Abstract
Objective: To assess the safety and effectiveness of a novel pathway of deferrred invasive angiography in low-risk NSTEMI patients with concurrent COVID-19 infections; contrary to current UK guidelines recommending invasive coronary angiography in NSTEMI patients within 72 hours. Methods: This was a single-centre, observational study of all NSTEMI patients referred for inpatient coronary angiography at Barts Heart Centre, between March 2020 and June 2022. Demographic, procedural and outcome data were collected as part of a national cardiac audit. Results: 201 COVID positive NSTEMI patients were referred for angiography at Barts Heart Centre. 10 patients died from COVID related respiratory complications prior to angiography. Therefore, 191 patients underwent deferred angiography (median time 16 days from COVID diagnosis). The median GRACE score was 128 (IQR 86-153). Troponin levels were significantly elevated on initial COVID diagnosis compared to time of their procedure. 73% patients had a culprit lesion identified. 61.2% receiving PCI. Patients were followed-up for a median of 363 days (IQR 120-485 days) with MACE rates of 7.3%. This is comparable to the MACE event for NSTEMI patients (n=4529) without COVID at our institution treated during the same time-period (8.1%). Conclusion: This study demonstrates the safety and effectiveness of deferred coronary angiography on a COVID-Recovered pathway after a period of medical management for patients presenting with NSTEMI and concurrent COVID-19 infection. There was no adverse signal associated with the wait for angiography with similar MACE rates to the non-deferred NSTEMI cohort without COVID-19.
Keywords: Coronavirus-19, deferred angiography, non-ST elevation MI
Introduction
Indication for invasive coronary angiography in NSTEMI patients
All major clinical practice guidelines e.g. GIRFT, ESC, ACC/AHA [1-3] recommend early invasive coronary angiography for patients presenting with non-ST elevation myocardial infarction (NSTEMI). In acute coronary syndrome (ACS) patients, there is clear evidence of reduced rates of cardiac events from routine angiography-guided management compared with routine conservative or selective invasive management [4-6]. The optimal management strategy for patients with NSTEMI with concurrent coronavirus disease 2019 (COVID-19) infection, however, is not known.
COVID-19 infection and increased thrombogenicity
Infection with severe acute respiratory syndrome coronavirus-2 (SARS-COV-2), the causative virus for COVID-19, is associated with increased platelet aggregation and the release of inflammatory cytokines and pro-coagulant factors, resulting in a pro-thrombotic state. The incidence of thrombotic complications in patients with COVID-19 is up to 43% [7,8].
COVID-19 and increased stent thrombosis
Importantly, percutaneous coronary intervention (PCI) in ACS (ST-Elevation myocardial infarction (STEMI) and NSTEMI) patients with COVID-19 is associated with worse outcomes than in non-infected patients, with reported higher rates of in-hospital mortality [9,10]. There are further reports of increased rates of stent thrombosis in COVID-19 patients undergoing primary PCI [11-14], with one large multi-centre cohort study, showing COVID-19 infection was independently associated with a five-fold increase in the rate of stent thrombosis [9].
Furthermore, infection prevention and control protocols in COVID-19 infected patients with NSTEMI delay invasive management beyond the recommended timeframe and are inefficient for the wider healthcare system.
The COVID recovered pathway
In response, we developed a regional clinical pathway for the delivery of deferred, early outpatient, coronary angiography in stabilised patients with NSTEMI who had concurrent COVID-19 infection “The COVID Recovered Pathway” with the aim of balancing these considerations in patient management.
Our aim was to assess the safety and effectiveness of patients put on this novel pathway. In this paper, we present the demographics, procedural information and outcomes for this novel pathway.
Methods
Inclusion criteria
We performed a single-centre observational cohort study of all NSTEMI patients referred for inpatient coronary angiography at Barts Heart Centre, a regional heart attack centre in London, between March 2020 and June 2022.
The diagnosis of NSTEMI was based on the universal definition of acute myocardial infarction and required symptoms and/or ECG changes without ST elevation coupled with elevation in plasma cardiac biomarker concentrations consistent with acute myocardial injury.
All patients were screened for SARS-CoV-2 on hospital admission by nasal/throat swab using real time-polymerase chain reaction and plasma antibody testing.
Patients with a diagnosis of NSTEMI who tested positive for COVID-19 were entered onto the COVID Recovered pathway.
