Myocardial Infarction in Patients with and Without Covid-19: Comparison of Characteristics, Clinical Course and Outcome

doi:10.21203/rs.3.rs-694225/v1

Background

Covid-19 has quickly become a global health emergency. This infection can cause damage to various organs. Injury to myocardial cells is one of the most important manifestations of Covid-19. The clinical course and outcome of Acute Coronary Syndrome (ACS) are influenced by a variety of factors, including comorbidities and concomitant diseases. One of these acute concomitant diseases is Covid-19 which can affect the clinical course and outcome of acute Myocardial Infarction (MI).

Methods

In this cross-sectional study, the clinical course and outcome of MI and some of its effective factors in patients with and without Covid-19 were compared. 180 patients (129 males and 51 females) with the diagnosis of acute MI were included in the study. 80 patients of them had Covid-19 infection at the same time.

Results

Increase rate in creatinine, arrhythmia, and need for CPR (cardiopulmonary resuscitation) was significantly higher in the Covid-19 group (p value in all three cases < 0.001). Although decline in left ventricular EF (Ejection Fraction) was similar in both groups, the incidence of death was significantly higher in the Covid-19 group.

Conclusions

Based on this information, it appears that patients with ACS who are co-infected with Covid-19 infection need more essential care.

Cardiac & Cardiovascular Systems

Cardiothoracic Surgery

Myocardial infarction

Covid-19

Arrhythmia

Pneumonia

Myocardial injury

SARS-CoV-2

Covid-19 pneumonia started in December 2019 and quickly became a pandemic. Covid-19 not only affects the lungs, but also it causes damage to various organs of the body, especially the cardiovascular system. Covid-19 shows its effects through various mechanisms like cytokines, inflammatory and thrombogenic factors (1–3). Coronary heart disease is one of the most common causes of disability and death in the world (4). Acute MI is a cardiovascular emergency that has different types, with elevated ST segment and without elevated ST segment.

Unfortunately, Covid-19 is a highly contagious pneumonia that affects the diagnosis and treatment of patients with MI significantly (5). Studies in Europe and the United States have shown that the hospital admissions to the cause of ACS and cardiac interventions has decreased more than 50%. This can be justified by various reasons, and one of the reasons is fear of being in an infected environment (6).

Coronary heart disease can exacerbate the clinical course and outcome of Covid-19 patients (7). The coexistence of these two acute diseases can affect the outcome of MI in several ways like: delay in referral due to fear of Covid-19 infection, delay in diagnosis due to similarity of symptoms and laboratory findings, especially symptoms such as shortness of breath, chest pain, positive troponin and ECG changes can be seen in both (8–10). So because of all reasons above, we conducted this research.

Recent studies indicate that although the greatest emphasis in Covid-19 disease is on pulmonary complications, physicians need to be aware of the cardiovascular complications too (11).

MI with Covid-19 increases in-hospital mortality, so faster identification of these patients seems necessary (12).

The aim of this article was evaluation of the prevalence, clinical manifestations, angiographic results and outcome of MI with elevated and non-elevated ST segment in two groups with Covid-19 and without Covid-19 in patients referred to Imam Hossein Shahroud Medical Center.

Study design and participants

This cross-sectional study was performed on 180 patients admitted to the ICU of Covid-19 and the Coronary Care Unit (CCU) of Imam Hossein Hospital in Shahroud. They were admitted and treated with a definitive diagnosis of MI with or without acute Covid-19 infection. These patients were admitted from the beginning of the Covid-19 crisis until January 2021.

In this study, the criterion for Covid-19 was the presence of a positive PCR test with the Covid-19 pattern on the patient's lung CT scan. Criteria for MI were also associated with clinically relevant symptoms and serum positive troponin, with the diagnosis on ECG. It should be noted that this center has been able to perform P-PCI all day and night.

The diagnosis was made: 1-At the time that patients had symptoms of both diseases at the time of admission to the emergency department. 2-Other symptoms became more pronounced during hospitalization for one of these syndromes. The second disease was confirmed after hospitalization.

MI patients without Covid-19 were admitted to the Coronary Care Unit (CCU) and received treatment based on updated guidelines. P-PCI was possible in CCU. MI patients with Covid-19 were also admitted to the intensive care unit and received treatment for both diseases based on up-to-date guidelines.

In the case of clinical variables; The criterion was the notes of the doctor and the nurse in the file. Laboratory variables have been interpreted according to international standards after receiving from the valid hospital laboratory. ECG and arrhythmia are interpreted and diagnosed by a cardiologist.

