key: cord-1037889-66av8px2
authors: Trabattoni, Daniela; Montorsi, Piero; Merlino, Luca
title: Late STEMI and NSTEMI patients’ emergency calling in CoVID-19 outbreak
date: 2020-05-08
journal: Can J Cardiol
DOI: 10.1016/j.cjca.2020.05.003
sha: 1419276009d366a98d565aff14464ff1c0d3284d
doc_id: 1037889
cord_uid: 66av8px2

nan

The highly contagious coronavirus that causes COVID-19 disease is affecting daily clinical practice. The anticipated fast growth in cases has led to develop a regional re-structuring model in order to preserve timesensitive pathologies in northern Italy. On this way, Lombardy Region Government built up a big hub-and spoke-model to converge treatment of acute coronary syndromes (ACS) in 13 dedicated centers active 24/7 in the region, implementing availability of Intensive Care Unit beds in general hospitals converted to COVID-19 treatment 1 . Our Institute is one of the 4 selected hub in Milan for cardiovascular emergences, therefore, in order to prevent in-hospital infection spread and to proactively minimize in-hospital patients to exposure risk, we set an internal pathway for ACS allowing all patients to be timely treated and admitted to isolated ICU or ordinary ward beds, according to nasopharyngeal swab result.

Hospital admissions due to ACS of patients living in the hospital area only, were screened between March 8 th and April 10 th , period of national lockdown, and compared to the same time-frame of 2019.

We registered 46 (24 STEMI; 22 NSTEMI) admissions compared to 19 (10 STEMI; 9 NSTEMI) in the same 2019 time-period , accounting for a 2.5-fold increase in ACS cases (monthly rate 46 vs 18 cases in 2019) ( Figure 1) . A significant delay (> 24 hrs) in seeking for first medical contact after chest pain onset has been registered in 41% of this year STEMI patients (24.8±51 hrs) compared to 20% (6.4±6 hrs) of last year, resulting in an in-hospital mortality rate of 38% vs 10%. Among the reasons answering for the late arrival in the ER, the fear to be admitted in a potentially infected environment was reported by all the patients interviewed on admission.

Interestingly, following these initial observations, the Italian Society of Cardiology promoted a national campaign to raise public awareness in regards to MI symptoms during the outbreak that was followed, at our institute, by a significant fall in the time from symptoms to ER over the last 2 weeks. Additionally, among the NSTEMI cases a higher incidence of MINOCA (45%) was observed compared to 22% in 2019 same time-frame, reinforcing the inflammatory role of COVID-19 in ACS. Positive nasopharyngeal swab either in 

Critical care utilization for the COVID-19 outbreak in Lombardy, Italy; early experience and forecast during an emergency response

ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction-executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction) (erratum appears in

Figure legend: Panel Left: timing of presentation to ER from chest pain symptom onset during COVID-19 outbreak (Blue line) compared to the same time period of

Panel Right: Number of STEMI and NSTEMI cases occurring during COVID-19 outbreak (Green line) compared to the same time period of

COVID-19 symptomatic patients (6 STEMI and 6 NSTEMI) or carriers (10 STEMI and 8 NSTEMI) were observed.We believe that the hub-model planning did not deal with valid apprehension the pandemic triggered and in patients with CV disease may have led to hesitancy in seeking timely appropriate emergent care.When people behaviors are driven by fear, it can lead to decision-making out of line with public health recommendations, thus preventing patients from activating emergency care systems 2 . Therefore, based on these observations, we believe an effective strategy in this phase of pandemic outbreak maybe the hub-and spoke-model associated with a strong media campaign on importance of early hospital admission for suspected ACS in COVID-19 free hospital environment.