Changing pattern of admissions for acute myocardial infarction in India during the COVID-19 pandemic.

AIM: Studies on the changes in the presentation and management of acute myocardial infarction (AMI) during the COVID-19 pandemic from low- and middle-income countries are limited. We sought to determine the changes in the number of admissions, management practices, and outcomes of AMI during the pandemic period in India. METHODS & RESULTS: In this two-timepoint cross-sectional study involving 187 hospitals across India, patients admitted with AMI between 15th March to 15th June in 2020 were compared with those admitted during the corresponding period of 2019. We included 41,832 consecutive adults with AMI. Admissions during the pandemic period (n = 16414) decreased by 35·4% as compared to the corresponding period in 2019 (n = 25418). We observed significant heterogeneity in this decline across India. The weekly average decrease in AMI admissions in 2020 correlated negatively with the number of COVID cases (r = -0·48; r2 = 0·2), but strongly correlated with the stringency of lockdown index (r = 0·95; r2 = 0·90). On a multi-level logistic regression, admissions were lower in 2020 with older age categories, tier 1 cities, and centers with high patient volume. Adjusted utilization rate of coronary angiography, and percutaneous coronary intervention decreased by 11·3%, and 5·9% respectively. CONCLUSIONS: The magnitude of reduction in AMI admissions across India was not uniform. The nature, time course, and the patient demographics were different compared to reports from other countries, suggesting a significant impact due to the lockdown. These findings have important implications in managing AMI during the pandemic.

Pattern of acute MI admissions in India during COVID-19 era: A Cardiological Society of India study - Rationale and design.

BACKGROUND: COVID-19 pandemic has affected around 20million patients worldwide and 2.0 million cases from India. The lockdown was employed to delay the pandemic. However, it had an unintentional impact on acute cardiovascular care, especially acute myocardial infarction (AMI). Observational studies have shown a decrease in hospital admissions for AMI in several developed countries during the pandemic period. We aimed to evaluate the impact of COVID-19 on the AMI admissions patterns across India. METHODS: In this multicentric, retrospective, cross-sectional study, we included all AMI cases admitted to participating hospitals during the study period 15th March to 15th June 2020 and compared them using a historical control of all cases of AMI admitted during the corresponding period in the year 2019. Major objective of the study is to analyze the changes inthe number of hospital admissions for AMI in hospitals across India. In addition, we intend to evaluate the impact of COVID-19 on the weekly AMI admission rates, and other performance measures like rates of thrombolysis/primary percutaneous interventions (PCI), window period, door to balloon time, and door to needle time. Other objectives include evaluation of changes in the major complications and mortality rates of AMI and its predictors during COVID-19 pandemic. CONCLUSIONS: This CSI-AMI study will provide scientific evidence about the impact of COVID-19 on AMI care in India. Based on this study, we may be able to suggest appropriate changes to the existing MI guidelines and to educate the public regarding emergency care for AMI during COVID-19 pandemic.

Single or dual antiplatelet therapy after PCI.

The optimal duration and type of antiplatelet therapy after implantation of a drug-eluting stent (DES) remains uncertain. At the time of the first-in-man implantation of the sirolimus DES in 1999, the protocol-defined dual antiplatelet therapy (DAPT) duration was only 2 months. Subsequently, DAPT duration was extended to 1 year on the basis of anecdotal historical data, and this practice was then incorporated into clinical guidelines. For >1 decade, trialists have sought to compare the safety and efficacy of abbreviated (<6 months) and prolonged (>12 months) DAPT regimens. However, the body of evidence is limited by the heterogeneity of end points, time of randomization, and bleeding criteria used in each trial. Pharmaceutical advances led to the introduction of new ADP-receptor antagonists, which are thought to be more effective than clopidogrel. The ADP-receptor antagonists moved the focus from the optimal duration of DAPT to the potential efficacy of single antiplatelet therapy after DES implantation. In this Review, we summarize the current evidence on the duration of DAPT and the risk of bleeding and adverse cardiac events after DES implantation, and describe the pitfalls of trial interpretation. The ongoing, prospective trials to test single antiplatelet therapy after DES implantation are also discussed.

Early, late and very late incidence of bioresorbable scaffold thrombosis: a systematic review and meta-analysis of randomized clinical trials and observational studies.

INTRODUCTION: The aim of this paper was to determine the incidence of bioresorbable vascular scaffold thrombosis. EVIDENCE ACQUISITION: A systematic review of the published literature between October 2012 and August 2016 was performed using PubMed, Medline and Embase databases. Articles published in the English language that reported the rate of bioresorbable scaffold thrombosis according to Academic Research Consortium criteria were included. Titles and abstracts were screened independently by two authors and further evaluated and assessed for study details, population characteristics and scaffold thrombosis rates. Scaffold thrombosis rates were pooled with meta-analysis using a random effect model. Meta-regression was performed to explore the predictors of device thrombosis. Randomized clinical trials (RCT), observational registries and case series of patients with obstructive coronary artery disease treated with the ABSORB bioresorbable scaffolds (BVS) that reported the rate of definite or probable scaffold thrombosis and the time of the event after implantation (i.e., acute, sub-acute, late and very late) were selected. EVIDENCE SYNTHESIS: Overall, 16,830 patients treated with ABSORB BVS in 59 studies were included. A total of 256 definite or probable scaffold thrombosis (ScT) were identified and included in the present analysis. The overall rate of definite or probable ScT was 1.8% (CI 95% 1.5% to 2.0%) the median follow-up was 12.0 months (interquartile range 7.5 to 15). The rate of very late definite or probable ScT was 1.0% (95% CI 0.6% to 1.5%; 10 studies, 2331 patients). A higher rate of definite and probable scaffold thrombosis was found in studies with patients presenting with acute myocardial infarction (3.6% vs. 1.8%, Q=13.9, df=1, P=0.010). In the meta-regression analysis, the residual per cent diameter stenosis was the only factor associated with ST after scaffold implantation (coefficient 0.091, 95% CI -0.0009 to 0.183, P=0.052). CONCLUSIONS: Using the largest available dataset of patients treated in randomized trials and observational registries, the present meta-analysis shows that the overall rate of definite or probable ScT is 1.8%, with a rate of very late ST of 1.0%. Residual stenosis after scaffold implantation was associated with the occurrence of scaffold thrombosis.

Cardiac anaphylaxis: a case of acute ST-segment elevation myocardial infarction after IM epinephrine for anaphylactic shock.

A 62-year-old male smoker with no other comorbidities presented to emergency department with systemic anaphylaxis, due to oral diclofenac for toothache. He developed acute anterior wall myocardial infarction following IM epinephrine 1 mg 1:1000. Primary percutaneous coronary intervention was done, which showed a thrombus in the mid left anterior descending artery with no evidence of obstructive coronary artery disease after thrombus aspiration.