PCI still the treatment of choice for COVID-positive STEMI patients
The impact of the COVID-19 pandemic on cardiovascular care is well documented, even if the condition/patient population data aren’t terribly granular, but a recent registry study suggests that primary percutaneous coronary intervention (PPCI) is still the way to go to treat ST-segment elevation myocardial infarction (STEMI). The objective of the North American COVID-19 and STEMI (NACMI) registry was to track outcomes of COVID-19 patients with STEMI with special attention paid to demographic characteristics and management strategies, an effort that involved three medical societies. These data were formed from STEMI patients with confirmed COVID and those whom clinicians believed may have been infected with the SARS-CoV-2 virus. A third group, which serves as the control group, consists of STEMI patients matched for age and sex who were treated prior to the pandemic, which aided in comparing treatment strategies and outcomes. The primary outcome is a four-point composite consisting of in-hospital death, stroke, recurrent myocardial infarction, or repeat unplanned revascularization. This study was based on the registry data available as of Dec. 6, 2020, at which point nearly 1,200 patients were included in the registry, 460 of which were the pre-pandemic STEMI patients. COVID-positive patients were more likely to be members of minority ethnic groups and had a higher prevalence of diabetes mellitus (46%). COVID-positive patients were also more likely to present with cardiogenic shock (at 18%) but less likely to receive invasive angiography. Among COVID-positive patients who received angiography, roughly seven in 10 received PPCI while 20% received medical therapy (for both, the p score was < 0.001 relative to control patients). The primary outcome occurred in 36% of COVID-positive patients, but 13% of those only believed to have been infected, and 5% of the pre-pandemic control. The authors concluded that COVID-positive patients with STEMI “represent a high-risk group of patients with unique demographic and clinical characteristics,” but that PPCI is nonetheless feasible “and remains the predominant reperfusion strategy, supporting current recommendations.” These findings are reported in the April 2021 issue of the Journal of the American College of Cardiology.
Utility of risk scores for TAVR patients questioned
Risk scoring for patients with aortic stenosis has been used since transcatheter aortic valve replacement (TAVR) devices first gained market access, but there are some researchers that believe that the fact that higher-risk populations were the first patients doesn’t stipulate that these patients benefit more from a TAVR procedure. A recent meta-analysis of eight randomized clinical trials for TAVR examined both mortality and stroke outcomes, and made use of meta-regression to determine the association between mean surgical risk using the Society of Thoracic Surgeons score and hazard ratio observed in each of these studies. The authors said their analysis makes clear that the use of these devices was associated with “a significant reduction of both mortality and stroke across the whole spectrum of patients enrolled, with no evidence of significant heterogeneity.” Given the seeming absence of a statistically significant association between the clinical benefit of TAVR for both mortality and stroke, it may be time to reconsider the use of risk scores to prioritize TAVR utilization in higher risk patients, the authors said, recommending that a better use of resources might be to focus on the patient's life expectancy as determined by device durability. The authors make their argument in the April 17, 2021, issue of Current Problems in Cardiology.
Plaque similarly predictive in women and men
Teasing out the differences between men and women in heart disease has required substantial study, but a new trial suggests that despite a number of differences in accumulation of plaque in the coronary arteries, imaging studies depictive of plaque seem to render essentially the same predictive power in both sexes. The underlying study was designed to establish whether assessment of coronary plaque with coronary CT angiography might explain differences in the prognosis of men and women who present with angina. The study was undertaken with the recognition that women and men presenting with angina carry different risk factors and symptoms, as well as different degrees of prevalence of coronary artery disease. This multi-center randomized, controlled trial yielded CT angiography for nearly 1,800 participants, 43% of whom were female. The women in this study were statistically more likely to have normal coronary arteries and less likely to have adverse plaque characteristics, as well as lower total plaque burden, including calcified and noncalcified. This was true of low-attenuation plaque burden as well. Over a medial follow-up of approximately four and a half years, infarct was seen in 1.4% of women and 3% in men, and women who suffered an infarct exhibited similar total, noncalcified, and low-attenuation plaque burden as men. Men exhibited higher calcified plaque burden, but low-attenuation plaque burden predicted infarcts similarly between the two sexes, which the researchers said indicates that “quantitative low-attenuation plaque is as strong a predictor of subsequent [infarct] in women as in men. This study appears in the April 14, 2021, issue of JACC: Cardiovascular Imaging.