Crowding at hospitals- the main reason for not seeking medical care when affected by an acute myocardial infarction during the first wave of COVID-19
Authors: Lidin M , Lynga P , Kinch Westerdahl A , Nymark C 
Published: October 2021

Abstract

Background
Delay in seeking treatment for AMI reduces the success rate of reperfusion therapy and affects both morbidity and mortality. During the outbreak of COVID-19 pandemic, rates of hospitalization for cardiovascular diseases has decreased nationally as well as internationally and a reduction of STEMI patients with 25–48% was reported in European and US registries. The reasons for this change in health care seeking behaviour in AMI are still unknown.

Purpose
To evaluate possible behavioral changes in patients seeking medical care when affected by an acute myocardial infarction during the first wave on ongoing COVID-19 pandemic.

Methods
This was a cross sectional study in a Region in Sweden during the first wave of the COVID-19 pandemic (March-June) with patients selected from the national registry (SWEDEHEART). Eligible were patients with AMI and totally 602 patients were invited. A self-administrated psychometric evaluated queastionnaire (PA-AMI) was sent to the patientes by post and questions regarding COVID-19 were added.
PA-AMI includes 14 items regarding thoughts, feelings and actions prior to care-seeking. All items are answered on a Likert-type rating scale with six grades from 1 'do not agree at all' to 6 'totally agree'. Additionally, there were questions about age, gender, country of birth, when symptoms started and when decide to seek medical care.
COVID-19 questions were 'would you have sought medical care earlier if the pandemic COVID-19 would not have existed', 'if yes, why did you not seek medical care' with follow-up questions.
From SWEDEHEART the following were obtained, e.g. type of AMI, history of: AMI, diabetes and percutaneous coronary intervention (PCI), date and time of first symptoms to arrival at hospital/ward or PCI lab.

Results
A total of 326 patients answered the questionnaire. Of these, 17% hesitated to seek medical care due to the pandemic. Patients characteristics are shown in Table 1. These patients mainly hesitated due to a fear that the healthcare was overcrowded with patients with COVID-19, followed by a fear of becoming infected by COVID-19 at the hospital (Fig 1). Women and patients not born in SWEDEN were significant more represented in this group. The self-assessed patient delay was 22 h (median) versus 4.5 h registered in SWEDEHEART.
PA-AMI displayed that symptom perception and seriousness of symptoms, unsureness where to turn and difficulties to decide seek medical care, was ssociated to those who hesitated to seek medical care due to the pandemic.

Conclusions
During the first wave of the COVID-19 pandemic, women and patients not born in SWEDEN, as well as patients with more than one risk factor (smoking, diabetes) had a longer delay in seeking medical care for AMI due to fear of overcrowded hospitals. Therefore, these patients should be encouraged to seek medical care and there is an importance of information about how and when to seek medical care, especially in the light of COVID-19.

Funding Acknowledgement
Type of funding sources: None. Table 1Figure 1