key: cord-0745356-hhsllxpo
authors: Boukhris, Marouane; Azzalini, Lorenzo; Baystrukov, Vitaly; Aloui, Hatem; Kretov, Evgeny; Ribeiro, Marcelo Herada; Araujo, Gustavo N.; Wainstain, Marco V.; Hillani, Ali; Masson, Jean Bernard; Mansour, Samer; Nasri, Amine; Sestier, Maude; Moritz, Jorge Luis W.; Julien, Elson Julius S.; Souissi, Sami; Addad, Faouzi
title: Impact of the COVID-19 pandemic on acute coronary syndrome and stroke volumes in non-Western countries
date: 2020-07-18
journal: Cardiovasc Revasc Med
DOI: 10.1016/j.carrev.2020.07.017
sha: 7d7d85563b2f6df42096eab9b77e8644a258662d
doc_id: 745356
cord_uid: hhsllxpo

nan

The Coronavirus disease 2019 (COVID-19) has profoundly disrupted healthcare services both by a massive influx of critical COVID-19 patients and through indirect effects, including medical care avoidance behaviors and the decreased efficiency of existing pathways of care [1] . The indirect impact of COVID-19 on cardiovascular and cerebrovascular care has been poorly characterized outside North America and Europe, particularly in non-Western developing countries.

We conducted a multinational retrospective survey analyzing the overall volume and the delays in presentation of acute coronary syndromes (ACS) and ischemic strokes during the COVID-19 pandemic (January 1st to April 30th, 2020), comparing with historical controls In United States, Garcia et al. [2] reported a 38% decrease in cardiac catheterization laboratory STEMI activations. This was similar to reductions in PCI rates for ACS observed in Italy (32%),Spain (40%) and Austria (39.6%) [1, 3] .

In Spain, Tejada Meza et al. [4] reported that the number of stroke significantly dropped following the COVID-19 outbreak, which paralleled the number of stroke patients who received intravenous thrombolysis and/or endovascular therapy.

Several explanations could be identified. Patients are hesitant in seeking care due to concerns about possible in-hospital COVID-19 contagion. This latter fact is more relevant for ACS than for stroke, being this latter generally perceived as more worrying, which leads to emergency consultation. Second, the need to limit invasive procedures resulted in increased indication of conservative management whenever possible. Furthermore, social isolation, strict lockdown rules and the reduction in daily stressors and pollution could represent further explanations of our findings. Finally, patients could be at higher risk of dying at home from these conditions if they do not seek emergency services [1] .

It can be thought that delays in seeking acute care according to benchmarks have less of an impact in developing countries as there is generally less patients awareness, less emergency medical services access, and less efficient healthcare networks. Still, we observed an increase in patients with >2h delays in the setting of STEMI. Late presentations might be responsible for an increased incidence of previously uncommon mechanical complications of myocardial infarction [5] .

The current study had some limitations. First, only tertiary centers have been included which might be against the generalization of the findings to primary and secondary healthcare centers. Second, only NSTEMI patients who underwent invasive approach were included, which likely led to underestimation. Third, no data were available regarding COVID-19 positivity in ACS and stroke patients, as this was beyond the scope of the current survey.

Finally, no mortality data were available to assess the real impact of delays in seeking care during COVID-19 outbreaks. Nonethless, to the best of our knowledge, this is the first multinational study that quantifies the impact of COVID-19 pandemic on ACS and stroke care in non-Western countries. 

Cardiovascular implications of the COVID-19 pandemic: a global perspective

Reduction in ST-Segment Elevation Cardiac Catheterization Laboratory Activations in the United States during COVID-19

Decline of acute coronary syndrome admissions in Austria since the outbreak of COVID-19: the pandemic response causes cardiac collateral damage

Ischaemic Stroke in the Time of Coronavirus Disease

Collateral damage: medical care avoidance behavior among patients with myocardial infarction during the COVID-19 pandemic