Impact of in-hospital medical management for COVID-19 pandemic on door-to-balloon time in patients with ST-elevation myocardial infarction

Background: Delayed door-to-balloon (DTB) time and deterioration of inhospital mortality during the coronavirus disease 2019 (COVID-19) pandemic have been reported. Little is known about the impact of changes in in-hospital medical management before primary percutaneous coronary intervention (PCI) for COVID-19 such as screening test (antigen or polymerase chain reaction (PCR) tests, chest CT for excluding the pneumoniae) and primary PCI under full personal protective equipment (PPE) on DTB time and in-hospital mortality. Purpose(s): The purpose of this study was to evaluate the impact of inhospital medical management for COVID-19 on DTB time and in-hospital mortality during COVID-19 pandemic period. Method(s): We compared DTB time and in-hospital mortality of 502 STelevation myocardial infarction (STEMI) patients during COVID-19 pandemic (February 2020 and January 2021) with 2035 STEMI patients before pandemic (February 2016 and January 2020) using date from Mie ACS registry, a retrospective and multicenter registry. Result(s): The COVID-19 screening tests before primary PCI and/or primary PCI under full PPE was performed on 173/502 (34.5%) patients (antigen or PCR tests;39 (7.8%), chest CT;156 (31.3%), full PPE;11 (2.2%)). These patients had lower rate of achievement of DTB time <=90 min compared with others (Figure 1A). Moreover, In-hospital management of COVID-19 screening tests and/or primary PCI under full PPE was an independent factor of DTB time>90 min with odds ratio of 1.94 (95% confidential interval: 1.37-2.76, p<0.001). In addition, in-hospital mortality of those patients was higher compared with others (Figure 1B). Conclusion(s): In-hospital medical management for COVID-19 screening tests before primary PCI and/or primary PCI under full PPE was the independent factor of DTB time>90 min. This study reinforces the need to focus efforts on shortening DTB time, while controlling the epidemic of infection.

Modified STEMI protocol for Primary PCI during COVID-19 Pandemic:Does it prolong Door-To-Balloon performance?

Background: COVID-19 became a main health problem and causes heavy impact, especially for healthcare system. Managing ST-Segment Elevation Myocardial Infarction (STEMI) patients before COVID-19 pandemic was already challenging enough for Healthcare Professionals (HCP) to pursue time-sensitive treatment. After COVID-19 pandemic, the time-sensitive treatment of pursuing door-to-balloon (DTB) time put a lot more burden to HCP. In this study, We sought to analyze how a change in protocol of Primary PCI (PPCI) in STEMI patients before and during the pandemic influence the performance of DTB in the hospital. Method(s): This is a single-centered retrospective observational study among STEMI patients which was treated by PPCI. Secondary data from the medical record were collected consecutively from April 2018 to January 2022 (46 months). We compared DTB performances before and during the pandemic. Result(s): During 46 months period, the total population of this research was 880 patients. There were total 358 patients underwent PPCI before the pandemic and 522 patients after the pandemic. Modified protocol with the addition step to prevent the spread of COVID-19 had been implemented since April 2020. DTB increased significantly during the pandemic (90 (70-124) minutes vs 97 (76-135) minutes, p 0.002). The proportion of the patients who achieved DTB under 90 min was also significantly decreasing (56.4% vs 47.9%, p 0.0013). Conclusion(s): It is necessary for PPCI center to modify PPCI workflow during the pandemic. A decent workflow should consider practicality and simplicity without compromising HCP and patient safety. Implementing modified PPCI workflow during the pandemic significantly increased DTB time but it is still within the limit of being reasonable and acceptable for the benefit of the patients.

System delays and target points: analysis of STEMI response program a single center

