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Stemi

1) This document discusses the management of STEMI patients during the COVID-19 pandemic. It presents a case study of a 65-year-old woman who presented with STEMI and was found to be COVID-19 positive. 2) Key recommendations include treating all STEMI patients as if they are COVID-19 positive, performing SARS-CoV-2 testing as soon as possible, taking caution with PPE, and considering immediate complete revascularization if indicated. 3) Primary PCI within 120 minutes of symptom onset is the preferred reperfusion strategy when possible in a dedicated catheterization lab. Fibrinolysis should be considered for longer delays if not contraindicated.

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nadia shabri
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18 views

Stemi

1) This document discusses the management of STEMI patients during the COVID-19 pandemic. It presents a case study of a 65-year-old woman who presented with STEMI and was found to be COVID-19 positive. 2) Key recommendations include treating all STEMI patients as if they are COVID-19 positive, performing SARS-CoV-2 testing as soon as possible, taking caution with PPE, and considering immediate complete revascularization if indicated. 3) Primary PCI within 120 minutes of symptom onset is the preferred reperfusion strategy when possible in a dedicated catheterization lab. Fibrinolysis should be considered for longer delays if not contraindicated.

Uploaded by

nadia shabri
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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You are on page 1/ 29

STEMI PATIENT IN COVID.

WHAT SHOULD
WE DO? HOW TO PREPARE PATIENT
IN COVID PANDEMIC

supervisor:
dr. Adi Purnawarman, Sp. JP(K)-FIHA FAsCC

Program Pendidikan Dokter Spesialis Jantung dan Pembuluh Darah


Fakultas Kedokteran Unsyiah - RSUZA Banda Aceh
2020
INTRODUCTION

March 11 the World Health Organization (WHO) officially termed


coronavirus disease 2019 (COVID-19) 1

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-


2) has been shown to result in coagulation abnormalities and
predisposes patients to thrombotic disease. 1

Management of Acute Coronary Syndrome (ACS) has undergone


changes in both diagnosis and treatment since the beginning of
the pandemic. 2

Acute myocardial infarction and large coronary thrombosis in a patient with COVID-19. Catheter Cardiovasc Interv
The European Society for Cardiology. ESC Guidance for the Diagnosis and Management of CV Disease during the COVID-19 Pandemic.
Case illustration

Mrs. RM
65 yo
Pidie jaya
JKN
Case

September 12
September 12 October 2
Swab PCR positive –
Chestpain since 2 Pinere September Reccurrent
day 17 September chestpain,
Hospitalized for 6
Discharge 25 IgG IgM Sars
Referred from days October 6
pidie jaya hospital after Swab This patient Cov Positive
Foundaparinux, NTG, result Cor
with rapid had bad Hospitalized
aspilet, Clopidogrel, negative angiography
antibody Sars compliant in Pinere
Covid positive Atorvastatin, PCI couldn’t CAD 2 VD
Candesartan, medical Swab PCR
Acute STEMI be performed therapy PCI to RCA
Azitromicin, negative –
Inferior Late Raudah 1
onset
Oxeltamivir, Vit C, Vit
E, Zink
Case
• Chestpain since 2 day
• Referred from pidie jaya hospital with rapid antibody Sars Covid
positive
• Swab PCR positive
• Hospitalized for 7 days and discharge after Swab result negative
• PCI couldn’t be performed

Reccurrent chestpain, IgG IgM Sars Cov Positive


Hospitalized in Pinere

Swab PCR negative Raudah 1


Cor Angiography CAD 2 VD, PCI to RCA
Case
BP: 140/70 mmHg Previous medication:
HR: 96 bpm Foundaparinux, NTG, aspilet,
Clopidogrel, Atorvastatin,
RR: 22 /menit Candesartan, Azitromicin,
SpO2: 98% Oxeltamivir, Vit C, Vit E, Zink

UGD: loading aspilet 320mg, loading clopidogrel


300mg, atorvastatin 1x40mg, fondaparinux
1x2,5mg, candesartan 1x32mg, laxadyn 3x15cc,
asetil sistein 3x200mg
ECG September 14

Sinus rhythm with QRS rate 89 beats per minutes,


LAD, LVH aVL criteria (15 mV), Q path in V5-V6, ST
elevation in II, III, aVF
ECG October 3

