key: cord-0775323-8p9dh9kt
authors: Coughlan, J.J.; Chongprasertpon, N.; Arockiam, S.; Arnous, S.; Kiernan, T.J.
title: COVID-19 and STEMI: A snapshot analysis of presentation patterns during a pandemic
date: 2020-05-26
journal: Int J Cardiol Heart Vasc
DOI: 10.1016/j.ijcha.2020.100546
sha: bb3809cf1cf05a9587990464dd6894766d5758c7
doc_id: 775323
cord_uid: 8p9dh9kt

nan

The coronavirus disease 2019 (COVID-19) pandemic has emerged as a major global public health emergency 1 . Many countries, including the Republic of Ireland, have instituted restrictions on their citizens in order to reduce the transmission of the virus 2,3 , colloquially referred to as 'lockdown'.

Concern has been raised regarding an observed decrease in the number of ST elevation myocardial infarction (STEMI) presentations during this period 4, 5 . Numerous theories have been proposed regarding this phenomenon 4 . The most concerning hypothesis is that patients with symptoms of acute myocardial ischemia may not be presenting to medical attention due to lockdown measures or concern regarding COVID-19.

The Republic of Ireland has a population of approximately 4.9 million 6 with over 1,100 primary percutaneous coronary intervention (PPCI) procedures performed annually 7 . Based on the latest published data, our center performs the third highest number of PPCI procedures and has the highest rate of 'timely' PPCI in the Republic of Ireland as defined by a first medical contact to balloon time of less than 120 minutes 7 .

With this in mind, we analyzed the data for STEMI presentations at our center during the COVID-19 lockdown in order to determine any changes in the pattern of presentation compared to the same period in 2019. We have previously published data demonstrating an absence of seasonal or monthly variation in the pattern of STEMI presentations at our centre 8 . Therefore, any variation in the pattern of STEMI presentation was felt to likely be secondary to the current COVID-19 pandemic and resultant lockdown measures This study was performed in the Cardiology Department at University Hospital Limerick, a 24-hour primary percutaneous coronary intervention center in the Republic of Ireland. We analyzed STEMI presentations to our center for the first three weeks of lockdown in the Republic of Ireland, from 27/3/2020 until the 17/4/2020 2, 3 . We compared the data to the same period in 2019 (27/3/2019-17/4/2019). STEMI was diagnosed according to the European Society of Cardiology Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation 9 .

Data have been published suggesting that patients with COVID-19 may present as STEMI calls 10 .

Therefore, all STEMI patients were brought to the cardiac catheterization laboratory and treated by healthcare workers utilizing complete personal protective equipment (PPE) as recommended by the National Acute Coronary Syndrome subcommittee meeting on 18/3/2020. In our center, the usual unfractionated heparin dose given during PPCI is 70 to 100 units per kg to maintain an activated clotting time between 250 and 300 seconds; the same dosing protocol was utilized in both the reference group and the COVID-19 lockdown cohort. The baseline demographics are demonstrated in Table 1 and the outcomes of interest in Table 2 .

There were numerically fewer STEMIs presenting per day during the lockdown period compared to the same period in 2019 but this did not reach statistical significance (0. 4 Patients presenting to our service during lockdown had a longer total ischemic time, mainly driven by a delay from onset of symptom to first medical contact. Of note, one-third of patients during lockdown presented greater than 24 hours after the onset of chest pain. Taken together, these data suggest that patients are delaying seeking medical contact during lockdown, potentially due to isolation or reluctance to engage with medical services due to fears regarding COVID-19. This is particularly concerning given that previously published research had demonstrated a 7.5% increase in 1-year mortality for each 30-minute delay in the treatment of patients with STEMI 11 .

The relative risk reduction of 36% from our study is comparable to previous work which reported a 38% reduction in STEMI activations during the early phase of the COVID-19 pandemic in the United States 4 . Despite precautionary measures against COVID-19 with use of full PPE, there was no statistical significance demonstrated in the cath lab arrival to wire cross time.

We observed a numerically lower number of STEMIs during lockdown compared to the reference period, although this did not reach statistical significance. This non-statistically significant difference could be due to the small sample size resulting from the short duration of the period examined. Another limitation was that our study only reported in-hospital mortality and lacked additional longer-term outcome data. This was a snapshot analysis and the long-term clinical sequelae of the delayed time to presentation of patients suffering from STEMI remains to be seen.

This single PPCI center study in the Republic of Ireland suggests that public restrictions to minimize the transmission of the SARS-CoV-2 virus during the COVID-19 pandemic are associated with a delay in patients seeking medical attention for STEMI. The need to maintain accessibility to a 24/7 PPCI service has been previously highlighted 12 . We would suggest that emphasis should be placed at a national level to inform the public that life-saving interventions such as 24/7 PPCI are still available during lockdown. This is particularly pertinent for time dependent treatment modalities like primary percutaneous coronary intervention for STEMI. Our cardiology department has attempted to advise the public of this through local radio, national news channel and our hospital's Twitter account. It is similarly important for public health officials to consider the effect of lockdown measures on established systems of care and ensure that the public are aware of the importance of seeking medical assistance if they have concerning symptoms during lockdown. 

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