Introduction: STEMI carries the highest risk among the AMI and the mortality is influenced by many factors. Hospital delays are the most easily audited and should be analyzed and improved. Methodology: Participants were adults aged > 19 years enrolled in the AMI registry due to STEMI and treated with emergency PCI from January 2019 to June 2021. The door-to-balloon times and STEMI diagnosis-to-wire cross times were divided into Met and Unmet groups and time frames were compared using the Mann Whitney U test. For time frames with no significant difference, the median of the Met group was adopted while in time frames with a significant difference, the optimal target points were chosen from the highest percentages of Met if <= and Unmet if > the target point. Odds ratio (OR) with 95% confidence intervals from binary logistic regression were done to predict the Met status. Result(s): A total of 113 participants were analyzed. Significant delays were seen in ECG-Paging (p=<0.034), CFOD arrival-to-STEMI diagnosis (p=0.008), STEMI diagnosis-to-consent (p= <0.001), consent-to-Cath lab (p=<0.001) and Cath lab-to-puncture (p=0.003). The optimal targets in minutes: Door-ECG (median 9), ECG-Paging (<=1/>, 56.67%, 62.65%, OR 2.19, p=0.069), paging-to-CFOD arrival (median <2), CFOD arrival-to-STEMI diagnosis ( <=/>3, 66.67%, 51.81% OR 2.15, p=0.086), STEMI diagnosis-to-consent (<=/>10, 78.26%, 67.78%, OR 7.57, p=<0.001), consent-to-Cath lab (<=/>24, 73.91%, 67.78%, OR 15.38, p=<0.001), Cath lab-to-puncture (<=/>12, 65.22%, 58.89%, OR 2.68, p=<0.043). Conclusion(s): In a developing country and during the COVID-19 pandemic, the most significant delays of our STEMI program occurred in obtaining consent for emergency percutaneous coronary intervention and transferring the patient to the catheterization laboratory. Optimal target points for every time frame can provide concrete objectives that may increase the chance of achieving the door-to-balloon and STEMI diagnosis-to-wire cross goals.

The Impact of Emergency Department Arrival Time on Door-to-Balloon Time in Patients with ST-Segment Elevation Myocardial Infarction Receiving Primary Percutaneous Coronary Intervention.

Door-to-balloon (DTB) time significantly affects the prognosis of patients with ST-segment elevation myocardial infarction (STEMI). The effects of temporal differences in emergency department (ED) arrival time on DTB time and on different segments of DTB time remain inconclusive. Therefore, we performed a retrospective study in a tertiary hospital between January 2013 and December 2021 and investigated the relationship between a patient's arrival time and both their DTB time and different segments of their DTB time. Of 732 STEMI patients, 327 arrived during the daytime (08:01-16:00), 268 during the evening (16:01-24:00), and 137 at night (00:01-08:00). Significantly higher odds of delay in DTB time were observed during the nighttime (adjusted odds ratio (aOR): 2.87; 95% confidence interval (CI): 1.50-5.51, p = 0.002) than during the daytime. This delay was mainly attributed to a delay in cardiac catheterization laboratory (cath lab) activation-to-arrival time (aOR: 6.25; 95% CI: 3.75-10.40, p < 0.001), particularly during the 00:00-04:00 time range. Age, sex, triage level, and whether patients arrived during the COVID-19 pandemic also had independent effects on different segments of DTB time. Further studies are required to investigate the root causes of delay in DTB time and to develop specific strategies for improvement.

Comparison of STEMI Door-To-Device Time During the COVID-19 Crisis in a New Jersey Inner City Community Hospital.

As the novel COVID-19 pandemic was on the rise, its impact on the healthcare system was devastating. Patients became more reluctant to present to the hospital and elective procedures were being postponed for patient safety. We wanted to assess the effects of the COVID-19 pandemic on the door-to-device time in our small community hospital in the heart of Trenton, New Jersey. We created a retrospective study that evaluated all STEMI cases that presented to our institute from January 2018 until the end of May, 2021. Our primary outcome was the door-to-device time. Secondary outcomes were the length of hospital stay, ICU admission, length of ICU stay, cardiac arrest, and death during the hospitalization. We studied 114 patients that presented with STEMI to our emergency department, 77 of these patients presented pre-COVID-19, and 37 presented during the pandemic. Our median door-to-device for STEMI cases pre-COVID-19, and during the pandemic were 70 min (IQR 84-57) and 70 min (IQR 88-59) respectively with no significant difference found (P-value 0.55, Mann Whitney Test). It is, however, interesting to note that the number of STEMI admissions significantly decreased during the pandemic era. There are limitations to our study, most noticeably the number of STEMI cases at our small community hospital which limits its generalizability. Moreover, we did not assess other comorbidities which might have confounded our outcomes and we were also unable to follow patients post-discharge to assess the long-term sequela of their STEMI admission. Therefore, more dedicated studies of this clinical conundrum are required to further assess and implement guidelines for the future.