Exclusion criteria
Patients presenting with ST-elevation myocardial infarction (STEMI), those who did not fulfil the universal definition for diagnosis of NSTEMI and those with chronic coronary syndrome (CCS) were excluded from the study. Also excluded were NSTEMI patients with very high risk features warranting immediate invasive angiography such as haemodynamic instability, cardiogenic shock, refractory chest pain despite maximal medical treatment, life-threatening arrhythmias, mechanical complications of myocardial infarction(MI), acute heart failure clearly related to their NSTEMI, ST-segment elevation in aVR with ST-depression >1 mm/6 leads.
Patients with contraindications to invasive coronary angiography i.e. active GI haemorrhage, pregnancy, acute stroke, hypertensive crisis, inability for patient cooperation and severe contrast allergy were also excluded from our study.
NSTEMI patients who were negative on COVID-19 screening were entered into a control cohort.
COVID-19 recovered pathway
This involved patients undergoing coronary angiography with follow-on PCI, if indicated, at least 10 days after the positive COVID-19 diagnosis. This time period was measured from the time-point of positive COVID-19 serology confirmation not symptoms. Patients were discharged for outpatient angiography unless there was evidence of further myocardial ischaemia during the index hospital admission. In the absence of contraindications, patients were treated with standard medical therapy which included aspirin, a P2Y12 inhibitor, high-intensity statin therapy, a beta-blocker, and an ACE-inhibitor. Patients were then followed up via outpatient pathways (30 day, 6 and 12 month review).
Ethics
The COVID Recovered Pathway was registered as a clinical audit with the Barts Quality and Safety Board. The study protocols were approved by the Barts Heart Centre Board and conformed to the ethical guidelines of the 1975 Declaration of Helsinki. All data was anonymized with removal of patient identifiers prior to analysis.
Data collection
Demographic and procedural data were collected prospectively as part of the National Cardiac Audit Programme. All patient-identifiable fields were removed. Formal ethical approval for this study was, therefore, not required. The national audit data fields include patient age, sex, ethnicity, height, weight, cardiovascular risk factors, time of symptom onset, and time of arrival at the invasive cardiac centre. Procedural data collected comprised number of diseased vessels, use of diagnostic devices such as intravascular ultrasound (IVUS), optical coherence tomography (OCT) or pressure wire and, where relevant, target vessel, use of aspiration thrombectomy, post-dilatation, and administration of a glycoprotein (GP) IIb/IIIa inhibitor.
Interventional procedures
For patients who underwent PCI, the interventional strategy was at the discretion of the operator, including the use of direct stenting, pre- and/or post-dilatation, and treatment of bystander, non-infarct related coronary artery stenoses. All patients undergoing PCI received a loading dose of aspirin 300 mg and either clopidogrel 600 mg or ticagrelor 180 mg prior to the procedure. All patients then received regular aspirin 75 mg per day and either clopidogrel 75 mg per day or ticagrelor 90 mg twice-daily or converted to Prasugrel 10 mg od (after reloading maintenance therapy). During PCI, unfractionated heparin was given at a loading dose of 70-100 U/kg with the ACT maintained >250 sec as per unit policy. ACTs were recorded at 10-15 minute intervals after the initial dose of heparin. GP IIb/IIIa inhibitors were used at the operator’s discretion and according to local guidelines.
Study outcomes
The primary outcome was 12-month rate of major adverse cardiovascular events (MACE) consisting of a composite of all cause death, non-fatal stroke, non-fatal myocardial infarction or urgent myocardial revascularization. Follow-up began upon discharge after coronary angiography, however events following the index hospitalization for patients on the Recovered pathway were captured, documenting events which may have occurred prior to deferred coronary angiography. Clinical events during follow-up were assessed from electronic hospital and general practitioner records and from patients during structured virtual follow-up visits. Secondary outcomes included stent thrombosis, and the individual components of MACE, admission for decompensated heart failure, and any peri-procedural complication.
Statistical analysis
Comparisons were performed between the COVID-positive NSTEMI patients who underwent deferred coronary angiography on the COVID Recovered pathway and all other patients who underwent coronary angiography for NSTEMI over the same time-period (March 2020-June 2022). This control group consisted of 4,529 patients, all of whom were COVID-negative. Baseline clinical characteristics, angiographic findings, diagnosis, management, and 12-month MACE rates were compared between groups. Chi-squared analysis or Fisher’s-exact test was used to compare categorical data between groups. The independent samples Student t-test or ANOVA test was used to compare normally distributed continuous data and the Mann-Whitney U test was used to compare skewed continuous data between groups. Kaplan-Meier curves were constructed for MACE during 12-month follow-up. Descriptive statistical analyses were performed using SPSS Statistics version 25.0 (IBM, New York). A 2-sided p-value <0.05 defined statistical significance. Variables are expressed as counts (percentages), mean ± standard deviation (SD), and median (lower quartile-upper quartile), as appropriate.
