Reorganizing as a Covid-Free Heart Center: Does It Really Matter For The Primary Percutaneous Coronary Intervention Endpoints During the Covid-19 Pandemic?

Öz

Backrounds/Aims: With the emergence of the new and more transmissible COVID variants such as Omicron, the necessity of taking new measures began to be discussed. Methods: Data regarding the organizational arrangements as defining COVID-free heart centers during the first waves is scarce. We evaluated the 273 non-COVID acute coronary syndrome patients who were admitted to our COVID-free tertiary cardiovascular center during the lockdown period. None of these cases had hospital acquired SARS CoV-2 infection during the follow-up. Therefore, no COVID-related morbidity or mortality was observed in this vulnerable group. Results: However, when we analyzed the 88 primary percutaneous coronary intervention procedures of the non-COVID STEMI patients of the lockdown period and compared the 70 of them with the 50 STEMI patients of the previous year, the results were not that encouraging. Even our hospital was declared as a COVID-free cardiolovascular center, there was a significant delay in the symptom-to-door time (SDT) during the pandemic (4.8 vs. 2.5 hours, respectively; P<0.001). Door-to-balloon time (DBT) for the lockdown period was not different than the prepandemic era. The main difference regarding the angiographic endpoints was in corrected TIMI frame counts (cTFC) which was significantly higher during the pandemic (32.9 vs. 27.3) (P<0.001). Furthermore, a powerful positive correlation between SDT and TFC was represented (R=0.731, p<0.001). Hospitalization duration was shortened during the pandemic (2.3 days in pandemic and 3.4 days in 2019, P<0.001). None of the patients had hospital-acquired infection and related morbidity. However, in-hospital mortality was significantly higher than the previous year’s (11.4% vs. 1.8% respectively, P=0.039). TFC was found to be an independent predictor of in-hospital cardiac events (OR: 1.17, 95% CI: 1.05-1.31, P< 0.01). Conclusions: These results suggest that, when we exclude morbidity and mortality resulting from hospital-acquired infection, reorganizing as a COVID-free cardiac center doesn’t have satisfactory favorable impact on the adverse cardiovascular outcome during the pandemic, unless the public is well informed.

Anahtar Kelimeler

• COVID-19;
• percutaneous coronary intervention
• STEMI
• perkütan koroner girişim

Covid'siz Bir Kalp Merkezi Olarak Yeniden Yapılanma: Covid-19 Pandemisi Primer Perkütan Koroner Girişimin Sonlanim Noktalari Için Gerçekten Önemli Mi?

Öz

Amaç: Omicron gibi yeni ve daha bulaşıcı COVID varyantlarının ortaya çıkmasıyla birlikte yeni önlemlerin alınması gerekliliği tartışılmaya başlandı. Yöntemler: Pandemi döneminde COVID'siz kalp merkezlerini tanımlayan organizasyonel düzenlemelere ilişkin veriler azdır. 11 Mart 2020-11 Haziran 2020 tarihleri arasında başvuran 88 STEMI hastası (Grup 1) ve 2019 yılının aynı döneminde başvuran 79 hasta (Grup 2) incelendi. COVID-PCR testi pozitif çıkan hastalardan ikisi başka merkezlere sevk edildi. Ardından elde edilen verilerin analizi, grup 1'e 70 hastanın ve grup 2'ye 55 hastanın kaydıyla sonuçlandı. Bu vakaların hiçbirinde takip sırasında hastaneden edinilmiş SARS CoV-2 enfeksiyonu yoktu. Bu nedenle, bu savunmasız grupta COVID ile ilgili herhangi bir morbidite veya mortalite gözlenmedi. Bulgular: Sokağa çıkma yasağı döneminde COVID olmayan STEMI hastalarının 88 birincil perkütan koroner girişim prosedürünü analiz ettiğimizde ve bunların 70'ini önceki yılın 50 STEMI hastasıyla karşılaştırdığımızda sonuçlar o kadar da iç açıcı değildi. Hastanemiz COVID'siz bir kardiyovasküler merkez olarak ilan edilse bile, pandemi sırasında semptomlardan kapıya kadar geçen sürede (SDT) önemli bir gecikme oldu (sırasıyla 4,8 - 2,5 saat; P<0,001). Karantina döneminde kapıdan balona geçen süre (DBT), pandemi öncesi dönemden farklı değildi. Anjiyografik sonlanım noktalarına ilişkin temel fark, pandemi sırasında önemli ölçüde daha yüksek olan düzeltilmiş TIMI frame count (cTFC) olmuştur (32,9 - 27,3, P<0,001). Ayrıca, SDT ile TFC arasında güçlü bir pozitif korelasyon gösterildi (R=0.731, p<0.001). Pandemi sırasında hastanede kalış süresi kısaldı (pandemide 2,3 gün ve 2019'da 3,4 gün, P<0,001). Hastaların hiçbirinde hastane kaynaklı enfeksiyon ve buna bağlı morbidite yoktu. Ancak, hastane içi ölüm oranı bir önceki yıla göre önemli ölçüde yüksekti (sırasıyla %11,4'e karşı %1,8, P=0,039). TFC'nin hastane içi kardiyak olayların bağımsız bir belirleyicisi olduğu bulundu (OR: 1.17, %95 GA: 1.05-1.31, P< 0.01). Sonuçlar: Bu sonuçlar, hastane kaynaklı enfeksiyondan kaynaklanan morbidite ve mortaliteyi hariç tuttuğumuzda, COVID'siz bir kalp merkezi olarak yeniden yapılanmanın, halk iyi bilgilendirilmedikçe, pandemi sırasında olumsuz kardiyovasküler sonuç üzerinde tatmin edici olumlu bir etkiye sahip olmadığını göstermektedir.

