[Features of the course of non-ST elevation myocardial infarction in patients with a history of COVID-19].

Aim      To study the clinical course of non-ST segment elevation myocardial infarction (NSTEMI) in hospitalized patients after COVID-19 and to evaluate the effect of baseline characteristics of patients on the risk of complications.Material and methods  The study included 209 patients with NSTEMI; 104 of them had had COVID-19. The course of myocardial infarction (MI) was analyzed at the hospital stage, including evaluation of the incidence rate of complications (fatal outcome, recurrent MI, life-threatening arrhythmias and conduction disorders, pulmonary edema, cardiogenic shock, ischemic stroke, gastrointestinal bleeding).Results Mean age of patients after COVID-19 was 61.8±12.2 years vs. 69.0±13.0 in the comparison group (p<0.0001). The groups were comparable by risk factors, clinical data, and severity of coronary damage. Among those who have had СOVID-19, there were fewer patients of the GRACE high risk group (55.8 % vs. 74.3 %; p<0.05). Convalescent COVID-19 patients had higher levels of C-reactive protein and troponin I (p<0.05). The groups did not significantly differ in the incidence of unfavorable NSTEMI course (p>0.05). However, effects of individual factors (postinfarction cardiosclerosis, atrial fibrillation, decreased SpO2, red blood cell concentration, increased plasma glucose) on the risk of complications were significantly greater for patients after COVID-19 than for the control group (p<0.05).Conclusion      Patients with NSTEMI, despite differences in clinical history and laboratory data, are characterized by a similar risk of death at the hospital stage, regardless of the past COVID-19. Despite the absence of statistically significant differences in the incidence of in-hospital complications, in general, post-COVID-19 patients showed a higher risk of complicated course of NSTEMI compared to patients who had not have COVID-19. In addition, for this category of patients, new factors were identified that previously did not exert a clinically significant effect on the incidence of complications: female gender, concentration of IgG to SARS-CoV-2 ≥200.0 U/l, concentration of С-reactive protein ≥40.0 mg/l, total protein <65 g/l. These results can be used for additional stratification of risk for cardiovascular complications in patients with MI and also for development of individual protocols for evaluation and management of NSTEMI patients with a history of COVID-19.

Impact of COVID-19 Pandemic on the Outcomes of Acute Coronary Syndrome.

During the pandemic, health care resources were primarily focused on treating COVID-19 infections and its related complications, with various Clinical units were converted to COVID-19 units, This study aims to investigate the impact of the COVID-19 pandemic on the clinical course of patients who had developed acute coronary syndrome (ACS) including ST-elevation myocardial infarction (STEMI). In this large nationwide observational study utilizing National Inpatient Sample 2019 and 2020.The primary outcomes of our study were in-hospital mortality, length of stay (LOS), total hospital charges and time from admission to percutaneous coronary intervention (PCI). Using the National Inpatient Sample 2020 database we found 32,355,827 hospitalizations in 2020 and 521,484 of which had a primary diagnosis of STEMI that met our criteria. Patients with COVID-19 infection were similar in mean age, more likely to be men, were treated in the same hospital settings as those without COVID-19 and had higher rates of diabetes with chronic complications. These patients had a similar prevalence of traditional coronary artery disease risk factors including hypertension, peripheral vascular disease and obesity. There was higher inpatient mortality (adjusted odds ratios 3.10; 95% CI, 2.40-4.02; P < 0.01) and LOS (95% CI 1.07-2.25; P < 0.01) in STEMI patient with concurrent COVID-19 infection. The average time from admission to PCI was significantly higher among unstable angina (UA) and None ST-segment elevated myocardial infarction (NSTEMI) in patients with a secondary diagnosis of COVID-19 infection compared to patients without: 0.45 days (95% CI: .155-758; P < 0.01). The COVID-19 pandemic had a significant impact on the treatment of patients with ACS, resulting in increased inpatient mortality, higher costs, and longer lengths of stay. During the pandemic, for patients with UA and NSTEMI the time from admission to PCI was significantly longer in patients with a secondary diagnosis of COVID-19 compared to patients without. When comparing ACS outcomes between pre-pandemic to pandemic periods (2019 versus 2020), the 2020 data showed higher mortality, higher hospital costs, and a decrease in LOS. Finally, the time from admission to PCI was longer for UA and NSTEMI in 2020 but not for patients with STEMI.

