Edited by: Nicola Mumoli, ASST Ovest Milanese, Italy
Reviewed by: Antonia Anna Lukito, University of Pelita Harapan, Indonesia; Wenyang Jiang, Chinese Academy of Medical Sciences and Peking Union Medical College, China; Efstratios Karagiannidis, Aristotle University of Thessaloniki, Greece; Vinod Krishnappa, University of North Carolina Health Southeastern, United States
This article was submitted to Cardiovascular Epidemiology and Prevention, a section of the journal Frontiers in Cardiovascular Medicine
†These authors have contributed equally to this work and share first authorship
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This study aimed to investigate the differences in the characteristics, management, and clinical outcomes of patients with and that of those without coronavirus disease 2019 (COVID-19) infection who had ST-segment elevation myocardial infarction (STEMI).
Databases including Web of Science, PubMed, Cochrane Library, and Embase were searched up to July 2021. Observational studies that reported on the characteristics, management, or clinical outcomes and those published as full-text articles were included. The Newcastle-Ottawa Scale (NOS) was used to assess the quality of all included studies.
A total of 27,742 patients from 13 studies were included in this meta-analysis. Significant delay in symptom onset to first medical contact (SO-to-FMC) time (mean difference = 23.42 min; 95% CI: 5.85–40.99 min;
This study revealed that COVID-19 infection had an impact on the time of initial medical intervention for patients with STEMI after symptom onset and showed that COVID-19 patients with STEMI were more likely to have thrombosis and had poorer outcomes.
An eventual pandemic brought by the coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) resulted in plenty of deaths and has had a strong impact on the world's healthcare system (
A type of heart attack called ST-segment elevation myocardial infarction (STEMI) is usually caused by thrombotic occlusion at the site of a ruptured plaque in the coronary artery (
We performed a literature search using databases including Web of Science (Beijing), PubMed (Bethesda), Cochrane Library (UK), and Embase (Amsterdam) for relevant papers without language limitation on July 31, 2021. The search strategy included a mix of MeSH and free-text terms relevant to the critical concept of “STEMI” and “COVID-19” (
Search strategy.
PubMed | (1) “ST Segment Elevation Myocardial Infarction”: 9451 | (10) SARS-CoV-2: 106826 |
(2) “ST Elevated Myocardial Infarction”: 317 | (11) “Coronavirus disease 19”: 1603 | |
(3) STEMI: 28060 | (12) “Severe Acute Respiratory Syndrome Coronavirus 2”: 16865 | |
(4) “Acute myocardial infarction”: 61630 | (13) “novel coronavirus”: 9766 | |
(5) AMI: 25165 | (14) “2019 novel coronavirus”: 1550 | |
(6) “Acute coronary syndromes”: 13188 | (15) #1 or #2 or #3 or #4 or #5 or #6 or #7: 208085 | |
(7) ACS: 116546 | (16) #8 or #9 or #10 or #11 or #12 or #13 or #14: 169136 | |
(8) “SARSCoV-2 pandemic”: 120 | (17) #15 and #16: 1340 | |
(9) COVID-19: 168784 | ||
Web of science | (1) “ST Segment Elevation Myocardial Infarction”: 17531 | (10) SARS-CoV-2: 127748 |
(2) “ST Elevated Myocardial Infarction”: 1899 | (11) “Coronavirus disease 19”: 3460 | |
(3) STEMI: 23388 | (12) “Severe Acute Respiratory Syndrome Coronavirus 2”: 58794 | |
(4) “Acute myocardial infarction”: 145384 | (13) “novel coronavirus”: 14678 | |
