Brazilian Registry of Interventional Cardiology during the COVID-19 Pandemic (RBCI-COVID19)

Abstract

Background: At the beginning of the COVID-19 pandemic, patients with myocardial infarction (MI) took longer to present to hospitals because of fear of contamination and health care access difficulties.

Objectives: To assess interventional cardiology procedures performed during the COVID-19 pandemic and its implications for MI approach.

Methods: Prospective registry of 24 cardiac catheterization laboratories in Brazil, with adult patients undergoing interventional cardiology procedures between May 26 and November 30, 2020. The outcomes were cardiovascular (CV) and non-CV complications, death, and MI. Concomitant COVID-19 was confirmed using RT-PCR. Machine learning techniques were used with nonparametric Classification Trees models, and Simple Correspondence Analysis, with R statistical software package. Significance level adopted of 5%.

Results: This study included 1282 patients, 435 of whom (33.9%) had MI as follows: ST-segment elevation MI (STEMI), 239 (54.9%); and non-ST-segment elevation MI (NSTEMI), 196 (45.1%). Of the 1282 patients, 29 had CV complications, 47 had non-CV complications, and 31 died. The diagnosis of COVID-19 was confirmed in 77 patients (6%), with 15.58% mortality and non-CV complications in 6.49%. Most patients had significant coronary artery disease (63%), and an intracoronary thrombus was more often found in the presence of STEMI (3.4%) and COVID-19 (4%). A door-to-table time longer than 12 hours in NSTEMI was associated with 30.8% of complications, 25% in COVID-19 patients.

Conclusions: All deaths were preceded by CV or non-CV complications. The presence of COVID-19 was associated with death and non-fatal complications of patients undergoing interventional cardiology procedures during the pandemic.

Figura 1. – Árvore de classificação para o desfecho composto ‘óbito & complicações cardiovasculares e não cardiovasculares’ em todos os pacientes do registro (n=1.282). O nó principal (nó 1) indica a ocorrência ou não de óbito. O nó 9 representa os 31 pacientes que morreram de complicações cardiovasculares e não cardiovasculares (COVID-19, sepse, causas respiratórias, etc). Dos sobreviventes, 705 foram atendidos em uma unidade do SUS, 31 dos quais tiveram complicações (nó 3). Dos 546 pacientes não atendidos em uma unidade do SUS (nó 4), 30 tinham insuficiência renal e 20 tinham COVID-19, 7 dos quais tiveram complicações cardiovasculares (nó 8) e 5 tiveram complicações não cardiovasculares (nó 7).

Figura 2. – Árvore de classificação para o desfecho ‘complicações (cardiovasculares e não cardiovasculares)’ em 196 pacientes com IMSSST. O nó principal (nó 1) indica a ocorrência ou não de óbito. O nó 9 representa os 7 pacientes que morreram, 3 dos quais por complicações cardiovasculares. Entre os sobreviventes, a presença de dislipidemia e idade superior a 78 anos (nó 8, n=7) associou-se a complicações não cardiovasculares (n=2) e cardiovasculares (n=2). Entre aqueles com idade ≤ 78 anos (nó 7, n=69), 3 pacientes tiveram complicações não cardiovasculares e 1 teve complicações cardiovasculares. Entre os sobreviventes sem dislipidemia, o diagnóstico de COVID-19 (nó 5, n=9) associou-se com complicações não cardiovasculares (n=1).

Figura 3. – Árvore de classificação para o desfecho ‘complicações (cardiovasculares e não cardiovasculares)’ em 239 pacientes com IMCSST. O nó principal (nó 1) indica a ocorrência ou não de óbito. Nove pacientes morreram, 3 com complicações cardiovasculares e 1 com complicações de COVID-19 (nó 7). Entre os sobreviventes, a presença de 1 stent no TCE ou na ADA (nó 6, n=106) foi associada com complicações não cardiovasculares (n=2) e cardiovasculares (n=1). Entre os sobreviventes que não precisaram de stent ou que receberam stent na ACD ou ACx, a presença de área inativa ao ECG (nó 5, n=10) foi associada com complicações cardiovasculares em 2 pacientes. Dois pacientes sem área inativa ao ECG (nó 4, n=114) apresentaram complicações cardiovasculares relacionadas ao procedimento. TCE: tronco de coronária esquerda; ADA: artéria descendente anterior; ACx: artéria circunflexa; ACD: artéria coronária direita.

