key: cord-0691964-h37rnxls authors: Rangé, Grégoire; Hakim, Radwan; Beygui, Farzin; Angoulvant, Denis; Marcollet, Pierre; Godin, Matthieu; Deballon, Ronan; Bonnet, Philippe; Fichaux, Olivier; Barbey, Christophe; Viallard, Louis; Lesault, Pierre Francois; Durand, Eric; Boiffard, Emmanuel; Dutheil, Gerard; Collet, Jean‐Philippe; Benamer, Hakim; Commeau, Philippe; Montalescot, Gilles; Koning, Rene; Motreff, Pascal title: Incidence, delays, and outcomes of STEMI during COVID‐19 outbreak: Analysis from the France PCI registry date: 2020-11-23 journal: J Am Coll Emerg Physicians Open DOI: 10.1002/emp2.12325 sha: bb18fbd226a37c0bd99f6771328dc51cb8c37113 doc_id: 691964 cord_uid: h37rnxls OBJECTIVES: The aim of this study was to assess the impact of the coronavirus disease 2019 (COVID‐19) outbreak on incidence, delays, and outcomes of ST‐elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PPCI) in France. METHODS: We analyzed all patients undergoing PPCI <24 hours STEMI included in the prospective France PCI registry. The 2 groups were compared on mean monthly number of patients, delays in the pathway care, and in‐hospital major adverse cardiac events (MACE: death, stent thrombosis, myocardial infarction, unplanned coronary revascularization, stroke, and major bleeding). RESULTS: From January 15, 2019 to April 14, 2020, 2064 STEMI patients undergoing PPCI were included: 1942 in the prelockdown group and 122 in the lockdown group. Only 2 cases in the lockdown group were positive for COVID‐19. A significant drop (12%) in mean number of STEMI/month was observed in the lockdown group compared with prelockdown (139 vs 122, P < 0.04). A significant increase in “symptom onset to first medical contact” delay was found for patients who presented directly to the emergency department (ED) (238 minutes vs 450 minutes; P = 0.04). There were higher rates of in‐hospital MACE (7.7% vs 12.3%; P = 0.06) and mortality (4.9% vs 8.2%; P = 0.11) in the lockdown group but the differences were not significant. CONCLUSION: According to the multicenter France PCI registry, the COVID‐19 outbreak in France was associated with a significant decline in STEMI undergoing PPCI and longer transfer time for patients who presented directly to the ED. Mortality rates doubled, but the difference was not statistically significant. Acute ST-elevation myocardial infarction (STEMI) is the major cardiac emergency that most hospital cardiologists deal with daily. Rapid reperfusion of the culprit artery by primary percutaneous coronary intervention (PPCI) is recommended for optimal outcomes. 1, 2 Emergency medical systems (EMS) are organized to minimize the time required to transfer patients to the catheterization laboratory (cath lab). 3 The Interventions (EAPCI) continue to recommend PPCI as the standard treatment of STEMI patients during the current pandemic. 4, 5 However, there are no data available on the effects of this strategy during a pandemic. In many countries, a lockdown was imposed by the authorities in order to slow the progression of the virus and avoid hospital crowding. In France, the lockdown was implemented throughout the country. This situation may have discouraged patients from coming to the hospital. An impact on time from onset to first medical contact (FMC) for STEMI patients can be expected, but it may be influenced by opposing factors: overwhelmed EMSs would delay care, for example, but reduced intensity of road traffic would speed up transfer to care centers. The aim of this study was to assess the impact of the COVID-19 outbreak on incidence, delays, and outcomes of STEMI in patients undergoing PPCI in France. The prospective multicenter France PCI registry, started on January 1, 2014, collects all patients undergoing coronary angiography or coronary angioplasty at 16 interventional cardiology centers (ICC) participating in 3 different French regions (Centre Val de Loire, Auvergne Rhône Alpes, and Normandie; Figure 1 ). The basic methodology for the France PCI registry (originally named CRAC) has been previously described. Out-of-hospital, clinical, and procedural data are collected prospectively by cardiologists at the time of the patient's admission to ICC and recorded in electronic reporting software (CardioReport; CVX Medical, Croissy-Beaubourg, France). The data are of high quality, 99.6% of completeness and with 89% of consistency. 6 The registry is registered with clinicaltrials.org (NCT02778724). The following outcomes were analyzed: (1) From January 15, 2019 to April 14, 2020, 2064 STEMI patients undergoing PPCI were included: 1942 in the prelockdown group and 122 in the lockdown group ( Figure 2 ). There were no significant differences in baseline characteristics between the 2 groups ( Rates of in-hospital composite outcomes were higher in the lockdown group (7.7% vs 12.3% v; P = 0.06) and mortality almost doubled (4.9% vs 8.2%; P = 0.10) (Table 3 ) but the differences for these comparisons were not statistically significant. The main limitation of this study is the modest sample size and duration of follow-up in the postlockdown data that reduced the statistical power of the analysis. Several differences did not reach statistical This is to the best of our knowledge the largest multicenter study to date to report data on pathway delays and in-hospital outcomes for STEMI patients during the COVID-19 outbreak. In addition to a significant 12% drop in the number of STEMI patients treated by PPCI in France, the "symptom onset-FMC" delay in patients who presented directly to the ED almost doubled after the national lockdown. Reductions in STEMI admissions as a result of the COVID-19 pandemic have been reported from Austria (25.5%), Italy (26.5%), Spain (40%), and the United States (48%). [9] [10] [11] [12] The centers in the France PCI registry are located in the western part of France, which was less affected than other parts by the COVID-19 outbreak, which probably explains the smaller reduction in admissions observed in our data. The decrease in admissions may be related either to a reduction in the incidence of STEMI or to fewer cases arriving at the hospital. A reduced incidence in acute coronary syndromes may be owing to reduced air pollution, less work-related stress, and less physical activity such as sport during the lockdown. The correlation between urban air pollution and myocardial infarction is controversial. 13 Italian survey likewise report significantly higher mortality in patients admitted for myocardial infarction during the COVID-19 outbreak compared with the same period in 2019. 10 In our cohort, the doubling of mortality in the lockdown group was not statistically significant, but this was possibly because of a modest sample size. In conclusion, these data from the large multicenter France PCI registry show that the COVID-19 outbreak in France was associated with a significant decline in STEMI undergoing PPCI and longer transfer times for patients who presented directly to the ED. Mortality doubled but the difference was not statistically significant. With an ongoing second wave of COVID-19 infections, the reasons for this adverse situation need to be clearer identified in order to target appropriate actions to reduce inefficiencies in care delivery, as well as promote changes in patient awareness and behavior. 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The INFUSE-AMI Trial (INFUSE-Anterior Myocardial Infarction) Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts Incidence, delays and outcomes of STEMI during COVID-19 outbreak: Analysis from the France PCI registry The authors have no conflicts of interest to declare. GR, PM, RK, and GM obtained research funding.GR, RH, and PM conceived and designed the study. GR, RH, and PM drafted the manuscript and all authors contributed substantially to its revision. All authors were involved in the execution of the study. GR takes responsibility for the paper as a whole.