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Canadian Journal of Cardiology
Research Letters|Articles in Press

Effect of COVID-19 Infection in Patients Presenting with Acute Myocardial Infarction and Cardiogenic Shock

Published:March 10, 2023DOI:https://doi.org/10.1016/j.cjca.2023.03.005
      The coronavirus disease 2019 (COVID-19) pandemic resulted in substantial challenges in cardiovascular care.(
      • Nadarajah R
      • Wu J
      • Hurdus B
      • Asma S
      • Bhatt DL
      • Biondi-Zoccai G
      • Mehta LS
      • Ram CVS
      • Ribeiro ALP
      • Van Spall HGC
      • Deanfield JE
      • Lüscher TF
      • Mamas M
      • Gale CP
      The collateral damage of COVID-19 to cardiovascular services: a meta-analysis.
      ) Acute myocardial infarction with cardiogenic shock (AMI-CS) is an emergency and is associated with high in-hospital mortality. The immunological and pro-inflammatory response in viral infections has been shown to increase the risk of cardiovascular events such as acute myocardial infarction (AMI) and to depress cardiac contractility.(
      • Bavishi C
      • Bonow RO
      • Trivedi V
      • Abbott JD
      • Messerli FH
      • Bhatt DL
      Acute myocardial injury in patients hospitalized with COVID-19 infection: a review.
      ) Previous data have demonstrated variable morbidity and mortality in patients with respiratory infections and AMI-CS.(
      • Patlolla SH
      • Sundaragiri PR
      • Cheungpasitporn W
      • Doshi R
      • Vallabhajosyula S
      Impact of concomitant respiratory infections in the management and outcomes acute myocardial infarction-cardiogenic shock.
      ) However, the impact of the COVID-19 pandemic on patients presenting with AMI-CS remains unknown.
      We aimed to analyze a large, nationally representative database to assess the impact of COVID-19 on patients with AMI-CS, as well as their demographic and clinical characteristics.
      We queried the National Inpatient Sample in the year 2020 for all hospitalizations of adults (≥18 years) using ICD-10 codes for AMI-CS (R57.0) stratified by presence of concomitant COVID-19 infection (U07.1). The primary outcome of interest was the in-hospital mortality rate. Secondary outcomes included respiratory failure, cardiac arrest, percutaneous coronary intervention (PCI), hospital length of stay, and hospitalization costs. A 1:1 propensity score-matched analysis using a caliper width of 0.1 was performed to adjust for possible confounders. STATA 16.0 was used for statistical analysis
      A total of 39,010 AMI-CS admissions was identified, with 560 (1.4%) hospitalizations having concomitant diagnosis of COVID-19. The median age of AMI-CS with concomitant COVID-19 was 65 years (interquartile range 57, 75) with no significant age differences between patients with and without COVID-19. AMI-CS patients hospitalized with COVID-19 were more likely to be African American (25.9% vs. 9%, p<0.001), Hispanic (14.3% vs. 8.5%, p=0.023), and have diabetes (55.4% vs. 44.1%, p= 0.018). Among the AMI-CS hospitalizations with concomitant COVID-19, 395 (70.5%) were ST elevation MI and 165(29.5%) were non-ST elevation MI compared with 22,755 (59.2%) and 15,696 (40.8%) respectively in hospitalizations without COVID-19.
      Following propensity score matching, both groups had 545 hospitalizations each. The in-hospital mortality was significantly higher among AMI-CS admissions with COVID-19 infection (48.6% vs. 25.7%, odds ratio (OR) 2.7 [95% confidence interval (CI) 1.6, 4.5], p < 0.001). Patients with COVID-19 were also less likely to be discharged home (19.6% vs. 26.9%, p=0.031). The prevalence of AMI-CS with concomitant COVID-19 increased through the year; however, there was a trend toward decreasing COVID-19-associated mortality in AMI-CS hospitalizations (Figure 1). Respiratory failure was more common in patients with AMI-CS and concomitant COVID-19 (69.7% vs. 56.0%, p=0.015). There was no significant difference in the PCI rates in the two groups (52.3% vs. 53.2%, p=0.88).
      Figure thumbnail gr1
      Figure 1A – Propensity matched outcomes of AMI-CS stratified by COVID-19 (Variables used for propensity matching included age, sex, hypertension, diabetes, obesity, chronic kidney disease, chronic pulmonary obstructive disease, and stroke). B – Trends in hospitalizations and mortality of AMI- CS with COVID-19. C- Trends in hospitalizations and mortality of AMI-CS without COVID-19