Effects of COVID-19 on STEMI Patients: Single-Center Experience.

Aim: The purpose of this study is to assess the effect of the COVID-19 pandemic on the volume of ST-elevation myocardial infarction (STEMI) patients and also to assess changes in patient characteristics, door-in-to-door-out (DIDO) time, door-to-balloon time (D2B) time, and STEMI outcomes during the pandemic. Methods: Patient data were retrieved retrospectively from the electronic medical record system of King Hamad University Hospital and Mohammed Bin Khalifa Cardiac Centre in the Kingdom of Bahrain. Data were compared and analyzed for the two time periods: before the pandemic (January 2019-March 2020) and during the pandemic (April 2020June 2021). Results: There was a decline of 11.1% in patients who presented with STEMI during the pandemic. There were no major differences between the patient demographics and the baseline characteristics during the two study periods. Recommended DIDO time and D2B time could be achieved only for 7.1% and 35.7% of all STEMI cases during the pandemic. However, no significant differences were noted in the 30 days of mortality, reinfarction, cardiogenic shock, hospital length of stay, and return to the hospital within 30 days for the STEMI patients in the two time periods. Conclusions: There was a decline in patients who presented with STEMI during the pandemic. This was also associated with a lower number of STEMI cases achieving the recommended DIDO time and D2B time as compared to the prepandemic period. However, there was no significant difference in the patient outcomes in the two time periods.

The Impact of the Early COVID-19 Pandemic on ST-Segment Elevation Myocardial Infarction Presentation and Outcomes-A Systematic Review and Meta-Analysis.

BACKGROUND: The influence of the early COVID-19 pandemic on non-COVID-19 emergencies is uncertain. We conducted a systematic review and a meta-analysis to evaluate the impact of the first months of the COVID-19 pandemic on the presentation, management, and prognosis of patients presenting with ST-segment elevation myocardial infarction (STEMI). METHODS: We searched the PubMed, Scopus, and Embase databases from January to August 2020. A meta-analysis of studies comparing the profile, STEMI severity at presentation, reperfusion delay, and in-hospital mortality for patients presenting before and during the early COVID-19 pandemic was conducted. Fifteen cross-sectional observational studies including 20,528 STEMI patients from the pre-COVID period and 2190 patients diagnosed and treated during the first months of the COVID-19 pandemic met the inclusion criteria. RESULTS: Patients presenting with STEMI during the pandemic were younger and had a higher comorbidity burden. The time interval between symptoms and first medical contact increased from 93.22 ± 137.37 min to 142 ± 281.60 min (p < 0.001). Door-to-balloon time did not differ significantly between the two periods (p = 0.293). The pooled odds ratio (OR) for low left ventricular ejection fraction at presentation during the pandemic was 2.24 (95% confidence interval (CI) 1.54-3.26) and for a presentation delay >24 h was 2.9 (95% CI 1.54-5.45) relative to before the pandemic. In-hospital mortality did not increase significantly during the outbreak (p = 0.97). CONCLUSION: During the first months of the COVID-19 pandemic, patients presenting with STEMI were addressed later in the course of the disease with more severe left ventricular impairment. In-hospital emergency circuits and care functioned properly with no increase in door-to-balloon time and early mortality.

Impact of SARS-CoV2 pandemic onto acute ST-elevation myocardial infarction care and patient outcomes in a large tertiary cardiac center

