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Best treatment for Heart Attacks in the Covid-19 Pandemic

This week I have published a Review Article that addresses the latest research and provides guidance for UK Doctors and Cardiologists treating heart attacks in the era of Covid-19. It has been published by Heart, which is part of the British Medical Journals (BMJ) group.

The full paper is available by following this link. It is open access and should be free to read.

I lead the writing process and was supported by my close friends and colleagues Dr Ricardo Petraco and Dr Sayan Sen, Consultant Cardiologists with whom I practice at the Hammersmith Hospital and One Heart Clinic. I am grateful for working with such caring and innovative colleagues. Together, we have worked on the some of the biggest changes that have come through in Interventional Cardiology.

The review paper is a highly technical article designed for those with specialist knowledge, but I thought I would provide a higher level overview, that may be easier to understand.

Please also see my article on my personal experience of treating heart attack patients during the Covid-19 Pandemic.

Covid-19 has had both Direct and Indirect consequences on Cardiovascular Healthcare

The pandemic has altered all the usual care pathways and stopped face to face clinic appointments in many places. In many Hospitals, elective procedures including coronary intervention were stopped. This will have a significant affect on patients awaiting treatment for their ischaemic heart disease.

There is also a direct effect. The virus appears to increase thrombosis (clotting) and this appears to be linked to heart attacks and clots in the lungs (pulmonary embolus). There is heart injury associated with the Covid-19 infection and those patients with cardiac troponin elevation have a higher rates of mortality compared to those who do not.

Acute Coronary Syndrome (ACS) should be diagnosed in the usual manner

There was debate on how to diagnose acute coronary syndrome (ACS) – an umbrella term used to describe different types of heart attack, in the context of Covid-19. However, it is clear that those having true heart attacks, the classical symptoms and ECG changes remain. There is still difficulty with troponin-leak in the context of infection (called a Type II myocardial infarction) and patients who suffer this, should be treated according to clinical factors. Invasive angiography may still be indicated.

Reperfusion therapy for heart attacks

Patients who suffer ST elevation myocardial infarctions (STEMI) should be offered primary angioplasty in the normal manner, even if they have Covid-19. In those patients who have fulminant infection and where primary angioplasty is not feasible, then thrombolysis should be considered and made available.

Unique issues in the Covid-19 pandemic

  1. STEMI-Mimic: There are some patients with apparently focal myocarditis that have significant ST elevation on an ECG that have normal coronary arteries on angiography. These patients are typically critically unwell on the intensive care department. Patients should still be offered angiography as the risk of the incorrect diagnosis and impact of under-treating a heart attack are severe.
  2. Delayed Attendance: The Covid-19 pandemic has caused a dramatic reduction in patients attending with heart attack. There are many possible explanations but a likely one is that patients have been afraid to attend Hospitals due to fears of inundating stretched services, or a fear of catching the virus from the Hospital. Late presentation means patients are more likely to be sick and less likely to have a good outcome from treatment.

Potential new pathways

  1. Reduced inpatient stay: for patients with uncomplicated heart attacks we suggest streamlined admissions with early invasive angiography and echocardiography which should permit prompt treatment. This should allow early discharge and reduce the risk of acquiring Coronavirus from an inpatient stay.
  2. Clustering of patients: Separation of Covid-Positive and Negative patients is essential and should be done with early onsite swab testing
  3. Surgical Disease: there remains around 10-15% of patients with non-ST elevation myocardial infarctions that require bypass surgery. At the height of the pandemic, traditional operations were not readily available and so complex coronary intervention is required instead.

Read the entire article to read the latest evidence and see the case examples of patients we have treated.

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Dr Sukhjinder Nijjer

Dr Nijjer is a Consultant Cardiologist, working London, UK. He specialises in treating patients with complex coronary artery disease and is an expert in coronary physiology.

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Dr Sukhjinder Nijjer Consultant Cardiologist

One Heart Clinic
68 Harley Street
London, W1G 7HE

0203 9838 001

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