(5) AMI: 44201 | (14) “2019 novel coronavirus”: 2224 | |
(6) “Acute coronary syndromes”: 27560 | (15) #1 or #2 or #3 or #4 or #5 or #6 or #7: 248982 | |
(7) ACS: 58425 | (16) #8 or #9 or #10 or #11 or #12 or #13 or #14: 262441 | |
(8) “SARSCoV-2 pandemic”: 25 | (17) #15 and #16: 1098 | |
(9) COVID-19: 248069 | ||
Cochrane library | (1) “ST Segment Elevation Myocardial Infarction”: 4031 | (10) SARS-CoV-2: 322 |
(2) “ST Elevated Myocardial Infarction”: 156 | (11) “Coronavirus disease 19”: 43 | |
(3) STEMI: 3616 | (12) “Severe Acute Respiratory Syndrome Coronavirus 2”: 631 | |
(4) “Acute myocardial infarction”: 9325 | (13) “novel coronavirus”: 497 | |
(5) AMI: 3603 | (14) “2019 novel coronavirus”: 55 | |
(6) “Acute coronary syndromes”: 2562 | (15) #1 or #2 or #3 or #4 or #5 or #6 or #7: 19050 | |
(7) ACS: 4853 | (16) #8 or #9 or #10 or #11 or #12 or #13 or #14: 6784 | |
(8) “SARSCoV-2 pandemic”: 52 | (17) #15 and #16: 31 | |
(9) COVID-19: 6666 | ||
Embase | ('acute myocardial infarction':ti,ab,kw OR ami:ti,ab,kw OR 'acute coronary syndromes':ti,ab,kw OR acs:ti,ab,kw OR 'st segment elevation myocardial infarction':ti,ab,kw OR 'st elevated myocardial infarction':ti,ab,kw OR stemi:ti,ab,kw) AND ('sarscov-2 pandemicor COVID-19':ti,ab,kw OR 'sars cov 2':ti,ab,kw OR 'coronavirus disease 19':ti,ab,kw OR 'novel coronavirus':ti,ab, kw OR 'severe acute respiratory syndrome coronavirus 2':ti,ab,kw) AND [1-1-1900]/sd NOT [1-8-2021]/sd; result = 233 |
Studies were included if they met the following inclusion criteria: (i) studies involving STEMI patients; (ii) the exposure group included patients diagnosed with COVID-19 using PCR test or had a high index of clinical suspicion, and the control group included patients without COVID-19; (iii) studies that reported at least one of the following information: characteristics, management strategy, or clinical outcomes; (iv) relevant cohort studies, cross-sectional studies, case series, and case-control studies. Two independent authors screened the titles and abstracts of all relevant studies and identified whether they met the inclusion criteria by reviewing the full text of each potential study. Any discrepancy was resolved through consensus with a third author.
Relevant data from all included studies were extracted by two authors independently, and any disagreement was resolved by discussion with a third author. The following data were extracted: authors, publication year, country, study design, study subject, sample size, mean age of patients/subjects, sex, comparison period, participant characteristics, management strategies, and clinical outcomes. The Newcastle–Ottawa Scale (NOS), which includes participant selection, comparability, and outcome, was used to assess the quality of the included studies. Likewise, all included studies were rated by two authors independently, and any discrepancy was adjudicated by consensus.
We used Review Manager 5.4 (The Nordic Cochrane Center, Cochrane Collaboration, 2020, Denmark) to perform the statistical analysis. If studies only reported median values and interquartile ranges (IQR), means and
A total of 2,702 articles were retrieved through electronic database searches, of which 1,371 were duplicates. After screening the titles and abstracts, 24 potential articles were assessed for eligibility after a full-text review, and 13 articles (
PRISMA flow diagram.
Characteristics of included studies.