Figura 4. Análise de correspondência para os eventos: complicações (CV e não CV), IM, ausência de eventos e as combinações de eventos (‘IM & complicações’; ‘complicações & óbito’; ‘IM & complicações & óbito’). O diagnóstico de COVID-19 e a necessidade de implantar 3 stents associaram-se com ‘IM & complicações & óbito’. IMCSST, número de stents, implante de stent na artéria culpada e admissão de emergência no laboratório de hemodinâmica contribuíram para explicar a combinação de eventos ‘IM & complicações’ sem óbito. Para a combinação de eventos ‘complicações & óbito’, ‘cirurgia cardíaca prévia’ foi a variável identificada. O evento ‘complicações (CV e não CV)’ associou-se com insuficiência cardíaca, diabetes, revascularização prévia, IM prévio, história de DAC, sexo masculino, hipertensão arterial, sedentarismo e dislipidemia. Duas dimensões explicaram 97% da variabilidade dos dados. DAC: doença arterial coronariana; CV: cardiovascular; IM: infarto do miocárdio.

Figura 5. – Análise gráfica das conexões obtidas no modelo log-linear implementado para analisar as variáveis associadas com óbito. As interações de segunda ordem estão representadas em preto; as outras cores representam as interações de terceira ordem. A espessura das arestas é proporcional ao índice V de Cramer, que mede a dependência entre as variáveis discretas. IMCSST: infarto do miocárdio com supra de ST; IMSSST: infarto do miocárdio sem supra de ST; DAC: doença arterial coronariana.

Figura Central. : Registro Brasileiro de Cardiologia Intervencionista durante a Pandemia de COVID-19 (RBCI-COVID19)

Figure 1. – Classification tree for the composite outcome ‘death & cardiovascular and non-cardiovascular complications’ in all patients of the registry (n=1282). The major node (node 1) indicates the occurrence or not of death. Node 9 represents the 31 patients who died from cardiovascular and non-cardiovascular complications (COVID-19, sepsis, respiratory causes, etc). Of the survivors, 705 were cared for at a SUS unit, 31 of whom had complications (node 3). Of the 546 patients not cared for at a SUS unit (node 4), 30 had kidney failure and 20 had COVID-19, 7 of whom had cardiovascular complications (node 8) and 5 had non-cardiovascular complications (node 7).

Figure 2. – Classification tree for the outcome ‘complications (cardiovascular and non-cardiovascular)’ in 196 patients with NSTEMI. The major node (node 1) indicates the occurrence or not of death. Seven patients died, 3 of whom from cardiovascular complications (node 9). Among the survivors, the presence of dyslipidemia and age over 78 years (node 8, n=7) associated with non-cardiovascular (n=2) and cardiovascular (n=2) complications. Among those aged 78 years or under (node 7, n=69), 3 patients had non-cardiovascular complications and 1 had cardiovascular complications. Among survivors without dyslipidemia, the diagnosis of COVID-19 (node 5, n=9) associated with non-cardiovascular complications (n=1).

Figure 3. – Classification tree for the outcome ‘complications (cardiovascular and non-cardiovascular)’ in 239 patients with STEMI. The major node (node 1) indicates the occurrence or not of death. Nine patients died, 3 with cardiovascular complications and 1 with COVID-19 complications (node 7). Among the survivors, the presence of a stent in the LMCA or ADA (node 6, n=106) was associated with non-cardiovascular (n=2) and cardiovascular (n=1) complications. Among the survivors not requiring a stent or who underwent RCA or CxA stenting, the presence of an inactive area on ECG (node 5, n=10) was associated with cardiovascular complications in 2 patients. In the absence of an inactive area on ECG (node 4, n=114), 2 patients had cardiovascular complications related to the procedure. Note: RCA: right coronary artery; CxA: circumflex artery; ADA: anterior descending artery; LMCA: left main coronary artery.

Figure 4. – Correspondence analysis for the events: complications (cardiovascular and non-cardiovascular), MI, absence of events, and the combinations of events: ‘MI & complications’; ‘complications & death’; and ‘MI & complications & death’. The diagnosis of COVID-19 and the need to implant three stents associated with ‘MI & complications & death’. STEMI, number of stents, stenting of the culprit artery, and emergency admission to the cath lab contributed to explain the combination of events ‘MI & complications’ without death. For the combination of events ‘complications & death’, ‘previous cardiac surgery’ was the variable identified. Complications (cardiovascular and non-cardiovascular) associated with heart failure, diabetes, previous revascularization, previous MI, history of CAD, male sex, arterial hypertension, sedentary lifestyle, and dyslipidemia. Two dimensions explained 97% of data variation. CAD: coronary artery disease; cath lab: catheterization laboratory; CV: cardiovascular; MI: myocardial infarction.

Figure 5. – Graphical analysis representing the connections obtained in the log-linear model implemented to analyze the variables associated with death. Second-order interactions were characterized by the color black; the other colors represent the third-order interactions. Edge thicknesses are proportional to the Cramer’s V index, a measure of dependence between discrete variables. STEMI: ST-segment elevation myocardial infarction; NSTEMI: non-ST-segment elevation myocardial infarction; CAD: coronary artery disease.

Central Illustration. : Brazilian Registry of Interventional Cardiology during the COVID-19 Pandemic (RBCI-COVID19)