Results
During the study period, 4,730 patients with NSTEMI were referred for early invasive coronary angiography. Of these, 201 (4.2%) had concurrent COVID-19 infection at the point of referral and were treated on the COVID Recovered pathway. Ten patients died from COVID-19 related respiratory complications prior to discharge from their index hospitalisations. All these patients died from COVID-19 related respiratory complications.
Patient characteristics
The baseline clinical characteristics of the remaining 191 COVID-positive patients who entered the COVID recovered pathway are presented in Table 1. The mean age was 63 years, 143 (75%) were male and 90 (47%) were Caucasian. The median GRACE score was 128 (IQR 86-153). Compared to the COVID-negative NSTEMI control group, patients on the COVID Recovered pathway were less likely to be Caucasian (P<0.0001), were more often male (P<0.0001), and had more cardiovascular risk factors (P=0.0013). GRACE scores were similar in the two groups. The median peak plasma troponin concentration was significantly lower in patients on the Recovered pathway than in controls. At the time of coronary angiography, there were no significant differences between COVID-positive patients and controls in WCC, ferritin, or d-dimer concentrations.
Table 1.
Baseline patient characteristics
| Recovered (n=191) | Control cohort (n=4529) | P value | |
|---|---|---|---|
| Baseline Characteristics | |||
| Age (Mean ± SD) | 63 yr ± 12.0 | 69.1 ± 11.5 | 0.0012 |
| Male sex - no. (%) | 74.9% (143/191) | 67.1% (3039/4529) | <0.0001 |
| Black, Asian, Minority Ethnic - no. (%) | 52.9% (101/191) | 35.6% (1612/4529) | <0.0001 |
| Median BMI (IQR) | 27.4 (24.7:31.1) | 28.0 (26.1:29.9) | 0.058 |
| Past Medical History - no. (%) | |||
| Hypertension | 60.2% (115/191) | 56.1% (2541/4529) | <0.0001 |
| Hypercholesterolemia | 64.9% (124/191) | 40.7% (1843/4529) | <0.0001 |
| Diabetes mellitus | 40.8% (78/191) | 36.4% (1649/4529) | 0.0013 |
| Smoking history | 44.0% (84/191) | 25.3% (1146/4529) | <0.0001 |
| Previous MI | 44.0% (84/191) | 33.6% (1522/4529) | <0.0001 |
| Previous PCI | 37.2% (71/191) | 27.4% (1241/4529) | <0.0001 |
| Median GRACE score | 128 (86:153) | 135 (105:169) | 0.106 |
| Median laboratory values (IQR)- at time of procedure | |||
| Troponin T - ng/L (initial COVID diagnosis/referral) | 111.5 (54:455) | 135 (64:745) | <0.0001 |
| Troponin T - ng/L (at time of procedure) | 27 (16:151) | NA | |
| White-cell count - 109/L | 8.3 (6.9:10.2) | 7.5 (5.8:9.2) | 0.077 |
| Lymphocyte count - 109/L | 1.8 (1.4:2.3) | 2.1 (1.7:2.6) | 0.069 |
| LDH - unit/L | 229 (199:250) | 145 (124:223) | 0.053 |
| D-Dimer - mg/L (0-0.5) | 0.3 (0.3:0.7) | 0.2 (0.1:0.4) | 0.112 |
| Fibrinogen - g/L | 1.65 (0.55:5.04) | 1.41 (1.02:2.69) | 0.104 |
| Ferritin - ug/L (30-400) | 202 (84:263) | 189 (131:287) | 0.005 |
| Creatinine - umol/L | 81 (69:98) | 77 (70:88) | 0.230 |
| Creatine kinase (CK) - u/L | 85 (58:130) | 81 (68:113) | 0.398 |
| C-reactive protein (CRP) - mg/L | 4 (2:8) | 3 (1:5) | 0.276 |
Procedural characteristics
Patients on the Recovered pathway underwent coronary angiography a median of 16 (interquartile range 12-19) days after COVID-19 diagnosis. 10% remained as inpatients based on high-risk features with 90% being discharged prior to angiography. No patients suffered adverse events whilst waiting for angiography.
