Nima Ghasemzadeh, Interventional Cardiologist at Georgia Heart Institute, discusses ST elevation in myocardial infarction (STEMI) in patients with COVID-19 at the first inaugural Heart & Vascular Symposium hosted by Georgia Heart Institute at Chateau Elan Resort & Winery in Braselton, Georgia.
So it's my pleasure to ask Neema Gaza Masada, my friend and new partner to uh come up and present his data that he's really spent a lot of time on working with COVID and COVID acute Coronary syndrome in particular stem E uh which is a wealth of information and you're gonna learn a lot here. So, Neema take it away. Thank you. Good afternoon, everyone. It's a pleasure to be here in front of you all. Thank you Greg. So I wanted to discuss uh basically data behind S T elevation and my in its care and patients with COVID 19, I have no disclosure. The mechanisms behind uh COVID 19 leading into acute micro infarction are um are a few. So as, as you can see in this figure, as the COVID 19 enters the alveoli epithelial cells, it gets replicated in there. And then once it gets released, it basically induces an immune response and uh hyper inflammatory states with the release of several inflammatory biomarkers like TNF alpha L six I L two or GM CSF. And this could lead to plaque rupture in patients of atherosclerosis. Other mechanism behind uh COVID 19. Leading to acute myocardial infarction includes platelet activation, which could um cause basically a throne, symbolic event involving a large epic cardio um coronary artery or microvascular thrombosis involving the micro circulation. So this is an example of a 40 year old gentleman who was admitted with COVID 19 pneumonia and developed an inferior S T elevation M I. As you can see a human humongous amount of thrombosis in this right coronary artery. He underwent successful um basically aspiration, thrown back to me. And uh despite that, there was a symbolic occlusion of the distal right uh posterior descending artery. This is another case of similar um 35 year old gentleman who was admitted with COVID 19 pneumonia and developed info poster or lateral stem me. But as you can see here, angiogram uh did not find any culprit lesion. The thought process in this case was that this patient had micro thrown by causing uh basically his steamy. So um there is uh you know, studies have shown that there is an increased risk of mortality in patients with cardiovascular disease who acquired COVID-19 infection. And uh there are several data that showed that elevated troponin level uh is present in up to 15 to 28% of patients admitted with COVID 19 and stem E patients who have COVID 19 infection are particularly unique and and challenging to care for. So, initially, during the COVID 19 era, uh we went through the phases which there was uncertainty about what to do with these patients, whether to take them to the Cath Lab. Initially, there were some recommendations but some societies that perhaps fiber analytics were where better approach, but we really didn't know what to do. So um several um uh basically institutions came together from uh in, in North America, uh primarily in the U S and Canada and established the North American COVID 19 S T elevation, my column function registry or Knock Me Registry, which we're fortunate to be a part of. And I see personally grateful to our research department, I see some of our research team uh in the right side corner there. Um uh and personally grateful for their efforts and uh making us one of the larger contributors to this uh registry. So an ACME was a perspective in investigator initiated multi center observational registry of hospitalized patient with confirmed or suspected COVID 19 infection in North America. This is the baseline characteristic of the initial phase of the study. As you can see um initially as comparing COVID 19 patients in the in the first column uh to the second column, which is uh those because the rapid tests were not available. So the in the year 2020 um basically those who were suspected of having COVID, that was one of the groups before their tests become available. And then comparing them to propensity matched stem E patients from Midwest uh stem E Consortium as you can see these patients were more likely to be African American and, uh, and basically more likely to be, uh diabetic and more likely to be also Hispanic. Uh, those patients with COVID 19 and pneumonia who presented with stem E, uh, we're more likely to have infiltrated on the chest X ray and more likely to present with Disney as the primary symptom rather than chest pain in the initial phase of the COVID 19 pandemic. As you can see here shows the treatment strategies. Those with COVID 19 pneumonia were less likely to take to be taken to the Cath lab compared to their propensity matched counterparts. And primary PC I was initially less likely to be used as the treatment modality for these patients with COVID 19 who uh basically had Stamey, the door to balloon time was overall a numerically higher, but this did not reach statistical uh significance. Uh There was no difference between uh the culprit artery, the location of the corporate artery. Uh This figure shows the comparison of outcomes between COVID 19 patients who had stem E versus uh their