Background: SARS-CoV2 pandemic has caused major impact on patient care worldwide. We experienced a surge of cases beginning March 2020 leading to the government imposing a movement control order, more commonly known as 'lockdown' starting 18th March 2020. As such, various changes were implemented by our center to the clinical pathway for STEMI patients including using thrombolysis as the preferred initial treatment modality. Purpose: We aim to determine the impact of SARS-CoV2 pandemic on the clinical outcome of acute STEMI patients in our center which is a large regional tertiary hospital for cardiology. Methods and results: This is a single center retrospective cross-sectional study from 1st January 2020 until 31st May 2020. We compared clinical outcomes of patients admitted for acute STEMI before (group 1) and after (group 2) 15th March 2020 which is the date our center implemented changes to our STEMI care pathway. A total of 172 cases of acute STEMI was admitted to our center during this period. Admission for STEMI was noticeably lower after the lockdown implementation (group 1, n = 97 vs group 2, n = 75). The median time from symptom to presentation at our center did not differ between the two groups being 4.15h[2.78,7.28] vs 4.42h[2.97,8.01] p = 0.702, suggesting no outof- hospital delays in management. Majority of the patients in group 1 (n = 75, 77.2%) received primary percutaneous coronary intervention (PCI) vs only 17 (22.7%) in group 2. Most in group 2 (n = 54, 72%) received thrombolytic therapy and subsequently underwent coronary intervention within the same admission. This shows a shift in the preferred initial treatment modality for STEMI at our center during this period. The door to balloon time for patients undergoing primary PCI during this period was also numerically higher in group 2 but the difference was not statistically significant at 46min [38,63] vs 59min [45,72], p = 0.063, most likely due to the additional preparation needed in terms of SARS-CoV2 testing and personal protective equipment (PPE) prior to the procedure. The primary composite endpoint of in-hospital mortality and cardiogenic shock between the two groups (17.5% vs 24.3%, p = 0.275) did not show any significant difference. The incidence of inhospital mortality and cardiogenic shock were 4.1% vs 6.7% (p = 0.458) and 15.5% vs 21.9% (p = 0.281) respectively. Conclusions: This study suggests that thrombolysis as the preferred initial treatment modality for STEMI could be a reasonable temporary measure during the initial phase of a global pandemic to reduce infection risk of healthcare providers without compromising patient outcomes until adequate PPE and testing modalities are available for primary PCI to be performed safely. A follow-up study is needed to determine the long-term outcome of these patients.

COVID-19-mediated patient delay caused increased total ischaemic time in ST-segment elevation myocardial infarction.

BACKGROUND: The current study aimed to evaluate changes in treatment delay and outcome for ST-segment elevation myocardial infarction (STEMI) in the Netherlands during the first coronavirus disease 2019 (COVID-19) outbreak, thereby comparing regions with a high and low COVID-19 hospitalisation rate. METHODS: Clinical characteristics, STEMI timing variables, 30-day all-cause mortality and cardiovascular complications of all consecutive patients admitted for STEMI from 1 January to 30 June in 2020 and 2019 to six hospitals performing a high volume of percutaneous coronary interventions were collected retrospectively using data from the Netherlands Heart Registry, hospital records and ambulance report forms. Patient delay, pre-hospital delay and door-to-balloon time before and after the outbreak of COVID-19 were compared to the equivalent periods in 2019. RESULTS: A total of 2169 patients were included. During the outbreak median total treatment delay significantly increased (2 h 51 min vs 2 h 32 min; p = 0.043) due to an increased patient delay (1 h 20 min vs 1 h; p = 0.030) with more late presentations > 24 h (1.1% vs 0.3%) in 2020. This increase was particularly evident during the peak phase of COVID-19 in regions with a high COVID-19 hospitalisation rate. During the peak phase door-to-balloon time was shorter (38 min vs 43 min; p = 0.042) than in 2019. All-cause 30-day mortality was comparable in both time frames (7.8% vs 7.3%; p = 0.797). CONCLUSIONS: During the outbreak of COVID-19 patient delay caused an increase in total ischaemic time for STEMI, with a more pronounced delay in high-endemic regions, stressing the importance of good patient education during comparable crisis situations.

Impact of COVID-19 pandemic on door-toballoon time and mortality within a high reliability STEMI system of care

