key: cord-0903741-6kteuqgh
authors: Tanner, Richard; MacDaragh Ryan, Paul; Caplice, Noel M.
title: COVID-19 - Where have all the STEMIs gone?
date: 2020-05-01
journal: Can J Cardiol
DOI: 10.1016/j.cjca.2020.04.032
sha: 902d17f0b2e2de2877cef634497f61687f99507c
doc_id: 903741
cord_uid: 6kteuqgh

nan

The coronavirus disease (COVID-19) pandemic has required acute and long-term services to accommodate surges in hospital admissions. Cardiovascular care has experienced challenges to primary percutaneous coronary intervention (PPCI) from a safety (personal protective equipment-PPE), staffing (healthcare worker infection rates) and patient welfare perspective. Recently an ~40% reduction in ST-elevation myocardial infarction (STEMI) presentations for PPCI has been reported during the COVID-19 crisis. 1 Reduced STEMI admissions could relate to altered patient behaviour, disrupted care pathways, or altered cardiovascular risk factors pertaining to partial or complete lockdown conditions during the pandemic ( Figure 1 ).

Human psychological responses to STEMI symptoms are well known, with ~20% of patients ignoring symptoms or presenting late (>12 hours) despite chest pain, 2 a cohort resistant to change since the 1980s. Moreover, a proportion of STEMIs including elderly, female and diabetic patients present silently or atypically delaying acute diagnosis. COVID-19 public health warnings may have inadvertently contributed to reduced STEMI patient contact with emergency medical services (EMS) or primary care physicians. Cocooned elderly patients through reduced family contact may also have impaired ability to raise the alarm. Thus altered patient behaviour is one likely contributing factor to reduced STEMI presentations.

Moreover, early COVID-19 advice to smokers worldwide suggested cessation would reduce hand to face contact and thus virus transmission and if implemented this could have impacted on STEMI event rates. 3 Additionally altered stress levels in home-bound subjects may have reduced blood pressure and increased exercise and compliance with medication with the latter effect likely to be beneficial within a 2 month time window. 4 At risk subjects may also have improved lifestyle given public health warnings regarding cardiovascular risk and poor COVID-19 outcomes. Additional factors include disruption to acute triage and inhospital care as EMS, emergency room and in-hospital services became overwhelmed by the number and severity of COVID-19 cases to the relative exclusion of other acute medical admissions.

To confirm this trend of reduced STEMI presentation is real a comprehensive analysis of STEMI registries worldwide is required. In the short-term, STEMI under-detection is likely to presage more acute deaths from under-revascularization, including by lethal arrhythmias, cardiogenic shock and cardiac rupture at rates unheralded in recent PPCI history. Medium and long-term complications such as heart failure, sudden cardiac death and post-infarct angina are also likely to increase. Dealing with the legacy of this unrevascularized cohort will present challenges to multiple cardiology services from structural heart disease, to arrhythmia management to cardiac surgery. 

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

Practice variation and missed opportunities for reperfusion in ST-segment-elevation myocardial infarction: findings from the Global Registry of Acute Coronary Events (GRACE)

Impact of smoking status on outcome in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention

Withdrawal of pharmacological treatment for heart failure in patients with recovered dilated cardiomyopathy (TRED-HF): an openlabel, pilot, randomised trial

The authors have no duality of interest to declare.

Dr. Caplice has received funding from Science Foundation Ireland Grant Number 12/RC/2273_P2.