Impact of COVID-19 pandemic on a developing STEMI care system from a low-middle income country- a prospective observational study
Authors: Gnanaraj J , Sindhu E , Nandakumaran M , Veeramani R , Kannan K , Anne Princy S , Cecily Mary M , Arumugam M A , Kannan P , Sabapathy K , Swaminathan N , Senthil Kumar G , Nambirajan N , Balasubramanian T , Ravichandran Edwin J M ,   Heart Attack Management Program, National Health Mission-Government of Tamil Nadu
Published: October 2021

Abstract

Background
COVID-19 pandemic has produced a great impact in the STEMI (ST Elevation Myocardial Infarction) care systems across the world. Patient hesitancy to seek medical attention for suspected STEMI, necessity of the health care systems to prioritize COVID-19 care, safety concerns of health care workers etc., have brought in unprecedented times for both patients and health care workers. The impact of COVID-19 pandemic on the establishment of a STEMI care system is less known

Purpose
To identify the impact of COVID-19 pandemic on a developing public STEMI care system in a low-middle income country in Asia, with reference to the type of reperfusion offered and outcome.

Methods
Data on number of STEMI admissions, type of reperfusion therapy and outcome are being collected from 12 teaching hospitals as a part of a developing public regional STEMI care system based on a hub and spoke model in a low middle-income country from August 2018. These 12 “thrombolysis only” hospitals were being upgraded as “primary percutaneous coronary intervention (PPCI) capable hub hospitals” in 2019. Though the hassles of COVID-19 pandemic affected this process significantly, daily data collection in our STEMI care system continued. The maximal COVID impacted period in 2020 was identified from the online database (1) as from April to December 2020. The number, type of reperfusion and outcome of the STEMI patients treated during this period were compared to the same data collected during April-December 2019.

Results
A total of 13,137 STEMI patients were treated in our system during the two time periods “April to December 2019” and “April to December 2020”. There was a 13.3% drop in the number of STEMI treated in 2020, compared to the number treated in 2019 (6101 vs 8925; P&lt;0.001). This drop was in proportion to the number of new cases of COVID-19 reported in our state (Fig. 1a)
We also noted a significant drop in the rate of PPCI and Pharmaco-invasive therapy (PIT) offered for STEMI in 2020 compared to 2019 in the same period (PPCI: 0.13% vs 5.9%-P&lt;0.001 and PIT 0.64% vs 11%- P&lt;0.001). This decrease in PPCI and PIT for STEMI also corresponded to the increase in number of new cases of COVID-19 reported (Fig. 1b). More patients received thrombolytic therapy for STEMI in 2020 compared to 2019 (73.6 vs 61.2% P&lt;0.001). There was no change in the mortality of STEMI during this period. (Fig. 2)

Conclusion
We found a significant drop in number of patients seeking medical care for STEMI during COVID-19 pandemic. There was significant drop in the rate of PPCI and PIT offered in our STEMI care system. Thrombolytic therapy remained the predominant mode of reperfusion as before, but with a significant increased rate of thrombolysis. There was no change in mortality rate in STEMI patients. Thrombolytic therapy is an acceptable mode of reperfusion, when the balance of a STEMI care system is disturbed by extraneous influences like the COVID-19 pandemic.

Funding Acknowledgement
Type of funding sources: Public hospital(s). Main funding source(s): Tamil Nadu Innovation Initiative- Department of Planning and development, Govt of Tamil NaduNational Health Mission, Government of India