Background: The COVID-19 pandemic is associated with delayed revascularization and worse clinical outcomes for patients with ST-Elevation MI (STEMI). The purpose of this study was to evaluate whether a comprehensive STEMI protocol (CSP), which improved door-to-balloon times (D2BT) and mortality prior to the pandemic, mitigated the pandemic's negative effect on STEMI care and outcomes. Methods: We performed a prospective, single-center, registry-based study of 433 patients who received PCI for STEMI though an established CSP. We compared D2BT and in-hospital mortality of the period immediately prior to the pandemic (control period;1/1/19 -3/14/20, N=291) with the period from 3/15/20 to 12/31/20 (study period, N=142), in-line with the declaration of a state of emergency by the state of Ohio. Results: Between control and study period, patients were similar in regards to age (61.2 +/- 12.0 yrs vs. 61.7 +/-13.2 yrs), female sex (32.3% vs 30.3%), nonwhite race (30% vs 26%), smoking status, BMI (30.4 +/- 8.9 vs 29.9 +/- 6.3), and other comorbidities. There was no significant difference in % meeting D2BT goals for STEMI (<=90 minutes for ED and in-hospital, <=120 minutes for hospital transfer patients) during control and study periods (79.0% v 78.9%, p = 0.97). When stratified by STEMI presenting location, there was no significant difference between control and study period D2BT for patients presenting in primary ED (48 min [IQR 36-66] vs 60 min [IQR 42-73], p = 0.09), as hospital transfers (96 min [IQR 79-119] vs 95 min [IQR 80-112], p = 0.86), or from in-hospital locations (95 min [IQR 80-112] vs 95.8 min [IQR 52-120], p = 0.50). There was no significant difference in in-hospital mortality between the control and study periods (4.5% and 2.1%, p = 0.22). Conclusions: Despite the profound effect of pandemic on overall health care operations, there was little overall change in STEMI process and outcome metrics within a high reliability CSP.

Comparison of clinical and angiographic results in COVID-19-positive and -negative patients undergoing primary coronary intervention due to ST-elevation myocardial infarction

Introduction: Although coronavirus disease-19 (COVID-19) primarily causes respiratory system infection, it may cause thrombosis in the cardiovascular system. In this regard, we aimed to compare cardiovascular outcomes between COVID-19-positive and -negative patients with ST-segment elevation myocardial infarction (STEMI). Methods: This was a retrospective study that consecutively included 96 COVID - and 36 COVID+ patients with STEMI. Clinical, laboratory, and angiographic characteristics were obtained from hospital records, and these variables were compared between groups. Results: COVID-19 patients with STEMI had higher Killip score (3-4) (78 vs. 30, P < 0.001) and mortality (42% vs. 21%, P = 0.017). Among COVID-19 patients with STEMI, 83% had lung infiltration. According to the angiographic findings, COVID-19 patients had a shorter door to balloon time (35 ± 20 vs. 49 ± 17, P = 0.013), glycoprotein IIb/IIIa antagonist use, and shorter door to balloon time. Conclusion: COVID-19 patients with STEMI had a higher rate of cardiogenic shock and mortality.

Comparison of door-to-balloon time and in-hospital outcomes in patients with ST-elevation myocardial infarction between before versus after COVID-19 pandemic.

The situation around primary percutaneous coronary intervention (PCI) has dramatically changed since coronavirus disease 2019 (COVID-19) pandemic. The impact of COVID-19 pandemic on clinical outcomes as well as door-to-balloon time (DTBT), which is known as one of the indicators of early reperfusion, has not been fully investigated in patients with ST-elevation acute myocardial infarction (STEMI). The purpose of this study was to compare DTBT and in-hospital outcomes in patients with STEMI between before versus after COVID-19 pandemic. The primary interest was DTBT and the incidence of in-hospital outcomes including in-hospital death. We included 330 patients with STEMI who underwent primary PCI, and divided them into the pre COVID-19 group (n = 209) and the post COVID-19 group (n = 121). DTBT was significantly longer in the post COVID-19 group than in the pre COVID-19 group (p < 0.001), whereas the incidence of in-hospital death was comparable between the 2 groups (p = 0.238). In the multivariate logistic regression analysis, chest CT before primary PCI (OR 4.64, 95% CI 2.58-8.34, p < 0.001) was significantly associated with long DTBT, whereas chest CT before primary PCI (OR 0.76, 95% CI 0.29-1.97, p = 0.570) was not associated with in-hospital death after controlling confounding factors. In conclusion, although DTBT was significantly longer after COVID-19 pandemic than before COVID-19 pandemic, in-hospital outcomes were comparable between before versus after COVID-19 pandemic. This study suggests the validity of the screening tests including chest CT for COVID-19 in patients with STEMI who undergo primary PCI.

