Given the recommendations regarding a non-IRA, consideration should be made regarding the best revascularization strategy for an unprotected LM artery stenosis detected during an anterior STEMI. 8 It will be interesting and valuable to see the long-term patient outcomes data from this registry. Initial data from the North American COVID-19 Myocardial Infarction Registry reveals that primary PCI is the predominant reperfusion strategy for COVID-19-positive STEMI patients. Impella or IABP can be used for management of left ventricular overdistension in VA ECMO patients. Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is the recommended device for COVID-19 patients with hemodynamic and respiratory failure. Regarding the location for the management of STEMI patients with cardiogenic shock who are positive for COVID-19, the EAPCI recommends expert centers which can provide different options for mechanical circulatory support.įor COVID-19-positive patients experiencing a STEMI with mechanical complications, an intra-aortic balloon pump (IABP) is an option if other mechanical circulatory support devices are not available. 5 The North American Society Leadership also recommends primary PCI for most STEMI patients and selective pharmacoinvasive therapy in accordance with regional practice. 4 Primary PCI as first-line therapy for STEMI is also recommended by the European Association of Percutaneous Cardiovascular Intervention (EAPCI) if it can be performed within 120 minutes from symptom onset (Figure 3). ACC, SCAI and the American College of Emergency Physicians recommend PCI as the main/preferred reperfusion strategy for STEMI patients during the COVID-19 pandemic (Figure 2). Primary PCI as the main reperfusion strategy for STEMI has been recommended by several cardiovascular societies. Emergency surgical revascularization is recommended for patients with cardiogenic shock if the coronary anatomy is not suitable for PCI (Class I, ESC 2018 guideline). The AHA scientific statement also supports a hybrid approach of culprit lesion PCI (with or without stent placement) followed by staged surgical revascularization for patients with acute MI complicated by cardiogenic shock and multivessel CAD. This approach is supported by the ESC 2018 guideline, which recommends against routine revascularization of the non-IRA lesion during STEMI PCI complicated by cardiogenic shock (Class III). 3 The scientific statement further recommends that for most patients, PCI should be limited to the culprit lesion with possible staged revascularization of the nonculprit lesions. In patients for whom surgical revascularization is intended, if a large myocardium is at risk or there is hemodynamic instability, the guideline allows for proceeding with surgery after discontinuing dual antiplatelet therapy (DAPT) without the usual waiting period for full recovery of platelet function (ESC 2017 guideline).Ī 2021 American Heart Association scientific statement recommends PCI of the IRA for acute MI complicated by cardiogenic shock regardless of time delay. 2Įmergency surgical revascularization can be considered for STEMI patients with IRA anatomy not suitable for PCI, ongoing ischemia and a large myocardial area at risk (Class IIa, ESC 2018 guideline). 1 In STEMI patients with multivessel coronary artery disease (CAD), non-IRA revascularization should be considered prior to hospital discharge (Class IIa, Level of Evidence A, ESC 2018 guideline). In acute STEMI, primary PCI of the IRA is recommended (Class I, ESC 2017 guideline). Diagnostic coronary angiography reveals an 80% ostial left main (LM) lesion stenosis, multiple stenoses in the left anterior descending artery (LAD) with TIMI 2 flow distally (80% proximal LAD, 99% mid LAD and 70% distal LAD), an anomalous left circumflex (LCx) which arose from the right cusp and multiple obstructive lesions in the right coronary artery ( Figure 1). Aspirin 324 mg, clopidogrel 600 mg and IV heparin 7000 Unit bolus are administered and bilevel positive airway pressure is initiated for respiratory support. The patient's electrocardiogram shows ST elevation in leads V2 -V6 concerning for an acute anterior STEMI. Chest X-ray shows diffuse bilateral airspace disease. He is tachycardiac (heart rate 138 bpm), tachypneic (respiratory rate 37 breaths/minute) and slightly hypertensive (blood pressure 139/100 mm Hg). His medical history is significant for hypertension, diabetes, hyperlipidemia and active COVID-19 (on treatment with casirivimab/imdevimab). A 60-year-old man unvaccinated for COVID-19 presents to an emergency department of a community hospital with severe chest pain and shortness of breath lasting one to two hours.
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