In one patient, arterial access could not be obtained so computed tomography coronary angiography was performed instead.
Final clinical diagnosis
Among the 191 patients in this group, 139 (73%) were confirmed to have acute coronary syndrome by invasive angiography with culprit coronary disease identified (Table 2). The remaining 52 (27%) patients were diagnosed with myocardial infarction with non-obstructive coronary artery disease (MINOCA). Subsequent cardiac magnetic resonance imaging (MRI) suggested myocarditis in 22 (11.5%) of these patients and takotsubo cardiomyopathy in 11 patients (5.7%). Of those with confirmed NSTEMI, 117 (61.2%) underwent PCI, 21 (11%) underwent coronary artery bypass grafting (CABG), and 54 (28%) patients were managed medically. Most (77%) patients were discharged taking dual anti-platelet therapy (DAPT), 8% patients were treated with triple anti-thrombotic therapy (aspirin, clopidogrel and a novel oral anticoagulant) and in 3% of patients, all anti-thrombotic agents were stopped after coronary angiography. Patients on the COVID Recovered pathway were more likely to receive a final diagnosis of MINOCA compared to the NSTEMI control group. Consequently, they were less likely to undergo PCI and to receive DAPT.
Table 2.
Outcomes
| Recovered (n=191) | Control Cohort (n=4529) | P value | |
|---|---|---|---|
| Time for follow-up, median (IQR) - days | 363 (120-485) | 366 (131-463) | 0.479 |
| Median COVID-diagnosis to angiography (IQR) - days | 16 (12:19) | NA | |
| Final Clinical Diagnosis - no. (%) | |||
| Acute coronary syndrome | 73.0% (139/191) | 82.5% (3736/4529) | 0.0065 |
| MINOCA | 27.0% (52/191) | 13.1% (594/4529) | <0.0001 |
| Myocarditis | 11.5% (22/191) | 4.9% (222/4529) | |
| Takotsubo | 5.7% (11/191) | 2.2% (100/4529) | |
| Unknown | 9.9% (19/191) | 6.0% (272/4529) | |
| Percutaneous coronary intervention - no. (%) | 61.2% (117/191) | 70.9% (3211/4529) | <0.0001 |
| Coronary Artery Bypass Grafting - no. (%) | 11.0% (21/191) | 10.8% (489/4529) | 0.103 |
| Medical management - no. (%) | 27.8% (54/191) | 18.3% (829/4529) | <0.0001 |
| IVUS Use | 37.2% (71/191) | 26.4% (1196/4529) | <0.0001 |
| OCT Use | 13.6% (26/191) | 8.8% (399/4529) | <0.0001 |
| Pressure Wire | 3.1% (6/191) | 5.6% (254/4529) | <0.0001 |
| PCI vessel | <0.0001 | ||
| LMS | 1.6% (3/191) | 1.0% (47/4529) | |
| LAD | 27.7% (53/191) | 26.6% (1205/4529) | |
| Cx | 9.9% (19/191) | 10.1% (457/4529) | |
| IM | 1.0% (2/191) | 2.9% (131/4529) | |
| RCA | 9.9% (19/191) | 12.3% (557/4529) | |
| Venous graft | 3.1% (6/191) | 2.9% (131/4529) | |
| Single anti-platelet | 4.2% (8/191) | 3.9% (177/4529) | 0.003 |
| NOAC only | 5.2% (10/191) | 3.6% (163/4529) | <0.0001 |
| Warfarin only | 1.0% (2/191) | 1.0% (47/4529) | 0.995 |
| NOAC + single antiplatelet | 2.1% (4/191) | 1.1% (50/4529 | 0.698 |
| DAPT | 77.0% (147/191) | 86.5% (3918/4529) | <0.0001 |
| Triple therapy | 7.9% (15/191) | 4.8% (217/4529) | <0.0001 |
| No anti-platelets/anti-coagulation | 3.1% (6/191) | 2.1% (95/4529) | 0.466 |
| Stent thrombosis (in PCI patients) - no. (%) | 0.0% | 0.11% (5/4529) |
Clinical outcomes
In-hospital outcomes
Among the patients who underwent deferred coronary angiography on the Recovered pathway, three (1.6%) patients developed MACE; one patient developed a cerebrovascular event after coronary angiography, one patient was referred for CABG but suffered a myocardial infarction (0.5% event rate) before surgery could be performed, and one patient died (0.5% event rate) from heart failure. In addition, one patient developed a retroperitoneal bleed after follow-on transfemoral PCI.
