key: cord-0872169-rentu5da
authors: Sutherland, Nigel; Dayawansa, Nalin; Filipopoulos, Benjamin; Vasanthakumar, Sheran; Narayan, Om; Ponnuthurai, Francis A.; van Gaal, William
title: Letter to the Editor: Acute Coronary Syndrome Trends and COVID-19 Waves (Response to the Letter of Čulić et al.)
date: 2022-01-13
journal: Heart Lung Circ
DOI: 10.1016/j.hlc.2021.12.001
sha: 9bbba23ceba59bb22817b9e3ec9b92ac7893a6e4
doc_id: 872169
cord_uid: rentu5da

nan

Heart, Lung and Circulation (2021) -, --- We would like to thank Professor Č uli c and colleagues for their interest in our paper [1] and for their comments [2] . We agree that multiple factors contributed to both a reduction in acute coronary syndrome (ACS) presentations during the first and second waves of the COVID-19 pandemic in Melbourne, as well as for the rebound in presentations when restrictions were eased. In their letter. Professor Č uli c et al. identify reduced air pollution and physical activity as causes for reduced ACS presentations. Public health restrictions resulted in reduced air and noise pollution levels in Melbourne during the first and second waves of the pandemic in 2020 [3] . However, when pandemic restrictions eased pollution levels returned to average which does not plausibly explain the rebound 20% increase in ACS presentations that occurred in our cohort. Similarly, restrictions reduced opportunity to participate in team sport and exercise, but possibly increased time to participate in regular physical activity. This is reflected by an Australian survey of 272 adults which reported 44% of adults reduced exertion during the pandemic, but 23% increased their physical activity [4] .

The contribution of psychological stressors to ACS presentations in our cohort is difficult to ascertain. Psychological stressors were highly prevalent throughout the pandemic with a high prevalence of depression, anxiety and insomnia noted in multiple studies. Psychological distress was enhanced by isolation and unemployment [5, 6] . However, our study noted a reduction in presentations when psychological stressors were high. As restrictions eased, social isolation was reduced and people returned to work, yet we found a rebound increase in ACS presentations.

There are multiple possible triggers for the rebound in ACS presentations. The degree to which they contribute to the increased presentations requires further research. Increased population vulnerability during the pandemic has been well established with higher rates of snacking, smoking and alcohol consumption reported in the Australian population [7, 8] . However, it is unlikely that less than one year of unhealthy lifestyles would result in a 20% increase in presentations that coincided with the easing of restrictions. In our anecdotal experience, some patients delayed presentation due to fear of contracting COVID-19 as well as a desire to avoid burdening the health care system.

Identification of mechanisms that increase population cardiovascular vulnerability and trigger ACS, which can be addressed by population health measures should be a focus of further research. Campaigns have been developed to address the reduced cardiac presentations such as the American Heart Association's 'Don't Die of Doubt' campaign and the European Society of Cardiology 'You can't pause a heart' effectiveness should be evaluated and adapted to improve access to cardiovascular health care [9, 10] 

Acute coronary syndrome in the COVID-19 pandemic: reduced cases and increased ischaemic time

Letter to the Editor regarding: acute coronary syndromes in the COVID-19 pandemic: reduced cases and increased ischaemic time by Sutherland et al. Heart Lung Circ

Environmental impacts of COVID-19 on Victoria, Australia, witnessed two waves of Coronavirus

Physical activity during COVID-19 lock-down. Insights into Australians' physical activity and fitness during the covid-19 shut-down

Reis Marques T. Mental health risk factors during the first wave of the COVID-19 pandemic

Prevalence of and risk factors associated with mental health symptoms among the general population in China during the Coronavirus disease 2019 pandemic

The impact of COVID-19 lockdown on snacking habits, fast-food and alcohol consumption: a systematic review of the evidence

Smokers' cognitive and behavioural reactions during the early phase of the COVID-19 pandemic: findings from the 2020 ITC four Country Smoking and Vaping Survey

Don't Die of Doubt 2020