Reduction in emergency access for acute myocardial infarction during the COVID-19 pandemic: a survey from the greater area of Rome.

BACKGROUND: On March 9, 2020, the Italian government imposed a national lockdown to tackle the COronaVIrus Disease 19 (COVID-19) pandemic, including stay at home recommendations. The precise impact of COVID-19 scare and lockdown on emergency access for acute myocardial infarction (MI) is still subject to debate. METHODS: Data on all patients undergoing invasive coronary angiography at 9 hospitals in the greater area of Rome, Italy, between February 19, 2020 and March 29, 2020 were retrospectively collected. Incidence of ST-elevation MI (STEMI), and non-ST-elevation MI (NSTEMI), as well as corresponding percutaneous coronary intervention (PCI), was compared distinguishing two different 20-day time periods (before vs. on or after March 10, 2020). RESULTS: During the study period, 1068 patients underwent coronary angiography, 142 (13%) with STEMI and 169 (16%) with NSTEMI. The average daily number of STEMI decreased from 4.3 before the lockdown to 2.9 after the lockdown (P=0.021). Similarly, the average daily number of NSTEMI changed from 5.0 to 3.5 (P=0.028). The average daily number of primary PCI changed from 4.2 to 2.9 (P=0.030), while the average daily number of PCI for NSTEMI changed from 3.5 to 2.5 (P=0.087). For STEMI patients, the time from symptom onset to hospital arrival (onset-to-door time less than three hours) showed a significant increase after the lockdown (P=0.018), whereas door-to-balloon time did not change significantly from before to after the lockdown (P=0.609). CONCLUSIONS: The present study, originally reporting on the trends in STEMI and NSTEMI in the Rome area, highlights that significant decreases in the incidence of both acute coronary syndromes occurred between February 19, 2020 and March 29, 2020, together with increases in time from symptom onset to hospital arrival, luckily without changes in door-to-balloon time.

Reconsidering treatment guidelines for acute myocardial infarction during the COVID-19 pandemic.

BACKGROUND: COVID-19 affects healthcare resource allocation, which could lead to treatment delay and poor outcomes in patients with acute myocardial infarction (AMI). We assessed the impact of the COVID-19 pandemic on AMI outcomes. METHODS: We compared outcomes of patients admitted for acute ST-elevation MI (STEMI) and non-STEMI (NSTEMI) during a non-COVID-19 pandemic period (January-February 2019; Group 1, n = 254) and a COVID-19 pandemic period (January-February 2020; Group 2, n = 124). RESULTS: For STEMI patients, the median of first medical contact (FMC) time, door-to-balloon time, and total myocardial ischemia time were significantly longer in Group 2 patients (all p < 0.05). Primary percutaneous intervention was performed significantly more often in Group 1 patients than in Group 2 patients, whereas thrombolytic therapy was used significantly more often in Group 2 patients than in Group 1 patients (all p < 0.05). However, the rates of and all-cause 30-day mortality and major adverse cardiac event (MACE) were not significantly different in the two periods (all p > 0.05). For NSTEMI patients, Group 2 patients had a higher rate of conservative therapy, a lower rate of reperfusion therapy, and longer FMC times (all p < 0.05). All-cause 30-day mortality and MACE were only higher in NSTEMI patients during the COVID-19 pandemic period (p < 0.001). CONCLUSIONS: COVID-19 pandemic causes treatment delay in AMI patients and potentially leads to poor clinical outcome in NSTEMI patients. Thrombolytic therapy should be initiated without delay for STEMI when coronary intervention is not readily available; for NSTEMI patients, outcomes of invasive reperfusion were better than medical treatment.

Global effect of COVID-19 pandemic on the rate of acute coronary syndrome admissions: a comprehensive review of published literature.

