A. Mafrici

B. Conconi

D. Gentile

G. Tumminello

L. Barbieri

M. Centola

S. Carugo

S. Lucreziotti

English

AIR Universita degli studi di Milano

IJC Heart & Vasculature 30 (2020) 100600Contents lists available at ScienceDirect
IJC Heart & Vasculature
journa l homepage: www. journals .e lsevier .com/ i j c -hear t -and-vascula tureImpact of COVID-19 on STEMI: Second youth for fibrinolysis or time to
centralized approach?https://doi.org/10.1016/j.ijcha.2020.100600
2352-9067/ 2020 The Authors. Published by Elsevier B.V.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
⇑ Corresponding author at: UOC Cardiology – ASST Santi Paolo e Carlo, Via Pio II 3,
20153 Milan, Italy.
E-mail address: tumminellogabriele@gmail.com (G. Tumminello).Gabriele Tumminello ⇑, Lucia Barbieri, Stefano Lucreziotti, Domitilla Gentile, Barbara Conconi,
Marco Centola, Antonio Mafrici, Stefano Carugo
Cardiology Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy
a r t i c l e i n f o a b s t r a c tArticle history:
Received 17 May 2020
Received in revised form 26 June 2020
Accepted 18 July 2020
Available online 23 July 2020
Keyword:
COVID-19
STEMI therapyOn March 11th 2020 the World Health Organization declared the pandemic infection of SARS-CoV-2
(COVID-19) and Italy was one of the most affected country. The regional Emergency Medical System
(EMS) founded itself facing an exponential increase in hospitalizations with a consequent organizational
system crisis. Experts from Cina, UK and US suggested to reconsider thrombolysis as the best treatment in
term of balance between time consumption and operators safety for ST-segment elevation myocardial
infarction (STEMI) patients respect to primary PCI (pPCI). The system reorganization consisted in a cen-
tralization of all the emergency nets: from 55 hospitals with cardiac catheterization laboratories dis-
tributed within our region offering a 24/7 service we passed to 13 Hub and 42 Spoke centres.
Dedicated in-hospital paths for patients COVID positive or suspected (pCOV+) and COVID negative
(pCOV) were instituted. We analysed all consecutive patients undergoing emergency coronary angio-
gram from March 14 to April 14, 2020 at San Carlo Hospital in Milan comparing the two different in-
hospital paths. We collected 30 STEMI patients. Eighteen patients (60%) were treated in pCOV, while
twelve patients (40%) in pCOV+. No significant differences were found among the two groups regarding
key time points of STEMI care and interestingly we didn’t find any treatment delay in pCOV+. In conclu-
sion, a focused overhaul of the EMS may allow to maintain pPCI as the treatment of choice for patients
and operators.
 2020 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).1. Introduction
On March 11th 2020 the World Health Organization (WHO)
declared the pandemic infection of SARS-CoV-2 (COVID-19). Italy
was one of the most affected countries reaching 159.516 confirmed
cases with 20.465 death (WHO data Report-85 April 14th 2020).
Our regional Emergency Medical System (EMS) net was reorga-
nized dividing the 55 hospital equipped with cardiac catheteriza-
tion laboratories offering 24/7 service in to 13 Hub and 42 Spoke
centres in order to centralize the resources. In ST-segment eleva-
tion myocardial infarction (STEMI) primary percutaneous coronary
intervention (pPCI) is to date the recommended therapy [1] if the
estimated time is 120 min from the diagnosis, otherwise fibri-
nolytic therapy must be preferred. Considering the dramatic
impact of COVID-19 on emergency services, experts from China,
UK and US proposed to reconsider fibrinolytic therapy as a first-choice approach [2,3] thanks to the better balance between sys-
tems delays and workforce protection.2. Material and methods
Our population is represented by consecutive STEMI patients
undergoing emergency coronary angiography from March 14 to
April 14, 2020 at San Carlo Hospital in Milan, HUB center according
to EMS network reorganization. Patients were divided in 2 groups
(suspected /defined and low probability/no evidence of Covid-19)
at the first medical contact according to presence of at least one
of the following: recent history of fever, dyspnea, cough, fatigue,
gastrointestinal symptoms and contact with Covid-19 cases. All
cardiac arrests were treated as suspected. The defined diagnosis
of SARS-COV-2 was performed by nasal swab test immediately
after pPCI. Two distinct in-hospital paths (pCOV+ and pCOV)
were identified with two different cath labs, setted up with ade-
quate protective personal equipment (PPE). Clinical data and main
time components of STEMI care were collected for all patients. The
protocol was performed in accordance to the Declaration of
Table 1
Time components of STEMI care.
COV+ path
M-SD
COV path
M-SD
p value
Symptom onset - first allarm (min) 130.11 ± 224.19 138.41 ± 234.13 0.93
Symptom onset - STEMI diagnosis (min) 162.4 ± 219.17 168.94 ± 240.04 0.94
Symptom onset - balloon (min) 227.00 ± 219.53 222.53 ± 237.05 0.48
STEMI diagnosis - balloon (min) 64.6 ± 21.48 53.59 ± 30.50 0.60
Door-to-balloon (min) 58.25 ± 42.78 35.35 ± 17.85 0.18
Abbreviations: STEMI, ST-elevation myocardial infarction.
2 G. Tumminello et al. / IJC Heart & Vasculature 30 (2020) 100600Helsinki statements as requested by our local Ethical Committee;
