Does a pharmacoinvasive strategy offer a safe and effective alternative to primary PCI for STEMI patients during the COVID-19 pandemic?
During the COVID-19 pandemic, a pharmacoinvasive strategy using fibrinolytic therapy may be a necessary and safe alternative to primary PCI for STEMI patients due to systemic delays.
In this issue we publish 2 differing cardiovascular perspectives on how to manage ST-segment-elevation myocardial infarction (STEMI) during the coronavirus disease 2019 (COVID-19) pandemic.COVID-19 has disrupted many processes of care related to emergency cardiac conditions.These perspectives offer 2 opinions understanding that capacity of treating hospitals will continue to evolve and management should change based on it.Placing these side-by-side will allow readers to understand the tradeoffs inherent in such decisions. The coronavirus disease 2019 (COVID-19) pandemic has dramatically altered the delivery of reperfusion therapy for patients with ST-segment-elevation myocardial infarction (STEMI).At this crucial time, it seems prudent to reevaluate STEMI reperfusion pathways (Figure).Although primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy when available, its benefit depends on rapidly achieving firstmedical-contact-to-device times within 90 to 120 minutes.Delayed reperfusion results in larger myocardial infarct size, increased risk for heart failure and shock, and no survival advantage compared with fibrinolytic therapy.Moreover, in the STREAM trial (Strategic Reperfusion Early after Myocardial Infarction), a pharmacoinvasive strategy of early fibrinolytic therapy coupled with timely PCI compared with primary PCI provided similar 30-day clinical outcomes and 1-year mortality. 1Half-dose tenecteplase in those ≥75 years obviated major bleeding and intracranial hemorrhage rates and in a large real-world registry, this pharmacoinvasive strategy was associated with improved 1-year clinical outcomes compared with primary PCI without differences in major bleeding or intracranial hemorrhage rates. 2 STEMI rates have declined during the COVID-19 pandemic, perhaps partly because of patients unwilling to access the emergency medical system or risk hospital exposure to COVID-19.Those presenting to hospitals without PCI-capability are subject to transfer delays for primary PCI, or even transfer refusal, because of COVID-19 demands.Those presenting by ambulance directly to hospitals with PCIcapability are not receiving the benefit of prehospital cardiac catheterization laboratory activation because it has been suspended. 3Emergency department evaluations are prolonged with additional screening for COVID-19 and STEMI mimics that affect troponin release and confound ST-segment elevation interpretation.Transfer from the emergency department to the catheterization laboratory is complicated by risks of additional staff exposure and delays in preparation associated with personal protective equipment.As the frequency and duration of PCI-related delays for reperfusion therapy increase, fibrinolytic therapy and the pharmacoinvasive strategy offer a logical, effective, simple, and safe alternative for an overtaxed health system while decreasing COVID-19 exposure risk for healthcare providers.
Bainey et al. (Mon,) studied this question.