propensity match counterparts uh and those who were suspected of having COVID, but their test results were still pending. As you can see those with in the red bars with COVID 19 and stemming had statistically significantly higher in hospital mortality. They had statistically higher um odds of in hospital stroke, they had uh longer length of stay and longer. Basically ice you staying Again, this figure summarizes the results of the uh primary analysis of the national registry. As you can see, initially, there were more blacks and Hispanics that suffered stemming and had COVID-19 pneumonia. They were less likely to receive angiography and there were more likely to suffer a major adverse cardiovascular events and death and, and stroke. Um This um slide also shows uh the difference between the outcomes between several studies that have been reported outcomes. As you can see those with uh those with um COVID 19 pneumonia who had stem e had much higher odds of in hospital death, excuse me. And higher basically odds of stroke compared to their basically uh propensity matched uh compared to the historical cohorts. Now, the knack me uh group analyzed the results of the registry uh and compared to 2020 with 2021, was when we had vaccine available. And as you can see, um there were uh the non non Caucasian group. Actually, the proportion of those uh subgroups declined in year 2021 in the year 2021. Those who actually presented with semi were more likely to have actual chest pain rather than dysthymia and less likely to have infiltrates on chest X ray and less likely to have Shaq pre PC I as compared to uh the year prior, The uh these patients were in the year 2021, as you can see in this table were more likely to be taken to the Cath lab for angiogram and uh PCI. This graph basically compares and shows the difference between the in hospital mortality and all cause mortality and other outcomes between the year 2020 when the vaccines were not available in 2021 when vaccines became available. So as you, You can see uh the composite outcome was significantly lower in, in 2021 compared to 2020. Similarly, uh the components of the composite outcome including the all cause mortality. Um And uh basically uh stroke, uh we're uh we're lower, stroke was numerically lower. But that did not reach statistical significance as similarly, total length of stay was lower in the year 2021 compared to 2020. And uh total, I see length of stay was also shorter. Um This slide basically summarizes the findings um as as we went through between 2021 2020. Uh So basically, um it shows that um Uh they had less likely to have uh infiltrates more likely to receive vaccine and overall mortality was lower in the year 2021. Uh compared to 2020 overall risk of in hospital mortality was 25% lower in, in 2021 relative to year 2020. And the risk was uh 70% higher. Uh if there was infiltrates observed on the chest X ray and nearly three times higher if cardiogenic shock was present, um during the admission risk was also higher in patients who are older. Uh This slide from Dr Tim Henry um basically summarizes the direct and indirect effect of COVID 19 and its effect on stemming care overall and cardiovascular care as um as a whole. So as you can see in the direct effects, we can mentioned that those patients who have COVID 19 pneumonia had worse outcomes, also elevated troponin was also shown to be associated with worse outcomes. And you can see that COVID-19 pneumonia can cause a variety of cardiovascular um effects including venus and arterial thrown by uh including pe acute myocardial infarction stroke and so on and so forth. The indirect effects that were observed were um predominantly initially, they stay at home orders. Basically, patients were told not to come to the hospital, sit at home. So this resulted in uh patients basically ignoring their symptoms come late. And uh we were noticing initially, especially uh more um complications of acute myocardial infarction such as free ball rupture or VSD. Uh And uh and uh in addition to that, there are also psychological effect of COVID 19. And uh and uh it is also important to mention that vaccines are also have been significantly reducing the severity of the endless, but in rare circumstances were shown to have uh to uh to uh lied to my card itis and some young individuals. So, in summary, as the elevation occurred more frequently in blacks, Hispanics and diabetics who had COVID 19 as compared to their COVID 19 negative match controls, COVID 19 patients with stem E were more likely to present with cardiogenic shock but not cardiac arrest. Um We're more likely to have lower ef and more likely to have a typical symptoms such as Disney to and not necessarily chest pain, especially initially in the pandemic. Initial reports suggested that as high as 21% of COVID 19 patients with stem E, we're not undergoing angiography and PC I COVID-19 patients with semi had higher incidents of in hospital mortality and stroke with longer length of stay uh compared to their match to COVID-19, negative controls in hospital mortality decreased by 25% in year 21 as compared to 2020. And overall vaccinated patients were less likely to develop respiratory complications and none of them expired. Thank you very much.