12-month outcomes
Patients were followed-up for a median of 363 (IQR 120-485) days. The combined primary outcome occurred in 14 patients in the COVID Recovered group, equating to a 12-month MACE rate of 7.3% (95% CI 2.8-10.2%) (Table 3). The individual components of MACE comprised 4 deaths (2 cardiovascular and 2 non-cardiovascular deaths), 5 NSTEMIs, 2 CVAs and 3 patients cases of urgent revascularisation for unstable angina. This is comparable to the MACE rate for the control NSTEMI patient population treated at our institution during the same time period (8.1% (95% CI 3-9.1%)) (Figure 1) and the literature [15,16] (Figure 2). Secondary outcomes were made up of two non-cardiovascular deaths and two admissions for decompensated heart failure. There were no cases of stent thrombosis.
Table 3.
12-month clinical outcomes
| Recovered (n=191) | Control Cohort (n=4529) | |
|---|---|---|
| Major adverse cardiovascular events | 14 (7.3%) | 367 (8.1%) |
| Cardiovascular death | 2 (1.0%) | 68 (1.5%) |
| Non-Cardiovascular Death | 2 (1.0%) | 70 (1.5%) |
| Unscheduled revascularisation | 3 (1.6%) | 115 (2.5%) |
| Cerebrovascular Accident (CVA) | 2 (1.0%) | 47 (1.0%) |
| Myocardial infarction | 5 (2.6%) | 114 (2.5%) |
| Stent thrombosis (in PCI patients) | 0 (0.0%) | 5 (0.16%) |
Figure 1.
Kaplan-Meier curves of cumulative incidence of major adverse cardiovascular events over 1 year in COVID-recovered arm compared to control arm.
Figure 2.
12-month major adverse cardiovascular event rates in COVID-recovered versus non-COVID and compared to the current literature.
Discussion
This study is the first to assess the safety and effectiveness of a deferred coronary angiography pathway (COVID Recovered) in patients with NSTEMI and COVID-19 infection. Among 191 patients, deferred coronary angiography after a period of medical management was associated with equivalent 12-month clinical outcomes to patients without COVID-19 who underwent inpatient coronary angiography. The approach to patients with ACS and concurrent COVID-19 infection has varied from hospital to hospital throughout the world because of uncertainties regarding the benefits of early invasive management in patients with COVID-19, the risks of viral transmission to staff and other patients, the inefficiencies of individual patients waiting in hospital for procedures, and the knock-on effect of this on the scarce resource of bed availability during the pandemic. The results of this study provide reassurance that initial medical stabilisation of patients with NSTEMI and COVID-19 infection with a view to outpatient coronary angiography 2-3 weeks later is a safe alternative to extended hospitalisation while infection prevention and control protocols are completed prior to invasive management.
The latest ESC guidelines recommend early invasive coronary angiography in patients with an established diagnosis of NSTEMI [1,2]. However, in patients with concurrent COVID-19 infection that is associated with a pro-thrombotic state. Several studies reporting thrombotic complications in patients with severe COVID-19 found thrombotic rates ranging from 31% to 43% [7,8]. Therefore, it is no surprise that invasive angioplasty is likely to carry significant more risks in patients with active COVID-19 patients. In patients with COVID-19 undergoing PCI for ST-elevation myocardial infarction (STEMI), stent thrombosis rates have been reported as high as 8.1% and in-hospital mortality up to 12.9% [9,10]. One large, multi-centred retrospective cohort study, COVID-19 infection was independently associated with 5x increased risk of in-stent thrombosis [9].
Most previous studies of COVID-19 positive patients with ACS have focused on STEMI, with a relative lack of data concerning management of patients with NSTEMI. Data from two registries, however, both raise safety concerns regarding the early invasive management of patients with NSTEMI who have concurrent COVID-19 infection. In the International COVID-ACS Registry, in-hospital mortality rates were more than four-fold higher (6.6% vs. 1.2%; P<0.001) in 121 NSTEMI patients with COVID compared with a pre-pandemic NSTE-ACS cohort. In-hospital rates of MI and stroke of 4.1% and 0.8%, respectively, contributed to an in-hospital MACE rate of 11.5% in COVID-positive patients [15]. In the UK MINAP registry, 517 (4.0%) of 12,958 patients hospitalised with ACS were COVID-19-positive. These patients had considerably higher rates of in-hospital (24.2% vs. 5.1%) and 30-day mortality (41.9% vs. 7.2%) compared with non-COVID-19 ACS patients, with the highest rates seen at 30 days in the NSTEMI cohort (adjusted OR 8.45; 95% CI: 6.03-11.83) [16]. In our study, there were four deaths (two cardiovascular and two non-cardiovascular) among the 191 patients in the deferred coronary angiography group equivalent to a 2.1% 12-month mortality rate.
