Heart vs. Brain in a Warzone: The Effects of War on Acute Cardiovascular and Neurological Emergencies

Background: Armed conflicts impose complex logistical and behavioral challenges on healthcare systems, particularly in managing acute conditions such as ST-elevation myocardial infarction (STEMI) and ischemic stroke. Although both diagnoses require timely intervention, their clinical pathways differ significantly. Few studies have systematically compared their management during active warfare, particularly within the warzone. Methods: This retrospective cohort study was conducted at Soroka University Medical Center (SUMC), the sole tertiary hospital in southern Israel and the main referral center for cardiovascular and neurological emergencies in the region. We included all adult patients (≥18 years) admitted with new-onset STEMI or ischemic stroke during three-month periods of wartime (October-December 2023) and matched routine periods in 2021 and 2022. Patients with in-hospital events, inter-hospital transfers, or foreign citizenship were excluded. Data on demographics, comorbidities, arrival characteristics, treatment timelines, and outcomes were extracted from electronic medical records. Categorical variables were compared using Chi-squared or Fisher's exact test, and continuous variables using t-tests or Mann-Whitney U tests, as appropriate. Multivariable logistic and linear regression models were adjusted for age, sex, Charlson Comorbidity Index (CCI), and mode of arrival. Interaction terms assessed whether wartime modified the associations differently for STEMI and stroke. Results: A total of 410 patients were included (193 with STEMI and 217 with stroke). Patients with STEMI were significantly more likely to arrive by self-transport during the war (38, 57.6% vs. 32, 25.2%, p < 0.001) and had higher rates of late arrival beyond 12 h (19, 28.8% vs. 13, 10.2%, p = 0.002). These findings support the conclusion that patients were more prone to delayed and unstructured presentations during a crisis. In contrast, patients with stroke showed a reduction of 354 min in symptom-to-door times during the war [median 246 (30-4320 range) vs. 600 min (12-2329 range), p = 0.026]. Regression models revealed longer delays for stroke vs. STEMI in routine settings [β = 543.07 min (239.68-846.47 95% CI), p < 0.001], along with significantly lower in-hospital (OR = 0.39, 95% CI= 0.15-0.97, p = 0.05) and 30-day mortality (OR = 0.43, 95% CI= 0.19-0.94, p = 0.04). However, these differences were no longer significant during wartime. Patients with STEMI showed a trend toward lower 180-day mortality during the war (OR = 0.33, 95% CI = 0.09-0.99; p = 0.07), although this difference did not reach statistical significance. Conclusions: During wartime, patients with stroke arrived earlier and in greater numbers, while patients with STEMI showed reduced admissions and delayed, self-initiated transport. Despite these shifts, treatment timelines and short-term outcomes were maintained. These diagnosis-specific patterns highlight the importance of reinforcing EMS access for STEMI and preserving centralized protocol-based coordination for stroke during crises.