Challenges in managing ST elevation myocardial infarction during the COVID-19 pandemic
Megan Smith1, Aniruddha Singh1, Douglas McElroy2
1Department ofCardiology, University of Kentucky College of Medicine, Bowling Green, KY 42101, United States.
Insights
Patients with ST-elevation myocardial infarction (STEMI) experienced longer delays in seeking medical care during the COVID-19 pandemic. This delay was associated with increased major adverse cardiac events (MACE), indicating worse clinical outcomes.
Area of Science:
- Cardiology
- Public Health
- Epidemiology
Background:
- The COVID-19 pandemic may have led to delayed presentations of acute myocardial infarction (AMI).
- Delayed presentation and reperfusion in AMI are linked to increased mechanical complications and adverse outcomes.
- Potential delays in AMI care during the pandemic may stem from COVID-19 screening protocols and personal protective equipment (PPE) use.
Purpose of the Study:
- To compare performance metrics and clinical outcomes of ST-elevation myocardial infarction (STEMI) patients during the COVID-19 pandemic versus a pre-pandemic cohort.
- To assess the impact of the COVID-19 pandemic on the timeliness of care and subsequent outcomes for STEMI patients.
Main Methods:
- A comparative study matched STEMI patients presenting during the COVID-19 pandemic with a cohort from the same period in 2019.
- Patients with unknown symptom onset time and inpatient STEMI were excluded.
- The primary outcome was in-hospital and 14-day major adverse cardiac events (MACE), including death, myocardial infarction, cardiac arrest, or stroke. Statistical analyses included ANOVA and Chi-square tests.
Main Results:
- A significantly longer interval from symptom onset to first medical contact (FMC) was observed in the COVID-19 pandemic group (P < 0.02).
- Time to first electrocardiogram, door-to-balloon, and FMC-to-balloon times were not significantly different between the groups.
- In-hospital and 14-day MACE were significantly more prevalent in the COVID-19 pandemic group (P < 0.01 and P < 0.001, respectively).
Conclusions:
- This study suggests a delay in seeking medical attention for STEMI patients during the COVID-19 pandemic.
- The observed delay in presentation appears to correlate with worse clinical outcomes, including increased MACE.
- Findings highlight the need to address barriers to timely STEMI care during public health crises.
Background:
Coronavirus disease 2019 (COVID-19) may contribute to delayed presentations of acute myocardial infarction. Delayed presentation with late reperfusion is often associated with an increased risk of mechanical complications and adverse outcomes. Inherent delays are possible as every patient who is acutely sick is being considered a potential case or a career of COVID-19. Also, standardized personal protective equipment precautions are established for all members of the team, regardless of pending COVID-19 testing which might further add to delays.
Aim:
To compare performance measures and clinical outcomes of all patients who presented to our facility with ST elevation myocardial infarction (STEMI) during the COVID-19 pandemic to same time cohort from 2019.
Methods:
All patients who presented to our facility with STEMI during the pandemic were compared to a matched cohort during the same time period in 2019. STEMI with unknown time of symptom onset and inpatient STEMI patients were excluded. Primary outcome was major adverse cardiac events (MACE) in-hospital and up to 14 d after STEMI, including death, myocardial infarction, cardiac arrest, or stroke. Significant differences among groups for continuous variables were tested through ANOVA, using SYSTAT, version 13. Chi-square tests of association were used to compare patient characteristics among groups using SYSTAT. Relative risk scores and associated tests for significance were calculated for discrete variables using MedCalc (MedCalc Software, Ostend, Belgium).
Results:
There was a significantly longer time interval from symptom onset to first medical contact (FMC) in the COVID-19 group (P < 0.02). Time to first electrocardiogram, door-to-balloon time, and FMC to balloon time were not significantly affected. The right coronary artery was the most common culprit for STEMI in both the cohorts. Over 60% of patients had one or more obstructive (> 50%) lesion(s) remote from the culprit site. In-hospital and 14 d MACE were more prevalent in the COVID-19 group (P < 0.01 and P < 0.001).
Conclusion:
This single academic center study in the United States suggests that there is a delay in patients with STEMI seeking medical attention during the COVID-19 pandemic which could be translating into worse clinical outcomes.
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