Clinical Research in Cardiology https://doi.org/10.1007/s00392-020-01702-0 LETTER TO THE EDITORS Identifying very low‑risk STEMI patients for early ICU discharge in the COVID‑19 era Omar Abdul‑Jawad Altisent1,2 · Xavier Carrillo1,2 · Rishi Puri3 · Antoni Bayés‑Genís1,2 Received: 1 June 2020 / Accepted: 30 June 2020 © Springer-Verlag GmbH Germany, part of Springer Nature 2020 Keywords STEMI · Primary percutaneous coronary intervention · COVID-19 Sirs: before the procedure. We recorded in a prospective dedicated database clinical characteristics, peri-procedural complica- Assessment of individual patient risk for short-term out- tions including arrhythmias, Killip-Kimball class, reperfu- comes following acute ST-elevation myocardial infarction sion time, and procedural characteristics; 24-h ICU cardiac (STEMI) has focused on risk scores with high sensitivity to complications including ventricular fibrillation/tachycardia, identify high-risk patients [1]. By contrast, there is a lack A-V block or asystole, acute pulmonary edema, mechanical of uniformly accepted scores for predicting the absence of ventilation, shock, acute stent thrombosis and cardiac death; complications following primary percutaneous intervention and 30-day cardiac death. Patients were divided in two (pPCI), and current guidelines still recommend admission in cohorts: a derivation cohort (n = 1492; years 2012–2016) to intensive care unit (ICU) during at least 24 h after symptoms identify independent very low-risk predictors; and a valida- onset in patients with uncomplicated STEMI [1–3]. Mini- tion cohort (n = 693; years 2017–2019). mizing ICU admissions, particularly in the current COVID- Univariate and multivariate logistic regression analysis 19 era, is paramount for minimizing patient exposure and were used to determine predictors of 24-h cardiac com- optimizing resource allocation [4–6]. plications and 30-day cardiac death. Multivariate analysis We hypothesized whether in the era of regional pPCI rep- included clinical and procedural predictors that exhibited a erfusion networks, uncomplicated STEMI patients remain- p value < 0.05 in the univariate analysis. First, multivariable- ing event-free following prompt TIMI 3 flow restoration, independent predictors allowed patient stratification in to would facilitate early discharge from the ICU [7, 8]. The very low-risk (odds ratio ≤ 0.85 for early cardiac complica- present study aimed to identify predictors of very low-risk tions and 30-day cardiac death) and other risk groups. Next, STEMI patients following uncomplicated pPCI, and to cardiac events beyond the first 6 h in the ICU were character- assess the safety of an early ICU discharge strategy. ized in the very low-risk group. Finally, specificity to predict To test our hypothesis, we analyzed consecutive STEMI early cardiac complications and 30-day cardiac death in the patients undergoing pPCI in our referral area (~ 850,000 very-low risk group was also assessed. inhabitants) arriving within 12 h after symptom onset, Derivation cohort independent predictors of very low- between 2012 and 2019 (n = 2185). Per protocol all patients risk were age ≤ 75 years-old, absence of primary malignant received a loading dose of 300 mg of aspirin plus 600 mg of arrhythmias during the first assistance, Killip-Kimball class clopidogrel or 180 mg of ticagrelor or 60 mg of prasugrel I, radial access, absence of left main or three-vessel coro- nary disease, and successful angioplasty-stenting (defined as final TIMI 3 flow), as shown in Table 1. The same very * Omar Abdul‑Jawad Altisent low-risk predictors emerged in the validation cohort (data oabduljawadaltisent@gmail.com not presented). 1 In the derivation cohort, 144 of 1492 (9.7%) patients Germans Trias I Pujol University Hospital, Universitat Autònoma de Barcelona, Carretera de Canyet s/n, had a 24-h-cardiac event (21 patients with stent throm- 08916 Badalona, Barcelona, Spain bosis); 50 (3.4%) suffered a 30-day cardiac death; and 2 CIBERCV, Madrid, Spain 638 (43%) met very-low risk criteria. In the very-low-risk 3 group, seven patients (1.1%) had a 24-h-cardiac event, all Cleveland Clinic, Cleveland, OH, USA 13 Vol.:(0123456789) Clinical Research in Cardiology Table 1  Univatiate and multivariate analysis of predictors of very low-risk of 24-h cardiac events and 30-day cardiac death following primary percutaneous coronary intervention Clinical and procedural predictors No complica- Complication (n = 144) p Early complica- p 30-day cardiac p tion (n = 1348) tion* [OR, 95% death [OR, 95% CI] CI] Age ≤ 75 year old 1074 (80) 88 (61) < 