key: cord-0960370-prywy4mb authors: Garcia, Santiago; Stanberry, Larissa; Schmidt, Christian; Sharkey, Scott; Megaly, Michael; Albaghdadi, Mazen S.; Meraj, Perwaiz M.; Garberich, Ross; Jaffer, Farouc A.; Stefanescu Schmidt, Ada C.; Dixon, Simon R.; Rade, Jeffrey J.; Smith, Timothy; Tannenbaum, Mark; Chambers, Jenny; Aguirre, Frank; Huang, Paul P.; Kumbhani, Dharam J.; Koshy, Thomas; Feldman, Dmitriy N.; Giri, Jay; Kaul, Prashant; Thompson, Craig; Khalili, Houman; Maini, Brij; Nayak, Keshav R.; Cohen, Mauricio G.; Bangalore, Sripal; Shah, Binita; Henry, Timothy D. title: Impact of COVID‐19 pandemic on STEMI care: An expanded analysis from the United States date: 2020-08-07 journal: Catheter Cardiovasc Interv DOI: 10.1002/ccd.29154 sha: 456fb46bde6352e9feb1acd55cd6fc49cff9bdf4 doc_id: 960370 cord_uid: prywy4mb OBJECTIVE: To evaluate the impact of COVID‐19 pandemic migitation measures on of ST‐elevation myocardial infarction (STEMI) care. BACKGROUND: We previously reported a 38% decline in cardiac catheterization activations during the early phase of the COVID‐19 pandemic mitigation measures. This study extends our early observations using a larger sample of STEMI programs representative of different US regions with the inclusion of more contemporary data. METHODS: Data from 18 hospitals or healthcare systems in the US from January 2019 to April 2020 were collecting including number activations for STEMI, the number of activations leading to angiography and primary percutaneous coronary intervention (PPCI), and average door to balloon (D2B) times. Two periods, January 2019–February 2020 and March–April 2020, were defined to represent periods before (BC) and after (AC) initiation of pandemic mitigation measures, respectively. A generalized estimating equations approach was used to estimate the change in response variables at AC from BC. RESULTS: Compared to BC, the AC period was characterized by a marked reduction in the number of activations for STEMI (29%, 95% CI:18–38, p < .001), number of activations leading to angiography (34%, 95% CI: 12–50, p = .005) and number of activations leading to PPCI (20%, 95% CI: 11–27, p < .001). A decline in STEMI activations drove the reductions in angiography and PPCI volumes. Relative to BC, the D2B times in the AC period increased on average by 20%, 95%CI (−0.2 to 44, p = .05). CONCLUSIONS: The COVID‐19 Pandemic has adversely affected many aspects of STEMI care, including timely access to the cardiac catheterization laboratory for PPCI. study extends our early observations using a larger sample of STEMI programs representative of different US regions with the inclusion of more contemporary data. Methods: Data from 18 hospitals or healthcare systems in the US from January 2019 to April 2020 were collecting including number activations for STEMI, the number of activations leading to angiography and primary percutaneous coronary intervention (PPCI), and average door to balloon (D2B) times. Two periods, January 2019-February 2020 and March-April 2020, were defined to represent periods before (BC) and after (AC) initiation of pandemic mitigation measures, respectively. A generalized estimating equations approach was used to estimate the change in response variables at AC from BC. Results: Compared to BC, the AC period was characterized by a marked reduction in the number of activations for STEMI (29%, 95% CI:18-38, p < .001), number of activations leading to angiography (34%, 95% CI: 12-50, p = .005) and number of activations leading to PPCI (20%, 95% CI: 11-27, p < .001). A decline in STEMI activations drove the reductions in angiography and PPCI volumes. Relative to BC, the D2B times in the AC period increased on average by 20%, 95%CI (−0.2 to 44, p = .05). The COVID-19 Pandemic has adversely affected many aspects of STEMI care, including timely access to the cardiac catheterization laboratory for PPCI. The coronavirus 2019 (COVID-19) pandemic has significantly impacted healthcare delivery around the globe. 1,2 To preserve hospital beds and intensive care unit capacity, elective cardiovascular procedures have been canceled or postponed, and access to in-person outpatient clinics have been severely restricted. 3 An unexpected and troublesome decline in the number of patients seeking medical care for cardiovascular emergencies has been reported during the early phase of the pandemic. 4, 5 Concomitantly, the number of patients suffering cardiac arrest at home has significantly increased in areas most affected by COVID-19. 6, 7 Taken together, these observations suggest that many patients with acute cardiovascular conditions may be circumventing needed medical care. We previously reported a 38% decline in cardiac catheterization laboratory activations for ST-segment elevation myocardial infarction (STEMI) in 9 high-volume STEMI centers in the early phase of the Pandemic. 