Implications of COVID-19 on Time-Sensitive STEMI Care: A Report From a North American Epicenter
Kevin Haddad1, Brian J Potter1, Alexis Matteau1
1Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada; Centre Hospitalier de l'Université de Montréal (CHUM) Research Center, Montréal, Québec, Canada.
Insights
During COVID-19 lockdowns, patients with ST-elevation myocardial infarction (STEMI) experienced longer delays in seeking medical care, leading to more unstable presentations and worse outcomes. However, healthcare systems maintained timely cardiac care despite new safety protocols.
Area of Science:
- Cardiology
- Public Health
- Emergency Medicine
Background:
- The COVID-19 pandemic significantly altered global healthcare delivery.
- The impact of pandemic-related policies on time-sensitive cardiovascular emergency care, specifically ST-elevation myocardial infarction (STEMI), remains under-evaluated.
- Cities heavily affected by COVID-19 (
- hot spot
- cities) present unique challenges for emergency cardiovascular care.
Purpose of the Study:
- To assess the early effects of the COVID-19 pandemic on STEMI management and patient outcomes in the Greater Montreal Area.
- To compare STEMI patient care during the COVID-19 lockdown period with pre-pandemic and early pandemic periods.
- To evaluate the efficiency of healthcare systems in providing timely cardiac care amidst new safety protocols.
Main Methods:
- A retrospective study comparing 167 STEMI patients across three periods: pre-COVID-19 (2019), early COVID-19 (2020), and COVID-19 lockdown (mid-March to mid-May 2020).
- Analysis of patient data including symptom onset, first medical contact (FMC), and first intracoronary device activation.
- Assessment of patient stability (Killip classes) and in-hospital outcomes, including major adverse cardiac events (MACE).
Main Results:
- STEMI admissions remained constant, but delays between symptom onset and FMC significantly increased during the lockdown period (P=0.007).
- Delays between FMC and intracoronary device activation were not significantly affected by safety protocols (P=0.37).
- Patients during lockdown presented with greater instability (higher Killip classes, P=0.008) and experienced significantly worse in-hospital outcomes, including higher MACE rates (P=0.007).
Conclusions:
- Patients' reluctance to seek care during the COVID-19 lockdown led to delayed presentation, increased instability, and poorer in-hospital outcomes for STEMI patients.
- Despite delays in initial patient contact, the healthcare system demonstrated capacity to manage STEMI cases effectively while adhering to COVID-19 safety measures.
- Public health messaging encouraging timely medical attention for cardiovascular emergencies is crucial during pandemics.
Background:
Coronavirus disease 2019 (COVID-19) has forced dramatic changes to the healthcare systems throughout the world. Time-sensitive management of cardiovascular emergencies such as ST-elevation myocardial infarction (STEMI) has yet to be evaluated in the context of these new policies, particularly in so-called "hot spot" cities.
Methods:
We evaluated the early impact of the pandemic on STEMI performance in the Greater Montreal Area. A total of 167 patients from 3 different study periods were included. Patients presenting in the lockdown period from mid-March to mid-May 2020 (Group C, 53 patients) were compared to those from mid-March to mid-May 2019 (Group A, 60 patients) and the 2020 pre-COVID-19 period (Group B, 54 patients).
Results:
The number of STEMI admissions was unaffected during the lockdown. However, significantly longer delays between symptom onset and first medical contact (FMC) were noted (Group C 189.0 IQR [70.0, 840.0] min vs. Group A 103.0 IQR [42.5, 263.0] min vs. Group B 91.0 IQR [38.0, 235.5 min], P = 0.007). In contrast, additional safety protocols do not appear to have significantly affected delays between FMC and first intracoronary device activation (Group C 102 IQR [73.0, 133.0] min vs. Group A 104 IQR [87.0, 146.0] min vs. Group B 99.5 IQR [80.0, 150.0] min, P = 0.37). Patients that presented during the outbreak were more likely to be unstable with a higher incidence of Killip classes II-IV compared to groups A and B (28.3% vs. 18.3% vs. 5.6% respectively, P = 0.008). Worse in-hospital outcomes were also noted with a significantly higher rate of major adverse cardiac events (Group A 5.0% vs. Group B 11.1% vs. Group C 22.6%, P = 0.007).
Conclusion:
During the lockdown period, many patients appear to have been reluctant to present to hospitals. This was associated with more unstable STEMI presentations and worse in-hospital course. Importantly, the health care system appears able to ensure timely acute cardiac care while ensuring that COVID-19 protocols are respected.
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