0.01 0.56 [0.37–0.84] < 0.01 0.10 [0.04–0.20] < 0.01 Female gender 296 (22) 41 (29) 010 Diabetes mellitus 328 (24) 44 (31) 0.12 Previous vascular disease (any) 274 (20) 43 (30) 0.01 Anterior myocardial infarction 546 (41) 75 (52) 0.01 Killip class I at presentation 1179 (88) 59 (41) < 0.01 0.14 [0.10–0.22] < 0.01 0.12 [0.06–0.26] < 0.01 No arrhythmia first a­ ssistance† 180 (13) 59 (41) < 0.01 0.32 [0.21–0.21] < 0.01 0.36 [0.17–0.76] < 0.01 Radial access 1320 (98) 125 (87) < 0.01 0.50 [0.24–1.04] 0.06 0.18 [0.07–0.46] < 0.01 No three vessel/LM disease 283 (21) 46 (32) < 0.01 0.85 [0.56–1.30] 0.40 0.51 [0.25–1.00] 0.05 Stent implanted 1321 (98) 144 (100) 0.20 Successful angioplasty-stenting‡ 1263 (94) 121 (84) < 0.01 0.42 [0.10–0.21] < 0.01 0.16 [0.07–0.37] < 0.01 Complete revascularization 519 (39) 46 (32) 0.16 Reperfusion time (minutes) 191 (130–309) 181 (129–299) 0.60 IIb/IIIa inhibitors use 547 (41) 50 (34) 0.36 Dual antiplatelet load 1348 (100) 144 (100) NA Baseline oral anticoagulation 44 (3) 12 (8) 0.02 ICU cardiac predictors** LVEF < 40% 1166 (86) 77 (54) < 0.001 NA NA Creatinin clearance (ml/min) 92 (42) 68 (38) < 0.001 NA NA Values presented as n (%) or mean (SD) or median (Q1–Q3) ICU intensive care unit, NA not assessed, LM left main, LVEF left ventricular ejection fraction *Including 24-h cardiac death, malignant arrhythmias, severe heart failure, stent thrombosis/re-acute myocardial infarction **Intensive Care Unit predictors were not included in the multivariate analysis † Including atrial or ventricular fibrillation, ventricular tachycardia, A-V block or asystole appeared until the end of primary percutaneous coro- nary intervention procedure ‡ Defined as final TIMI 3 flow without major procedural complications due to stent thrombosis, one with concomitant ventricular This is the first study to focus on predictors of very low- fibrillation (specificity = 0.95, p < 0.01). No 30-day cardiac risk of complications following STEMI in the pPCI reperfu- deaths were recorded in the very low-risk group (specific- sion era. We found that younger patients with uncomplicated ity = 1, p < 0.01). STEMI without complex coronary anatomy are highly likely In the validation cohort, 78 of 693 (11.3%) patients had to remain uncomplicated providing the infarct related artery a 24-h-cardiac event (16 of them stent thrombosis); 17 is successfully opened via transradial pPCI. Importantly, the (2.5%) suffered a 30-day cardiac death; and 369 (53%) identified variables may be easily recorded upon completion met criteria of very-low risk. In the very-low risk group, of the pPCI procedure. Proper identification of such very ten patients (2.7%) had a 24-h-cardiac event, nine due to low-risk patients should improve current post-procedural stent thrombosis, (one with concomitant ventricular fibril- decision-making algorithms, including very early (within lation) and one due to heart failure (patient with active 6 h) patient transfer from the intensive care to a conventional hemolytic anemia complicated with systemic inflamma- ward, thus optimizing intensive care resources for other life- tory syndrome) (specificity = 0.88, p < 0.01). No 30-day threatening pathologies. cardiac deaths were recorded in the very low-risk group Stent thrombosis is always concerning, and in this very- (specificity = 1, p < 0.01). low risk stratification model, it was the least accurate event The 6-h ICU cut-point analysis performed in the very- to predict; nevertheless, stent thrombosis usually manifests low risk group only revealed one stent thrombosis event early post-pPCI. Indeed, only one patient presented stent beyond the 6 h (0.9 ‰), without other complications thrombosis beyond 6 h after ICU admission. These data (specificity ≈ 1, p < 0.01). should be interpreted in the context of a regional pPCI rep- erfusion network that includes a high percentage of radial 13 Clinical Research in Cardiology access and stenting, and short reperfusion delay [2]. Never- with primary angioplasty: implications for early discharge. Cir- theless, pending confirmation in larger prospective studies, culation 109:2737–2743 4. Abdi S, Salarifar M, Mortazavi SH et al (2020) COVID-19 sends an early discharge strategy from the ICU within 6 h post- STEMI to quarantine!? Clin Res Cardiol. https​://doi.org/10.1007/ successful pPCI may be a reasonably safe option in almost s0039​2-020-01664​-3(Epub ahead of print) half of STEMI patients. 5. Grasselli G, Pesenti A, Cecconi M (2020) Critical case utilization for the COVID-19 outbreak in Lombardy, Italy. 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