key: cord-1010225-skqwjqzw
authors: Rinfret, Stéphane; Jahan, Israth; McKenzie, Kevin; Dendukuri, Nandini; Bainey, Kevin R; Mansour, Samer; Natarajan, Madhu; Ybarra, Luiz F; Chong, Aun-Yeong; Bérubé, Simon; Breton, Robert; Curtis, Michael J; Rodés-Cabau, Josep; Amlani, Shy; Bagherli, Alireza; Ball, Warren; Barolet, Alan; Beydoun, Hussein K; Brass, Neil; Chan, Albert W; Colizza, Franco; Constance, Christian; Fam, Neil P; Gobeil, François; Haghighat, Tinouch; Hodge, Steven; Joyal, Dominique; Kim, Hahn Hoe; Lutchmedial, Sohrab; MacDougall, Andrea; Malik, Paul; Miner, Steve; Minhas, Kunal; Orvold, Jason; Palisaitis, Donald; Parfrey, Brendan; Potvin, Jean-Michel; Puley, Geoffrey; Radhakrishnan, Sam; Spaziano, Marco; Tanguay, Jean-François; Vijayaraghaban, Ram; Webb, John G; Zimmermann, Rodney H; Wood, David A; Brophy, James M
title: COVID-19 pandemic and coronary angiography for ST-elevation myocardial infarction, use of mechanical support and mechanical complications in Canada; a Canadian Association of Interventional Cardiology national survey
date: 2021-05-12
journal: CJC Open
DOI: 10.1016/j.cjco.2021.04.017
sha: f1c246b03cf832741d70f0d2018682bccd595725
doc_id: 1010225
cord_uid: skqwjqzw

Background As a result of the COVID-19 pandemic first wave, reductions in STEMI invasive care ranging from 23% to 76% have been reported from various countries. Whether it had any impact on coronary angiography (CA) volume or on mechanical support device use for ST-elevation myocardial infarction (STEMI) and post-STEMI mechanical complications in Canada is unknown. Methods We administered a Canada-wide survey to all Cardiac Catheterization Laboratory Directors seeking the volume of CA for STEMI performed during 01/03/2020-31/05/2020 (pandemic period) and from two control periods (01/03/2019-31/05/2019 and 01/03/2018-31/05/2018). The number of left ventricular support devices used, as well as the number of ventricular septal defects or papillary muscle rupture cases diagnosed, were also recorded. We also assessed if the number of COVID-19 cases recorded in each province was associated with STEMI CA volume. Results Forty-one out of 42 Canadian catheterization laboratories (98%) provided data. There was a modest but statistically significant 16% reduction (Incidence Rate Ratio or IRR 0.84; 95%CI 0.80-0.87) in CA for STEMI during the first wave of the pandemic compared to control periods. IRR was not associated with provincial COVID-19 caseload. We observed a 26% reduction (IRR 0.74; 95%CI 0.61-0.89) in the use of intra-aortic balloon pump in STEMI. Use of Impella® and mechanical complications from STEMI were exceedingly rare. Conclusion We observed a modest 16% decrease in CA for STEMI during the pandemic first wave in Canada, lower than reported in other countries. Provincial COVID-19 caseload did not influence this reduction.

As a result of the COVID-19 pandemic first wave, important reductions in ST-elevation myocardial infarction (STEMI) invasive care have been reported from various countries.

Whether it had any impact on coronary angiography (CA) volume for this indication in Canada is unknown. We observed a modest 16% decrease in CA for STEMI during the pandemic first wave, lower than reported in other countries. Provincial COVID-19 caseload did not influence the reduction in CA.

Background. As a result of the COVID-19 pandemic first wave, reductions in STEMI invasive care ranging from 23% to 76% have been reported from various countries.

Whether it had any impact on coronary angiography (CA) volume or on mechanical support device use for ST-elevation myocardial infarction (STEMI) and post-STEMI mechanical complications in Canada is unknown.

Laboratory Directors seeking the volume of CA for STEMI performed during 01/03/2020-31/05/2020 (pandemic period) and from two control periods (01/03/2019-31/05/2019 and 01/03/2018-31/05/2018). The number of left ventricular support devices used, as well as the number of ventricular septal defects or papillary muscle rupture cases diagnosed, were also recorded. We also assessed if the number of COVID-19 cases recorded in each province was associated with STEMI CA volume.

