Evolving Strategies for the Management of Patients with Acute Coronary Syndrome during the COVID-19 Era

Background:

The RAPID N-STEMI trial investigated whether a very early invasive strategy (IS) improves clinical outcomes as compared to a standard of care strategy in higher-risk non-ST elevation acute coronary syndrome (NSTE-ACS). The study was terminated early due to the COVID-19 pandemic. The focus of this thesis pivoted to investigate the impact of COVID-19 on patients with acute coronary syndrome (ACS).

Methods:

A systematic review and meta-analysis of randomised-controlled trials that investigated timing of IS in NSTE-ACS was undertaken. Additionally, two multicentre observational studies examined the impact of COVID-19 on: 1) COVID-19 positive ACS patients undergoing invasive coronary angiography; 2) complex coronary artery disease patients who were treated with percutaneous coronary intervention (PCI) rather than coronary artery bypass grafting (CABG).

Results:

An early IS was not associated with a reduction in clinically significant hard endpoints (death and myocardial infarction) in unselected all-comer patients with NSTE-ACS. Additionally:

1) COVID-19 ACS patients present later, have increased in-hospital mortality and excess rates of cardiogenic shock as compared to a pre-COVID population. Adverse outcomes appear to be driven by delays in seeking medical care and timely reperfusion therapy.

2) PCI undertaken using contemporary techniques with high rates of intravascular imaging and calcium modification provides equivalent acute results to historical CABG reference data, and to PCI reference cohorts of lower complexity.

Conclusions: 

The COVID-19 pandemic has had an unprecedented direct and indirect impact on patients with ACS. Future clinical research initiatives to better understand COVID-19 and the multiple mechanistic factors at play are essential.