key: cord-0749675-usq41tnk
authors: Rodriguez-Leor, Oriol; Cid-Alvarez, Belen
title: STEMI care during COVID-19: losing sight of the forest for the trees
date: 2020-04-23
journal: JACC. Case reports
DOI: 10.1016/j.jaccas.2020.04.011
sha: 52adf5cea42845d04aeed217e25e0295e00f424b
doc_id: 749675
cord_uid: usq41tnk

[Figure: see text]

By the end of December 2019, a new coronavirus, SARS-CoV-2, was identified as the cause of a disease outbreak that originated in the city of Wuhan, China. The disease it causes was called coronavirus disease 2019 . The infection spread rapidly, and the World Health Organization, on March 11, characterized COVID-19 as a pandemic. On April 11, 2020, more than 1.6 million cases had been diagnosed in 179 countries in five continents with nearly 100.000 confirmed deaths (1) . Since the start of the outbreak, as the weeks pass by, unexpected side effects that directly affect medical attention to other pathologies are being witnessed. In this issue of JACC: Case reports, Moroni et al (2) report 3 cases of ST-segment elevation myocardial infarction (STEMI) that were attended in the midst of the COVID-19 pandemic in the Lombardy region of Italy, which at that time had the highest incidence of cases worldwide. In all 3 cases, despite presenting clear symptoms and having a hospital nearby, patients decided not to go to the emergency room due to fear of acquiring the virus in the hospital, which was overwhelmed COVID-19 patients. After a few days they ended up going to the hospital after suffering serious complications related to STEMI, which caused serious sequelae or even death. Risk perception is irrational, and fear of infection opens a new scenario in which patients with serious pathologies avoid going to hospitals, despite the fact that the risk of untreated STEMI exceeds by far the risk of COVID-19 itself.

Preliminary analysis have shown an important and disturbing decrease in the number of STEMI patients attending hospitals in Europe and in North America during COVID-19 outbreak.

A nationwide analysis in 73 Spanish centers involved in STEMI care networks revealed a 40% decrease in patients treated for STEMI when comparing activity before and during the current outbreak (3). In the same direction, an American study revealed an estimated 38% reduction in catheterization laboratories STEMI activations in 9 high-volume centers during the early phase of the COVID-19 pandemic (4). In both cases STEMI care networks were working normally, so potential etiologies for this decrease should be a combination of avoidance of medical care due to social distancing, concerns of contracting COVID-19 in the hospital, STEMI misdiagnosis or increased use of pharmacological reperfusion.

Regarding reperfusion therapy, primary angioplasty has consistently proven to reduce mortality, reinfarction, stroke, mechanical complications and avoid bleeding events when compared to thrombolysis as reperfusion treatment in STEMI patients if delay to treatment between both options is similar (5), and should probably be kept as the first treatment option. Conversely, in Spain, the Interventional Cardiology Association recommended primary angioplasty as first choice treatment, considering thrombolysis only in the case that the patient was in a center without primary angioplasty capability and required a transfer that would delay treatment for more than 120 minutes or in patients who have tested positive to COVID-19 with poor clinical state that makes transfer difficult or in patients who have tested positive to COVID-19 with low hemorrhagic risk and symptoms of less than 3 hour-duration (7) . Primary angioplasty also allows early discharge without further invasive examinations in a significant percentage of patients which simplifies the management of these patients, limits patient's exposition to the hospital environment and reduces hospital occupation.

In addition to the decrease in the number of patients who consult in hospitals, those who consult will do so with a longer delay. A recent study by Tam et al (8) during the actual COVID-19 outbreak in Hong Kong, China, showed an almost 4-fold increase in median time from symptoms onset to first medical contact (from 82.5 to 318 minutes), and more than a 2-fold increase in median time from door to device (from 84.5 to 110 minutes). Ischemic time duration is the major determinant of infarct size and is directly related to short and long-term survival (9) .

The increase in ischemic time may be due to patient's delay in consulting and/or due to delay in diagnosis because of the work overload of the emergency services and/or due to the difficulty of organizing and performing the procedure with appropriate personal protective equipment (10).

In the current situation, in which patients avoid going to the emergency services -or if they go they do it with long delays-, a disturbing increase in out-of-hospital sudden cardiac arrest (OHSCA) mortality should also be expected. Although it is difficult to know the real incidence of OHSCA in the setting of STEMI, it is estimated that up to 75% of mortality occurs before contact with health system (11) and the main way to prevent OHSCA is to seek hospital treatment as soon as symptoms of STEMI occur (12) . Furthermore, very controversially, it has been suggested not to start chest compressions or ventilation in patients who are in cardiac arrest if they have suspected or diagnosed COVID-19 unless they are in the emergency department and staff are wearing full personal protective equipment (13) .

As described in the paper by Moroni et al 2 , lack of or delayed access to reperfusion treatment will lead to an increase in short-term STEMI complications, such as left ventricle systolic disfunction, cardiogenic shock, intraventricular thrombus formation and peripheral embolism or mechanical complications (14) . Short-term complications, in addition to increasing mortality, require prolonged admission in critical care units, which could be a serious problem in these times of scarce resources.

In the long-term, suboptimal revascularization and larger infarct size will lead to an increase in complications related to worse ventricular remodeling, such as chronic heart failure or ventricular arrhythmias (15).

Last but not least, the current moment requires special care by healthcare organizations to prevent nosocomial infection in patients with cardiovascular disease, who are especially vulnerable if affected by COVID-19 (16) . Healthcare personnel caring for patients must be equipped with appropriate personal protective equipment. It is absolutely inadmissible that the lack of these equipment causes situations such as those experienced these days in Spain, the United States or Italy, where up to 20% of responding health-care workers were infected, and some have died (17).

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Collateral damage: the indirect impact of the COVID-19 pandemic on acute coronary syndromes. JACC: Clinical Cases

Impact of the COVID-19 pandemic on interventional cardiology activity in Spain

Reduction in ST-segment elevation cardiac catheterization laboratory activations in the United States during COVID-19 pandemic

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Impact of coronavirus disease 2019 (COVID_19) outbreak on ST-segment-elevation myocardial infarction care in Hong Kong, China

Impact of treatment delay on mortality in STsegment elevation myocardial infarction patients presenting with and without haemodynamic instability: results from the German prospective, multicenter FITT-STEMI trial

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