key: cord-0980866-k9tilk8f
authors: Secco, Gioel Gabrio; Zocchi, Chiara; Parisi, Rosario; Roveta, Annalisa; Mirabella, Francesca; Vercellino, Matteo; Pistis, Gianfranco; Reale, Maurizio; Maggio, Silvia; Audo, Andrea; Kozel, Daniela; Centini, Giacomo; Maconi, Antonio; Di Mario, Carlo
title: Decrease and Delay in Hospitalization for Acute Coronary Syndromes during the 2020 SARS-CoV-2 Pandemic
date: 2020-05-22
journal: Can J Cardiol
DOI: 10.1016/j.cjca.2020.05.023
sha: c4adb942ef3b473a733caf8a1a3e5da215e40982
doc_id: 980866
cord_uid: k9tilk8f

The diffusion of SARS-CoV-2 forced the Italian population to restrictive measures that modified the patients’ response to non-SARS-CoV-2 medical conditions. We evaluated all ACS-patients admitted in three high-volume hospitals during the first month of SARS-CoV-2 Italian-outbreak and compared them to ACS-patients admitted during the same period 1-year before. Hospitalization for ACS decreased from 162 patients in 2019 vs 2020:84 patients in 2020. In 2020 both door-to-balloon and symptoms-to-PCI were longer and admission levels of hs-cTnI were higher. They had a lower discharged residual LV-function and an increased predicted late cardiovascular mortality based on their GRACE score.

After the first outbreak in late December 2019 in the Chinese city of Wuhan, Italy soon became the center of a fast-growing epidemic in late February-March 2020, more severe in some areas of Northern and Center Italy (1) . After the first confirmed case reported on February 20 th 2020 in Codogno, a small town near Milan, the rapid diffusion of the infection prompted the Italian Government to proclaim a national lockdown on 9 th March 2020, forcing the entire population to severe restrictive isolation measures. These measures, certainly helpful in reducing the diffusion of SARS-CoV-2 infection, significantly modified the patients' response to non-SARS-CoV-2 medical conditions, including acute coronary syndrome (ACS) (2) . Since ACS is a lifethreatening condition with outcome strictly dependent on prompt recognition and treatment, under-or misdiagnosis and late or missed treatment might be deleterious. In the current study we report data from high-volume hospitals from three variably affected regions Piedmont, Marche and Tuscany in order to evaluate changes in ACS-hospitalization rate during the first month of the SARS-CoV-2 Italian outbreak.

This is a multicenter, observational, retrospective study involving 3 high-volume centers distributed in northern and central Italy. Epidemiological data of consecutive ACS-patients admitted in March 2019 and March 2020 were anonymously extracted and entered into a dedicated database. Data collections included procedural results and in-hospital outcome.

The "case period" was set in the month of March because it was when the severe social containing measures were adopted. The rate of ACS-related hospitalization during March 2020 was compared with the rate in the control period (March 2019). Sub-analyses comprised the rate of ACS-type (STEMI, NSTEMI and STEMI with a time to reperfusion delay > 24h), the delay between admission to percutaneous coronary intervention (PCI) and symptoms to PCI. Risk of NSTEMI was stratified using the TIMI score. Time to reperfusion, basal admission and peak high sensitivity-troponin level as well as left ventricular ejection fraction (LVEF) at discharge and in hospital mortality were also collected and compared. Patients signed an informed consent for data collection and the study was conducted according to the Declaration of Helsinki.