Impact of COVID-19 lockdowns on STEMI percutaneous interventions

Background: Measures taken to mitigate the spread of coronavirus disease 2019 (COVID-19) have been correlated to a decline in the number of patients seeking medical care for emergency cardiovascular illness. Here we evaluate the impact of a state-wide lockdown on ST-elevation myocardial infarction (STEMI) care. Purpose: The purpose of this study is to help understand the impact of COVID-related lockdowns on STEMI interventions. Methods: All consecutive adult patients admitted with an acute STEMI diagnosis and percutaneous intervention (PCI) performed between January 17, 2020, and July 14, 2020, at five sites across our health care network, were included in this study. Patient demographics, medical history and procedure details were collected retrospectively from electronic medical records. Data were segregated according to date into pre-lockdown, lockdown (March 17 to May 13, 2020) and post-lockdown groups. Results: A total of 225 patients formed the study cohort. Median age was 62 (IQR: 53-71) years. Patients were predominantly male (n=154, 68%), white (n=208, 92%), hypertensive (n=139, 61%) and dyslipidemic (n=135, 60%). The average weekly rate of STEMI PCIs performed pre-lockdown decreased by 40% during the lockdown from 10.9 to 6.5 PCIs per week (p<0.05). Door-to-balloon (D2B) times increased from 42 (IQR: 28-68) min pre-lockdown to 53 (IQR: 40-72) min during the lockdown (p=0.01). No significant differences were observed in in-hospital mortality or cardiac troponin measurements within 24 h of procedure between the three groups. Conclusion: Adverse effects of COVID-19-related lockdowns on acute STEMI care include a decrease in PCI volumes and prolonged D2B times. Our results provide valuable data-driven criteria to help inform patient decisions to seek care and to find ways to protect healthcare workers without compromising timely critical intervention.

The prevalence and characteristics of patients with ST-elevation myocardial infarction during the first two months of the COVID-19 pandemics

Background: ST-Segment elevation MI (STEMI) is one of the leading cause of mortality in the western world. The coronavirus disease-2019 (COVID-19) pandemic might have implications of the treatment of STEMI patients. Our aim was to evaluate the treatment of STEMI patients during 2 months of the COVID-19 pandemic as compared with the year before. Methods: Data of 90 STEMI patients treated at the Shaare Zedek Medical Center intensive coronary care unit (ICCU) Between March-April 2019 and March-April 2020 were collected. Patients were divided into 2 groups: The pre COVID-19 group and the COVID-19 era group. Data regarding complications upon arrival and during hospitalization, door to balloon time and echocardiographic exams. Results: Fifty one (56%) patients were admitted with STEMI in the pre COVID-19 group and only 39 (44%) in the COVID-19 era group. Of them 13.7% vs. 20.5% were female, p=0.392 with a mean age of 62.1 (±13.5) vs. 63.4 (±11) years old, p=0.635 in the pre vs. post COVID-19 era group, respectively. Interestingly, more Jewish vs. non-Jewish were admitted with STEMI in the COVID-19 era group. There were no differences regarding baseline characteristics, catheterization access, culprit vessel and percutaneous coronary intervention rate. Door to balloon time was also similar in both pre and post COVID-19 era groups 35.4 (±32) vs. 30.5 (±29.1) minutes (p=0.896). Moreover, there was no difference regarding infarct size. Complications including acute renal failure, cardiogenic shock, and the use of intra-aortic balloon pump were similar in both groups. 30-day mortality rate was low and similar in both pre and post COVID-19 era groups (5.9% vs. 2.6%, respectively, p=0.426). Conclusions: During the beginning of COVID-19 era there was a reduction in STEMI admission rate, while no significant difference was found regarding baseline characteristics, door to balloon time, infarct size and mortality rate.

Indirect effects of COVID-19 Pandemic in ST-segment elevation myocardial infarction: insights from a multicentric national survey

