For patients experiencing an ST-Elevation Myocardial Infarction (STEMI), the medical term for a heart attack, time is muscle.
“When a clot closes the coronary artery, the heart muscle starts dying, and patients can experience chest pain and other symptoms,” said Mauricio Cohen, M.D., professor of medicine and director of the Cardiac Catheterization Laboratory at the University of Miami Miller School of Medicine. “They need to be treated promptly because the longer you take to treat the patient with a heart attack, the more muscle is dying.”
Most often, in the United States and Europe, heart attack patients receive cardiovascular catheterization procedures, such as a balloon angioplasty and stent, to unclog their blood vessels and keep them open.
Ideally, in a heart emergency, a cath procedure would begin within 90 minutes of the patient entering the hospital. However, concerns over COVID-19 can complicate that timeline, as patients are checked for infection and medical staff protect themselves.
“If the patient is suspected of having a COVID infection, that can cause significant delays,” said Dr. Cohen. “In addition, medical staff need to don PPEs (personal protective equipment) and that also takes time. So, the benefits of primary PCI (cardiac catheterization) may be offset by the treatment delays.”
But cardiologists have an alternative treatment that could help solve these problems. In an opinion piece published in the journal Circulation, Dr. Cohen and colleagues suggest that fibrinolytic therapy – injecting clot-busting drugs to clear blocked blood vessels – could be a sensible STEMI alternative during the COVID-19 pandemic.
Fibrinolytic therapy offers several advantages. It could be delivered in a patient’s room, within 30 minutes of their entering the hospital and with minimal staffing. This approach could accelerate time to treatment and reduce infection risks.
The authors acknowledge that fibrinolytic therapy is not as effective as catheterizations at removing clots and can slightly elevate a patient’s stroke risk. In addition, unlike some cardiac catheterization procedures, fibrinolytics do not provide any diagnostic information to show which blood vessels are clogged and how badly.
Still, the risk of relying solely on cath procedures may be quite high. In addition to potentially delaying treatment, COVID-19 is a constant threat to medical staff. Even with the most sophisticated personal protective equipment, cath procedures put clinicians at higher risk for COVID-19 infection.
“We have to remember that cardiologists and other heart specialists are scarce resources in a hospital,” said Dr. Cohen. “If we lose people because they are ill or quarantined, that will reduce our ability to care for patients.”
The authors encourage all interventional cardiologists to use their best judgment and find the right balance to provide excellent care for patients and reduce infection risks for staff. But they believe that, under current circumstances, fibrinolytic therapy should be one option.
“These are not guidelines,” said Dr. Cohen, “rather they are merely an educated opinion. We simply want doctors to think hard about these tradeoffs. In some cases, fibrinolytic therapy may be the best choice for first-line STEMI treatment.”