Thrombus Burden and Outcomes in Patients With COVID-19 Presenting With STEMI Across the Pandemic

Abstract

Background: It has been previously reported during the first COVID-19 outbreak that patients presenting with ST-segment elevation myocardial infarction (STEMI) and concurrent COVID-19 infection have increased thrombus burden and poorer outcomes. To date, there have been no reports comparing the outcomes of COVID-19-positive STEMI patients across all waves of the pandemic.

Objectives: This study compared the baseline demographic, procedural, and angiographic characteristics alongside the clinical outcomes of patients presenting with STEMI and concurrent COVID-19 infection across the COVID-19 pandemic in the United Kingdom.

Methods: This was a single-center, observational study of 1,269 consecutive patients admitted with confirmed STEMI treated with percutaneous coronary intervention (between January 3, 2020 and October 3, 2022). COVID-19-positive patients were split into 3 groups based upon the time course of the pandemic, and a comparison was made between waves.

Results: A total of 154 COVID-19-positive patients with STEMI were included in the present analysis and were compared with 1,115 COVID-19-negative patients. Early during the pandemic (wave 1), STEMI patients presenting with concurrent COVID-19 infection had high rates of cardiac arrest, evidence of increased thrombus burden, bigger infarcts, and worse outcomes. However, by wave 3, no differences existed in outcomes between COVID-19-positive and -negative patients, with significant differences compared with earlier COVID-19-positive patients. Poor outcomes later in the study period were predominantly in unvaccinated individuals.

Conclusions: Significant changes have occurred in the clinical characteristics, angiographic features, and outcomes of STEMI patients with COVID-19 infection treated by primary percutaneous coronary intervention during the course of the pandemic. Importantly, outcomes of recent waves and in vaccinated individuals are no different to a non-COVID-19 population.

Keywords: COVID-19; ECG; PCI; STEMI.

Graphical abstract

Figure 1

Modified Thrombus Grade Over Time and COVID-19 Status Modified thrombus grade was assessed in all patients with a baseline thrombus grade 5. Data are presented by COVID-19 status and wave. Data expressed as mean ± SEM. ∗∗∗P < 0.001, for 2-way repeated measures analysis of variance.

Figure 2

Requirement for Heparin During Primary Percutaneous Coronary Intervention (A) Correlation between baseline heparin dose and first activated clotting time (ACT) measured after a 10- to 15-min interval in non–COVID-19 patients (P < 0.0001). (B) Correlation between baseline heparin dose and first ACT measured after a 10- to 15-min interval in COVID-19 wave 1 group (P = 0.144).

Central Illustration

Outcomes of ST-Segment Elevation Myocardial Infarction in COVID-19 Infection Across the Pandemic ST-segment elevation myocardial infarction in COVID-19 infection was associated with significantly higher rates of stent thrombosis (P = 0.0410), multivessel thrombus (P = 0.030), modified thrombus grade 4 to 5 (P = 0.0008), lower rates of myocardial blush grade 2 to 3 (P = 0.0001), and mortality (P = 0.0041) during wave 1 of the pandemic. However, these differences have disappeared over time (vaccinations/strains) ∗P < 0.05. ∗∗P < 0.01. ∗∗∗P < 0.001.

Figure 3

Outcomes Based on Vaccination Status Unvaccinated COVID-19–positive patients had worse outcomes compared with both vaccinated COVID-19 patients and non–COVID-19 patients. Unvaccinated COVID-19–positive patients were more likely to present in cardiogenic shock (P = 0.045), have a higher thrombus burden (P = 0.005), require admission to the intensive care unit (ICU) (P = 0.044), and have higher rates of in-hospital mortality (P = 0.023). ∗P < 0.05. ∗∗P < 0.01.