In- and out-of-hospital mortality for myocardial infarction during the first wave of the COVID-19 pandemic in Emilia-Romagna, Italy: A population-based observational study.

BACKGROUND: The COVID-19 pandemic has put several healthcare systems under severe pressure. The present analysis investigates how the first wave of the COVID-19 pandemic affected the myocardial infarction (MI) network of Emilia-Romagna (Italy). METHODS: Based on Emilia-Romagna mortality registry and administrative data from all the hospitals from January 2017 to June 2020, we analysed: i) temporal trend in MI hospital admissions; ii) characteristics, management, and 30-day mortality of MI patients; iii) out-of-hospital mortality for cardiac cause. FINDINGS: Admissions for MI declined on February 22, 2020 (IRR -19.5%, 95%CI from -8.4% to -29.3%, p = 0.001), and further on March 5, 2020 (IRR -21.6%, 95%CI from -9.0% to -32.5%, p = 0.001). The return to pre-COVID-19 MI-related admission levels was observed from May 13, 2020 (IRR 34.3%, 95%CI 20.0%-50.2%, p<0.001). As compared to those before the pandemic, MI patients admitted during and after the first wave were younger and with fewer risk factors. The 30-day mortality remained in line with that expected based on previous years (ratio observed/expected was 0.96, 95%CI 0.84-1.08). MI patients positive for SARS-CoV-2 were few (1.5%) but showed poor prognosis (around 5-fold increase in 30-day mortality). In 2020, the number of out-of-hospital cardiac deaths was significantly higher (ratio observed/expected 1.17, 95%CI 1.08-1.27). The peak was reached in April. INTERPRETATION: In Emilia-Romagna, MI hospitalizations significantly decreased during the first wave of the COVID-19 pandemic. Management and outcomes of hospitalized MI patients remained unchanged, except for those with SARS-CoV-2 infection. A concomitant increase in the out-of-hospital cardiac mortality was observed. FUNDING: None.

Electrocardiographic features of 431 consecutive, critically ill COVID-19 patients: an insight into the mechanisms of cardiac involvement.

AIMS: Our aim was to describe the electrocardiographic features of critical COVID-19 patients. METHODS AND RESULTS: We carried out a multicentric, cross-sectional, retrospective analysis of 431 consecutive COVID-19 patients hospitalized between 10 March and 14 April 2020 who died or were treated with invasive mechanical ventilation. This project is registered on ClinicalTrials.gov (identifier: NCT04367129). Standard ECG was recorded at hospital admission. ECG was abnormal in 93% of the patients. Atrial fibrillation/flutter was detected in 22% of the patients. ECG signs suggesting acute right ventricular pressure overload (RVPO) were detected in 30% of the patients. In particular, 43 (10%) patients had the S1Q3T3 pattern, 38 (9%) had incomplete right bundle branch block (RBBB), and 49 (11%) had complete RBBB. ECG signs of acute RVPO were not statistically different between patients with (n = 104) or without (n=327) invasive mechanical ventilation during ECG recording (36% vs. 28%, P = 0.10). Non-specific repolarization abnormalities and low QRS voltage in peripheral leads were present in 176 (41%) and 23 (5%), respectively. In four patients showing ST-segment elevation, acute myocardial infarction was confirmed with coronary angiography. No ST-T abnormalities suggestive of acute myocarditis were detected. In the subgroup of 110 patients where high-sensitivity troponin I was available, ECG features were not statistically different when stratified for above or below the 5 times upper reference limit value. CONCLUSIONS: The ECG is abnormal in almost all critically ill COVID-19 patients and shows a large spectrum of abnormalities, with signs of acute RVPO in 30% of the patients. Rapid and simple identification of these cases with ECG at hospital admission can facilitate classification of the patients and provide pathophysiological insights.

[Being cardiologist at the time of SARS-CoV-2: what do not forget during the post-pandemic phase?] / Essere cardiologo ai tempi del SARS-CoV-2: cosa non dimenticare nella fase post-pandemia?

In Italy, the epidemic explosion stage of COVID-19 seems to have been overcome; however, the virus has not been eradicated and the re-emergence of some outbreaks of infection substantiates the danger that the disease may persist. It is therefore necessary to keep the level of surveillance high, to maintain social distancing measures and to act in the control of disease risk factors of a serious or complicated course. Among the risk factors of severe COVID-19 in addition to age, male gender, hypertension and cardiovascular diseases, a major role seems to be played by other cardiovascular risk factors conditioned by an unhealthy lifestyle such as obesity, metabolic syndrome, diabetes and smoking. The new phase requires the maintenance of measures that avoid crowding and close interpersonal contact especially during exercise, in addition to controlled access to hospitals. This will require the reorganization of the traditional methods of cardiovascular prevention and rehabilitation activities, such as gyms and collective educational sessions, and the dilution of outpatient checks. The risk that this scenario may worsen the already suboptimal control of cardiovascular risk factors is therefore real. We do not currently know how long this new phase will last, therefore it is necessary to give impetus to new tele-health initiatives to stimulate the adoption of a healthy lifestyle in primary prevention and tele-monitoring and tele-rehabilitation programs in secondary prevention.

[Being a cardiologist at the time of SARS-COVID-19: is it time to reconsider our way of working?] / Essere cardiologo ai tempi del SARS-COVID-19: è tempo di riconsiderare il nostro modo di lavorare?

The SARS-COVID-19 pandemic is bringing to light significant issues that require deliberations on how to manage patients at high cardiovascular risk or with proven heart disease. The evidence that the hospital can be a place where one might contract the infection and spread the disease has drastically reduced non-COVID-19 accesses to emergency rooms (ER) and to elective non-COVID-19 hospital activities. If this, on one hand, results in reducing improper access to the ER and hospital, on the other hand it substantiates the risk of underestimating problems not connected to COVID-19, such as an increased delay in the diagnosis and treatment of acute myocardial infarction and other cardiovascular emergencies. In addition, the need to reorganize hospital activities to treat patients suffering from serious COVID-19 disease forms forces us to reflect on how to safely manage patients who stay at home with milder COVID-19 disease forms and the need to keep the most vulnerable subjects, such as patients with chronic heart failure, away from the hospital. The problem is furtherly amplified by the uncertain trend of the epidemic, by the duration of forced isolation and limited mobility measures and by the inadequate integration between hospital and territory, especially in high-risk areas such as residences for the elderly or in socially and economically fragile environments. Our opinion is that a syndemic approach, which considers the complex interplay between social, economic, environmental and clinical problems, can be the most appropriate and achieved by means the contribution of telemedicine and telecardiology, intended as integration and not as an alternative to traditional management. A flexible use of telematic tools, now available for teleconsultation, and/or remote monitoring adapted to the needs of clinical, family and social-health contexts could allow the creation of integrated and personalized management programs that are effective and efficient for the care of patients.