Effect of the COVID-19 Pandemic on ST-Segment–Elevation Myocardial Infarction Presentations and In-Hospital Outcomes
2020; Lippincott Williams & Wilkins; Volume: 13; Issue: 7 Linguagem: Inglês
10.1161/circinterventions.120.009438
ISSN1941-7632
AutoresSimon Wilson, Michelle Connolly, Ziyad Elghamry, Claudia Cosgrove, Sami Firoozi, Pitt Lim, Rajan Sharma, James C. Spratt,
Tópico(s)Acute Myocardial Infarction Research
ResumoHomeCirculation: Cardiovascular InterventionsVol. 13, No. 7Effect of the COVID-19 Pandemic on ST-Segment–Elevation Myocardial Infarction Presentations and In-Hospital Outcomes Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBEffect of the COVID-19 Pandemic on ST-Segment–Elevation Myocardial Infarction Presentations and In-Hospital Outcomes Simon J. Wilson, Michelle J. Connolly, Ziyad Elghamry, Claudia Cosgrove, Sami Firoozi, Pitt Lim, Rajan Sharma and James C. Spratt Simon J. WilsonSimon J. Wilson Correspondence to: Simon J. Wilson, MBCHB, Cardiovascular Department, St. George's Hospitals and University Foundation NHS Trust, London, United Kingdom. Email E-mail Address: [email protected] https://orcid.org/0000-0002-1999-5103 Department of Cardiology, St. George's University Foundation Hospitals NHS Trust, London, United Kingdom. , Michelle J. ConnollyMichelle J. Connolly Department of Cardiology, St. George's University Foundation Hospitals NHS Trust, London, United Kingdom. , Ziyad ElghamryZiyad Elghamry Department of Cardiology, St. George's University Foundation Hospitals NHS Trust, London, United Kingdom. , Claudia CosgroveClaudia Cosgrove Department of Cardiology, St. George's University Foundation Hospitals NHS Trust, London, United Kingdom. , Sami FirooziSami Firoozi Department of Cardiology, St. George's University Foundation Hospitals NHS Trust, London, United Kingdom. , Pitt LimPitt Lim Department of Cardiology, St. George's University Foundation Hospitals NHS Trust, London, United Kingdom. , Rajan SharmaRajan Sharma Department of Cardiology, St. George's University Foundation Hospitals NHS Trust, London, United Kingdom. and James C. SprattJames C. Spratt Department of Cardiology, St. George's University Foundation Hospitals NHS Trust, London, United Kingdom. Originally published30 Jun 2020https://doi.org/10.1161/CIRCINTERVENTIONS.120.009438Circulation: Cardiovascular Interventions. 2020;13:e009438Preliminary reports suggest there has been a marked reduction in the number of patients presenting with acute ST-segment–elevation myocardial infarction (STEMI) during the coronavirus disease 2019 (COVID-19) pandemic.1–3 However, the available data are limited. Moreover, it remains to be determined what effect COVID-19 has had on STEMI in-hospital outcomes. Here we report changes in presentation and prognostic markers in patients admitted to our institution with STEMI following the outbreak of COVID-19.Index admission data were collected on all patients referred for primary percutaneous coronary intervention (PPCI) to our tertiary cardiac center between February 19 and April 14 for the past 4 consecutive years. The COVID-19 era was defined as March 18, 2020, onward, corresponding to the introduction of restrictions of movement and a public health drive to combat rising cases in the United Kingdom. Poisson regression modeling was used to estimate the impact of COVID-19 on weekly number of PPCI referrals, cardiac catherization laboratory (cath-lab) activations, and true STEMI numbers adjusting for calendar week and year. To further investigate the impact on in-hospital survival, the observed-to-predicted mortality ratio was determined using the US National Cardiovascular Data Registry risk calculator. Effect on time to call for help from symptom onset (early, 12 hours), in-hospital mortality, percentage of PPCI referrals resulting in cath-lab activation, and percentage of cath-lab activations resulting in STEMI diagnosis were assessed by the χ2 test. Mean difference in index admission echocardiogram-derived quantitatively determined left ventricular ejection fraction was examined by an unpaired t test. A two-sided P of <0.05 was considered statistically significant. All calculations were performed using the statistical package R (www.R-project.org). The study was conducted in accordance with local ethic guidelines with all procedures undertaken as part of standard care and informed consent provided. The data, analytical methods, and study materials will be made available upon reasonable request.Across the 8-week window, the total number of PPCI referrals, cath-lab activations, and STEMI presentations were 952, 441, and 388, respectively. Compared with before COVID-19, incidence rate ratios showed weekly PPCI referrals in the COVID-19 era decreased by a factor of 42.8% ([95% CI, 23.7%–57.6%]; P<0.001), cath-lab activations by 53.1% ([95% CI, 27.7%–70.1%]; P 0.2 for all).Recent data from the United States have suggested a major decline in STEMI activations during the early phase of COVID-19.1 However, it is unclear whether this reflected a true reduction in STEMI presentations or a decrease in inappropriate referrals/cath-lab activations. Coincident with a rise in COVID-19 in the United Kingdom and the introduction of social distancing measures, we observed a fall of ≈50% in both cath-lab activations and STEMI admissions. Comparing the COVID-19 era to historic data, there was no change in the relative number of inappropriate PPCI referrals or false cath-lab activations. Thus, our data indicate the occurrence of a true decline in STEMI presentations with a similar fall in STEMI numbers reported in Europe.2Besides a reduction in STEMI admissions, we observed a striking change in presentation and prognostic indicators. Time to call for help lengthened considerably with more than a 3-fold increase in the number of patients presenting late. This is in line with evidence that falls in STEMI admission are being driven, at least in part, by behavior change.4 The impact of this delay to presentation is a major concern with STEMI patients admitted in the COVID-19 era found to have a significantly worse left ventricular ejection fraction than before the outbreak. This reduction in left ventricular ejection fraction will be likely to translate to increased future morbidity and mortality.5 Indeed, we observed a numerical increase in STEMI in-hospital mortality not explained by intercurrent COVID-19 illness or changes in baseline characteristics, although it should be emphasized the difference was nonsignificant.In conclusion, we have shown a substantial decline in STEMI presentations since the outbreak of COVID-19 and demonstrate for the first time an increase in markers of adverse prognosis. Our results indicate a high potential for major cardiac collateral damage during the COVID-19 pandemic and support measures to combat this where possible.Sources of FundingNone.DisclosuresNone.FootnotesFor Sources of Funding and Disclosures, see page 3.Correspondence to: Simon J. Wilson, MBCHB, Cardiovascular Department, St. George's Hospitals and University Foundation NHS Trust, London, United Kingdom. Email simonwilson3@nhs.netReferences1. 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July 2020Vol 13, Issue 7 Advertisement Article InformationMetrics © 2020 American Heart Association, Inc.https://doi.org/10.1161/CIRCINTERVENTIONS.120.009438PMID: 32600109 Originally publishedJune 30, 2020 Keywordshospital mortalitypandemicsprognosispublic healthstroke volumePDF download Advertisement SubjectsPercutaneous Coronary Intervention
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