Inclusion criteria:

1. The diagnosis of MI has been made according to the criteria of the latest guideline.

2. The diagnosis of Covid-19 is based on the presence of at least one of the following criteria:

A- The detection of novel coronavirus nucleic acid is positive in respiratory or blood specimens by Real-time -PCR,

B- Existence of typical pattern in lung CT scan for Covid-19 pneumonia

3- The patient has arrived at the hospital in less than 14 days from the onset of symptoms.

Patients do not have multiple and advanced comorbidities.

Exclusion criteria:

1- Existence of multiple advanced comorbidities.

2- Incomplete file.

3- Acute phase of inflammatory diseases.

Findings were entered into the software and analyzed using Chi-square, t-test and regression tests and the results were interpreted based on significance value (p < 0.05).

Data Collection:

All clinical information was extracted from patients' records and Covid-19 information registration system.

Statistical analysis:

Continuous variables with normal and non-normal distributions were shown based on mean plus and minus standard deviation and median, respectively. Categorical variables are represented by number and percentage. Comparison of continuous variables with normal and non-normal distributions was performed by the Student's t ‐ test and the Mann ‐ Whitney U test, respectively. Categorical variables were compared by chi ‐ squared test or Fisher exact test. Categorical and continuous variables were evaluated for their ability to predict mortality, hospitalization in ICU, intubation, positive troponin rate, cardiac enzyme and CRP in logistic regression model and were evaluated for their ability to predict mean leukocyte, lymphocyte, platelet mean Systolic and diastolic blood pressure, heart rate and respiration rate, arterial blood oxygen saturation in the linear regression model (ANOVA).

A 2‐sided α of less than 0.05 was considered statistically significant. Data were analyzed using SPSS 21.0 for Windows.

180 patients who were admitted and treated with a definitive diagnosis of MI from March 2020 crisis until January 2021 were included in the study. 80 patients also had Covid-19 infection at the same time. Of these patients, 129 subjects (71.7%) were male and 51 subjects (28.3%) were female. The minimum and maximum age of patients was 31 and 94 years in the group with Covid-19 and 40 and 88 years in the group without Covid-19, respectively, but the mean age was 69.44 for the Covid-19 groups and 65.62 for the non-Covid-19 group.

The most important comorbidities in both groups were diabetes mellitus and anemia which had a prevalence of 50.5% and 71.1% totally, respectively, but had a similar frequency in both groups (p value = 1,000). The mean of hemoglobin in the Covid-19 group and without Covid-19 group was 12.20 g/dL vs. 13.26 g/dL (p value = 0.001), respectively, and the mean FBS in these two groups was 134.8 mg/dL vs. 129.3 mg/dL, respectively (p value = 0.500).