Although the benefit of immediate coronary angiography is established in patients presenting with STEMI, the timing and net benefit of immediate angiography is not so clear cut in patients with NSTEMI. Several large studies [17,18] have failed to demonstrate a significant reduction in all-cause mortality or non-fatal MI for immediate (<24 hours) vs. deferred angiography (>36 hours) in the overall NSTEMI population. In the TIMACS trial, early invasive angiography have been shown to be beneficial in high-risk NSTEMI populations(defined by a GRACE score >140) as shown by the separation of the Kaplan-Meier curves for all-cause death, non-fatal MI or stroke, but not in the low-intermediate group [18]. Furthermore, the median time from randomization to angiography in the deferred angiography group was 50 hours. There have been no studies so far where NSTEMI patients had deferred angiography after at least 10 days (median 16 days).
The more recent VERDICT trial showed similar findings with a reduction in the primary composite outcome (comprising of all-cause death, non-fatal recurrent MI, hospital admission for refractory myocardial ischaemia or hospital admission for heart failure) for high risk NSTEMI (GRACE score >140) patients undergoing immediate angiography (within 12 hours of diagnosis) vs. delayed angiography (48-72 hours of diagnosis) [17].
Given the lack of proven benefit in immediate angiography for low-to-intermediate risk NSTEMI patients, combined with the increased thrombotic risk associated with COVID infection, we felt that it was reasonable to adopt a deferred angiography management strategy in these patients.
So far, there has been no other studies assessing the effect of deferring coronary angiography until recovery from COVID-19 in NSTEMI patients.
Our study has shown that this is safe and efficacious with only 14 (7.3%) out of 191 patients suffering a MACE. There were no deaths attributed to the wait for coronary angiography. There were no cases of stent thrombosis in the COVID-recovered group.
This study has several limitations. Firstly, this is an observational study with the inherent biases and confounders associated with this type of study. Secondly, severe COVID-19 infection may be associated with elevated plasma troponin concentrations due to myocardial injury which is not caused by an ACS, for example, due to myocarditis, sepsis, or pulmonary embolism [19]. Defining a cohort of “pure” NSTEMI is therefore potentially problematic in the context of concurrent COVID infection. Nevertheless, myocardial revascularisation rates were high in the study group and consistent with other NSTEMI cohorts, albeit slightly lower than among our control group. We believe that the diagnosis of NSTEMI was accurate in the majority of patients in our study group, but it is possible that the troponin elevations in a minority were due to causes other than myocardial infarction. This issue is not restricted to NSTEMI populations with concurrent COVID infection.
Conclusion
This study has demonstrated that deferring invasive coronary angiography for 2-3 weeks via a COVID ‘Recovery pathway’ is safe in stable NSTEMI patients who have concurrent COVID infection. These data have potential implications for the management of NSTEMI patients with COVID-19, providing an alternative to routine early invasive management with the potential to improve outcomes in this group of patients.
Disclosure of conflict of interest
None.