BACKGROUND: The COVID-19 pandemic has disrupted healthcare systems across the world. The rate of acute coronary syndrome (ACS) admissions during the pandemic has varied significantly. OBJECTIVES: The purpose of this study is to investigate the effect of the pandemic on ACS hospital admissions and to determine whether this is related to the number of COVID-19 cases in each country. METHOD: Search engines including PubMed, Embase, Ovid and Google Scholar were searched from December 2019 to the 15 September 2020 to identify studies reporting ACS admission data during COVID-19 pandemic months in 2020 compared with 2019 admissions. RESULTS: A total of 40 studies were included in this multistudy analysis. They demonstrated a 28.1% reduction in the rate of admission with ACS during the COVID-19 pandemic period compared with the same period in 2019 (total of 28 613 patients in 2020 vs 39 225 in 2019). There was a significant correlation between the absolute risk reduction in the total number of ACS cases and the number of COVID-19 cases per 100 000 population (Pearson correlation=0.361 (p=0.028)). However, the correlation was not significant for each of the ACS subgroups: non-ST-elevation myocardial infarction (STEMI) (p=0.508), STEMI (p=0883) and unstable angina (p=0.175). CONCLUSION: There was a significant reduction in the rate of ACS admission during the COVID-19 pandemic period compared with the same period in 2019 with a significant correlation with COVID-19 prevalence.

Undiagnosed SARS-CoV-2 infection and outcome in patients with acute MI and no COVID-19 symptoms.

OBJECTIVE: We aimed to determine the prevalence and outcome of occult infection with SARS-CoV-2 and influenza in patients presenting with myocardial infarction (MI) without COVID-19 symptoms. METHODS: We conducted an observational study from 28 June to 11 August 2020, enrolling patients admitted to the National Institute of Cardiovascular Disease Hospital, Dhaka, Bangladesh, with ST-segment elevation MI (STEMI) or non-ST-segment elevation MI who did not meet WHO criteria for suspected COVID-19. Samples were collected by nasopharyngeal swab to test for SARS-CoV-2 and influenza virus by real-time reverse transcriptase PCR. We followed up patients at 3 months (13 weeks) postadmission to record adverse cardiovascular outcomes: all-cause death, new MI, heart failure and new percutaneous coronary intervention or stent thrombosis. Survival analysis was performed using the Kaplan-Meier method. RESULTS: We enrolled 280 patients with MI, 79% male, mean age 54.5±11.8 years, 140 of whom were diagnosed with STEMI. We found 36 (13%) to be infected with SARS-CoV-2 and 1 with influenza. There was no significant difference between mortality rate observed among SARS-CoV-2 infected patients compared with non-infected (5 (14%) vs 26 (11%); p=0.564). A numerically shorter median time to a recurrent cardiovascular event was recorded among SARS-CoV-2 infected compared with non-infected patients (21 days, IQR: 8-46 vs 27 days, IQR: 7-44; p=0.378). CONCLUSION: We found a substantial rate of occult SARS-CoV-2 infection in the studied cohort, suggesting SARS-CoV-2 may precipitate MI. Asymptomatic patients with COVID-19 admitted with MI may contribute to disease transmission and warrants widespread testing of hospital admissions.

The missing acute coronary syndromes in the COVID-19 era.