Table 1

Demographic characteristics and variables frequency in patients
				Total N(%)	MI with COVID19 N(%)	MI without COVID19 N(%)
Age(year)	Mean			65.62(± 13.86)	69.44(± 13.77)	62.56(± 13.22)
sex	Male			129(71.7)	57(71.25)	72 (72)
sex	Female			51(28.3)	23(28.75)	28 (28)
Comorbidities	Diabetes Mellitus Hx.			91(50.5)	36(45)	55(55)
Comorbidities	Anemia			128(71.1)	62(48.5)	66(51.5)
BMI	Mean			26.40(± 3.50)	26.56(± 3.45)	26.31(± 3.9)
	20-24.9			52(28.9)	19 (23.75)	33 (33)
	25-29.9			101(56.1)	50(62.5)	51(51)
	≥ 30			27(15)	11(13.75)	16 (16)
MI Type	STEMI			75(41.7)	24(30)	51(51)
MI Type	NSTEMI			105(58.3)	56(70)	49(49)
STEMI Location	Anterior			55(73.3)	21(87.5)	34(66.6)
STEMI Location	Inferior			20(26.7)	3 (12.5)	17 (33.4)
MI Course Rrlated Variables	Hgb mean			12.8(± 2.04)	12.20(± 2.33)	13.26±(1.64)
	Serum urea mean			45.19(± 27.92)	55.94(37.26)	36.59(± 11.55)
	WBC	mean		8838.89(± 4625)	10797.50(± 5974)	7272(± 2150)
		Leukocytosis		51(28.3)	41(51.25)	10(10)
		Leukopenia		25(13.9)	12(15)	13(13)
	PLT	mean		232438.9(± 94109.56)	231489(± 83887)	251293.1(± 105293)
		Thrombocytosis		9(5)	5(6.25)	4 (4)
		Thrombocytopenia		19(10.6)	10 (13)	8(8)
	CRP	Positive		71(39.4)	59(83)	12(17)
	CRP	Mean		9.34(±	19.4(± 12.1)	11.2(± 3.2)
	Cr. mean			1.196(± 0.51)	1.359(± 0.70)	1.067(± 0.20)
	ESR mean			22.50(± 2.95)	42.73(± 31)	5.90(± 14.1)
	CAG Results		No CAG	41(22.8)	39(48.75)	2(2)
			Mild CAD	6(3.3)	0[0]	6(4.1)
			Significant Stenosis	133(75.9)	41(100)	92(93.9)
			SVD	52(28.9)	27(65.8)	25(25.5)
			2VD	49(27.2)	7(17)	42(42.8)
			3VD	32(17.8)	7(17)	25(25.5)
	MI related mechanical complication		Acute MR	8(4.4)	5(62.5)	3(37.5)
			P.E.	14(7.7)	10(71.4)	4(28.6)
			HF	133(73.9)	63(47.4)	70(52.6)
	EF		Mean	44.5(± 10.40)	42.38(± 12.72)	46.20(± 9.18)
			> 55	47(26.1)	17(21.25)	30(30)
			< 55	13375.9)	63(78.75)	70(70)
			45–55	69\|(51.9)	29(46)	40(57.1)
			30–45	46(34.6)	22(34.9)	24(34.3)
			< 30	18(13.5)	12(19)	6(8.6)
	MI related Electrical complication		Cardiac Arrhythmia(Total)	71(39.4)	43(53.7)	33(29)
			AF Rhythm	6(8.5)	5(11.6)	1(3)
			LBBB	16(22.5)	8(18.6)	8(24.2)
			RBBB	13(18.3)	8(18.6)	5(15.1)
			AVB G1	14(19.7)	5(11.6)	9(27.2)
			AVB G2	5(7)	2(4.6)	3(9)
			CHB	4(5.6)	3(7)	1(3)
			VT	18(25.3)	12(28)	6(18.2)
	MI related Hemodynamic complication		Tamponade	1(0.6)	1(100)	0
	MI related Hemodynamic complication		Cardiogenic Shock	2(1.2)	1(50)	1(50)
	CPR			15(8.3)	13(86.7)	2(13.3)
	Intubation			13(7.2)	13(100)	0
Outcome Variable	Death(In Hospital Mortality)			15(8.3)	15(100)	0
Cr.=Creatinine; PLT = Platelet; ESR = Erythrocyte Sedimentation Rate; WBC = White blood cell, LYMPH = Lymphocyte, ICU = Intensive care unit, CRP = C-Reactive protein; LBBB: Left Bundle Branch Block; RBBB: Right Bundle Branch Block; AVG G1,2: Atria-Ventricular Block grade1,2; CHB: Complete Heart Block ; VT: Ventricular Tachycardia; EF: Ejection Fraction; P.E.: Pericardial Effusion; HF: Heart Failure; Acute MR: Acute Mitral Regurgitation; CAG: Coronary Angiography; CAD: Coronary Arteries Disease; SVD: Single Vessels Disease; 2VD: Two Vessels Disease; 3VD: three Vessels Disease; STEMI: ST Segment Elevation Myocardial Infarction; NSTEMI: Non ST Segment Elevation Myocardial Infarction; Hgb: Hemoglobin; BMI: Body Mass Index;

Both groups had similar conditions in terms of distribution of BMI status, and the average BMI in the two groups was 26.56 and 26.31, respectively (p value = 0.665). In 41.7% of cases, MI was in the form of STEMI, and in 58.3% of cases was in the form of NSTEMI. This difference in the form of MI was statistically significant (p value = 0.006). Difference between the two groups and the incidence of NSTEMI was more frequent in the group with Covid-19 (70% vs. 49% with p value = 0.006). Anterior and inferior MI was the most common form of involvement in both groups, but anterior MI was significantly more common in the Covid-19 group (p value = 0.005).

The prevalence of Kidney Injury (Creatinine > 1.5 mg) was 16.1% overall, which only 2% of without Covid-19 group had high Creatinine level. Overall, 67% of patients with high serum urea and 93% of patients with high Creatinine were in the group with Covid-19, and this difference between the two groups was statistically significant (for both p value < 0.001). The mean serum urea in with and without Covid-19 group was 55.94 and 36.59, respectively. The mean creatinine was 1.35 and 1.06, respectively.