References
- 1.Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GCM ESC Scientific Document Group. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021;42:1289–1367. doi: 10.1093/eurheartj/ehaa575. [DOI] [PubMed] [Google Scholar]
- 2.“GIRFT. Cardiology - Getting It Right First Time,”. 2017. [Online]. Available: https://www.gettingitrightfirsttime.co.uk/medical-specialties/cardiology/#:~:text=GIRFT%20is%20an%20opportunity%20to,in%20practice%20and%20clinical%20performance.%E2%80%9D. [Accessed 11 August 2022]
- 3.Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS Jr, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: a report of the american college of cardiology/american heart association joint committee on clinical practice guidelines. J Am Coll Cardiol. 2022;79:e21–e129. doi: 10.1016/j.jacc.2021.09.006. [DOI] [PubMed] [Google Scholar]
- 4.Fanning JP, Nyong J, Scott IA, Aroney CN, Walters DL. Routine invasive strategies versus selective invasive strategies for unstable angina and non-ST elevation myocardial infarction in the stent era. Cochrane Database Syst Rev. 2016;2016:CD004815. doi: 10.1002/14651858.CD004815.pub4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Fox KA, Clayton TC, Damman P, Pocock SJ, de Winter RJ, Tijssen JG, Lagerqvist B, Wallentin L FIR Collaboration. Long-term outcome of a routine versus selective invasive strategy in patients with non-ST-segment elevation acute coronary syndrome a meta-analysis of individual patient data. J Am Coll Cardiol. 2010;55:2435–2445. doi: 10.1016/j.jacc.2010.03.007. [DOI] [PubMed] [Google Scholar]
- 6.Mehta SR, Cannon CP, Fox KA, Wallentin L, Boden WE, Spacek R, Widimsky P, McCullough PA, Hunt D, Braunwald E, Yusuf S. Routine vs selective invasive strategies in patients with acute coronary syndromes: a collaborative meta-analysis of randomized trials. JAMA. 2005;293:2908–2917. doi: 10.1001/jama.293.23.2908. [DOI] [PubMed] [Google Scholar]
- 7.Helms J, Tacquard C, Severac F, Leonard-Lorant I, Ohana M, Delabranche X, Merdji H, Clere-Jehl R, Schenck M, Fagot Gandet F, Fafi-Kremer S, Castelain V, Schneider F, Grunebaum L, Anglés-Cano E, Sattler L, Mertes PM, Meziani F CRICS TRIGGERSEP Group (Clinical Research in Intensive Care and Sepsis Trial Group for Global Evaluation and Research in Sepsis) High risk of thrombosis in patients with severe SARS-CoV-2 infection: a multicenter prospective cohort study. Intensive Care Med. 2020;46:1089–1098. doi: 10.1007/s00134-020-06062-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Klok FA, Kruip MJHA, van der Meer NJM, Arbous MS, Gommers DAMPJ, Kant KM, Kaptein FHJ, van Paassen J, Stals MAM, Huisman MV, Endeman H. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res. 2020;191:145–147. doi: 10.1016/j.thromres.2020.04.013. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.De Luca G, Debel N, Cercek M, Jensen LO, Vavlukis M, Calmac L, Johnson T, Ferrer GR, Ganyukov V, Wojakowski W, Kinnaird T, von Birgelen C, Cottin Y, IJsselmuiden A, Tuccillo B, Versaci F, Royaards KJ, Berg JT, Laine M, Dirksen M, Siviglia M, Casella G, Kala P, Díez Gil JL, Banning A, Becerra V, De Simone C, Santucci A, Carrillo X, Scoccia A, Amoroso G, Van’t Hof AW, Kovarnik T, Tsigkas G, Mehilli J, Gabrielli G, Rios XF, Bakraceski N, Levesque S, Cirrincione G, Guiducci V, Kidawa M, Spedicato L, Marinucci L, Ludman P, Zilio F, Galasso G, Fabris E, Menichelli M, Garcia-Touchard A, Manzo S, Caiazzo G, Moreu J, Forés JS, Donazzan L, Vignali L, Teles R, Benit E, Agostoni P, Ojeda FB, Lehtola H, Camacho-Freiere S, Kraaijeveld A, Antti Y, Boccalatte M, Deharo P, Martínez-Luengas IL, Scheller B, Varytimiadi E, Moreno R, Uccello G, Faurie B, Gutierrez Barrios A, Milewski M, Bruwiere E, Smits P, Wilbert B, Di Uccio FS, Parodi G, Kedhi E, Verdoia M. Impact of SARS-CoV-2 positivity on clinical outcome among STEMI patients undergoing mechanical reperfusion: insights from the ISACS STEMI COVID 19 registry. Atherosclerosis. 2021;332:48–54. doi: 10.1016/j.atherosclerosis.2021.06.926. