Impact of COVID-19 pandemic and diabetes on mechanical reperfusion in patients with STEMI: insights from the ISACS STEMI COVID 19 Registry
Authors: De Luca Giuseppe , Cercek Miha , Jensen Lisette Okkels , Vavlukis Marija , Calmac Lucian , Johnson Tom , Roura i Ferrer Gerard , Ganyukov Vladimir , Wojakowski Wojtek , von Birgelen Clemens , Versaci Francesco , Ten Berg Jurrien , Laine Mika , Dirksen Maurits , Casella Gianni , Kala Petr , Díez Gil José Luis , Becerra Victor , De Simone Ciro , Carrill Xavier , Scoccia Alessandra , Lux Arpad , Kovarnik Tomas , Davlouros Periklis , Gabrielli Gabriele , Flores Rios Xacobe , Bakraceski Nikola , Levesque Sébastien , Guiducci Vincenzo , Kidawa Michał , Marinucci Lucia , Zilio Filippo , Galasso Gennaro , Fabris Enrico , Menichelli Maurizio , Manzo Stephane , Caiazzo Gianluca , Moreu Jose , Sanchis Forés Juan , Donazzan Luca , Vignali Luigi , Teles Rui , Bosa Ojeda Francisco , Lehtola Heidi , Camacho-Freiere Santiago , Kraaijeveld Adriaan , Antti Ylitalo , Boccalatte Marco , Martínez-Luengas Iñigo Lozano , Scheller Bruno , Alexopoulos Dimitrios , Uccello Giuseppe , Faurie Benjamin , Gutierrez Barrios Alejandro , Wilbert Bor , Cortese Giuliana , Moreno Raul , Parodi Guido , Kedhi Elvin , Verdoia Monica 
Published: December 2020

Abstract
Background
It has been suggested the COVID pandemic may have indirectly affected the treatment and outcome of STEMI patients, by avoidance or significant delays in contacting the emergency system. No data have been reported on the impact of diabetes on treatment and outcome of STEMI patients, that was therefore the aim of the current subanalysis conducted in patients included in the International Study on Acute Coronary Syndromes–ST Elevation Myocardial Infarction (ISACS-STEMI) COVID-19.

Methods
The ISACS-STEMI COVID-19 is a retrospective registry performed in European centers with an annual volume of > 120 primary percutaneous coronary intervention (PCI) and assessed STEMI patients, treated with primary PCI during the same periods of the years 2019 versus 2020 (March and April). Main outcomes are the incidences of primary PCI, delayed treatment, and in-hospital mortality.

Results
A total of 6609 patients underwent primary PCI in 77 centers, located in 18 countries. Diabetes was observed in a total of 1356 patients (20.5%), with similar proportion between 2019 and 2020. During the pandemic, there was a significant reduction in primary PCI as compared to 2019, similar in both patients with (Incidence rate ratio (IRR) 0.79 (95% CI: 0.73–0.85, p < 0.0001) and without diabetes (IRR 0.81 (95% CI: 0.78–0.85, p < 0.0001) (p int = 0.40). We observed a significant heterogeneity among centers in the population with and without diabetes (p < 0.001, respectively). The heterogeneity among centers was not related to the incidence of death due to COVID-19 in both groups of patients. Interaction was observed for Hypertension (p = 0.024) only in absence of diabetes.
Furthermore, the pandemic was independently associated with a significant increase in door-to-balloon and total ischemia times only among patients without diabetes, which may have contributed to the higher mortality, during the pandemic, observed in this group of patients.

Conclusions
The COVID-19 pandemic had a significant impact on the treatment of patients with STEMI, with a similar reduction in primary PCI procedures in both patients with and without diabetes. Hypertension had a significant impact on PCI reduction only among patients without diabetes. We observed a significant increase in ischemia time and door-to-balloon time mainly in absence of diabetes, that contributed to explain the increased mortality observed in this group of patients during the pandemic.
Trial registration number: NCT 04412655.