Results. Forty-one out of 42 Canadian catheterization laboratories (98%) provided data.

There was a modest but statistically significant 16% reduction (Incidence Rate Ratio or

For the management of ST-elevation MI (STEMI), reperfusion therapy with primary percutaneous coronary intervention (PCI) has become standard therapy when accessible and provided in a timely fashion. 1 As a result of the first COronaVirus Infectious Disease (COVID)-19 pandemic wave, several publications that gathered single or multi-center experience from diverse regions have reported significant reductions in STEMI invasive care, measured as catheterization laboratory activations, acute coronary angiography (CA), or hospitalization for STEMIs, ranging from 23% to 76% 2-14 compared to control periods, with the sole exception of New Zealand, 15 where no change was observed.

Proposed explanatory hypotheses include over-observance of lockdown policies (although such policies were never meant to turn patient away from seeking medical attention in case of emergency), reduced or delayed emergency visits due to patient fears of contracting COVID-19 in the medical system, increased use of fibrinolytic therapy in a period with limited human and physical resources, and increased out-of-hospital mortality. Anecdotal evidence supports increased delayed or late presentations leading to increased mechanical complications. [16] [17] [18] [19] [20] The first wave of the COVID-19 pandemic has not occurred homogeneously throughout Canada. While the province of British Columbia (BC) was affected first, Quebec and Ontario experienced the greatest infection burden during the first wave of the pandemic. Nevertheless, a country-wide lockdown was imposed by all provinces from mid-March to May, with progressive unlocking throughout May and June from region to region. Whether the regional caseload had any impact on patient's or health-care provider's behavior is not known.

Based on shared subjective impression among the interventional cardiology community, we hypothesized that invasive management for STEMI may have decreased during the worst phase of the pandemic (March 1 st to May 31 st 2020) compared with the same months in 2018 and 2019. We also hypothesized that use of mechanical support devices for STEMI would be higher, consequence of presentation delays or worse clinical features and we assumed an increase in mechanical complications during the pandemic period compared with the previous months. Finally, we hypothesized that the regional intensity of the pandemic, as reflected by the COVID-19 caseload, may be associated with CA for STEMI volumes.

We performed an observational health-services research study utilizing a survey sent Results showing 95% confidence intervals excluding the null value or p-values lower than 0.05 were considered statistically significant. Analyses were performed using the R Statistical Software environment.

Questionnaires were sent on June 1 st , 2020. By October 15, 2020, we had received data from 41(98%) of the 42 Canadian hospitals equipped with a cardiac catheterization laboratory. Only one laboratory did not provide data within the allocated time frame.

Coronary angiography for STEMI. Table 1 and Figure 1 show the main study results.

Size of the square in figure 1 Figure 2 shows a comparison by provincial severity of the pandemic. As displayed, we did not observe any significant trend (p-value=0.52) in decrease of the IRR by COVID-19 case load.

Mechanical left ventricular or circulatory support. Table 2 shows IRR for the whole country, as counts were small for each center. We did not observe any significant variation in the use of Impella® or VA-ECMO support during the pandemic compared to control periods, although counts were very low and clinically meaningful increases or decreases cannot be excluded. However, there was a significant 26% reduction (IRR Because of the statistical instability associated with these low counts, we did not perform any statistical comparisons.

In this national survey that gathered data from 98% of Canadian cardiac catheterization laboratories, we observed a modest but statistically significant 16% decrease in CA for STEMI during the first wave of the pandemic compared to the same months in the 2 previous years, a decrease lower than reported in other countries. We could not demonstrate any association between higher CA reductions and higher COVID-19

caseloads. Also, we did not observe any increase in the use of mechanical support for STEMI, but rather a decrease in the use of IABP, following the reduction in CA for STEMI. This does not support our original hypothesis of more higher-risk STEMIs from delayed presentation requiring more invasive mechanical support. Because of low counts, we could not draw any conclusion about the variation in Impella® or VA-ECMO use, and in mechanical complications.