Popovic et al. ( |
France | Monocentric cohort study | COVID-19 STEMI | 26/2/2020–10/5/2020 | RT-PCR or typical clinical features plus CT results/NA | D2B time, Laboratory values, Primary angioplasty, MINOCA, Stent implantation, Gp2b3a inhibitor use, TIMI status, In-hospital mortality | |
Non-COVID-19 STEMI | 26/2/2020–10/5/2020 | ||||||
Siudak et al. ( |
Poland | Multicentric cohort study | COVID-19 STEMI | 13/3/2020–13/5/2020 | Swabs for molecular RT-PCR testing/NA | SO-to-FMC time | |
Non-COVID-19 STEMI | 13/3/2020–13/5/2020 | ||||||
Kiris et al. ( |
Turkey | Multicentric cross-sectional study | COVID-19 STEMI | 11/3/2020–15/5/2020 | Nasal/pharyngeal swabs or semptoms plus radiological imaging/NA | SO-to-FMC time, Laboratory values, Primary angioplasty, Thrombus aspiration, Gp2b3a inhibitor use, Baseline thrombus grade, Modified thrombus grade, TIMI status, In-hospital mortality, Bleeding, Stent thrombosis, Cardiogenic shock | |
Non-COVID-19 STEMI | 11/3/2020–15/5/2020 | ||||||
Koutsoukis et al. ( |
France | Multicentric cross-sectional study | COVID-19 STEMI | 1/4/2020–22/4/2020 | RT-PCR on nasopharyngeal samples/NA | Laboratory values, Primary angioplasty, Thrombus aspiration, MINOCA, Stent implantation, Gp2b3a inhibitor use, In-hospital mortality | |
Non-COVID-19 STEMI | 1/4/2020–22/4/2020 | ||||||
Garcia et al. ( |
USA & Canada | Multicentric cohort study | COVID-19 STEMI | 1/1/2020–6/12/2020 | Comfirmed COVID+ by any commercially available test/NA | D2B time, Primary angioplasty, MINOCA, In-hospital mortality, LOS | |
Non-COVID-19 STEMI | 1/2015–12/2019 | ||||||
Kite et al. ( |
Data from 55 international centers | Multicentric corhort study | COVID-19 STEMI | 1/3/2020–31/7/2020 | RT-PCR or clinical status plus CXR or CT findings/NA | D2B time, Laboratory values, Thrombus aspiration, In-hospital mortality, Bleeding, Cardiogenic shock, LOS | |
Non-COVID-19 STEMI | 2018–2019 | ||||||
Little et al. ( |
UK | Multicentric cohort study | COVID-19 STEMI | 1/3/2020–30/4/2020 | RT-PCR on oro/nasopharyngeal throat swabs or typical symptoms plus radiographic appearances and characteristic blood test/NA | D2B time, Laboratory values, Thrombus aspiration, Gp2b3a inhibitor use, TIMI status, In-hospital mortality, Cardiogenic shock, ICU admission, LOS | |
Non-COVID-19 STEMI | 1/3/2020–30/4/2020 | ||||||
Marfella et al. ( |
Italy | Multicentric cohort study | COVID-19 STEMI | 2/2020–11/2020 | RT-PCR on nasal/pharyngeal swabs/NA | D2B time, Laboratory values, Gp2b3a inhibitor use, Modified thrombus grade, TIMI status, In-hospital mortality, LOS, ICU admission, Cardiogenic shock | |
Non-COVID-19 STEMI | 2/2020–11/2020 | ||||||
Pellegrini et al. ( |
Italy | Monocentric cohort study | COVID-19 STEMI | 8/3/2020–20/4/2020 | RT-PCR on nasal swab or endotracheal aspirate/3–6 h | Thrombus aspiration, MINOCA, Stent implantation, Gp2b3a inhibitor use, In-hospital mortality, Cardiogenic shock, Bleeding | |
Non-COVID-19 STEMI | 8/3/2020–20/4/2020 | ||||||
Rodriguez-Leor et al. ( |
Spain | Multicentric cohort study | COVID-19 STEMI | 14/3/2020–30/4/2020 | PCR assay/NA | SO-to-FMC time, Primary angioplasty, Thrombus aspiration, MINOCA, Stent implantation, Gp2b3a inhibitor use, TIMI status, In-hospital mortality, Cardiogenic shock, Stent thrombosis, bleeding | |
Non-COVID-19 STEMI | 14/3/2020–30/4/2020 | ||||||
Choudry et al. ( |
UK | Monocentric cohort study | COVID-19 STEMI | 1/3/2020–20/5/2020 | PT-PCR on nasal/ pharyngeal swabs/NA | D2B time, Laboratory values, Primary angioplasty, Thrombus aspiration, Gp2b3a inhibitor use, Baseline thrombus grade, Modified thrombus grade, TIMI status, In-hospital mortality, Stent thrombosis | |
Non-COVID-19 STEMI | 1/3/2020–20/5/2020 | ||||||
Blasco et al. ( |
Spain | Monocentric cross-sectional study | COVID-19 STEMI | 23/3/2020–11/4/2020 | RT-PCR on nasopharyngeal and throat swab samples/NA | Laboratory values | |
Non-COVID-19 STEMI | 7/2015–12/2015 | ||||||
Güler et al. ( |
Turkey | Monocentric cross-sectional study | COVID-19 STEMI | 11/3/2020–10/1/2021 | RT-PCR on nasopharyngeal swabs / NA | SO-to-FMC time, D2B time, Laboratory values, Thrombus aspiration, Gp2b3a inhibitor use, Baseline thrombus grade, TIMI status, In-hospital mortality, ICU admission, LOS | |
Non-COVID-19 STEMI | 11/3/2020–10/1/2021 |
Baseline characteristics of study subjects.
