Update ACS Guidelines

during Pandemic: What

Should We Know?

Muhammad Fadil
The curious case of ACS during Pandemic Era

Pessoa-Amorim G et al, European Heart Journal - Quality of Care and Clinical Outcomes (2020) 6, 210–216
Pessoa-Amorim G et al, European Heart Journal - Quality of Care and Clinical Outcomes (2020) 6, 210–216
Pessoa-Amorim G et al, European Heart Journal - Quality of Care and Clinical Outcomes (2020) 6, 210–216
 “Possible causes of reductions in presentation include mainly the
reluctance of patients to present to the emergency departments, but
also a delay in response of an overloaded emergency medical service
during the Covid-19 pandemic with respect to the transfer times that
may occur.”

Tam CF, et al. Circulation Cardiovasc Qual Outcome 2020; 13: e006631.
CASE ILLUSTRATION
Case 1
• 48 years old man came to ER
• Typical chest pain since 6 hours before admission
• Hypertension (+), smoker (+), diabetes (+)
• Cough (+), fever (+)
• BP 160/90, HR 70, RR 16, T 38.8oC
• Other physical exam findings: unremarkable
• ECG: ST elevation on II, III, aVF and ST depression on I and aVL
• CXR: infiltrate (+), Lab: leukocytosis
• If the hospital isn’t the PCI capable center, and you need more than
120 minutes to transfer patient to the hospital with dedicated cathlab
for COVID-19, what is your best recommendation to treat the
patient?
a. Perform COVID-19 test then fibrinolytic if there’s no contraindication
b. Perform COVID-19 test and admit to isolated room without perform
fibrinolytic
c. Referred to PCI capable hospital with dedicated cathlab even its more than
120 minutes
d. I really don’t know what to do sir. 
Case 2
• 44 years old woman came to ER
• Typical chest pain since 8 hours before admission
• Without CAD risk factors
• Cough (-), fever (-), been living in pandemic area
• BP 130/70, HR 65, RR 16, T 36.8oC
• Other physical exam findings: unremarkable
• ECG: ST depression V5-V6
• CXR: infiltrate (-), Lab: HsTrop I < 2 ng/mL
• The patient was admitted to the hospital and you plan to perform the
further test. What is your best recommendation to be performed to
the patient?
a. Dobutamine stress echocardiography
b. Coronary angiography
c. Coronary CT angiography
d. Cardiac MRI
e. I think its not really necessary because of the pandemic condition.
Covid-19 in Indonesia

https://covid19.go.id/peta-sebaran
Covid-19 in West Sumatera

https://corona.sumbarprov.go.id/details/peta_covid19
 Acute Coronary Syndrome
• Major health problem
• High mortality and morbidity

20% Similar with the

other country
1.1 M 72% patient
experienced ACS
Mortality in Incidence in
European USA
(2016) (2016)

Ibanez B, et al. European Heart Journal. 2017;39:119-177.

 ACS in Indonesia

Patients Patients
686 patients 18,446 patients

194 patients 5,507 patients

Unclassified ACS Unclassified ACS

Unclassified ACS: Unclassified ACS:

iSTEMI registry. 2019

 General Approaches in ACS Patients

Adapted from : Roffi M et al. Eur Heart J 2016;37(3):267-315

 ACS Diagnosis

10 minutes

No need to
wait the result

Khalill R et al. Exp Clin Cardiol.2009; 14(2): e25 – e30; 2. Hamm CW et al. Eur Heart J. 2011
 STEMI ECG
New ST-elevation at the
J-point in two
contiguous leads with
the cut-point: ≥ 1 mm
in all leads other than
leads V2–V3 where
the following cut-points
apply: ≥ 2mm in men ≥
40 years; ≥ 2.5 mm in
men < 40 years, or ≥ 1.5
mm in women
regardless of age

17
ACS Diagnosis
0-3 h
Algorithm
ACS Diagnosis
0-1 h
Algorithm
 Increased of Troponin Levels in COVID-19:
Myocardial Infarction or Injury?
• 20% of patients hospitalized for Covid-19 infections had elevation of troponin
levels consisting of:
• Type-1 MI based on pre-existing or new coronary disease
• Type-2 MI in patients with:
• Lung infection and related respiratory distress.
• RV pressure increase in pulmonary embolism (frequently associated with
a Covid-19 infection due to an increased prothrombotic milieu)
• Tachyarrhythmia
• Coronary microvascular disease
• Stress cardiomyopathy
• A rare case of viral myocarditis during Covid-19 infection

Huber and Goldstein. EHJ. 2020. 222-228

 INITIAL TREATMENT
2018
Morphine • Can be repeated per 10 – 30 min, for
M sulfate iv
1-5 mg
patient who not responsive

O O2 • when SaO2 < 90% or PaO < 60

N NTG / ISDN • If ongoing chest pain by the time admitted at ER

A ASPIRIN
Loading
Ticagrelor
or
• 180 mg loading dose + 90 mg BID
• 300 mg loading dose + 75 mg OD if ticagrelor is
not available or contraindicated
160 – 320mg clopidogrel*

22
Pedoman Tatalaksana Sindroma Koroner Akut PERKI 2018
There are no significant differences in case
of general management of ACS patients
before and during COVID-19 pandemic
beside the safety of HCP in ER
The main difference is the consideration of
reperfusion strategy in STEMI and invasive
strategy in NSTE-ACS patients
STEMI
The importance of time to reperfusion in
STEMI patients

Bohula EA. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 11 ed. 2019(1): 1128. 26
 Maximum target
times for STEMI
patients according
to reperfusion
strategy selection
in patients
presenting via EMS
or in a non-PCI
center

Ibanez B, et al. European Heart Journal. 2017;39:119-177.