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Hamadeh A, Aldujeli A, Briedis K, Tecson KM, Sanz-Sánchez J, Al Dujeili M, Al-Obeidi A, Diez JL, Žaliūnas R, Stoler RC, McCullough PA. Characteristics and outcomes in patients presenting with COVID-19 and ST-segment elevation myocardial infarction. Am J Cardiol. 2020;131:1–6. doi: 10.1016/j.amjcard.2020.06.063. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Choudhary R, Kaushik A, Sharma JB. COVID-19 pandemic and stent thrombosis in a post percutaneous coronary intervention patient-a case report highlighting the selection of P2Y12 inhibitor. Cardiovasc Diagn Ther. 2020;10:898–901. doi: 10.21037/cdt-20-485. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Hinterseer M, Zens M, Wimmer RJ, Delladio S, Lederle S, Kupatt C, Hartmann B. Acute myocardial infarction due to coronary stent thrombosis in a symptomatic COVID-19 patient. Clin Res Cardiol. 2021;110:302–306. doi: 10.1007/s00392-020-01663-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Lacour T, Semaan C, Genet T, Ivanes F. Insights for increased risk of failed fibrinolytic therapy and stent thrombosis associated with COVID-19 in ST-segment elevation myocardial infarction patients. Catheter Cardiovasc Interv. 2021;97:E241–E243. doi: 10.1002/ccd.28948. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Prieto-Lobato A, Ramos-Martínez R, Vallejo-Calcerrada N, Corbí-Pascual M, Córdoba-Soriano JG. A case series of stent thrombosis during the COVID-19 pandemic. JACC Case Rep. 2020;2:1291–1296. doi: 10.1016/j.jaccas.2020.05.024. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Kite TA, Ludman PF, Gale CP, Wu J, Caixeta A, Mansourati J, Sabate M, Jimenez-Quevedo P, Candilio L, Sadeghipour P, Iniesta AM, Hoole SP, Palmer N, Ariza-Solé A, Namitokov A, Escutia-Cuevas HH, Vincent F, Tica O, Ngunga M, Meray I, Morrow A, Arefin MM, Lindsay S, Kazamel G, Sharma V, Saad A, Sinagra G, Sanchez FA, Roik M, Savonitto S, Vavlukis M, Sangaraju S, Malik IS, Kean S, Curzen N, Berry C, Stone GW, Gersh BJ, Gershlick AH International COVID-ACS Registry Investigators. International prospective registry of acute coronary syndromes in patients with COVID-19. J Am Coll Cardiol. 2021;77:2466–2476. doi: 10.1016/j.jacc.2021.03.309. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Rashid M, Wu J, Timmis A, Curzen N, Clarke S, Zaman A, Nolan J, Shoaib A, Mohamed MO, de Belder MA, Deanfield J, Gale CP, Mamas MA. Outcomes of COVID-19-positive acute coronary syndrome patients: a multisource electronic healthcare records study from England. J Intern Med. 2021;290:88–100. doi: 10.1111/joim.13246. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Kofoed KF, Kelbæk H, Hansen PR, Torp-Pedersen C, Høfsten D, Kløvgaard L, Holmvang L, Helqvist S, Jørgensen E, Galatius S, Pedersen F, Bang L, Saunamaki K, Clemmensen P, Linde JJ, Heitmann M, Wendelboe Nielsen O, Raymond IE, Kristiansen OP, Svendsen IH, Bech J, Dominguez Vall-Lamora MH, Kragelund C, Hansen TF, Dahlgaard Hove J, Jørgensen T, Fornitz GG, Steffensen R, Jurlander B, Abdulla J, Lyngbæk S, Elming H, Therkelsen SK, Abildgaard U, Jensen JS, Gislason G, Køber LV, Engstrøm T. Early versus standard care invasive examination and treatment of patients with non-st-segment elevation acute coronary syndrome. Circulation. 2018;138:2741–2750. doi: 10.1161/CIRCULATIONAHA.118.037152. [DOI] [PubMed] [Google Scholar]
- 18.Mehta SR, Granger CB, Boden WE, Steg PG, Bassand JP, Faxon DP, Afzal R, Chrolavicius S, Jolly SS, Widimsky P, Avezum A, Rupprecht HJ, Zhu J, Col J, Natarajan MK, Horsman C, Fox KA, Yusuf S TIMACS Investigators. Early versus delayed invasive intervention in acute coronary syndromes. N Engl J Med. 2009;360:2165–2175. doi: 10.1056/NEJMoa0807986. [DOI] [PubMed] [Google Scholar]
- 19.Driggin E, Madhavan MV, Bikdeli B, Chuich T, Laracy J, Biondi-Zoccai G, Brown TS, Der Nigoghossian C, Zidar DA, Haythe J, Brodie D, Beckman JA, Kirtane AJ, Stone GW, Krumholz HM, Parikh SA. Cardiovascular considerations for patients, health care workers, and health systems during the COVID-19 pandemic. J Am Coll Cardiol. 2020;75:2352–2371. doi: 10.1016/j.jacc.2020.03.031. [DOI] [PMC free article] [PubMed] [Google Scholar]