Popovic et al. ( |
COVID-19 STEMI | 11 | 63.6 ± 17.4 | 63.9 | 25.1 ± 8.1 | 18.2 | 45.5 | 27.3 | 36.4 | 0 | NA |
Non-COVID-19 STEMI | 72 | 62.5 ± 12.6 | 73.6 | 27.02 ± 4.8 | 19.4 | 43.1 | 38.9 | 55.6 | 12.5 | NA | |
Siudak et al. ( |
COVID-19 STEMI | 145 | 63.19 ± 12.55 | 71.33 | NA | 14.48 | 46.21 | NA | 37.24 | NA | 12.41 |
Non-COVID-19 STEMI | 2,276 | 65.43 ± 12.23 | 67.65 | NA | 16.86 | 57.55 | NA | 31.08 | NA | 15.94 | |
Kiris et al. ( |
COVID-19 STEMI | 65 | 66.8 ± 12.0 | 68 | NA | 26 | 48 | NA | 34 | 44 | NA |
Non-COVID-19 STEMI | 668 | 60.0 ± 12.3 | 78 | NA | 29 | 42 | NA | 33 | 40 | NA | |
Koutsoukis et al. ( |
COVID-19 STEMI | 17 | 63.4 ± 13.2 | 70 | NA | NA | NA | NA | NA | 30.7 | NA |
Non-COVID-19 STEMI | 99 | 63.8 ± 13.9 | 67 | NA | NA | NA | NA | NA | 61.2 | NA | |
Garcia et al. ( |
COVID-19 STEMI | 230 | 18–55 yrs: 23%; 55–65 yrs: 32%; 66–75 yrs: 28%; >75 yrs: 17% | 71 | 29.3 ± 7.6 | 46 | 73 | 46 | 44 | 0 | 13 |
Non-COVID-19 STEMI | 460 | 18–55 yrs: 26%; 55–65 yrs: 30%; 66–75 yrs: 27%; >75 yrs: 17% | 68 | 29.5 ± 6.4 | 28 | 69 | 60 | 59 | 16 | 24 | |
Kite et al. ( |
COVID-19 STEMI | 144 | 63.1 ± 12.6 | 77.8 | 27.3 ± 4.5 | 34 | 64.8 | 46 | 31.7 | NA | 16.4 |
Non-COVID-19 STEMI | 24,961 | 65.6 ± 13.4 | 72.2 | 27.8 ± 5.5 | 20.9 | 44.8 | 28.9 | 33.7 | NA | 13 | |
Little et al. ( |
COVID-19 STEMI | 46 | 61.80 ± 7.95 | 80.4 | NA | 32.6 | 54 | 52.2 | 41.3 | NA | 10.9 |
Non-COVID-19 STEMI | 302 | 64.18 ± 13.41 | 79.8 | NA | 23.5 | 50.7 | 33.1 | 41.7 | NA | 12.6 | |
Marfella et al. ( |
COVID-19 STEMI | 46 | 56.13 ± 6.21 | 67.4 | 27.09 ± 1.81 | 17.4 | 39.1 | 15.2 | 6.5 | NA | NA |
Non-COVID-19 STEMI | 130 | 68.43 ± 6.46 | 66.2 | 29.55 ± 1.97 | 29.2 | 55.4 | 23.7 | 29.2 | NA | NA | |
Pellegrini et al. ( |
