Percutaneous coronary intervention in patients with COVID-19 and acute coronary syndrome: What if the old normal became the new normal?

Coronavirus disease 2019 (COVID‐19) remains a global pandemic by affecting more than 88 million persons worldwide with 2 million deaths as of January 2021. The spread of the infection caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) has at least two major consequences for patients with acute coronary syndrome (ACS). First, a decline in hospital admissions for ACS has been observed globally as probable consequence of the fear of exposure to in‐hospital infection. Second, the implementation of percutaneous coronary intervention (PCI), which represents the principal revascularization modality in the setting of ACS, has been particularly challenged during the COVID‐19 pandemic.

In this issue of the Journal, Secco and colleagues reported a multicenter experience including 31 patients with SARS‐CoV‐2 and ACS across five Italian hospitals. Obstructive coronary artery disease with thrombotic lesions was found in the majority of patients undergoing coronary angiography. However, a noticeable proportion of COVID‐19 patients had a normal angiogram with a final diagnosis of Takotsubo syndrome (N = 3) or myocarditis (N = 2). With the exception of one patient who died, clinical follow‐up was uneventful in the remaining cases.

Despite the very small numbers, this pilot study provides relevant insights for the management of COVID‐19 patients with ACS. In particular, it shows that coronary angiography in patients with ACS and COVID‐19 is safe for both patients and Cath‐Lab personnel. Hitherto, none of the staff involved during the procedures acquired COVID‐19. A more conservative approach has been advocated during the COVID‐19 pandemic for both non‐ST‐elevation (medical therapy) and ST‐elevation ACS (fibrinolysis). However, the study findings challenge this paradigm. Given the fact that we have to live with COVID‐19 for a while longer, should we switch to a new normal (i.e., routine invasive management)? And, is the new normal nothing more than the old normal? At the beginning of this pandemic, we witnessed a shortage of personal protective equipment (PPE) and very few were familiar with donning and removing PPE to manage COVID‐19 patients. Contrariwise, when the second wave of infection unfolded, the invasive cardiology community has not been caught unprepared. Early access to vaccine against COVID‐19 is becoming a top priority for healthcare personnel in almost all countries. Therefore, with the healthcare professionals provided with full equipment and acquired immunity against COVID‐19, a conservative management of ACS in patients with COVID‐19 will become more difficult to justify.

We know that fibrinolysis is inferior to primary PCI in terms of safety and efficacy and that a conservative management in patients with non‐ST‐elevation ACS is inferior to a routine invasive strategy in terms of reinfarction and refractory angina. Consequently, as long as invasive assessment can be safely and timely performed, we should go back to the “normal” guidelines supporting primary PCI and early invasive strategy for the majority of patients with ST‐elevation and non‐ST‐elevation ACS, respectively. Data suggest that patients with concomitant coronary artery disease and COVID‐19 have a threefold higher risk of mortality, which is mainly explained by the burden of comorbidities. Hence, invasive angiography with the possibility of revascularization not only should not be withheld in COVID‐19 patients with ACS, but rather supported as the authors brilliantly did.

Recent preliminary data from the US Centers for Disease Control and Prevention indicate that COVID‐19 was likely the third leading cause of death in the United States in 2020. Confirmed or not, cardiovascular diseases will remain the number 1 cause of death. As such, we should commit to deliver the most safe and effective therapies to patients with ACS irrespective of their COVID‐19 status.