Acute coronary syndrome in the time of the COVID-19 pandemic

Acute ST-segment elevation myocardial infarction (STEMI) is a common reason for hospital admission. In 2009, >683 000 patients were discharged from hospitals in the USA with a diagnosis of acute coronary syndrome (ACS). While the incidence rates for STEMI have declined over the past 10 years, STEMI admissions comprise between 25% and 40% of ACS presentations. The extent to which community outbreaks of infectious diseases such as COVID-19 burden other aspects of the healthcare system remains unknown. Real-time collection of data is challenging in an ongoing pandemic, and clinicians are learning from all sources available while taking care of critically ill patients. Even as supportive data lags, a noticeable trend has emerged with a sudden decrease in ACS (particularly STEMI) presentations to hospitals during the COVID-19 pandemic. We sought to review the current literature and discussion surrounding ACS during the COVID-19 outbreak. In the current issue of European Heart Journal, Indolfi et al. published a multicentre observational survey from Italy examining consecutive patients admitted with acute myocardial infarction (AMI) during the week of 12–19 March 2020 at the height of the COVID-19 outbreak in Italy, compared with the same time period in 2019. A total of 319 AMIs were recorded during the 1-week period in 2020, compared with 618 in the previous year, corresponding to a 48.4% reduction. There was a 26.5% reduction in STEMI admissions and a 65.4% reduction in NSTEMI admissions. There was a disproportionately greater decrease in STEMI reductions for women, 41.2%, than for men, 25.4%. The STEMI case fatality rate increased to 13.7% from 4.1% in 2019. The rate of major complications (cardiogenic shock, lifethreatening arrhythmias, cardiac rupture/ventricular septal defect, and severe functional mitral regurgitation) also increased to 18.8% from 10.4% the previous year. A total of 10.7% of all STEMI patients during this time period were COVID-19 positive, with a significantly higher case fatality rate of 28.6%. The pandemic also caused significant disruptions in workflow, with a 39.2% increase in time from symptom onset to coronary angiography, and the time from first medical contact to coronary revascularization was increased by 31.5%. The decline in admissions was not just concentrated in the Lombardy epicentre and also did not just pertain to AMIs. The reduction in AMI admissions was seen proportionately across northern, central, and southern Italy. Hospitalizations for heart failure also decreased by 46.8%, along with a 53.4, 63.2, and 29.4% reduction in admissions for atrial fibrillation, pulmonary embolism, and implantable device failure, respectively. Reductions in ACS admissions in Italy were also seen in a separate retrospective analysis examining 15 hospitals in Northern Italy. The group found a statistically significant difference in the rate of ACS admissions per day, with 13.3 admissions during the COVID-19 period (20 February–31 March 2020), compared with 18.9 during the same period in 2019. A similar reduction in STEMI was observed in a single-centre study from Hong Kong. Seven consecutive patients requiring percutaneous coronary intervention (PCI) for STEMI were compared with two cohorts of patients from the previous year, comprising 108 patients. The seven enrolled patients did not suffer from COVID-19 infection. The study found numerically longer median times in all components examined when compared with historical data from the previous year. There was a significant difference in the time from symptom onset to first medical contact; 318 min during the pandemic period compared with 82.5 and 91.5 min in the previous year’s cohorts. It is also difficult to ascertain the number of patients experiencing ACS who deferred seeking care. There was a notable difference in catheterization lab arrival time to balloon deployment, 33 min compared with 20.5 and 24 min. This could conceivably be a result of the increased time spent on properly donning personal protective equipment.