COVID-19 STEMI | 24 | 69.63 ± 11.00 | 83.3 | 26.60 ± 3.36 | 41.7 | 70.8 | 62.5 | 29.2 | 45.8 | 29.2 |
Non-COVID-19 STEMI | 26 | 64.65 ± 13.04 | 84.6 | 26.11 ± 3.43 | 15.4 | 53.9 | 65.4 | 38.5 | 28.6 | 19.2 | |
Rodriguez-Leor et al. ( |
COVID-19 STEMI | 91 | 64.8 ± 11.8 | 84.4 | NA | 23.1 | 51.7 | 48.4 | 18.7 | 37.4 | NA |
Non-COVID-19 STEMI | 919 | 62.5 ± 13.1 | 78.4 | NA | 20.9 | 53.3 | 46.9 | 45.5 | 37.1 | NA | |
Choudry et al. ( |
COVID-19 STEMI | 39 | 61.7 ± 11.0 | 84.6 | 26.7 (24.8–30.7) | 46.2 | 71.8 | 61.6 | 61.6 | NA | 15.4 |
Non-COVID-19 STEMI | 76 | 61.7 ± 12.6 | 75 | 26.7 (24.8–30.7) | 46.2 | 42.1 | 36.8 | 46.1 | NA | 3.9 | |
Blasco et al. ( |
COVID-19 STEMI | 5 | 62 ± 14 | 80 | 28.0 (27.3–30.1) | 0 | 80 | 0 | 40 | NA | NA |
Non-COVID-19 STEMI | 50 | 58 ± 12 | 88 | 27.6 (24.9–30.3) | 8 | 42 | 52 | 78 | NA | NA | |
Güler et al. ( |
COVID-19 STEMI | 62 | 60.2 ± 9.5 | 66.1 | NA | 48.4 | 59.7 | 43.5 | 51.6 | NA | 9.7 |
Non-COVID-19 STEMI | 64 | 63 ± 8 | 70.3 | NA | 54.7 | 57.8 | 34.3 | 56.3 | NA | 28.1 |
The symptom onset to first medical contact (SO-to-FMC) time among STEMI, which was reported in four studies (
The meta-analysis showed that compared to the non-COVID-19 group, the COVID-19 group had significantly higher levels of C-reactive protein (CRP), white blood cell count (WBC), and D-dimer (SMD = 0.76, 95% CI: 0.38 to 1.13,
There was no significant difference in the rate of primary angioplasty between the two groups (OR = 0.28, 95% CI: 0.08 to 1.01,
In-hospital mortality among patients with COVID-19 was significantly higher than that in patients without COVID-19 (OR = 5.98, 95% CI: 4.78 to 7.48,
The GRADE summary of findings tool was used to evaluate the quality of evidence, and the assessment for each outcome is presented in
GRADE summary of findings.