AIMS: To determine whether the number of patients presenting with acute coronary syndromes has reduced during the COVID-19 pandemic. METHODS: Numbers of primary percutaneous coronary intervention (PPCI) activations, ST elevation myocardial infarctions (STEMIs) and non-ST elevation myocardial infarctions (NSTEMIs) in a large tertiary Greater London centre and a large district general hospital, both of which have on-site heart attack centres, were collected. We compared the number of PPCI activations, STEMI, NSTEMIs and all MIs prior to the COVID-19 era (January to third week of February 2020), after the start of some COVID-19 restrictions taking place (fourth week of February 2020) and after formal instruction by the United Kingdom Government that all citizens were to observe strict social distancing measures (20 March 2020). We further obtained data for the corresponding weekly figures from 2019. RESULTS: The average weekly figure of all myocardial infarction in 2020, prior to the COVID-19 social distancing restrictions/awareness in the UK (beginning of January to third week of February), did not differ when compared with corresponding weeks in 2019 (23.3 ± 5.4 in 2019 versus 21.13 ± 3.5, p = 0.411).With increased media reporting and associated public awareness of the threat of COVID-19 (last week of February), there was a significant reduction in all myocardial infarction (27.1 ± 4.7 in 2019 versus 15.9 ± 3.6 in 2020, p < 0.001). Following official governmental instruction that mandated strict social distancing and the 'stay at home' campaign, the weekly figures of STEMI (15 ± 3.5 in 2019 versus 10 ± 4.4 in 2020, p = 0.013), NSTEMI (13 ± 2.6 in 2019 versus 4.7 ± 2.3 in 2020, p = 0.038) and all myocardial infarction (28 ± 6.1 in 2019 versus 14.7 ± 5.7 in 2020, p = 0.008) have remained significantly reduced. CONCLUSION: We have observed an unexpected major decline in presentations (and treatment) of the entire spectrum of acute coronary syndromes following the beginning of the COVID-19 pandemic and nationwide public-health measures that have promoted the importance of strict social distancing and self-quarantine.

Clinical features of patients with acute coronary syndrome during the COVID-19 pandemic.

Although a reduction in hospital admissions of acute coronary syndromes (ACS) patients has been observed globally during the coronavirus disease 2019 (COVID-19) pandemic, clinical features of those patients have not been fully investigated. The aim of the present analysis is to investigate the incidence, clinical presentation, and outcomes of patients with ACS during the COVID-19 pandemic. We performed a retrospective analysis of consecutive patients who were admitted for ACS at our institution between March 1 and April 20, 2020 and compared with the equivalent period in 2019. Admissions for acute myocardial infarction (AMI) reduced by 39.5% in 2020 compared with the equivalent period in 2019. Owing to the emergency medical services (EMS) of our region, all time components of ST-elevated myocardial infarction care were similar during the COVID-19 outbreak as compared with the previous year's dataset. Among the 106 ACS patients in 2020, 7 patients tested positive for COVID-19. Higher incidence of type 2 myocardial infarction (29% vs. 4%, p = 0.0497) and elevated D-dimer levels (5650 µg/l [interquartile range (IQR) 1905-13,625 µg/l] vs. 400 µg/l [IQR 270-1050 µg/l], p = 0.02) were observed in COVID-19 patients. In sum, a significant reduction in admission for AMI was observed during the COVID-19 pandemic. COVID-19 patients were characterized by elevated D-dimer levels on admission, reflecting enhanced COVID-19 related thrombogenicity. The prehospital evaluation by EMS may have played an important role for the timely revascularization for STEMI patients.

In-Hospital Management and Outcomes of Acute Myocardial Infarction Before and During the Coronavirus Disease 2019 Pandemic.

The outbreak of coronavirus disease 2019 (COVID-19) has rapidly spread worldwide. This study sought to share our experiences with in-hospital management and outcomes of acute myocardial infarction (AMI) during the COVID-19 pandemic. We retrospectively analyzed consecutive AMI patients, including those with ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI), from February 1, 2020, to April 15, 2020 (during the COVID-19 pandemic), and from January 1, 2019, to December 31, 2019 (before the COVID-19 pandemic), respectively. Fifty-three AMI patients (31 STEMI, 22 NSTEMI) during the COVID-19 pandemic were matched to 53 AMI patients before the pandemic. Baseline characteristics were comparable between the matched patients. STEMI patients during the COVID-19 pandemic had a longer delay time, less primary or remedial PCI and more emergency thrombolysis than those before the pandemic. Less coronary angiography and stenting were performed in AMI patients during the COVID-19 pandemic than before the pandemic. There were no statistically significant differences in the clinical outcomes between the matched patients. However, STEMI patients during the COVID-19 pandemic had a 4-fold (12.9% vs. 3.2%) increase in all-cause mortality rate compared with those before the pandemic. AMI combined with COVID-19 infection was associated with higher rates of mortality than AMI alone. This study demonstrates that the COVID-19 pandemic results in significant reperfusion delays in STEMI patients and has a marked impact on the treatment options selection in AMI patients. The mortality rate of STEMI patients exhibits an increasing trend during the pandemic of COVID-19.