8 The purpose of this investigation is to extend and expand on our early observations by (a) including 18 hospitals or healthcare systems representative of different regions of the US with varying COVID-19 incidence rates, (2) analyzing other metrics relevant to STEMI care including the number of cardiac catheterization laboratory activations leading to angiography and primary percutaneous coronary intervention (PPCI), and door to balloon (D2B) times, and (3) continuation of our analysis of STEMI decline into April 2020, including a comparison with March 2020 to assess novel trends. A total of 18 sites representing PPCI hospitals and healthcare systems across the US were included in the study (Table S1 and Figure S1 ). In this study, March 1, 2020, was identified as the date when US medical operations were significantly affected. It was also the day that New York City, the current epicenter of the US pandemic, reported its first COVID-19 case through social distancing was not recommended by the federal government until March 15th. Therefore, we identified two periods before and after March 1, 2020, and label them as BC and AC, accordingly. The BC period encompasses the 14 months from January 1, 2019, to February 29, 2020. The AC period includes March and April of 2020. Data on monthly volumes of cardiac catheterization laboratory activations for STEMI, cardiac catheterization laboratory activations leading to angiography, and PPCI were collected. In addition, monthly mean door-to-balloon (D2B) times (in minutes) were collected for each study site. Since COVID-19 cases in the US initially clustered in the Tri-state area in the Northeast of the US, we grouped STEMI programs into four geographic regions (Northeast, South, West, and Midwest) to account for potential differential effects according to COVID-19 disease burden and testing (Table S2) . Continuous study variables were summarized using median and interquartile ranges (median Q1, Q3). For each response variable, the change in volumes at AC from BC were estimated using a generalized estimating equations approach to account for within-site dependencies. Poisson models were used for variables reflecting procedural volumes (STEMI, angiography, and PCI), and a Gaussian distribution was used to estimate changes in the door to balloon times (log scale). The covariates in each model included a natural cubic spline to adjust for seasonal trends, an indicator variable for the year, categorical variable for the region, and an indicator variable for influenza epidemics (October-April). The COVID pandemic period was either coded as an indicator for BC/AC or a three-level categorical variable (BC, March 2020, April 2020). The estimates are reported either as percent change from baseline or incidence rate ratios (IRR) together with the 95% confidence intervals (CI) and p-values. The analysis was conducted using R v4.0 in the Rstudio environment (Rstudio Inc.). No Institutional review board (IRB) approval was required to conduct this survey of the cardiac catheterization laboratory during the COVID-19 Pandemic. Table 1 Figures 1 and S2) . The reduction in STEMI activation volumes from BC was observed in all four regions (Figure 1 ). Nearly all participating sites experienced reductions in STEMI activation volumes in March 2020 relative to BC (Figure 1 ). The data also indicate sizeable variations in STEMI activations from March to April 2020, even within the same geographic region, with some STEMI programs returning to prepandemic levels (e.g., Iowa Heart, Christ Hospital, Northwell, Swedish), some remaining suppressed (e.g., MHI, NY Our study has important strengths, including 16 months of continuous STEMI metrics in 18 large hospitals or healthcare systems representative of diverse areas of the US, but also important limitations. First, given the observational study design, our results are hypothesisgenerating regarding the potential mechanisms leading to a reduction in STEMI metrics. Second, we were unable to provide individualpatient data, including demographic, angiographic, and treatment data. Third, we included STEMI hospitals and healthcare systems that may have different configurations (spoke and hub), transfer, and time to treatment protocols. We provided aggregate data for some STEMI metrics but lack granular information on transfer times and other aspects of STEMI care. The COVID-19 Pandemic has had a negative, widespread, and persistent impact on STEMI care in the US. Efforts to educate the public on the importance of timely care and to maintain unrestricted access to emergency medical care are needed to overcome these trends. The regional STEMI program at Abbott Northwestern Hospital is supported by the Minneapolis Heart Institute Foundation and Allina Health. Considerations for cardiac catheterization laboratory procedures during the COVID-19 pandemic ? CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F 2019-ncov%2Fhealthcare-facilities%2Fguidance-hcf.html. 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Management of acute myocardial infarction during the COVID-19 pandemic ST-segment elevation in patients with Covid-19-a case series ST-elevation myocardial infarction in patients with COVID-19: clinical and angiographic outcomes Impact of COVID-19 pandemic on STEMI care: An expanded analysis from the United States All authors have no conflict of interest related to this project.