key: cord-0853094-u3yd2f1d
authors: Vassilikos, Vassilios P.; Pagourelias, Efstathios D.; Katsos, Konstantinos; Zaggelidou, Eleni; Raikos, Nikolaos; Tzikas, Stergios; Cavousoglou, Halil; Kouparanis, Antonios; Anastasakis, Aristides; Papatheodorou, Efstathios; Kassimis, Georgios; Ziakas, Antonios; Sianos, Georgios; Karvounis, Haralampos; Kanonidis, Ioannis; Spiliopoulou, Chara
title: Impact of social containment measures on cardiovascular admissions and sudden cardiac death rates during Coronavirus Disease (COVID-19) outbreak in Greece.
date: 2020-09-15
journal: Hellenic J Cardiol
DOI: 10.1016/j.hjc.2020.09.009
sha: 6900314c9ac4cd32b3dfe1d41d05d78c6c856ec6
doc_id: 853094
cord_uid: u3yd2f1d

nan

To address the coronavirus disease (Covid-19) pandemic, strict social containment measures have been adopted worldwide, while significant changes in the pattern of hospital admissions have been noted [1] [2] [3] . Reports from various countries, have revealed an up to 60-70% decrease of admissions for acute coronary syndromes (ACS) during the early days of outbreak [1] [2] [3] . This trend has been theoretically attributed to a wide spectrum of causes, however worrisome anecdotal reports suggest an increase of pre-hospital-care deaths related to ACS, potentially leading to the observed admissions' reduction [1, 2] . Aim of this study was to investigate the impact of social containment measures on ACS admission and sudden cardiac death (SCD) rates in Greece, during Covid-19 outbreak era.

Data for this analysis were retrieved by the official records of University [4, 5] . The primary outcome was the frequency of ACSs and acute coronary deaths (ACDs). We also calculated incidence rates (IRs) for the primary outcome, by dividing the number of ACSs or deaths by the number of days. Overall, there has been a relative 38.9% reduction in ACS admissions in 2020, while 171 deaths in 2020 vs 208 in 2019 were referred for autopsies in the enrolled forensic departments (Table 1) . Gender and age distribution were not significantly different between case and control periods. There were no statistically significant differences in the frequency of deaths between the two periods examined, with the exception of deaths secondary to road traffic accidents [4(2.3%) in 2020 vs 20(9.6%) in 2019, p=0.001] and non-ischemic cardiovascular deaths (p=0.007) which significantly decreased during Covid-19 era.

In accordance with previous studies, we have shown a significant decrease in ACS-related hospitalization rates during the early days of the Covid-19 outbreak [1, 2] , without however a significant increase in autopsy defined ACDs or cardiovascular related mortality. Based on these data, our study provides for the firsttime evidence that the observed decline in admissions' rate due to coronary syndromes could not be attributed to an increase in out-of-hospital ACDs. This tendency could be attributed either to the reluctance of patients experiencing ACS to visit emergency departments due to fear of contracting an infection by Covid-19 or alternatively to a change in lifestyle or everyday activities which may interfere with ACS presentation.

Our results should be seen in the light of some limitations. Firstly, it is a common practice in Greece some death certificates to be issued even by general practitioners or family doctors without referral for autopsy. Even though this condition may have led to missing some sudden cardiac deaths in the community, we J o u r n a l P r e -p r o o f feel that this number is not essentially affecting the differences and frequencies reported, since this bias may exist during pre-and post-Covid-19 era. Another limitation is the lack of data from Covid-19 patients' autopsies, since these actions were legally prohibited in our country.

Our analysis offers evidence over a significant decrease in ACS-related hospitalization rates during Covid-19 outbreak. This decrease is not linked to an increase in pre-hospital, autopsy defined ACDs, implying that many ACS patients may not ask for help on time due to infection fear, being prone however to late-onset complications. These clues may be used to appropriately form policies, such as ACS informative media campaigns or re-organization and expansion of pre-hospital triage and care services, which will facilitate and speed-up access of cardiovascular patients to health-care systems during new pandemics' waves.

J o u r n a l P r e -p r o o f 

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Involvement of Cardiovascular System As The Critical Point in Coronavirus Disease 2019 (COVID-19) Prognosis and Recovery

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