Symptom-to-FMC time | The mean symptom-to-FMC time was 0 | MD 23.42 higher (5.85 higher to 40.99 higher) | – | 4,290 (4 observational studies) | ⊕○○○ Very low | NA |
D2B time | The mean D2B time was 0 | MD 12.27 higher (5.77 higher to 18.78 higher) | – | 26,643 (7 observational studies) | ⊕○○○ Very low | NA |
CRP | – | SMD 0.76 higher (0.38 higher to 1.13 higher) | – | 1,576 (7 observational studies) | ⊕○○○ Very low | NA |
WBC | – | SMD 0.39 higher (0.1 higher to 0.69 higher) | – | 1,205 (5 observational studies) | ⊕○○○ Very low | NA |
D–Dimer | – | SMD 0.79 higher (0.36 higher to 1.22 higher) | – | 324 (3 observational studies) | ⊕○○○ Very low | NA |
Lymphocyte count | – | SMD 0.52 lower (0.69 lower to 0.36 lower) | – | 848 (5 observational studies) | ⊕⊕○○ Low | NA |
Primary angioplasty | 942 per 1,000 | 820 per 1,000 (566 to 943) | OR 0.28 (0.08 to 1.01) | 2,796 (7 observational studies) | ⊕○○○ Very low | NA |
MINOCA | 55 per 1,000 | 356 per 1,000 (110 to 712) | OR 9.57 (2.14 to 42.83) | 1,949 (5 observational studies) | ⊕○○○ Very low | NA |
Stent implantation | 895 per 1,000 | 704 per 1,000 (483 to 858) | OR 0.28 (0.11 to 0.71) | 1,264 (4 observational studies) | ⊕○○○ Very low | NA |
Baseline thrombus grade > 3 | 677 per 1,000 | 866 per 1,000 (793 to 916) | OR 3.09 (1.83 to 5.23) | 974 (3 observational studies) | ⊕○○○ Very low | NA |
Modified thrombus grade > 3 | 350 per 1,000 | 759 per 1,000 (423 to 931) | OR 5.84 (1.36 to 25.06) | 1,024 (3 observational studies) | ⊕○○○ Very low | NA |
Thrombus aspiration | 204 per 1,000 | 301 per 1,000 (243 to 367) | OR 1.68 (1.25 to 2.26) | 2,498 (7 observational studies) | ⊕⊕○○ Low | NA |
Gp2b3a inhibitor | 176 per 1,000 | 379 per 1,000 (275 to 496) | OR 2.86 (1.78 to 4.62) | 2,757 (9 observational studies) | ⊕○○○ Very low | NA |
TIMI-3 Flow | 892 per 1,000 | 832 per 1,000 (776 to 874) | OR 0.60 (0.42 to 0.84) | 2,572 (7 observational studies) | ⊕⊕○○ Low | NA |
In- hospital mortality | 57 per 1,000 | 265 per 1,000 (224 to 311) | OR 5.98 (4.78 to 7.48) | 25,266 (11 observational studies) | ⊕⊕⊕○ Moderate | NA |
Cardiogenic shock | 84 per 1,000 | 201 per 1,000 (156 to 256) | OR 2.75 (2.02 to 3.76) | 24,085 (5 observational studies) | ⊕⊕○○ Low | NA |
Stent thrombosis | 10 per 1,000 | 52 per 1,000 (23 to 114) | OR 5.65 (2.41 to 13.23) | 1,858 (3 observational studies) | ⊕⊕○○ Low | NA |
Bleeding | 5 per 1,000 | 13 per 1,000 (4 to 39) | OR 2.82 (0.88 to 9.05) | 15,850 (4 observational studies) | ⊕○○○ Very low | NA |
ICU admission | 83 per 1,000 | 277 per 1,000 (184 to 394) | OR 4.26 (2.51 to 7.22) | 650 (3 observational studies) | ⊕○○○ Very low | NA |
Length of stay | The mean length of stay was 0 | MD 4.63 higher (2.56 higher to 6.69 higher) | - | 26,445 (5 observational studies) | ⊕○○○ Very low | NA |
The leave-one-out approach was applied for sensitivity analysis to evaluate the impact of a single study on outcomes with a high degree of heterogeneity. As shown in
Leave-one-out analysis.
