Persistent One-Year Mortality Gradient After STEMI and COVID-19: Long-Term Outcomes From the NACMI Registry

Background Patients with COVID-19 and ST-elevation myocardial infarction (STEMI) from the North American COVID-19 Myocardial Infarction (NACMI) registry had elevated in-hospital mortality compared with COVID-19-negative patients and historical controls. We examined 1-year mortality outcomes from the NACMI registry. Methods This was a substudy of NACMI centers that participated in long-term follow-up. Patients in the NACMI registry were stratified into COVID-19-positive and COVID-19-negative groups. A historical 2018-2019 control group was derived from the Midwest STEMI Consortium registry. The primary outcome was 1-year mortality. Results A total of 2358 STEMI patients (30% female) were included in this study, divided into 3 subgroups: COVID-19-positive (n = 623), COVID-19-negative (n = 694), and historical controls (n = 1041). One-year mortality in COVID-19-positive patients was 45% (HR, 4.88; 95% CI, 3.73-6.39; P < .001), compared with 27% (HR, 3.93; 95% CI, 2.92-5.29; P < .001) in COVID-19-negative patients and 11% in matched controls ( P < .001). Most deaths (86%) occurred during the index hospitalization, with a median time to death of 27 days (IQR 6, 343) in the COVID-19-positive group. Among survivors of index hospitalization, 1-year mortality was 12% (COVID-19-positive; HR, 2.20; 95% CI, 1.26-3.85; P = .006), 9.6% (COVID-19-negative; HR, 2.31; 95% CI, 1.26-4.21; P = .007), and 5.3% (controls) ( P < .001). Conclusions This study describes long-term outcomes in patients with STEMI and COVID-19. We demonstrate that the excess mortality risk associated with COVID-19 STEMI extends beyond the index hospitalization and exhibits a clear risk gradient. The cause is likely multifactorial, including pandemic-era disruptions in care, longer time-to-treatment, and the unique pathophysiology of COVID-19 STEMI.