The 16% reduction in Canada is among the lowest reductions in CA reported in the world. Geographically closer to Canada, a more important reduction in the number of activations for STEMI (29%), CA (34%) and primary PCI (20%) were observed in 18

high-volume US centers. 21 Due to these concerns, a reappraisal of STEMI care in the context of COVID-19 has been suggested. 22 23 While it would be tempting to conclude that universal medical access mitigated risk-averse behaviour from patients in Canada, data from the large BCIS registry in the UK, also in a public healthcare system, reported a larger 43% decline. 24 Lower absolute number of COVID-19 cases in Canada might have not discouraged as much Canadian patients to seek medical attention compared to UK or US patients, where COVID-19 mortality was higher. Our data show the modest reduction to be similar across provinces, despite different COVID-19 caseload. As such, the intensity of the pandemic did not seem to influence the observed reduction in coronary angiography.

Beyond reduction in incidence, delayed presentations have been more common during the first wave, 25, 26 with increases in overall symptom-to-hospital delays 24, 27 along with increased out of hospital cardiac arrest rates, 11 and anecdotal evidence of increased delayed presentations and mechanical complications. [16] [17] [18] [19] [20] However, the incidence of cardiogenic shock has not increased in a large Danish registry. 28 In one Canadian study, the incidence of STEMI admission was not reduced during the pandemic period in

Montreal, but unstable STEMI presentations and worse in-hospital course was more frequent, 29 data that we could not replicate with a much larger and broader sample size.

Our study is the first to gather usage data for LV or circulatory support devices. We did not observe any significant increase in the use of LV or circulatory support, but rather a consistent decrease in the use of IABP across all provinces, larger than the decrease in CA, which goes against, to some extent, an increase in shock patients during the pandemic. Such reduction cannot be explained by preferential use of Impella®, which remained low across the country. While our data suggest a true reduction in cardiogenic shock patients reaching the catheterization laboratory, the phenomenon in unlikely explained by a true reduction in the incidence of severe STEMI. A more plausible explanation is an increased mortality rate of sickest patients not reaching the catheterization laboratory during the pandemic. While an increase in mechanical complication may have occurred, especially for PMR, the very low number of events preclude any strong conclusion.

Our study has other limitations to acknowledge. First, it is a survey on resource use, without patient-level data. Patient-related outcomes and patient perspectives were not captured by the design of this study. Although such a design alleviated the need for research contracts and approval nationwide, it limited the scope of possible analyses. complications or the need of Impella® and VA-ECMO was too infrequent to use it as a surrogate of medical assistance delay. Moreover, the uneven access to Impella® or VA-ECMO throughout the country, which is available in less than 20% of laboratories, further reduced the power to detect any real change in use during the pandemic. Finally, our study design could not assess if the pandemic altered the type of patient presenting for STEMI care. As mentioned earlier, while no increase in IABP was observed, we cannot exclude the possibility of an increase in late presenters and higher-risk STEMIs leading to higher out-of-hospital death. Also, volume of coronary angiography might not represent a true reflection of patient's behavior to seek medical attention, as some patients might have presented to centers without primary PCI capacity and been managed with thrombolytics rather than transferred for primary PCI. Only a true regional or provincial evaluation of hospitalization for STEMI, including lethal cases, could answer that question.

We observed a modest but significant 16% decrease in CA for STEMI during the first wave of the pandemic, lower than reported in other countries. Such decrease could be attributable to patient behavior, reduction in transfer for CA, or increased in mortality prior to CA. Although numerically higher, we could not draw any conclusion regarding the effect of the pandemic on mechanical complications from STEMI or use of Impella® given low counts. The reduction in CA for STEMI was accompanied with a decrease in the use of IABP, which most likely suggest an increased in mortality of sickest patients, not reaching the catheterization laboratory. Finally, the intensity of the pandemic in each province, much less lethal than in other parts of the world at that time, was not associated with the reduction in CA observed. A Canadian study using pre-hospital and hospital clinical or medico-administrative patient-level data, gathering all treatments including fibrinolytics and primary angioplasty with related outcomes would be required to further understand our findings. 

Montreal, QC 2. Department of medicine and biostatistics

Division of cardiology

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