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Association Between COVID-19 Diagnosis and In-Hospital Mortality in Patients Hospitalized With ST-Segment Elevation Myocardial Infarction

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Key Points

Question  In patients with ST-segment elevation myocardial infarction (STEMI), is a concomitant diagnosis of COVID-19 associated with differences in clinical outcome?

Findings  In this retrospective cohort study that included 80 449 patients, the rates of in-hospital mortality for patients with vs without a concomitant diagnosis of COVID-19 were 15.2% vs 11.2% among those with out-of-hospital STEMI and 78.5% vs 46.1% among those with in-hospital STEMI; both differences were statistically significant.

Meaning  Among patients with STEMI, a concomitant diagnosis of COVID-19 was associated with significantly higher rates of in-hospital mortality.


Importance  There has been limited research on patients with ST-segment elevation myocardial infarction (STEMI) and COVID-19.

Objective  To compare characteristics, treatment, and outcomes of patients with STEMI with vs without COVID-19 infection.

Design, Setting, and Participants  Retrospective cohort study of consecutive adult patients admitted between January 2019 and December 2020 (end of follow-up in January 2021) with out-of-hospital or in-hospital STEMI at 509 US centers in the Vizient Clinical Database (N = 80 449).

Exposures  Active COVID-19 infection present during the same encounter.

Main Outcomes and Measures  The primary outcome was in-hospital mortality. Patients were propensity matched on the likelihood of COVID-19 diagnosis. In the main analysis, patients with COVID-19 were compared with those without COVID-19 during the previous calendar year.

Results  The out-of-hospital STEMI group included 76 434 patients (551 with COVID-19 vs 2755 without COVID-19 after matching) from 370 centers (64.1% aged 51-74 years; 70.3% men). The in-hospital STEMI group included 4015 patients (252 with COVID-19 vs 756 without COVID-19 after matching) from 353 centers (58.3% aged 51-74 years; 60.7% men). In patients with out-of-hospital STEMI, there was no significant difference in the likelihood of undergoing primary percutaneous coronary intervention by COVID-19 status; patients with in-hospital STEMI and COVID-19 were significantly less likely to undergo invasive diagnostic or therapeutic coronary procedures than those without COVID-19. Among patients with out-of-hospital STEMI and COVID-19 vs out-of-hospital STEMI without COVID-19, the rates of in-hospital mortality were 15.2% vs 11.2% (absolute difference, 4.1% [95% CI, 1.1%-7.0%]; P = .007). Among patients with in-hospital STEMI and COVID-19 vs in-hospital STEMI without COVID-19, the rates of in-hospital mortality were 78.5% vs 46.1% (absolute difference, 32.4% [95% CI, 29.0%-35.9%]; P < .001).

Conclusions and Relevance  Among patients with out-of-hospital or in-hospital STEMI, a concomitant diagnosis of COVID-19 was significantly associated with higher rates of in-hospital mortality compared with patients without a diagnosis of COVID-19 from the past year. Further research is required to understand the potential mechanisms underlying this association.

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Article Information

Corresponding Author: Herbert D. Aronow, MD, MPH, Division of Cardiology, Warren Alpert Medical School of Brown University, Lifespan Cardiovascular Institute, 593 Eddy St, RIH APC 730, Providence, RI 02903 (

Accepted for Publication: October 4, 2021.

Published Online: October 29, 2021. doi:10.1001/jama.2021.18890

Author Contributions: Dr Aronow had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Saad, Louis, Aronow.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Saad, Louis, Aronow.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Saad, Kennedy, Shippey, Aronow.

Administrative, technical, or material support: Poppas, Wood, Aronow.

Supervision: Louis, Aronow.

Conflict of Interest Disclosures: Dr Poppas reported being a board member/officer of the American College of Cardiology, being a guest editor-in-chief of the Journal of the American College of Cardiology, receiving royalties from UpToDate as a contributor, and receiving royalties as co-editor of Hurst's The Heart. Dr Abbott reported receiving institutional grants from AstraZeneca and Abbott and personal fees for consulting from Boston Scientific, Philips, and Medtronic for consulting outside the submitted work. Dr Aronow reported receiving personal fees from Philips and Silk Road Medical for consulting outside the submitted work. No other disclosures were reported.

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