      In our analysis of 39,010 AMI-CS hospitalizations in the year 2020, concomitant COVID-19 was associated with 2.7 times increased odds of mortality, with a significantly higher rate of pulmonary failure. Previous reports have established the association of COVID-19 with AMI.(
      • Bavishi C
      • Bonow RO
      • Trivedi V
      • Abbott JD
      • Messerli FH
      • Bhatt DL
      Acute myocardial injury in patients hospitalized with COVID-19 infection: a review.
      ) However, data on AMI-CS with COVID-19 has been limited to case reports. There have been reports of AMI patients presenting in a delayed manner to the hospital during the COVID-19 pandemic which could potentially result in more extensive myocardial damage. (
      • Nadarajah R
      • Wu J
      • Hurdus B
      • Asma S
      • Bhatt DL
      • Biondi-Zoccai G
      • Mehta LS
      • Ram CVS
      • Ribeiro ALP
      • Van Spall HGC
      • Deanfield JE
      • Lüscher TF
      • Mamas M
      • Gale CP
      The collateral damage of COVID-19 to cardiovascular services: a meta-analysis.
      ,
      • De Rosa S
      • Spaccarotella C
      • Basso C
      • Calabrò MP
      • Curcio A
      • Filardi PP
      • Mancone M
      • Mercuro G
      • Muscoli S
      • Nodari S
      • Pedrinelli R
      • Sinagra G
      • Indolfi C
      Reduction of hospitalizations for myocardial infarction in Italy in the COVID-19 era.
      ,
      • Guddeti RR
      • Yildiz M
      • Nayak KR
      • Alraies MC
      • Davidson L
      • Henry TD
      • Garcia S
      Impact of COVID-19 on Acute Myocardial Infarction Care.
      ) Our study reports an increase in the trend of hospitalizations every month in 2020 for AMI-CS with COVID-19, similar to prior reports of increasing complications of AMI during the COVID-19 pandemic.(
      • De Rosa S
      • Spaccarotella C
      • Basso C
      • Calabrò MP
      • Curcio A
      • Filardi PP
      • Mancone M
      • Mercuro G
      • Muscoli S
      • Nodari S
      • Pedrinelli R
      • Sinagra G
      • Indolfi C
      Reduction of hospitalizations for myocardial infarction in Italy in the COVID-19 era.
      ) With COVID-19, initially there was likely time delay due to the possibility of transmission of the virus.(
      • Guddeti RR
      • Yildiz M
      • Nayak KR
      • Alraies MC
      • Davidson L
      • Henry TD
      • Garcia S
      Impact of COVID-19 on Acute Myocardial Infarction Care.
      ) In addition, the higher prevalence of respiratory failure due to the higher propensity to develop acute respiratory distress syndrome and refractory hypoxia in COVID-19 patients could contribute towards the worse outcomes. Further, requisite imaging may also delay primary PCI. While door to balloon times were not available in our study, the rate of PCI was similar between groups, indicating patients received appropriate interventional therapy. Finally, COVID-19 itself can result in a massive cytokine storm which can cause severe impairment of cardiac function.(
      • Bavishi C
      • Bonow RO
      • Trivedi V
      • Abbott JD
      • Messerli FH
      • Bhatt DL
      Acute myocardial injury in patients hospitalized with COVID-19 infection: a review.
      ) This, along with a multitude of factors, likely explains the ∼three times increased mortality in AMI-CS with COVID-19 seen in our study, as well as the respiratory failure and decreased percent of patients discharged home; however, further studies are needed to elucidate causality.
      Our study draws strength from utilization of a national database overcoming the biases seen with single center studies and encompasses the primary COVID-19 clinical year of 2020. It is encouraging to see that mortality in this group decreased over time, indicating improved protocols and timely intervention for these patients. As a limitation, data derived from such national databases can be subject to misclassification errors. Regardless, our findings may have significant implications in the management and prognosis of patients with AMI-CS and COVID-19 infection. In summary, COVID-19 significantly increases mortality with higher rates of respiratory failure in this sick cohort of AMI-CS patients and must be promptly managed. Vaccination has been shown to decrease the rate as well as severity of COVID-19 and should be prioritized at the community level.

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        The collateral damage of COVID-19 to cardiovascular services: a meta-analysis.
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        Reduction of hospitalizations for myocardial infarction in Italy in the COVID-19 era.
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