Sinus rhythm with QRS rate 89 beats per minutes,


LAD, ST elevation in II, III, aVF, Occasional PVC
laboratorium test
September 19 October 2
Haemoglobin 11,2 gr/dL 10,9 gr/dL 12-15 gr/dL
Haematokrit 33 % 33% 37-47 %
erythrocytes 3.9x 106 /mm3 3.8 x 106 /mm3 4.2-5.4 x 106 /mm3

Thrombocytes 348.000 /mm3 412.000 /mm3 150-450 x 106 / mm3

Leukocytes 7.200/ mm3 9.000/ mm3 4.5-10.5/ mm3


Ureum 29 mg/dl 28 mg/dl 13-43 mg/dL
Creatinine 1,4 mg/dl 1.25 mg/dl 0.51-0.95 mg/dL

Fasting blood 98 mg/dl 110 mg/dl <200 mg/dL


sugar
Sodium 131 mmol/L 137 mmol/L 132-146 mmol/L

Potassium 4,1 mmol/L 4.5 mmol/L 3.7-5.4 mmol/L


Chloride 94 mmol/L 104 mmol/L 98-106 mmol/L
D-dimer 2660ng/ml <500 ng/ml
Troponin T 0,560 <0,560
Swab PCR negative positive
Chest X-Ray
AP Presentation
Interpretation:
Trachea : medial
Soft tissue: swelling (-)
Bones: fractures (-), normal intercostal
space
Lungs: normal broncovascular
markings
Heart: Enlarged Size with CTR 65%.
Conclusion : Cardiomegaly

Cardiomegaly
LV systolic function decreased with EF 42% by Teich, Hipokinetic in
inferoseptal, inferior, anteroseptal regions. Normal RV systolic function.
LV diastolic dysfunction grade I. MR mild. LVH concentric.
Cor angiography

Cranial 40 AP CAO 40 AP
LAO 30 Wiring ke distal
Ballon inflated from mid-
proximal
Angiography evaluation: TIMI 3 flow to distal
Discusion
Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)
associated with coagulation abnormalities and predisposes
patients to thrombotic disease

COVID-19 ussually affects the respiratory system, including the


lung, but affects multiple organs, especially the cardiovascular
system

Several case of the cardiovascular system, including Acute


coronary syndrome, pericarditis, myocarditis, and arrhythmia
were reported

Cytokine plays an important role in the inflammatory response


against coronavirus infection.

The European Society for Cardiology. ESC Guidance for the Diagnosis and Management of CV Disease during the COVID-19 Pandemic.
Pathophysiology of Cytokine Storm

Peter Libby, Thomas Lüscher, COVID-19 is, in the end, an endothelial disease, European Heart Journal, Volume 41,Issue 32, 3038–3044
What should we do as management of STEMI in
pandemic era ??

The European Society for Cardiology. ESC Guidance for the Diagnosis and Management of CV Disease during the COVID-19 Pandemic.
• Our patient performed Cor angiography after swab
PCR result was negative

EAPCI Position Statement on Invasive Management of Acute Coronary Syndromes during the COVID-19 pandemic,  European Heart Journal,
Volume 41, Issue 19, 14 May 2020, Pages 1839–1851.
How to prepare?
• STEMI patient should be managed assuming
positive COVID-19
• STEMI patients should undergo testing for SARS-
CoV-2 as soon as possible reperfusion strategy
• Caution must be taken in donning and
removing PPE for HCP
• Consider immediate complete revascularization if
indicated and appropriate
• Perform a left ventricular angiogram to evaluate left
ventricular function.
The European Society for Cardiology. ESC Guidance for the Diagnosis and Management of CV Disease during the COVID-19 Pandemic.
Dedicated CCL
Recommendations for fibrinolytic therapy

The European Society for Cardiology. ESC Guidance for the Diagnosis and Management of CV Disease during the COVID-19 Pandemic.
Doses of fibrinolytic agents and antithrombotic co-therapies

The European Society for Cardiology. ESC Guidance for the Diagnosis and Management of CV Disease during the COVID-19 Pandemic.
Conclusions
• All STEMI patients should be managed as
COVID-19 positive.
• Primary PCI is first-line therapy if it can be
performed in a timely fashion—120 min
from symptom onset in dedicated CCL.
• Fibrinolysis if not contraindicated can be
considered when the delay is longer.
• Complete revascularization has to be
considered if indicated and appropriate.
Thank you

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