28.3% of patients (n = 51) had leukocytosis. The incidence of leukocytosis was 51.25% in the group with Covid-19 and 10% in the group without Covid-19). The difference between the two groups was statistically significant (p value < 0.001). 13.9% of patients (n = 25) had leukopenia, the incidence of leukopenia was 15% in the group with Covid-19 and 13% in the group without Covid-19 (p value < 0.001).

Also, in the case of platelets, the prevalence of thrombocytopenia was 10 % (n = 18) in all patients, 13% in the group with Covid-19 and 8% in the group without Covid-19, and this frequency was not statistically significant (p value = 0.329). The mean number of leukocytes in the two groups with and without Covid-19 was 10797 / µl vs. 7272 / µl, respectively, (p value = 0.001), and for platelets 231489 / µl vs. 251293 / µl (p value = 0.239).

The frequency of positive CRP in the two groups with and without Covid-19 was 73.75% vs. 12%, respectively, and for high ESR the frequency was 80% vs. 4% (p value = 0.001 in both cases). The mean CRP in the two groups with and without Covid-19 was 19.4 and 11.2 mg / L, respectively, and for ESR was 42.73 and 5.90 (p value = 0.001).

The incidence of left ventricular failure (LV EF < 55%) in two groups with and without Covid-19 was 78.75 and 70%, respectively (p value = 0.232) which was not statistically significant, but the decline in the rate of left ventricular EF after MI was significantly different in the two groups, and the decline rate in the group with Covid-19 was more. The difference between the mean EF in the two groups (42.38 vs. 46.20) was significant (p value = 0.020). Most patients with decreased EF were in category of mild decreased EF (45% < EF < 55%) (46% in the group with Covid-19 and 57.1% in the group without Covid-19). The rest of the people in each group (almost half of the people) were in the moderate and severe decreased EF categories (EF between 35 and 45 and EF less than 30%), but the distribution was different in the two groups. In the group with Covid-19, a higher percentage was in the category of 30%>EF (19% vs. 8.6% with a p value = 0.003). One-third of the subjects in each group were in 35–45% EF group (moderate) (34.9% in the Covid-19 group versus 34.3% in the Covid-19 group p value = 0.342).

39.4% of patients experienced at least one type of cardiac arrhythmia during hospitalization. The incidence of arrhythmias in general, including all types of arrhythmias in the Covid-19 and without Covid-19 group, was 53.7 versus 29%, respectively (p value = 0.001). The type of arrhythmia was different in the two groups, so that the incidence of AF rhythm, complete atrioventricular block (AVB), monomorphic ventricular tachycardia and complete right bundle branch block were more common in the group with Covid-19, but complete left bundle branch block, atrioventricular blocks except AVB grade 3 were more in the group without Covid-19 and the incidence of other arrhythmias was not significantly different between the two groups (Table 1).

16.25% of patients with Covid-19 needed CPR while this percentage in the other group was 2%, and this difference was statistically significant between the two groups (p value = 0.001). None of the patients in the group without Covid-19 required intubation, while 16.25% of patients in the group with Covid-19 required intubation (p value = 0.001). In the group without Covid-19, no in-hospital death occurred, but 18.75% of the group with Covid-19 died in hospital (p value = 0.001).

Regarding the results of angiography, 48.7% of patients in the group with Covid-19 did not undergo coronary catheterization, while 2% of the patients in the opposite group did not undergo coronary catheterization (p value = 0.001). Of the Covid-19 patients who underwent coronary catheterization, none had mild CAD, and all had significant coronary stenosis (F = 100%), but in the group without Covid-19, 4.1% had mild CAD. Of the patients who had severe coronary stenosis and required interventional revascularization, the most common group was SVD (65.8%) in the group with Covid-19. 2 VD and 3VD had 17% prevalence (SVD Freq > > 2VD = 3VD Freq) (p value = 0.001). In the group without Covid-19, the prevalence of 2VD and 3VD was 42.8% and 25.5%, respectively (2 VD Freq > 3VD = SVD Freq) (p value = 0.001).

Comparing the lipid profiles of the patients in the two groups by t-test, the group with Covid-19 had significantly more abnormal serum lipoproteins. In the group with and without Covid-19, respectively (for serum total cholesterol: means 168.06 and 144.76 and p value = 0.002; for LDL: means 93.82 and 83.25 and p value = 0.020 and for HDL: means are 45.20 and 51.47 with p value = 0.004).

