Baseline ECG Outperforms the Angiogram for Predicting Mortality in COVID-19–Associated STEMI: Insights From the NACMI Registry

<h2>Abstract</h2><h3>Background</h3> Patients with COVID-19 continue to present with ST-elevation myocardial infarction (STEMI). To date, there have been no core laboratory electrocardiogram (ECG) description of these patients. Accordingly, we aimed to evaluate the ECG characteristics and coronary angiograms of patients hospitalized with COVID-19–associated STEMI. <h3>Methods</h3> In a prespecified analysis from the North American COVID-19 Myocardial Infarction (NACMI) registry, we collected baseline STEMI ECGs in COVID-19–positive patients for core laboratory interpretation (Canadian VIGOUR Centre, Edmonton, Canada), including ST-segment analysis, worst lead ST-elevation (ST-E), sum ST-elevation (ΣST-E), and sum ST deviation (ΣST-D). Available core laboratory angiograms (Cardiovascular Imaging Research Core Laboratory, Vancouver, Canada) were also collected. ECG and angiographic variables associated with in-hospital death were analyzed. <h3>Results</h3> Of the 392 patients, 28.1% died in-hospital. Greater median ST-E (deviation) was observed in those who died (ST-E: 2.20 vs 1.65 mm; <i>P</i> = .006; ΣST-E: 7 vs 5 mm; <i>P</i> = .005; ΣST-D: 11 vs 9 mm; <i>P</i> = .013, respectively). Following adjustment for clinical characteristics, ΣST-D was a positive predictor of in-hospital death (relative risk [RR], 1.03; 95% CI, 1.01-1.05; <i>P</i> = .003). In 173 patients with available coronary angiograms, 32% of the baseline ECGs could not define infarct location (19% with angiography). Following adjustment, only ECG characteristics were independent predictors of in-hospital mortality (ST-E: RR, 1.14; 95% CI, 1.04-1.22; ΣST-E: RR, 1.03; 95% CI. 1.01-1.05: ΣST-D: RR, 1.03; 95% CI, 1.01-1.05). <h3>Conclusions</h3> In COVID-19–positive patients with STEMI, ST-E (deviation) is a predictor of in-hospital mortality and likely reflects microthrombi in multiple territories compromising myocardial perfusion. Our data support ECG as a simple tool to help risk stratify patients with COVID-19–associated STEMI.