, field-activated STEMI, and referral (non-PCI) hospitals EMS should include a brief assessment of COVID-19 status (positive, probable, or possible) in their report to the PCI center for an incoming STEMI patient. If a patient is COVID-19 positive or probable, EMS should follow CDC guidelines regarding droplet precautions during and immediately after transfer. All transfer STEMI patients should be re-evaluated at the primary PCI center ED or ICU for COVID-19 status and the concept of ED bypass should not be utilized during the pandemic. Patients with STEMI at a referral hospital with established COVID-19 infection should be discussed prior to transfer to a PCI center. Fibrinolysis within 30 min of STEMI diagnosis, and transfer for rescue PCI when necessary, may be preferable for all COVID-19 positive STEMI patients who are at a referral hospital, provided the diagnosis of a true STEMI is highly likely.CDC 14 Centers for Disease Control and Prevention; CCL 14 cardiac catheterization laboratory; COVID-19 14 coronavirus 2019; ED 14 emergency department; EMS 14 emergency medical system; ICU 14 intensive care unit; PCI 14 percutaneous coronary intervention; PPE 14 personal protective equipment; STEMI 14 ST-elevation myocardial infarction.system has its own inherent risk of COVID-19 infection/spread, as well as its own potential for delay in reperfusion for patients with STEMI.Based on early experience in China and Europe, key challenges include the availability of ICU beds, ventilators, ECMO, and the risk to HCWs (including EMS personnel, ED staff, and specialized diagnostic and treatment units like the CCL). As the U.S. experience with COVID-19 is rapidly evolving, definitive best practices are clearly challenging and require flexibility for a complex regional care system. Based on these new operational risks and patient comorbidities, it is imperative to consider immediate adjustments that maximize treatment options for patients with acute cardiovascular emergencies while protecting the safety of patients and providers. We propose the following guiding principles for Transfer STEMI Regional Systems of Care in the era of coronavirus (Table 2, [/table]