Role of Thrombolysis for STEMI in the Covid-19 Period
ST-segment elevation myocardial infarction (STEMI), usually resulting from thrombotic occlusion of a coronary artery, is a fatal cardiovascular emergency requiring early diagnosis and rapid reperfusion therapy. The COVID-19 outbreak reduced the number of STEMI cases reported. Consistent the percentage of patients undergoing primary percutaneous coronary intervention declined while the percentage of patients undergoing thrombolysis increased. (1)
Cardiac catheterization laboratories in the USA confirmed an estimated reduction of 38% in STEMI presentation (mean activation per month before vs. after COVID-19 period, 23.6 vs. 15.3 respectively, 95% CI 26, 49, p < 0.001) in the context of sudden COVID-19 outbreak. (2) A similar drop of 40% in STEMI admissions was observed by Rodriguez-Leor et al. in Spain. (3)
The superiority of PCI over thrombolysis in STEMI cases is well established. (4) In ST-segment elevation myocardial infarction (STEMI) primary percutaneous coronary intervention (PPCI) is to date the recommended therapy if the estimated time is ≤120 min from the diagnosis, otherwise fibrinolytic therapy must be preferred. (5)
Considering the dramatic impact of COVID-19 on emergency services, experts from China, UK and US suggested to reconsider thrombolysis as the best treatment in term of balance between time consumption and operators safety for STEMI patients respect to PPCI. (6)
In 2013, the Strategic Reperfusion Early after Myocardial Infarction (STREAM) study demonstrated that the use of fibrinolytic strategy in patients with STEMI who presented within 3 h after symptoms onset and were not capable for a primary PCI within 1 h, was at least as effective as in those undergoing primary PCI regarding to the composite of death, shock, congestive heart failure or reinfarction up to 30 days. (7)
A recently published algorithm for the management of STEMI during SARS-CoV-2 outbreak from “The COVID-19 and Acute Myocardial Infarction (AMI) committee of Peking Union Medical College Hospital” suggested a more leading role of fibrinolytic treatment in STEMI patients with confirmed or suspected COVID-19, in order to achieve the principle of “time is muscle”. (8)
On the other hand, an important issue to consider is that using fibrinolytic strategy may not be suitable for all patients, not only due to numerical contraindications, but also because a proportion of them may still need a PCI; something that may have an impact on health resources. Another promising idea is the use of robotic-assisted PCI in STEMI patients during SARS-CoV-2 outbreak, as the exposure risk of the catheterization laboratory staff may be reduced. (7)
- Cardiovascular disease is associated with increased severity of COVID-19.
- The number of people with STEMI has decreased during the pandemic and delays in the time looking for medical care have been reported.
- Changes in reperfusion strategies in the covid era.
- Fibrinolytic therapy or robotic-assisted PCI in early presenting STEMI patients may have an alternative role during this period if prevention measures cannot be taken.
Martinez Benitez Piter. MD, Duong Thanh Binh. MD
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