Table 2

Chi-Square test results for variables in both group of MI with and without COVID-19
		MI with COVID19 N(%)	MI without COVID19 N(%)	P Value
Age(year)	30-59.9	17(21.25)	41(41)	0.006
Age(year)	> 60	63(78.75)	59(59)	0.006
sex	Male	57(71.25)	72(72)	1.000
sex	Female	23(28.75)	28(28)	1.000
BMI	20-24.9	19(23.75)	33(33)	0.282
	25-29.9	50(62.5)	51(51)
	≥ 30	11(13.75)	16(16)
MI Type	STEMI	24(30)	51(51)	0.006
MI Type	NSTEMI	56(70)	49(49)	0.006
STEMI Location	Anterior	21(87.50	34(66.6)	0.005
STEMI Location	Inferior	3(12.5)	17(33.4)	0.005
DM	Yes	36(45)	55(55)	1.000
DM	No	44(55)	45(45)	1.000
Anemia	Yes	62(77.5)	66(66)	1.000
Anemia	No	18(22.5)	34(34)	1.000
Hgb	< 14	62(48.4)	66(51.6)	1.000
Hgb	> 14	18(34.6)	34(45.4)	1.000
Serum urea	< 45	47(58.75)	84(84)	< 0.001
Serum urea	> 45	33(41.25)	16(16)	< 0.001
Cr	< 1.5	53(66.25)	98(98)	< 0.001
Cr	> 1.5	27(33.75)	2(2)	< 0.001
WBC	< 5000	12(15)	13(13)	< 0.001
	5000–10000	27(33.75)	77(77)
	> 10000	41(51.25)	10(10)
PLT	< 150000	10(13)	8(8)	0.329
	150000–450000	69(86.25)	83(83)
	> 450000	5(6.25)	4(4)
CRP	Positive	59(73.75)	12(12)	< 0.001
CRP	Negative	19(26.25)	88(88)	< 0.001
ESR	< 20	16(20)	96(96)	< 0.001
ESR	> 20	64(80)	4(4)	< 0.001
HF(EF < 55(	Yes	63(78.75)	70(70)	0.232
HF(EF < 55(	No	17(21.25)	30(30)	0.232
EF(%)	> 55	17(21.25)	30(30)	0.232
EF(%)	< 55	63(78.75)	70(70)	0.232
EF < 55%	45–55	29(46)	40(57.1)	0.044
	30–45	22(34.9)	24(34.3)	0.342
	< 30	12(19)	6(8.6)	0.003
Cariac Arhythmia	No	37(46.3)	77(77)	< 0.001
Cariac Arhythmia	Yes	43(53.7)	33(33)	< 0.001
Acute MR	Yes	5(6.25)	3(3)	< 0.001
Acute MR	No	75(93.75)	97(97)	< 0.001
CPR	Yes	13(16.25)	2(2)	< 0.001
CPR	No	67(83.75)	98(98)	< 0.001
CAG Results	No CAG	39(48.75)	2(2)	< 0.001
	Mild CAD	0[0]	6(4.1)
	Significant Stenosisi	41(100)	92(93.9)
	SVD	27(65.8)	25(25.5)
	2VD	7(17)	42(42.8)
	3VD	7(17)	25(25.5)
Intubation	Yes	13(16.25)	0(0)	< 0.001
Intubation	No	67(83.75)	100(100)	< 0.001
Death	Yes	15(18.75)	0(0)	< 0.001
Death	No	65(81.25)	100(100)	< 0.001
Cr.=Creatinine; PLT = Platelet; ESR = Erythrocyte Sedimentation Rate; WBC = White blood cell, LYMPH = Lymphocyte, ICU = Intensive care unit, CRP = C-Reactive protein; LBBB: Left Bundle Branch Block; RBBB: Right Bundle Branch Block; AVG G1,2: Atria-Ventricular Block grade1,2; CHB: Complete Heart Block ; VT: Ventricular Tachycardia; EF: Ejection Fraction; P.E.: Pericardial Effusion; HF: Heart Failure; Acute MR: Acute Mitral Regurgitation; CAG: Coronary Angiography; CAD: Coronary Arteries Disease; SVD: Single Vessels Disease; 2VD: Two Vessels Disease; 3VD: three Vessels Disease; STEMI: ST Segment Elevation Myocardial Infarction; NSTEMI: Non ST Segment Elevation Myocardial Infarction; Hgb: Hemoglobin; BMI: Body Mass Index;; Death: In Hospital Mortality.

