Delays in ST-Elevation Myocardial Infarction Care During the COVID-19 Lockdown: An Observational Study
Cole R Clifford1,2, Michel Le May1, Alyssa Chow1
1Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
Insights
COVID-19 lockdowns saw fewer ST-elevated myocardial infarction (STEMI) hospitalizations. Delays in reperfusion therapy, particularly symptom-to-door times, increased significantly, impacting patient outcomes during the pandemic.
Area of Science:
- Cardiology
- Public Health
- Emergency Medicine
Background:
- ST-elevated myocardial infarction (STEMI) requires prompt reperfusion to prevent myocardial damage.
- The COVID-19 pandemic may have altered the management and presentation of STEMI cases.
- Assessing the impact of the pandemic on STEMI care is crucial for optimizing treatment strategies.
Purpose of the Study:
- To evaluate changes in STEMI hospitalization volumes during the COVID-19 lockdown.
- To analyze the impact of the pandemic on clinical time intervals for STEMI management.
- To compare STEMI care in urban and rural settings and across different revascularization strategies.
Main Methods:
- A retrospective analysis of 494 STEMI patients across pre-lockdown, lockdown, and re-opening phases.
- Comparison of clinical, temporal, and outcome data against a 10-year historical cohort.
- Stratification of data by patient location (urban/rural) and treatment type (primary PCI vs. pharmacoinvasive).
Main Results:
- STEMI hospitalizations decreased by 19.0% during lockdown compared to pre-lockdown periods.
- Symptom-to-balloon time increased by 44 minutes during lockdown, primarily due to a 41-minute increase in symptom-to-door time.
- Transferred patients from non-PCI facilities experienced longer door-to-reperfusion times; increased left ventricular dysfunction was observed during lockdown, but mortality rates remained unchanged.
Conclusions:
- The COVID-19 lockdown was associated with reduced STEMI presentations and prolonged reperfusion times.
- Delays in STEMI care were mainly attributed to patient-level delays and inter-facility transfer times.
- Public awareness campaigns and system-level adjustments are essential for maintaining optimal STEMI care during future health crises.
Background:
Management of ST-elevated myocardial infarction (STEMI) necessitates rapid reperfusion. Delays prolong myocardial ischemia and increase the risk of complications, including death. The COVID-19 pandemic may have impacted STEMI management. We evaluated the relative volume of hospitalizations and clinical time intervals within a regional STEMI system.
Methods:
494 patients with STEMI were grouped into pre-lockdown, lockdown and re-opening cohorts. Clinical, temporal and outcome data were collected and compared between groups for both urban and rural patients, receiving primary percutaneous coronary intervention (PCI) and pharmacoinvasive revascularization, respectively. Data was compared to a 10-year historical comparator.
Results:
During pre-lockdown there was 238 cases versus 193 in lockdown; a 19.0% reduction in volume. When lockdown was compared to the median caseload from a 10-year historical cohort, a 19.8% reduction was observed. For patients treated with primary PCI during lockdown, median symptom-to-balloon time increased by 44-minutes [217 (IQR 157-387) vs. 261 (160-659) minutes; p=0.03]; driven by an increase in median symptom-to-door time of 41-minutes [136 (IQR 80-267) vs. 177 (IQR 90-569) minutes; p<0.01]. Only patients transferred from non-PCI facilities demonstrated an increase in door-to-reperfusion time [116 (IQR 93-150) vs. 139 (IQR 100-199) minutes; p<0.01]. More patients had left ventricular dysfunction during the lockdown [35% vs. 44%; p=0.04], but there was no difference in mortality.
Conclusion:
During the COVID-19 lockdown, fewer patients presented with STEMI. Time-to-reperfusion was significantly prolonged and appeared driven predominantly by patient-level and transfer delays. Public education and systems-level changes will be integral to STEMI care during the second wave of COVID-19.
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