Reduction in acute coronary syndromes during coronavirus disease 2019 global pandemic: data from the Marche region of Italy.

AIMS: During the novel severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019) pandemic, a worldwide reduction in total acute coronary syndrome (ACS) has been reported. In early 2020, Italy became the most affected country and national lockdown was declared early on in March. We described trends in ACS from all the Marche coronary catheterization laboratories (CCL) during the global pandemic. METHODS: Retrospective study of all consecutive patients admitted to the four regional CCL. The coronavirus disease 2019 period (20 February 2020 to 15 April 2020) was compared with the interyear control period (1 January 2020 to 19 February 2020) and to the intrayear control period (20 February 2019 to 15 April 2019). All patients with an initial diagnosis of ACS were included in the analysis, and further stratified into ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI)/unstable angina. RESULTS: A total of 1239 patients were enrolled. Daily incidence of ACS was 6.1, 6.3 and 4.5 for the interyear control period, the intrayear control period and the case period, respectively. There was no difference in overall STEMI daily incidence while NSTEMI/unstable angina fell from 3.6 and 3.3-1.8 during the case period (P = 0.01). Incidence rate ratios were significantly lower when the case period was compared with the intrayear control period (incidence rate ratios: 0.49, 95% confidence interval 0.41-0.59, P = 0.001) and the interyear control period (incidence rate ratios: 0.67, 95% confidence interval 0.50-0.90, P = 0.008). CONCLUSION: During the global pandemic there was a significant reduction in total ACS and NSTEMI in the Marche region. Unlike previous reports, there was no difference in overall access to CCL for STEMI during the same period.

Patient response, treatments, and mortality for acute myocardial infarction during the COVID-19 pandemic.

AIMS: COVID-19 might have affected the care and outcomes of hospitalized acute myocardial infarction (AMI). We aimed to determine whether the COVID-19 pandemic changed patient response, hospital treatment, and mortality from AMI. METHODS AND RESULTS: Admission was classified as non-ST-elevation myocardial infarction (NSTEMI) or STEMI at 99 hospitals in England through live feeding from the Myocardial Ischaemia National Audit Project between 1 January 2019 and 22 May 2020. Time series plots were estimated using a 7-day simple moving average, adjusted for seasonality. From 23 March 2020 (UK lockdown), median daily hospitalizations decreased more for NSTEMI [69 to 35; incidence risk ratios (IRR) 0.51, 95% confidence interval (CI) 0.47-0.54] than STEMI (35 to 25; IRR 0.74, 95% CI 0.69-0.80) to a nadir on 19 April 2020. During lockdown, patients were younger (mean age 68.7 vs. 66.9 years), less frequently diabetic (24.6% vs. 28.1%), or had cerebrovascular disease (7.0% vs. 8.6%). ST-elevation myocardial infarction more frequently received primary percutaneous coronary intervention (81.8% vs. 78.8%), thrombolysis was negligible (0.5% vs. 0.3%), median admission-to-coronary angiography duration for NSTEMI decreased (26.2 vs. 64.0 h), median duration of hospitalization decreased (4 to 2 days), secondary prevention pharmacotherapy prescription remained unchanged (each > 94.7%). Mortality at 30 days increased for NSTEMI [from 5.4% to 7.5%; odds ratio (OR) 1.41, 95% CI 1.08-1.80], but decreased for STEMI (from 10.2% to 7.7%; OR 0.73, 95% CI 0.54-0.97). CONCLUSION: During COVID-19, there was a substantial decline in admissions with AMI. Those who presented to hospital were younger, less comorbid and, for NSTEMI, had higher 30-day mortality.

Impact of public health emergency response to COVID-19 on management and outcome for NSTEMI patients in Beijing: A single-center historic control.