Table 3

Student’s T-tast results for effect of COVID infection on some continuous numerical variables
	MI with COVID19 N = 80	MI without COVID19 N = 100	P Value
Age mean	69.44(± 13.77)	62.56(± 13.22)	0.001
BMI mean	26.56(± 3.45)	26.31(± 3.9)	0.665
Hgb mean	12.20(± 2.33)	13.26±(1.64)	0.001
FBS mean	134.8(± 70.15)	129.3(± 56.97)	0.500
WBC mean	10797.50(± 5974)	7272(± 2150)	0.001
PLT mean	231489(± 83887)	251293.1(± 105293)	0.239
Serum urea mean	55.94(37.26)	36.59(± 11.55)	0.001
Cr. mean	1.359(± 0.70)	1.067(± 0.20)	0.001
EF mean	42.38(± 12.72)	46.20(± 9.18)	0.020
ESR mean	42.73(± 31)	5.90(± 14.1)	0.001
CRP mean	19.4(± 12.1)	11.2(± 3.2)	0.001
TG mean	104.06(± 50.33)	117.65(± 45.18)	0.058
T.C mean	168.06(± 57.34)	144.76(± 38.67)	0.002
LDL mean	93.82(± 28.35)	83.25(± 32.00)	0.020
HDL mean	45.20(± 11.63)	51.47(± 16.06)	0.004
Cr.=Creatinine; PLT = Platelet; ESR = Erythrocyte Sedimentation Rate; WBC = White blood cell, LYMPH = Lymphocyte, ICU = Intensive care unit, CRP = C-Reactive protein; LBBB: Left Bundle Branch Block; RBBB: Right Bundle Branch Block; AVG G1,2: Atria-Ventricular Block grade1,2; CHB: Complete Heart Block ; VT: Ventricular Tachycardia; EF: Ejection Fraction; P.E.: Pericardial Effusion; HF: Heart Failure; Acute MR: Acute Mitral Regurgitation; CAG: Coronary Angiography; CAD: Coronary Arteries Disease; SVD: Single Vessels Disease; 2VD: Two Vessels Disease; 3VD: three Vessels Disease; STEMI: ST Segment Elevation Myocardial Infarction; NSTEMI: Non ST Segment Elevation Myocardial Infarction; Hgb: Hemoglobin; BMI: Body Mass Index; TG: Triglyceride; TC: Total Cholesterol; LDL: Low Density Lipoprotein; HDL: High Density Lipoprotein;

In order to adjust the confounding variables such as diabetes, BMI, age, sex and occupation in the logistic regression model, the above-mentioned variables were compared in two groups of MI patients with and without Covid-19 (Tables 4 and 5). Based on the results of the logistics test, Covid-19 was significantly predictive for: NSTEMI in comparison with STEMI (Odd ratio = 2.429, P value = 0,004), for anterior STEMI (Odd ratio = 4.361, P value = 0.045), for uremia (Odd ratio = 3.686, p value < 0.001), for kidney damage (Odd ratio = 24.962, P value < 0.001), for leukocytosis (Odd ratio = 11.693, P value < 0.001), Positive CRP (Odd ratio = 3.876, P value = 0.002), increased ESR (Odd ratio = 82.667, P value < 0.001), incidence of arrhythmia (Odd ratio = 2.988, P value < 0.001), acute mitral regurgitation (Odd ratio = 9.250, p value < 0.001), need for intubation (Odd ratio = 24.111, P value < 0.001), need for CPR (Odd ratio = 9.507, P value = 0.004) and in-hospital death (Odd ratio = 2.899, P value = 0.006).

In coronary angiography, the incidence of coronary artery disease with mild stenosis (Mild CAD) was significantly lower in Covid-19 patients, in other words, most stenoses in this group were severe (Odd ratio = 0.154 P value < 0.001).

Regarding the angiographic results in this model, the simultaneous presence of Covid-19 with less incidence of mild CAD, 2VD and 3VD in coronary angiography (Odd ratios = 0.154, 0.259, 0.123 and P value = <0.001, 0.008, 0.009, respectively) and more incidence of SVD (Odd ratio = 18.056 and P value = 0.782) was associated.

In the logistic model, a more diverse disturbance in the lipid profile of patients with MI was observed simultaneously with Covid-19: especially decrease in HDL (Odd ratio = 0.603 and P value = 0.095) and increase in LDL (Odd ratio = 1.883 and P value = 0.032) and total cholesterol (Odd ratio = 0.316 and P value = 0.008).

