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Thrombus Burden Outcomes in Patients With COVID-19 and STEMI
Quick Takes
- This single-center observational study of 1,269 patients admitted for STEMI during the COVID-19 pandemic examined variations in thrombus burden and outcomes across the pandemic waves.
- During the first wave of the pandemic, COVID-19–positive STEMI patients had significantly higher thrombus burden and worse outcomes compared to COVID-19–negative patients. These differences disappeared with subsequent waves and in vaccinated individuals.
- Vaccinations and evolving strategies may have mitigated COVID-19’s impact on STEMI patients.
Study Questions:
In patients with coronavirus disease 2019 (COVID-19) presenting with ST-segment elevation myocardial infarction (STEMI), how did the progression of the COVID-19 pandemic affect the thrombus burden, angiographic features, and clinical outcomes compared to STEMI patients without COVID-19?
Methods:
This observational study compared the thrombus burden and clinical outcomes in patients with COVID-19 (n = 154) presenting with STEMI across different waves of the pandemic (first wave n = 39, second wave n = 60, and third wave n = 55). The control group included 1,115 COVID-19–negative patients with STEMI during the same time periods. Angiographic features and clinical outcomes were used as primary measures: stent thrombosis, multivessel thrombosis, modified thrombus grade, myocardial blush grade, and mortality. The use of interventions such as glycoprotein IIb/IIIa inhibitors and aspiration thrombectomy, as well as the total heparin dose and the first activated clotting time, were accounted for.
Results:
Patients presenting with COVID-19 infection during the first wave exhibited a higher burden of cardiovascular risk factors (diabetes mellitus, hypertension, hyperlipidemia, age) compared to the other waves. During the first wave of the COVID-19 pandemic, patients with COVID-19 who presented with STEMI had significantly higher rates of stent thrombosis (10.3% vs. 1.5%), multivessel thrombosis (17.9% vs. 0%), and modified thrombus grade 4-5 (75% vs. 32.1%) compared to non–COVID-19 patients. These differences remained statistically significant in multivariable analyses. Those were not observed in the subsequent waves of the pandemic. In the third wave, the rates of stent thrombosis (2.5% vs. 1.0%) and modified thrombus grade 4-5 (35.9% vs. 33.3%) were comparable between COVID-19–positive and non–COVID-19 patients. Vaccinated COVID-19–positive STEMI patients had comparable angiographic features and outcomes to those of non–COVID-19 controls, and worse outcomes were seen in unvaccinated COVID-19–positive patients. Time from symptoms to reperfusion was similar in all waves.
Conclusions:
During the first wave of the pandemic, COVID-19–positive STEMI patients had significantly higher thrombus burden and worse outcomes compared to COVID-19–negative patients. These differences disappeared with subsequent waves and in vaccinated individuals.
Perspective:
The study provides intriguing insights into the changing nature of COVID-19’s impact on patients with STEMI. The authors suggest that the increased thrombogenicity observed in STEMI patients during the first wave of the pandemic could be due to endothelial damage, cytokine imbalance, and platelet activation, which created a prothrombotic environment. However, the temporal changes in COVID-19–positive STEMI patients might be due to a combination of factors, including the protective effects of vaccination, the use of steroids and antiviral agents for treating hospitalized COVID-19 patients, and mutational changes in the SARS-CoV-2 virus. These findings highlight the complex interplay between the virus, the host's immune response, and the cardiovascular system. The fact that the outcomes for vaccinated COVID-19–positive STEMI patients have become comparable to those of non–COVID-19 patients underscores the importance of vaccination in mitigating the cardiovascular impacts of the virus. One important caveat to keep in mind is that this is a single-center study with limited sample sizes of 39-60 STEMI patients per wave, with multiple comparisons performed.
Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Cardiac Surgery, COVID-19 Hub, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Anticoagulation Management and ACS, Cardiac Surgery and Arrhythmias, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging, Hypertension
Keywords: Acute Coronary Syndrome, Anterior Wall Myocardial Infarction, Coronary Angiography, COVID-19, COVID-19 Vaccines, Diabetes Mellitus, Heparin, Hyperlipidemias, Hypertension, Pandemics, Platelet Glycoprotein GPIIb-IIIa Complex, Reperfusion, Risk Factors, Secondary Prevention, Stents, Thrombectomy, Thrombosis, Vaccination, Vascular Diseases
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