BACKGROUND: During coronavirus disease 2019 (COVID-19) epidemic, reducing the number of invasive procedure and choosing conservative medication strategy for patients with non-ST-segment elevation myocardial infarction (NSTEMI) is unavoidable. Whether this relatively conservative strategy will impact in-hospital outcome for NSTEMI patients remains unclear. METHODS AND RESULTS: The current study included all consecutive NSTEMI patients who visited the emergency department in Fuwai Hospital from February 1 to March 31, 2020 and all the NSTEMI patients in the same period of 2019 as a historical control. Very-high-risk patients were defined as clinical presentation of heart failure, cardiac shock, cardiac arrest, recurrent chest pain, and life-threatening arrhythmias. The primary outcome was in-hospital major adverse cardiac events (MACE), defined as a composite of all-cause death, recurrent myocardial infarction, or heart failure. A total of 115 NSTEMI patients were enrolled since the outbreak of COVID-19, and a total of 145 patients were included in the control group. There was a tendency toward higher MACE risk in 2020 compared with 2019 (18.3% vs. 11.7%, p = .14). Among very-high-risk patients, early percutaneous coronary intervention (PCI) strategy in 2019 was associated with reduced MACE risk compared with delayed PCI in 2020 (60.6% [20/33] in 2020 vs. 27.9% [12/43] in 2019, p = .01). CONCLUSIONS: COVID-19 pandemic results in a significant reduction in immediate/early PCI and a trend toward higher adverse event rate during hospitalization, particular in very-high-risk patients.

Worrying decrease in hospital admissions for myocardial infarction during the COVID-19 pandemic.

BACKGROUND: How coronavirus 2019 (COVID-19) is affecting management of myocardial infarction is a matter of concern, as medical resources have been massively reorientated and the population has been in lockdown since 17 March 2020 in France. AIMS: To describe how lockdown has affected the evolution of the weekly rate of myocardial infarctions (non-ST-segment and ST-segment elevation) hospital admissions in Lyon, the second largest city in France. To verify the trend observed, the same analysis was conducted for an identical time window during 2018-2019 and for an unavoidable emergency, i.e. birth. METHODS: Based on the national hospitalisation database [Programme de médicalisation des systèmes d'information (PMSI)], all patients admitted to the main public hospitals for a principal diagnosis of myocardial infarction or birth during the 2nd to the 14th week of 2020 were included. These were compared with the average number of patients admitted for the same diagnosis during the same time window in 2018 and 2019. RESULTS: Before lockdown, the number of admissions for myocardial infarction in 2020 differed from that in 2018-2019 by less than 10%; after the start of lockdown, it decreased by 31% compared to the corresponding time window in 2018-2019. Conversely, the numbers of births remained stable across years and before and after the start of lockdown. CONCLUSION: This study strongly suggests a decrease in the number of admissions for myocardial infarction during lockdown. Although we do not have a long follow-up to determine whether this trend will endure, this is an important warning for the medical community and health authorities.

Will the hidden specter of acute coronary syndrome (ACS) and ST-segment elevation myocardial infarction (STEMI) emerge from the avalanche of COVID-19?

There has been a huge impact of the COVID-19 pandemic on global healthcare systems. Advisories across the world have appealed to people to stay at home and observe social distancing to slow down the pandemic. However it is important to realize as to how this is affecting acute cardiovascular care. Recent studies from Europe and USA have reported > 50% reduction in hospital admissions for ACS and declining rates of coronary interventions. The possible reasons for this noticeable reduction in patients with ACS/STEMI during the COVID-19 pandemic are multi-factorial. On one hand, it is due to change in thresholds for referring patients of ACS/STEMI for cardiac catheterization, with fibrinolysis being acceptable for many stable STEMI patients and conservative management being preferred for NSTEMI patients. Theories abound on how "staying at home" strategy may have led to an reduction in acute coronary events due to healthier lifestyle, better compliance and reduced stress. Realistically however, a more disquieting reason would be a "pseudo-reduction" ie. the incidence of ACS/STEMI is actually the same, but these patients are staying away from hospitals due to fear of contracting the infection. Lockdown restrictions have also limited transport options for patients seeking to reach hospitals in time. Healthcare systems need to be prepared for an anticipated downstream deluge of such untreated patients who may present with sequelae like heart failure, reinfarction, arrhythmias, mechanical complications etc. Scientific societies should have proactive campaigns to alleviate patient concerns, and encourage them to seek timely medical attention despite the COVID-19 pandemic.