Table 4

Logistic Regression analysis results for effect of COVID19 infection on predictive categorical variables of MI course and outcome after control effect of DM, Sex,Age, Anemia and Job
Variable For COVID Positive group		Beta coefficient	Odd Ratio (CI95%)	P Value
MI Type	STEMI	0.887	0.412(0.222–0.764	0.005
MI Type	NSTEMI	0.754	2.429(1.309–4.507)	0.004
STEMI Location	Anterior	1.143	4.361(2.789–8.432)	0.045
STEMI Location	Inferior	0.657	0.768(0.325–0.975)	0.014
Anemia	(Hgb < 14)	-0.573	0.564(0.289–1.099)	0.093
Uremia	Serum urea > 45	1.305	3.686(1.838–7.391)	< 0.001
Kidney Injury	Cr > 1.5	3.217	24.962(5.713-109.076)	< 0.001
Leukocyte change	Leukocytotsis(WBC > 10000)	2.459	11.693(5.901–34.267)	< 0.001
Leukocyte change	Leukopenia(WBC < 5000)	0.968	2.632(0.654–4.024)	0.035
PLT Change	Thrombocytosis(PLT > 450000)	1.125	3.080(0.580-16.365)	0.580
PLT Change	Thrombocytopenia(PLT < 150000)	-0.565	0.569(0.205–1.574)	0.277
CRP	Positive	4.235	3.876(1.348–8.758)	0.002
ESR	Increased(> 20)	4.415	82.667(26.718-255.778)	< 0.001
HF	(EF < 55%)	-0.463	0.630(0.317–1.250)	0.186
Cardiac Arrhythmia		1.095	2.988(1.609–5.552)	< 0.001
CPR Positive		2.252	9.507(2.078–43.504)	0.004
New Acute MR		2.225	9.250(4.159–20.571)	< 0.001
Intubation		21.603	24.111(13.198–56.345)	0.008
Death(In Hospital Mortality)		3.234	2.899(2.089–5.865)	0.006
CAG Result	No CAG	3.567	1.345(1.112–4.567)	0.033
	Mild CAD	-1.869	0.154(059-0.406)	< 0.001
	Significant Stenosis	-4.622	0.010(0.002–0.045)	< 0.001
	SVD	2.893	18.056(3.943–82.683)	0.782
	2VD	-1.350	0.259(0.095–0.406)	0.008
	3VD	-21.281	0.123(0.000-0.569)	0.009
High TC	TC > 200mg/dl	-1.151	0.316(0.134–0.745)	0.008
Low HDL	HDL < 45mg.dl	-0.506	0.603(0.041–0.866)	0.095
High LDL	LDL > 130mg/dl	-1.671	1.883(0.333–1.092	0.032
Cr.=Creatinine; PLT = Platelet; ESR = Erythrocyte Sedimentation Rate; WBC = White blood cell, LYMPH = Lymphocyte, ICU = Intensive care unit, CRP = C-Reactive protein; LBBB: Left Bundle Branch Block; RBBB: Right Bundle Branch Block; AVG G1,2: Atria-Ventricular Block grade1,2; CHB: Complete Heart Block ; VT: Ventricular Tachycardia; EF: Ejection Fraction; P.E.: Pericardial Effusion; HF: Heart Failure; Acute MR: Acute Mitral Regurgitation; CAG: Coronary Angiography; CAD: Coronary Arteries Disease; SVD: Single Vessels Disease; 2VD: Two Vessels Disease; 3VD: three Vessels Disease; STEMI: ST Segment Elevation Myocardial Infarction; NSTEMI: Non ST Segment Elevation Myocardial Infarction; Hgb: Hemoglobin; BMI: Body Mass Index; TG: Triglyceride; TC: Total Cholesterol; LDL: Low Density Lipoprotein; HDL: High Density Lipoprotein;

In general, according to the results of this study, the association of Covid-19 with acute MI increases the incidence of electrical and mechanical complications and predicts a worse clinical course of the disease with the need for intubation, CPR and in-hospital death. However, some confounding factors such as BMI did not differ significantly between the two groups, and others such as age, sex, occupation and diabetes when adjusted by the regression model, previous results were confirmed.

Studies have shown that cardiovascular disease increases the risk of severe clinical course in patients with Covid-19 (7). The clinical course and outcome of acute MI are also influenced by acute and chronic comorbidities (13).