Continuous variables were expressed as mean + sd, while categorical variables were presented as numbers and percentages. Distributions of continuous variables were examined for skewness and were logarithmically transformed as appropriate. Continuous variables with normal distribution were compared using the unpaired Student's t-test. Non-parametric continuous variables were compared using the U Mann-Whitney's test. Categorical variables were compared using the χsquare test. Incidence rate (IR) for ACS related hospitalization was calculated by dividing the number of cumulative events by the number of days for both time periods. A P value < 0.05 was considered statistically significant. Statistical analysis was performed using SPSS 26 (IBM Corporation, Armonk, NY, USA). There were no significant differences in patient clinical characteristics or risk factors in the two groups. In March-2019 NSTEMI was a more frequent admission diagnosis (57.4%vs39.3%, p< 0.01) and symptom to PCI was significantly shorter (18.8+20 vs 36.9+38.4 hours, p<0.001). In the STEMI subgroup, door-to-balloon and symptoms-to-balloons were significantly higher in March-2020 (66+17vs40+12min , p< 0.001 and 5.8+3.1hours vs 3.9+2.2 hours, p<0.001- Figure   1 ) with a delay from symptoms to wiring for STEMI-PCI >24 hours more frequent in March 2020 (17.8% vs 4.3%, p<0.001). The GRACE score was significantly higher in 2020 (126+27vs116+26, p<0.001) and more patients were in the higher ESC tertile predictive of higher in-hospital and 6-month mortality (GRACE score above 140: 33.3%vs18.5, p<0.01 and GRACE score above 118: 59.6vs44.4%, p<0.05).

In-hospital clinical outcome is summarized in table 2. Admission and peak high sensitivity troponin were significantly higher in 2020 (5138+9408vs1142+4017ng/L p<0.001, 13681+10936vs9143+13825ng/L, p< 0.01 -Figure1). Presence of an LVEF<40% at discharge was more frequent in March-2020 (42.8%vs24.7%, p< 0.01). No statistical difference in inhospital mortality was observed between the two groups.

The SARS-CoV-2 epidemic was associated with a significant decrease in ACS-hospitalization and late chronic heart failure. Numbers were too small and follow-up too short to show a survival difference at discharge or in the first month. The higher release of cardiac enzymes, more severe LVEF impairment and more frequent GRACE scores in the group with predicted higher 6-month mortality suggest high likelihood of a worse outcome at late follow-up. The time delay in the door-to-balloon of 10 extra minutes, probably explained by the need to carefully wear personal protective equipment was sufficient to be statistically significant compared with 2019 but unlikely to cause a clinically relevant worsening in prognosis. We have applied in these patients the same aggressive approach recommended in the current ESC-Guidelines. In Sichuan Provincial People's Hospital, a conservative approach with frequent use of thrombolysis was applied in most ACS-STEMI/NSTEMI syndromes certainly a suboptimal treatment in the urgent/primary PCI era. Possibly the fact that dedicated COVID-hospitals were created led to a dedicated path of treatment that made it difficult to retransfer patients already in a COVID-area into hospitals with PCI facilities, a problem not present in any of the three hospitals recruiting for this study (2) . The marked reduction of ACS-complications observed in the last decades are certainly justified by the widespread diffusion of an emergency network allowing most of our population to an early reperfusion therapy. If our findings will be confirmed in large scale registries, we might expect to face an increase of serious myocardial impairment that will represent a new challenge for the entire cardiological community.

The major limitation of our study is that our series comes from a retrospective evaluation, which is certainly susceptible to selection bias. Moreover, the small sample-size and the short-term follow-up did not allow us to draw any conclusions on hard endpoints. The correct antiplatelet/anticoagulant therapy in the prothrombotic state related to COVID infection remain a matter of concern; in our study the use of GP IIb/IIIa was low in both groups while Cangrelor infusions were used more often in the 2020-group. A larger sample size including more hospitals and multiple inter-year and intra-year control periods would have certainly improved the statistical power of our findings, but the reduction of ACS-hospitalization during the first three months of the Italian lockdown has been confirmed by our recently published large North Italian registry (1) Stay home is an important message able to contain spreading of the virus but this message should be tempered by a clear exclusion of chest pain and other medical emergencies that still require rapid in hospital treatment. 

Reduced Rate of Hospital Admissions for ACS during Covid-19 Outbreak in Northern Italy

Invasive strategy for COVID-patients presenting with Acute Coronary Syndrome: the First Multicenter Italian Experience. Cath Cardiovasc Interv

Influenza and Coronary Artery Disease: Exploring a Clinical Association With Myocardial Infarction and Analyzing the Utility of Vaccination in Prevention of Myocardial Infarction

Laboratory-Confirmed Respiratory Infections as Predictors of Hospital Admission for Myocardial Infarction and Stroke: Time-Series Analysis of English Data for

Coronaviruses and the cardiovascular system: acute and long-term implications

Disclosures: none