Manage-
ment of
patients
with
STEMI
during
COVID-19
pandemic

ESC Guidance for the Diagnosis and Management of CV Disease during the COVID-19 Pandemic . 2020
 Target reperfusion time in STEMI
during Pandemic
• The maximum delay from STEMI diagnosis to reperfusion of 120 minutes
should remain the goal for reperfusion therapy under the following
considerations:
• Primary PCI remains the reperfusion therapy of choice if feasible
(performed in facilities approved for the treatment of COVID-19
patients);
• Primary PCI pathways may be delayed during the pandemic (up to 60
minutes – according to multiples experiences);
• If the target time cannot be met and fibrinolysis is not contraindicated,
fibrinolysis should then become first line therapy;

ESC Guidance for the Diagnosis and Management of CV Disease during the COVID-19 Pandemic . 2020
 Consideration in Management of
STEMI patients during Pandemic
• As SARS-CoV-2 test results are not immediately available in STEMI patients,
any STEMI patient should be considered potentially infected;
• All STEMI patients should undergo testing for SARS-CoV-2 as soon as
possible following first medical contact irrespective of reperfusion strategy.
Until the result of the test is known, all precautionary measures should be
taken to avoid potential infection of other patients and HCP;
• Consider immediate complete revascularization if indicated and
appropriate in order to avoid staged procedures and reduce hospital stay;

ESC Guidance for the Diagnosis and Management of CV Disease during the COVID-19 Pandemic . 2020
NSTE-ACS
 Aggressive approach recommended
in HIGH RISK-NSTE-ACS Patient

Adapted from : Roffi M et al. Eur Heart J 2016;37(3):267-315

 Risk Criteria Mandating Invasive
Strategy in NSTE-ACS
• Hemodynamic instability or cardiogenic shock • Relevant rise or fall in troponin
VERY HIGH

• Dynamic ST- or T-wave changes

HIGH RISK
• Recurrent or ongoing chest pain refractory to
medical treatment (symptomatic or silent)
RISK

• Life-threatening arrhythmias or cardiac arrest • GRACE Score > 140

• Mechanical complications of MI
• Acute heart failure
• Recurrent dynamic ST-T wave changes,
particularly with intermittent ST-elevation
INTERMEDIATE

• Diabetes mellitus • Any characteristics not mentioned above

• Renal insufficiency

LOW RISK
(eGFR <60 mL/min/1.73 m²)
• LVEF < 40% or congestive HF
• Early post infarction angina
• Prior PCI
• Prior CABG
• GRACE risk score 109 - 140

Adapted from : Roffi M et al. Eur Heart J 2016;37(3):267-315

Recommendati
ons for
management
of patients
with NSTE-ACS
in the context
of COVID-19
outbreak

ESC Guidance for the Diagnosis and Management of CV Disease during the COVID-19 Pandemic . 2020
 Consideration in Management of
NSTE-ACS patients during Pandemic
• Testing for SARS-CoV-2 should be performed as soon as possible
following first medical contact, irrespective of treatment strategy.
• When there is a positive SARS-CoV-2 test, patients should be
transferred for invasive management to a COVID-19 hospital
equipped to manage COVID-19-positive patients.
• In the event any of the differential diagnoses seem plausible, a
noninvasive strategy should be considered and CCTA should be
favored, if equipment and expertise are available.

ESC Guidance for the Diagnosis and Management of CV Disease during the COVID-19 Pandemic . 2020
Organization of STEMI/high-risk NSTEMI
care in the age of Covid-19

Huber and Goldstein. EHJ. 2020. 222-228

 Conclusion

• There are no significant differences in case of general management of ACS

patients before and during COVID-19 pandemic beside the safety of HCP in ER
• Some patient with COVID-19 could have an increased of troponin level
• Primary PCI remains the reperfusion therapy of choice if feasible
• If the target time cannot be met and fibrinolysis is not contraindicated,
fibrinolysis should then become first line therapy;
• Invasive strategy only be performed in very high risk and high risk NSTE-
ACS

ESC Guidance for the Diagnosis and Management of CV Disease during the COVID-19 Pandemic . 2020
“Patients’ fears of becoming infected by going
to hospital must be addressed. Remember that
COVID-19 mortality is 10 times lower than that
of an untreated heart attack.”
Professor Barbara Casadei, ESC President.

Thank You