Objective: Coronavirus disease 2019 (COVID-19) pandemic may have indirect consequences in ST-segment elevation myocardial infarction (STEMI) outcomes due to difficulties in healthcare access, but also due to reperfusion delays. The objective of this study was to evaluate the performance indicators in STEMI during the early phase of the lockdown following the COVID-19 pandemic. Methods: The patient delay and the system delay were evaluated in 312 patients with suspected STEMI, in the period of the first State of Emergency in Portugal, through a survey called Moment COVID implemented within 18th March to 2 May 2020, in 18 national centers of Interventional Cardiology where PPCI is carried out 24/7. These patients were compared with a historical cohort of 267 patients from the 5th year after integration of SFL Initiative in Portugal (Moment 2015) in which the same survey was applied. Patients with late presentation of STEMI (>12 hours of symptoms onset) were excluded from this analysis. Results: In Moment COVID there was a trend towards a longer patient delay (incremental median 20 min;p=0.059) and a significant longer system-delay (incremental median 17 min;p=0.033) compared to the historical cohort of Moment 2015. Consequently, times to revascularization tended to be longer (incremental median 26 min;p=0.074). Indeed, in Moment COVID patients were less compliant with the times recommended by the European guidelines: door-to-balloon time <60 min was achieved in 47.6% of patients compared to 57.0% (p=0.052) in Moment 2015 and system-delay <90 min in 13.9% compared to 21.8% (p=0.033). Conclusion: These results from a multicentric national analysis demonstrated a trend to longer time from symptom onset to request healthcare system assistance and a significantly longer time from first medical contact to revascularization among patients with STEMI during COVID-19 pandemic. This delay for treatment could negatively impact the STEMI prognosis at the long-term.

The global effect of Covid-19 on acute coronary syndromes management

Aim: Covid-19 has had a dramatic impact on the healthcare systems globally. Despite efforts to maintain systems of cardiovascular care during the pandemic, public health responses to the virus have contributed to adverse cardiovascular outcomes. Herein, we summarize current evidence detailing the impact of Covid-19 on interventional cardiology. Methods: According to PRISMA criteria, a systematic review was performed through Medline, Embase, and Cochrane databases, to identify reports on the impact of Covid-19 on interventional cardiovascular procedures. We identified 50 published studies that met the prespecified inclusion and exclusion criteria. Results: In the acute setting, several datasets report a reduction of acute coronary syndrome (ACS) admission by 40% globally (-40%, 95% CI 37-43 from the National Health Service hospital trusts in England). Most surveys and registries reported a numerically higher impact on NSTEMI/unstable angina cases compared to STEMI (-42%, 95% CI 38- 46 and -23%, 95% CI 16-30 respectively, from the National Health Service hospital trusts in England). In STEMI care pathways, several studies report increased delays between symptom onset and first medical contact (105 min, 95% CI 45-222 during the pandemic vs 71 min, 95% CI 30-180 before it, p<0.001, from the National STEMI registry in Spain), with a subsequent increased duration of the ischaemic period (200 min, 95% CI 140-332 during the pandemic vs 233 min, 95% CI 150-375 before it, p<0.001, from the National STEMI registry in Spain). Importantly, hospital door-to-balloon times were unchanged. Most studies suggest similar in-hospital mortality for STEMI during the pandemic compared to historic controls (1.7% vs 1.8%, p=0.67 from British National Institute of Cardiovascular Outcomes Research database). An increased incidence of mechanical complications were observed (41.2% vs 19.6%, p=0.030, from an Italian monocentric experience). In the United States (New York city), overall mortality from ischemic heart diseases depicted a 2-fold increase during the pandemic (relative change 2.39, 95% CI 1.39-4.09). Of note, in the same city home deaths increased from 35/day in 2013-2017 to 200/day during the pandemic. These data suggest that ACS incidence has not decreased, but more likely patients presenting ischemic symptoms may have not contacted health care services, and have died at home. Conclusions: The Covid-19 pandemic has adversely impacted outcomes in patients with ischemic heart disease (IHD). The diagnosis and treatment of IHD should be designated a health system priority that remains intact during pandemic events as the magnitude of harm induced by its interruption is substantial.

Impact of the SARS-CoV-2 Pandemic on Primary Percutaneous Coronary Intervention for Patients with ST-Elevation Myocardial Infarction.