Anahtar Kelimeler

• STEMI
• COVID-19
• perkütan koroner girişim

Kaynakça

1. 1 Baigent C, Windecker S, Andreini D et al. Task for the management of COVID-19 of the European Society of Cardiology. European Society of Cardiology guidance for the diagnosis and management of cardiovascular disease during the COVID-19 pandemic: part 1-epidemiology, pathophysiology, and diagnosis. Cardiovasc Res 2022;118(6):1385-412.
2. 2 Mafham MM, Spata E, Goldacre R et al. COVID-19 pandemic and admission rates for and management of acute coronary syndromes in England. Lancet 2020;396(10248): 381-89.
3. 3 Kupferschmidt K, Vogel G. (). How bad is Omicron? Some clues are emerging. Science 2021;374(6573):1304-05.
4. 4 Torjesen I. Covid restrictions tighten as omicron cases double every two to three days. BMJ 2021;375:n3051.
5. 5 McNamara RL, Wang Y, Herrin J et al. Effect of door-to-balloon time on mortality in patients with ST-segment elevation myocardial infarction. J Am Coll Cardiol 2006;47(11):2180-86.
6. 6 Hannan EL, Zhong Y, Jacobs AK et al. Effect of onset-to-door time and door-to-balloon time on mortality in patients undergoing percutaneous coronary interventions for ST-segment elevation myocardial infarction. Am J Cardiol 2010;106(2):143-47.
7. 7 De Luca G, Suryapranata H, Ottervanger JP, Antman EM. Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts. Circulation 2004;109(10):1223-25.
8. 8 Xiang D, Xiang X, Zhang W et al. Management and outcomes of patients with STEMI during the COVID-19 pandemic in China. J Am Coll Cardiol 2020;76(11):1318-24.

9. 9 Erol MK, Kayıkçıoğlu M, Kılıçkap M et al. Treatment delays and in-hospital outcomes in acute myocardial infarction during the COVID-19 pandemic: A nationwide study. Anatol J Cardiol 2020;24(5):334-42.
10. 10 Redfors B, Mohebi R, Giustino G et al. Time delay, infarct size, and microvascular obstruction after primary percutaneous coronary intervention for ST-segment–elevation myocardial infarction. Circ Cardiovasc Interv 2021;14(2):e009879.
11. 11 Gibson CM, Cannon CP, Daley WL et al. TIMI frame count: a quantitative method of assessing coronary artery flow. Circulation 1996;93(5):879-88.
12. 12 D'Ascenzo F, De Filippo O, Borin A et al. Impact of COVID-19 pandemic and infection on in hospital survival for patients presenting with acute coronary syndromes: A multicenter registry. Int J Cardiol 2021;332:227-34.
13. 13 Elakabawi K, Huang X, Shah SA et al. Predictors of suboptimal coronary blood flow after primary angioplasty and its implications on short-term outcomes in patients with acute anterior STEMI. BMC Cardiovasc Disord 2020;20(1):1-12.
14. 14 Mesnier J, Cottin Y, Coste P et al. Hospital admissions for acute myocardial infarction before and after lockdown according to regional prevalence of COVID-19 and patient profile in France: a registry study. Lancet Public Health 2020;5(10):e536-42.
15. 15 De Rosa S, Spaccarotella C, Basso C et al. Reduction of hospitalizations for myocardial infarction in Italy in the COVID-19 era. Eur Heart J 2020;41(22):2083-88.
16. 16 Karagöz A, Keskin B, Kültürsay B et al. Temporal association of contamination obsession on the prehospital delay of STEMI during COVID-19 pandemic. Am J Emerg Med 2021;43:134-41.
17. 17 Lee CH, Tai BC, Lau C et al. Relation between door‐to‐balloon time and microvascular perfusion as evaluated by myocardial blush grade, corrected TIMI frame count, and ST‐segment resolution in treatment of acute myocardial infarction. J Interv Cardiol 2009; 22(5):437-43.
18. 18 Rezkalla SH, Kloner RA. No-reflow phenomenon. Circulation 2002;105(5):656-62.
19. 19 Kim MC, Cho JY, Jeong HC et al. Long-term clinical outcomes of transient and persistent no reflow phenomena following percutaneous coronary intervention in patients with acute myocardial infarction. Korean Circ J 2016;46(4):490-98.
20. 20 Harrison RW, Aggarwal A, Ou FS et al. Incidence and outcomes of no-reflow phenomenon during percutaneous coronary intervention among patients with acute myocardial infarction. Am J Cardiol. 2013;111(2):178-84.
21. 21 Gibson CM, Murphy SA, Rizzo MJ et al. Relationship between TIMI frame count and clinical outcomes after thrombolytic administration. Circulation 1999;99(15):1945-50.