Case and Plan:
43-year old male presented to ER late with anterior STEMI 40 hours after the symptom onset of chest pain, cough and low grade fever. A Cardiac Cath on March 23, 2020 revealed 1 V CAD: thrombotic occlusion of proximal LAD with LVEF = 20%. Patient underwent successful intervention of proximal LAD using aspiration Thromectomy and Promus Premier DES. Subsequently patient did well and managed on GDMT. A followup echo revealed LVEF 35% and no LV apical thrombus. Patient was discharged home 3 days later. Patient was tested positive for the COVID-19 virus post PCI and likely contributed to patient’s late prevention.
Q Is your hospital performing any elective procedures?
A. Since March we have been performing only urgent, Inpatient or Elective but high risk or very symptomatic pts; this policy applies to all structural or CAD or PAD cases. Our usual volume of daily average of 70 pts pre-Covid-19 has reduced to daily 5-7 cases; <10%. This allowed hospital to re-allocate our cardiac telemetry units to be used for Covid pts.
Q For urgent procedures, have you created a pathway for the patient to bypass the ER and reduce exposure to Covid-19 patients there?
A. Actually for urgent cases coming via ER, we bring them quickly to the cath lab holding and wait for the Covid test results before proceeding to invasive procedure. We did make exceptions to some STEMIs in young age <60 yrs age, where we proceeded with cath and PCI with proper PPE to the staff. For the field activation cardiac cases, we have not created a system of bypassing the ER.
Q Is hydroxychloroquine being used at your institution for healthcare providers?
A. Yes as a prophylaxis; 200mg per week of Hydroxycloroquin to the health care workers who are exposed to Covid-19 pts. We were using Hydroxycloroquin 400mg daily for 7 days for documented Covid-19 treatment but it has need stopped now due to latest FDA warning about its use.
Q Which lytic agent do your recommend?
A. TNK is preferred thrombolytic in this era as it is given as bolus only while tPA and Alteplase require weight ranging infusion of 90 minutes. Mount Sinai health system only carries only tPA.
Q Heparin or LMWH?
A. LMWH is being preferred to avoid dose titration at present in Covid-19 or PUI cases.
Q Clopigogrel or newer agents (maybe, not approved for use with lytics)?
A. With thrombolytic during STEMI, we are using 300mg Clopidogrel load and then 75mg po daily. Other potent P2Y12 agents are avoided as have not been studied and may cause more bleeding.
Q Why not get coronary CT for all Covid-19 patients prior to considering for Primary PCI?
A. Yes coronary CTA is preferred in cases of questionable STEMI in Covid-19 pts to triage them to cath if coronary obstruction or just GDMT if clean coronaries.
Q Any additional precautions for a code blue (cardiac arrest) for the STEMI patient in the cath lab?
A. For cardiac arrest during STEMI PCI in Covid-19 pts, proper full PPE of the staff is must, even it slightly delays the care of these pts. This issue has been well addressed in the recent Circulation paper. Cardiac arrest in Covid-19 STEMI pts with multiple comorbidities needs to be individualized and comfort care and DNR may even be appropriate.
Q For Covid-19 patients, do you prefer Radial or Femoral route?
A. In Covid-19 pts we prefer femoral approach for cath procedure to keep extra safe distance.
Q Since so many of the Covid positive, high-risk STEMI do so poorly, is there any benefit of placing IABP or Impella (large anterior wall MI, low EF)?
A. We try to minimize the instrumentation in Covid-19 pts and LV support device will be used as clinically strongly indicated but not prophylactically.
Did you use any bolus gp2b3a inhibitor in the stemi case with such a lot of thrombus….what’s your protocol of using gp2b in stemi
We have gone away from GP2b3a completely even during STEMI cases. If needed we use IV Cangrelor infusion for 4-24 hrs post PCI. Majority of these pts get Ticagrelor or Prasugrel and hence less need for additional agents. Hence at Sinai in STEMI cases we use GPI in 2% of cases and IV Cangrelor in 15-20% of cases.