During the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, patients with ST-elevation myocardial infarction (STEMI) should be treated as possibly infected individuals. Therefore, more time is considered necessary to conduct primary percutaneous coronary intervention (PCI). In this study, we sought to evaluate the impact of the SARS-CoV-2 pandemic on primary PCI for STEMI. Between March 2019 and March 2021, 259 patients with STEMI underwent primary PCI. Patients were divided into 2 groups: the pre-pandemic group (March 2019-February 2020) and the pandemic group (March 2020-February 2021). The patient demographics, reperfusion time including onset-to-door time, door-to-balloon time (DTBT), computed tomography (CT), peak creatinine phosphokinase (CPK), and 30-day mortality rate were investigated. The mean age of the patients was 70.4 ± 12.9 years, and 71.6% were male. There were 117 patients before the pandemic and 142 during the pandemic. The median DTBT was 29 (21.25-41.25) minutes before the pandemic and 48 minutes (31-73 minutes) during the pandemic (P < 0.001). The median door-to-catheter-laboratory time was 13.5 (10-18.75) minutes before the pandemic and 29.5 (18-47.25) minutes during the pandemic (P < 0.001). CT evaluation was performed before PCI in 39 (33.3%) patients and 63 (44.4%) patients (P = 0.08); their peak CPK levels were 1480 (358-2737.5) IU and 1363 (621-2722.75) IU (P = 0.56), and the 30-day mortality rates were 4.3% and 2.1% (P = 0.48), respectively. The SARS-CoV-2 pandemic changed the diagnostic procedure in the emergency department and affected the DTBT in patients with STEMI. Nonetheless, no adverse effects on the 30-day mortality rate were observed.

The Impact of SARS-CoV-2 on ST-Elevation Myocardial Infarction Volume, Time to Presentation, and Door-to-Balloon Time: A Report from a High-Volume Statewide Primary Percutaneous Intervention Program.

BACKGROUND: The novel severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) outbreak has affected ST-elevation myocardial infarction (STEMI) care worldwide. Reports from China, Europa, and North America showed a significant decline in STEMI volume with a simultaneous increase in time from symptoms to hospital presentation. AIM: The aim of the study was to study the effect of the SARS-CoV-2 outbreak on primary percutaneous coronary intervention (PPCI) volume performed for STEMI, symptom onset to hospital presentation time (symptom-to-door [S2D]), and door-to-balloon time (D2B) at the main nationwide PPCI center in Qatar. METHODS: A retrospective evaluation of prospectively collected quality improvement cardiac catheterization data in Qatar was performed. PPCI volume and S2D and D2B time during the outbreak from March 9, 2020, to May 14, 2020, were compared with that of the same period from the prior year and the period immediately preceding the outbreak. RESULTS: Since the SARS-CoV-2 outbreak in Qatar, 137 PPCI procedures were performed. There was a 40% reduction in the volume of PPCI when compared with the period immediately preceding the outbreak and 16% reduction in volume when compared with that of the same period in 2019. The median S2D time was 115 min (interquartile range [IQR: 124]), which was not statistically different from that of the preceding period or the same period in 2019. D2B time during the outbreak increased by an average of 7 min when compared with that of the same period preceding the outbreak (median: 47 min [IQR: 28] during the outbreak vs. median: 40 min [IQR: 21] during the preceding period, P = 0.016). CONCLUSION: In a statewide PPCI program in Qatar, we observed a mild reduction in PPCI cases during the SARS-CoV-2 outbreak (16% when compared with the same period in 2019), with a modest increase in D2B time. PPCI can be performed effectively during the SARS-CoV-2 outbreak at very high-volume centers with the adoption of strict infection control measures. With proper training and monitoring, both target D2B and hospital staff safety can be achieved.

The Impact of the COVID-19 Pandemic and the Importance of Telemedicine in Managing Acute ST Segment Elevation Myocardial Infarction Patients: Preliminary Experience and Literature Review.

The coronavirus disease 2019 (COVID-19), which is caused by a novel coronavirus (SARS-COV-2), has compromised health care systems and normal management of patients with cardiovascular diseases [1-3]. Patients with non-communicable diseases, including acute myocardial infarction (AMI) are vulnerable to this stress [4, 5]. Acute ST segment elevation myocardial infarction (STEMI), the most critical type of AMI, is associated with high mortality even with modern medicine [6-8]. Timely reperfusion therapy is critical for STEMI patients because a short ischemia time is associated with better clinical outcomes and lower acute and long -term mortality [9-12]. The COVID-19 pandemic placed the management of STEMI patients in a difficult situation due to the need to balance timely reperfusion therapy and maintaining strict infection control practices [13, 14]. Telemedicine, which is used to deliver health care services using information or communication technology, provides an opportunity to carry out the evaluation, diagnosis, and even monitor the patients after discharge when social distancing is needed [15]. In this article, we reported our preliminary experience with the usefulness of telemedicine in managing STEMI patients during the COVID-19 pandemic. We also provided a review of this topic.