The findings confirm that Covid-19 is more common at older ages although younger ages are not safe from Covid-19. These findings are consistent with another study (5), and the age range for MI may be changed if Covid-19 develops in patients.

Two models of MI do not have a good prognosis due to poor arteries and multiple stenoses (in NSTEMI) and due to the lack of adequate collaterals (in SVD)(13–15). LAD was the most involved vessel in the Covid-19 patients with STEMI which may explain the more decrease in EF in them after MI.

Injury to the patient's vital organs, including the kidney, is one of the causes of worsening prognosis in patients with ACS. Covid-19 increases the frequency of their occurrence simultaneously, so Covid-19 affects the prognosis of MI (8, 13). The prevalence of kidney injury (creatinine above 1.5 mg) was 16.1% which only 2% of them were in the group without Covid-19.

Leukocytosis, thrombocytopenia and even thrombocytosis can directly and indirectly affect the clinical course and acute MI in Covid-19 patients. They affect along with the rise of acute phase reactants including CRP are common findings (6). We clearly found these findings to be more common in patients with Covid-19 at the same time.

A combination of following factors causes the myocardial ischemia and necrosis and to be more prepared to develop arrhythmias: the more common LAD involvement, greater EF decline, the presence of severe inflammatory factors and cytokines in Covid-19 patients. 83% of AF cases and 66% of ventricular tachycardia cases were seen in the Covid-19 group.

All the above factors caused 16.25% of MI patients with Covid-19 to need CPR while this percentage was 2% in the second group. 16.25% of patients in the group with Covid-19 required intubation while no patient in without Covid-19 group did not require intubation.

In-hospital death was more frequent in Covid-19 group. This situation was similar in other articles (5).

48.75% of patients in the group with Covid-19 did not undergo coronary catheterization, while only 2% of the opposite group did not undergo the coronary catheterization. These are the reasons that overshadowed the rate of early angiography in these patients, especially in the early onset of pandemic: risk of transfer to the treatment team, sometimes unfavorable physical statue, electrolyte and coagulation conditions. They can be important factors in increasing patient mortality rate (6). All patients with Covid-19 and MI had significant coronary stenosis on angiography, mainly in one coronary artery. This finding could suggest a greater role for acute embolic events in MI compared with atherosclerosis.

Temporary abnormalities in the lipid profile of patients with acute MI are known. this disorder was particularly pronounced in the reduction of HDL and the increase in LDL in the Covid-19 group. This increase can be secondary to cytokine storm and as a cause for activation of iatrogenic mechanisms.

According to the results of the present study, co-infection with Covid-19 in patients with acute MI increases the incidence of electrical and mechanical complications. It predicts a worse clinical course of the disease with the need for intubation, CPR and in-hospital death. The following pathogenic mechanisms of Covid-19 are effective in creating these conditions: an increase in cytokines, activation of inflammatory and thrombogenic processes, and disturbance of water and electrolyte balance, along with worse demographic conditions in patients. This worse conditions will lead to higher in-hospital deaths and more severe morbidity in patients with acute MI.

According to the findings of this study, co-infection with Covid-19 in patients with acute MI worsens the clinical course and outcome of this ACS. Although the results of this study are consistent with previous studies, more studies with higher sample sizes are recommended due to the limited number of studies.

ACS

Acute Coronary Syndrome

CCU

Coronary Care Unit

CPR

cardiopulmonary resuscitation

CRP

C-Reactive Protein

EF

Ejection Fraction

FBS

Fast Blood Sugar

ICU

Intensive Care Unit

P-PCI

Primary Percutaneous Coronary Intervention

MI

myocardial infarction

NTEMI

Non ST Elevation MI

STEMI

ST Elevation MI

Ethics approval and consent to participate

Research Committee of Shahroud University of Medical Sciences has approved this study (grant number: 98126). The informed consent obtained from study participants was written and signed by participants. The protocol was performed in accordance with the Declaration of Helsinki.

Consent for publication

Not applicable

Availability of data and materials

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

No fund was taken.

Authors' contributions

SH wrote main text and took responsibility for the integrity of the content of the manuscript, SS collected data from patients and laboratory as a nurse, JM and GM wrote the other part of manuscript and edited text carefully, DS analysed all data of the manuscript. All authors read and approved the final manuscript.

Acknowledgement

We thank all front-line physicians and health care worker

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No competing interests reported.

Myocardial Infarction in Patients with and Without Covid-19: Comparison of Characteristics, Clinical Course and Outcome

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Abstract

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