Association Between COVID-19 Diagnosis and In-Hospital Mortality in Patients Hospitalized With ST-Segment Elevation Myocardial Infarction

Abstract

Importance: There has been limited research on patients with ST-segment elevation myocardial infarction (STEMI) and COVID-19.

Objective: To compare characteristics, treatment, and outcomes of patients with STEMI with vs without COVID-19 infection.

Design, setting, and participants: Retrospective cohort study of consecutive adult patients admitted between January 2019 and December 2020 (end of follow-up in January 2021) with out-of-hospital or in-hospital STEMI at 509 US centers in the Vizient Clinical Database (N = 80 449).

Exposures: Active COVID-19 infection present during the same encounter.

Main outcomes and measures: The primary outcome was in-hospital mortality. Patients were propensity matched on the likelihood of COVID-19 diagnosis. In the main analysis, patients with COVID-19 were compared with those without COVID-19 during the previous calendar year.

Results: The out-of-hospital STEMI group included 76 434 patients (551 with COVID-19 vs 2755 without COVID-19 after matching) from 370 centers (64.1% aged 51-74 years; 70.3% men). The in-hospital STEMI group included 4015 patients (252 with COVID-19 vs 756 without COVID-19 after matching) from 353 centers (58.3% aged 51-74 years; 60.7% men). In patients with out-of-hospital STEMI, there was no significant difference in the likelihood of undergoing primary percutaneous coronary intervention by COVID-19 status; patients with in-hospital STEMI and COVID-19 were significantly less likely to undergo invasive diagnostic or therapeutic coronary procedures than those without COVID-19. Among patients with out-of-hospital STEMI and COVID-19 vs out-of-hospital STEMI without COVID-19, the rates of in-hospital mortality were 15.2% vs 11.2% (absolute difference, 4.1% [95% CI, 1.1%-7.0%]; P = .007). Among patients with in-hospital STEMI and COVID-19 vs in-hospital STEMI without COVID-19, the rates of in-hospital mortality were 78.5% vs 46.1% (absolute difference, 32.4% [95% CI, 29.0%-35.9%]; P < .001).

Conclusions and relevance: Among patients with out-of-hospital or in-hospital STEMI, a concomitant diagnosis of COVID-19 was significantly associated with higher rates of in-hospital mortality compared with patients without a diagnosis of COVID-19 from the past year. Further research is required to understand the potential mechanisms underlying this association.

Figure 1.. Study Flow and Matching of Patients With ST-Segment Elevation Myocardial Infarction (STEMI) With or Without COVID-19

Out-of-hospital STEMI was defined through International Classification of Diseases, Tenth Revision coding (see eTable 1 in the Supplement) as being both present on admission and the primary diagnosis, while in-hospital STEMI was defined as nonprimary diagnosis coding and not present on admission. Patients in whom these were mixed (eg, STEMI present on admission but not the primary diagnosis) were excluded. Patients who presented to centers not capable of percutaneous coronary intervention (PCI), and were therefore excluded, may have entered the analysis if they subsequently transferred to a PCI-capable center.

Figure 2.. Association Between COVID-19 Diagnosis and Outcomes Among Propensity-Matched Patients With Out-of-Hospital and In-Hospital ST-Segment Elevation Myocardial Infarction (STEMI)