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Multicenter Study
. 2021 May 25;77(20):2466-2476.
doi: 10.1016/j.jacc.2021.03.309.

International Prospective Registry of Acute Coronary Syndromes in Patients With COVID-19

Thomas A Kite  1 , Peter F Ludman  2 , Chris P Gale  3 , Jianhua Wu  3 , Adriano Caixeta  4 , Jacques Mansourati  5 , Manel Sabate  6 , Pilar Jimenez-Quevedo  7 , Luciano Candilio  8 , Parham Sadeghipour  9 , Angel M Iniesta  10 , Stephen P Hoole  11 , Nick Palmer  12 , Albert Ariza-Solé  13 , Alim Namitokov  14 , Hector H Escutia-Cuevas  15 , Flavien Vincent  16 , Otilia Tica  17 , Mzee Ngunga  18 , Imad Meray  19 , Andrew Morrow  20 , Md Minhaj Arefin  21 , Steven Lindsay  22 , Ghada Kazamel  23 , Vinoda Sharma  24 , Aly Saad  25 , Gianfranco Sinagra  26 , Federico Ariel Sanchez  27 , Marek Roik  28 , Stefano Savonitto  29 , Marija Vavlukis  30 , Shankar Sangaraju  31 , Iqbal S Malik  32 , Sharon Kean  33 , Nick Curzen  34 , Colin Berry  35 , Gregg W Stone  36 , Bernard J Gersh  37 , Anthony H Gershlick  38 ; International COVID-ACS Registry Investigators
Affiliations
Multicenter Study

International Prospective Registry of Acute Coronary Syndromes in Patients With COVID-19

Thomas A Kite et al. J Am Coll Cardiol. .

Abstract

Background: Published data suggest worse outcomes in acute coronary syndrome (ACS) patients and concurrent coronavirus disease 2019 (COVID-19) infection. Mechanisms remain unclear.

Objectives: The purpose of this study was to report the demographics, angiographic findings, and in-hospital outcomes of COVID-19 ACS patients and compare these with pre-COVID-19 cohorts.

Methods: From March 1, 2020 to July 31, 2020, data from 55 international centers were entered into a prospective, COVID-ACS Registry. Patients were COVID-19 positive (or had a high index of clinical suspicion) and underwent invasive coronary angiography for suspected ACS. Outcomes were in-hospital major cardiovascular events (all-cause mortality, re-myocardial infarction, heart failure, stroke, unplanned revascularization, or stent thrombosis). Results were compared with national pre-COVID-19 databases (MINAP [Myocardial Ischaemia National Audit Project] 2019 and BCIS [British Cardiovascular Intervention Society] 2018 to 2019).

Results: In 144 ST-segment elevation myocardial infarction (STEMI) and 121 non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients, symptom-to-admission times were significantly prolonged (COVID-STEMI vs. BCIS: median 339.0 min vs. 173.0 min; p < 0.001; COVID NSTE-ACS vs. MINAP: 417.0 min vs. 295.0 min; p = 0.012). Mortality in COVID-ACS patients was significantly higher than BCIS/MINAP control subjects in both subgroups (COVID-STEMI: 22.9% vs. 5.7%; p < 0.001; COVID NSTE-ACS: 6.6% vs. 1.2%; p < 0.001), which remained following multivariate propensity analysis adjusting for comorbidities (STEMI subgroup odds ratio: 3.33 [95% confidence interval: 2.04 to 5.42]). Cardiogenic shock occurred in 20.1% of COVID-STEMI patients versus 8.7% of BCIS patients (p < 0.001).

Conclusions: In this multicenter international registry, COVID-19-positive ACS patients presented later and had increased in-hospital mortality compared with a pre-COVID-19 ACS population. Excessive rates of and mortality from cardiogenic shock were major contributors to the worse outcomes in COVID-19 positive STEMI patients.

Keywords: COVID-19; ST-segment elevation myocardial infarction; acute coronary syndrome; cardiogenic shock; non–ST-segment elevation myocardial infarction.

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Conflict of interest statement

Funding Support and Author Disclosures The study was supported by the Clinical Trials Unit at The University of Glasgow. Dr. Gale has received personal fees from AstraZeneca, Bayer, Boehringer Ingelheim, Daiichi-Sankyo, and Vifor Pharma; and has received grants from Abbott and Bristol Myers Squibb. Dr. Sabate has received personal fees from Abbott Vascular and IVascular. Dr. Sinagra has received personal fees from Biotronik, Boston Scientific, AstraZeneca, and Novartis. Dr. Savonitto has received personal fees from Bayer and Abbott. Dr. Curzen has received grants, personal fees, and nonfinancial support from Boston Scientific, Haemonetics, HeartFlow, and Abbott; has received grants from Beckmann Coulter; and has received nonfinancial support from Biosensors and Medtronic. Dr. Berry is supported by the British Heart Foundation (grant reference RE/18/6134217). Dr. Stone has received personal fees from Terumo, Cook, TherOx, Reva, Vascular Dynamics, Robocath, HeartFlow, Gore, Ablative Solutions, Matrizyme, Miracor, Neovasc, V-wave, Abiomed, Shockwave, MAIA Pharmaceuticals, and Vectorious; has received equity/options in Applied Therapeutics, Biostar, MedFocus, Aria, Cardiac Success, and Cagent; and has received personal fees and equity/options from SpectraWave, Valfix, Ancora, Orchestra Biomed, Qool Therapeutics, and Cardiomech. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

None
Graphical abstract
Figure 1
Figure 1
Patient Selection for the International COVID-ACS Registry Flow diagram detailing patients enrolled in the International COVID-ACS Registry. A total of 51 patients with type 2 myocardial infarction were excluded from comparative analyses with pre-COVID-19 BCIS/MINAP (British Cardiovascular Intervention Society/Myocardial Ischaemia National Audit Project) reference data. ACS = acute coronary syndrome; MI = myocardial infarction; NSTE-ACS = non–ST-segment elevation acute coronary syndrome; SCAD = spontaneous coronary artery disease; STEMI = ST-segment elevation myocardial infarction.
Central Illustration
Central Illustration
Time Delays and In-Hospital Outcomes in the International COVID-ACS Registry When compared with pre–coronavirus disease 2019 (COVID-19) reference data from the British Cardiovascular Intervention Society (BCIS) and Myocardial Ischaemia National Audit Project (MINAP) databases, patients enrolled in the International COVID-ACS registry were found to experience significant delays in presentation to hospital and time to reperfusion therapy, excess rates of cardiogenic shock, and greater in-hospital mortality. These novel data suggest 1 potential mechanism for the poorer outcomes observed in patients with acute coronary syndrome (ACS) and COVID-19, and yet again support the concept of “time is muscle” in myocardial infarction. Public health messaging during this and future pandemics should be clear—patients who experience cardiovascular symptoms should not delay in seeking medical attention. NSTE-ACS = non–ST-segment elevation acute coronary syndrome; STEMI = ST-segment elevation myocardial infarction.
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