all the data were collected anonymously; all the patients subscribe
a disclosure statement routinely for the use of personal data at the
beginning of hospitalization.
All categorical variables were expressed by percentage, while
continuous variables were expressed by mean ± standard deviation
(M-SD).
3. Results
We analysed a total of 30 patients, 70% male, with a mean age of
64 ± 11.7 years. Clinical and demographic characteristics are: dia-
betes 15.9%, hypertension 36.4%, family history of coronary artery
disease 13,6%, active smoke 20,5%, dyslipidaemia 9,1%, previous
PCI 2,3%, previous myocardial infarction 4,5%, chronic obstructive
pulmonary disease 4,5%. The first medical contact was in most
cases (73.3%) with the physicians of EMS out of hospital or in the
emergency department (20%). In only two cases patients were
already hospitalized: one in our HUB center and the in a Spoke dis-
tant 8,2 Km from our hospital. The maximum distance planned for
Spoke centers was 25 km. In 73.3% STEMI diagnosis was made in
pre-hospital setting and anterior STEMI was the most represented
(44.8%). Eighteen patients (60%) were treated in pCOV, while
twelve patients (40%) in pCOV+. For seven (58.3%) patients of the
pCOV+ COVID-19 diagnosis was confirmed, while, among pCOV
twelve (66.7%) resulted negative, one (5.6%) was positive and five
(27.8%) were not tested. No significant differences were found
among the two groups regarding key time points of STEMI care
(Table1), in particular regarding STEMI diagnosis-to-balloon
(64.6 ± 21.4 vs 53.59 ± 30.50, p = 0.60) and door-to-balloon (58.2
5 ± 42.78 vs 35.35 ± 17.85, p = 0.18) times.
4. Discussion
Our analysis shows that a dedicated and specific organizational
approach during pandemic may be effective to maintain pPCI as
the treatment of choice for STEMI patients.
After the defined diagnosis no statistically significant differ-
ences were found in all time components of STEMI care
independently from the path followed. Despite the time necessary
to wear the PPE, the presence of a dedicated pre-hospital path with
a specific cath lab did not significantly affect the total time and
allow a correct preparation of the environments and staff. From a
total of 8 physicians, 16 nurses and 13 technicians two members
resulted COVID-19 positive at serial test. The key point of this find-
ing is the reorganization of the emergency system at every level
which maintained in both paths the diagnosis-to-balloon anddoor-to-balloon times below the limits for the consideration of a
fibrinolytic therapy. In favour of this strategy there is also the fact
that the real risk related to fibrinolysis in the setting of COVID-19
infection, due to secondary coagulation alterations, is not well
defined [4].
5. Limitations
The sample size is too small to draw definite conclusion but are
in line with recent editorial guidelines [5]. Data are referred to a
specific geographical and logistic region where the public sanitary
system is well developed and distances are limited. These two fac-
tors may adversely affect the results in other world regions.
6. Conclusion
While a blanket policy of pPCI during a pandemic condition
might be not the right choice when applied to the usual organiza-
tional system, a complete and focused overhaul of the EMS and
STEMI pathways as the one here described may allow to maintain
pPCI as the treatment of choice for patients.
Declaration of Competing Interest
The authors declare that they have no known competing finan-
cial interests or personal relationships that could have appeared
to influence the work reported in this paper.
References
[1] B. Ibanez, S. James, S. Agewall et al., ESC Scientific Document Group, 2017 ESC
Guidelines for the management of acute myocardial infarction in patients
presenting with ST-segment elevation: The Task Force for the management of
acute myocardial infarction in patients presenting with ST-segment elevation of
the European Society of Cardiology (ESC), Eur. Heart J. 39(2) (2018) 119–177.
[2] T. Chor-Cheung Frankie, C. Kent-Shek, L. Simon et al., Impact of Coronavirus
Disease 2019 (COVID-19) Outbreak on ST-Segment–Elevation Myocardial
Infarction Care in Hong Kong, China, Circ. Cardiovasc. Qual. Outcomes 2020
Mar 17:CIRCOUTCOMES120006631. doi: 10.1161/CIRCOUTCOMES.120.006631
[Epub ahead of print].
[3] J.D. Matthew, G.C. Mauricio, A. Anthony, J.K. Dharam, Reperfusion of STEMI in
the COVID-19 Era – Business as Usual? 10.1161/CIRCULATIONAHA.120.047122.
[4] R.L. Medcalf, C.B. Keragala, P.S. Myles, Fibrinolysis and COVID-19: a plasmin
paradox, J. Thromb. Haemost. 2020 Jun 16, doi: 10.1111/jth.14960. Online
ahead of print.
[5] E. Mahmud, H.L. Dauerman, F.G.P. Welt, J.C. Messenger et al., Management of
acute myocardial infarction during the COVID-19 pandemic a consensus
statement from the society for cardiovascular angiography and interventions
(SCAI), American College of Cardiology (ACC), and the American College of
Emergency Physicians (ACEP). Catheter Cardiovasc Interv. 2020 Apr 20. doi:
10.1002/ccd.28946. Online ahead of print.


Impact of COVID-19 on STEMI: Second youth for fibrinolysis or time to centralized approach?

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Impact of COVID-19 on STEMI: Second youth for fibrinolysis or time to centralized approach?

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