Güler et al. ( |
12.66 | 2.96 to 22.35 | 0.01 |
Popovic et al. ( |
13.06 | 7.13 to 18.99 | <0.0001 |
Little et al. ( |
12.01 | 4.16 to 19.86 | 0.003 |
Choudry et al. ( |
12.52 | 4.35 to 20.68 | 0.003 |
Marfella et al. ( |
13.1 | 4.66 to 21.54 | 0.002 |
Garcia et al. ( |
9.92 | 4.47 to 15.35 | 0.0004 |
Kite et al. ( |
12.15 | 6.47 to 17.82 | <0.0001 |
Blasco et al. ( |
0.82 | 0.43 to 1.21 | <0.0001 |
Güler et al. ( |
0.83 | 0.40 to 1.26 | 0.0002 |
Koutsoukis et al. ( |
0.59 | 0.29 to 0.90 | 0.0001 |
Popovic et al. ( |
0.67 | 0.28 to 1.06 | 0.0007 |
Little et al. ( |
0.8 | 0.33 to 1.26 | 0.0007 |
Choudry et al. ( |
0.86 | 0.45 to 1.26 | <0.0001 |
Kiris et al. ( |
0.73 | 0.27 to 1.20 | 0.002 |
Blasco et al. ( |
0.35 | 0.04 to 0.67 | 0.03 |
Güler et al. ( |
0.5 | 0.25 to 0.76 | <0.0001 |
Choudry et al. ( |
0.42 | 0.04 to 0.81 | 0.03 |
Marfella et al. ( |
0.26 | 0.08 to 0.44 | 0.004 |
Kiris et al. ( |
0.038 | 0.18 to 0.59 | 0.0002 |
Güler et al. ( |
0.89 | 0.01 to 1.78 | 0.05 |
Popovic et al. ( |
0.62 | 0.35 to 0.88 | <0.0001 |
Choudry et al. ( |
1.00 | 0.38 to 1.62 | 0.002 |
Koutsoukis et al. ( |
0.27 | 0.05 to 1.43 | 0.12 |
Popovic et al. ( |
0.28 | 0.07 to 1.15 | 0.08 |
Pellegrini et al. ( |
0.31 | 0.01 to 1.24 | 0.10 |
Choudry et al. ( |
0.23 | 0.06 to 0.94 | 0.04 |
Rodriguez-Leor et al. ( |
0.12 | 0.08 to 0.17 | <0.0001 |
Garcia et al. ( |
0.36 | 0.09 to 1.49 | 0.16 |
Kiris et al. ( |
0.21 | 0.16 to 0.29 | <0.0001 |
Koutsoukis et al. ( |
7.63 | 1.44 to 40.43 | 0.02 |
Popovic et al. ( |
8.49 | 1.37 to 52.74 | 0.02 |
Pellegrini et al. ( |
9.81 | 1.84 to 52.38 | 0.01 |
Rodriguez-Leor ( |
18.62 | 8.73 to 39.72 | <0.0001 |
Garcia et al. ( |
7.56 | 1.38 to 41.37 | 0.02 |
Blasco et al. ( |
0.46 | 0.28 to 0.75 | 0.002 |
Koutsoukis et al. ( |
0.25 | 0.06 to 1.01 | 0.05 |
Popovic et al. ( |
0.25 | 0.07 to 0.90 | 0.03 |
Rodriguez-Leor et al. ( |
0.20 | 0.09 to 0.43 | <0.0001 |
Choudry et al. ( |
7.03 | 0.52 to 96.03 | 0.14 |
Marfella et al. ( |
2.72 | 1.25 to 5.94 | 0.01 |
Kiris et al. ( |
10.69 | 1.75 to 65.11 | 0.01 |
Güler et al. ( |
2.90 | 1.70 to 4.93 | <0.0001 |
Koutsoukis et al. ( |
2.93 | 1.75 to 4.90 | <0.0001 |
Popovic et al. ( |
3.03 | 1.87 to 4.93 | <0.0001 |
Little et al. ( |
3.02 | 1.72 to 5.30 | 0.0001 |
Pellegrini et al. ( |
2.99 | 1.79 to 5.01 | <0.0001 |
Choudry et al. ( |
2.37 | 1.81 to 3.11 | <0.0001 |
Rodriguez-Leor et al. ( |
2.93 | 2.19 to 3.92 | <0.0001 |
Marfella et al. ( |
2.41 | 1.83 to 3.17 | <0.0001 |
Kiris et al. ( |
3.01 | 2.25 to 4.03 | <0.0001 |
Pellegrini et al. ( |
3.30 | 0.77 to 14.07 | 0.11 |
Rodriguez-Leor et al. ( |
2.95 | 0.55 to 15.73 | 0.21 |
Kite et al. ( |
1.62 | 0.71 to 3.73 | 0.25 |
Kiris et al. ( |
3.62 | 0.92 to 14.23 | 0.07 |
Güler et al. ( |
5.11 | 2.17 to 8.06 | 0.0007 |
Little et al. ( |
4.84 | 2.41 to 7.27 | <0.0001 |
Marfella et al. ( |
5.42 | 3.24 to 7.26 | <0.0001 |
Garcia et al. ( |
3.56 | 1.85 to 5.27 | <0.0001 |
Kite et al. ( |
4.41 | 2.14 to 6.69 | 0.0001 |
This is the first meta-analysis to compare the characteristics, management, and clinical outcomes of patients with STEMI presenting with COVID-19 infection and that of those patients without COVID-19 infection. Compared to the non-COVID-19 group, the COVID-19 group had significant delays in SO-to-FMC and D2B times. Among the two groups, laboratory values, such as CRP, WBC, and D-dimer, were elevated in the COVID-19 group, while lymphocyte count was found to be lower compared to the non-COVID-19 group. In addition, STEMI concomitant with COVID-19 infection was characterized by a higher rate of MINOCA, lower rate of stent implantation, and higher thrombus grade, and associated higher use of thrombus aspiration and Gp2b3a inhibitors. Furthermore, we found that the COVID-19 group had an increased rate of in-hospital mortality, cardiogenic shock, stent thrombosis, ICU admission, longer length of hospital stays, and decreased TIMI flow post-procedure.
The COVID-19 pandemic started in late 2019 and has caused severe delays in the treatment of patients with STEMI compared to the pre-COVID-19 era, and this is mostly explained by the limited access to emergency medical services (EMS) and the lack of effective organization of healthcare systems (
The reperfusion strategy for patients with STEMI during the COVID-19 pandemic remains controversial. The Chinese Cardiac Society and the Canadian Association of Interventional Cardiology recommend thrombolysis as the preferred reperfusion strategy for patients with STEMI (
Previous studies have shown that COVID-19 may lead to a prothrombotic state and that a high thrombus burden is more common in STEMI patients with COVID-19 (
Hospital-mortality was dramatically higher in STEMI patients who presented with COVID-19 than in those without COVID-19. Longer ischemia time, higher thrombus burden, and increased rate of adverse cardiovascular events, including cardiogenic shock, may also be contributory (
In a meta-analysis, heterogeneity may exist while the sample estimates for the population risk were of different magnitudes (
To our knowledge, this is the first meta-analysis that summarizes the comparison of clinical information on STEMI patients presenting with vs. those presenting without COVID-19 infection. We included multiple studies that were conducted in Asia, Europe, and North America, so that our findings can provide a broad overview of COVID-19 infection in patients with STEMI. However, our study has several limitations. First, the delay time, laboratory values, and length of stay were reported in terms of median values and IQR in many studies, which have been adjusted to means and SDs using the Box-Cox method. Nevertheless, using this method to calculate SDs may entail inaccuracy and make the SDs greater than the mean in some cases, which is an inherent feature of the method (
In patients with STEMI, COVID-19 has had a deep impact on their therapeutic management and clinical outcomes. A longer time from SO-to-FMC and D2B was observed in STEMI patients with COVID-19 in our study. Moreover, patients with STEMI who also had COVID-19 had more severe thrombotic events adverse outcomes. Further studies are required to explore the mechanism of coronary thrombus burden and the optimal treatment for patients with STEMI and COVID-19.
The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.
YW, LK, C-WC, SX, and T-HT: conception. YW, LK, C-WC, JX, PY, SX, and T-HT: methodology. YW, LK, JX, PY, and T-HT: analysis. YW, LK, JX, and PY: interpretation and writing. C-WC, SX, and T-HT: supervision. All authors have read and agreed to the published version of the manuscript.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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