COVID-19 pandemic and admission rates for and management of acute coronary syndromes in England

Abstract

Summary Background Several countries affected by the COVID-19 pandemic have reported a substantial drop in the number of patients attending the emergency department with acute coronary syndromes and a reduced number of cardiac procedures. We aimed to understand the scale, nature, and duration of changes to admissions for different types of acute coronary syndrome in England and to evaluate whether in-hospital management of patients has been affected as a result of the COVID-19 pandemic. Methods We analysed data on hospital admissions in England for types of acute coronary syndrome from Jan 1, 2019, to May 24, 2020, that were recorded in the Secondary Uses Service Admitted Patient Care database. Admissions were classified as ST-elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), myocardial infarction of unknown type, or other acute coronary syndromes (including unstable angina). We identified revascularisation procedures undertaken during these admissions (ie, coronary angiography without percutaneous coronary intervention [PCI], PCI, and coronary artery bypass graft surgery). We calculated the numbers of weekly admissions and procedures undertaken; percentage reductions in weekly admissions and across subgroups were also calculated, with 95% CIs. Findings Hospital admissions for acute coronary syndrome declined from mid-February, 2020, falling from a 2019 baseline rate of 3017 admissions per week to 1813 per week by the end of March, 2020, a reduction of 40% (95% CI 37–43). This decline was partly reversed during April and May, 2020, such that by the last week of May, 2020, there were 2522 admissions, representing a 16% (95% CI 13–20) reduction from baseline. During the period of declining admissions, there were reductions in the numbers of admissions for all types of acute coronary syndrome, including both STEMI and NSTEMI, but relative and absolute reductions were larger for NSTEMI, with 1267 admissions per week in 2019 and 733 per week by the end of March, 2020, a percent reduction of 42% (95% CI 38–46). In parallel, reductions were recorded in the number of PCI procedures for patients with both STEMI (438 PCI procedures per week in 2019 vs 346 by the end of March, 2020; percent reduction 21%, 95% CI 12–29) and NSTEMI (383 PCI procedures per week in 2019 vs 240 by the end of March, 2020; percent reduction 37%, 29–45). The median length of stay among patients with acute coronary syndrome fell from 4 days (IQR 2–9) in 2019 to 3 days (1–5) by the end of March, 2020. Interpretation Compared with the weekly average in 2019, there was a substantial reduction in the weekly numbers of patients with acute coronary syndrome who were admitted to hospital in England by the end of March, 2020, which had been partly reversed by the end of May, 2020. The reduced number of admissions during this period is likely to have resulted in increases in out-o...

Management of cardiovascular emergencies during the COVID-19 pandemic

“…Even though primary percutaneous coronary intervention is recommended as the treatment of choice for patients with STEMI, 4 we observed a large decline in catheterization laboratory activation during the pre-lockdown and lockdown periods as most of the patients either presented late or the treating physician opted for thrombolysis. A recently published analysis from the UK did not show an overall increase in inhospital mortality, 5 however inhospital mortality rates in our study increased to 7.27% in the lockdown period compared with 2.79% in the pre-COVID period. An increase in ischaemic time due to a lack of or delayed reperfusion therapy and selective referral of patients with myocardial infarction related complications appears to have resulted in increased mortality rates in patients admitted during the prelockdown and lockdown periods, with the worst prognosis in patients presenting during lockdown.…”

Place and causes of acute cardiovascular mortality during the COVID-19 pandemic

“…Numerous international studies have reported the decline in hospital presentations for a range of CV emergencies. [6][7][8][9][10][11] To the best of our knowledge, this is the first study to show that this is associated with an adverse overall CV impact. While stroke and acute coronary syndrome accounted for the vast majority of acute CV deaths, the number of deaths in hospital due to these conditions fell below that expected for the time of year and it increased in the community, and particularly in people's homes.…”

“…[1][2][3][4][5] Yet, we and others have shown a substantial reduction in presentations to hospitals with acute cardiovascular (CV) conditions including acute coronary syndrome, heart failure, cardiac arrhythmia and stroke during the pandemic. [6][7][8][9][10][11] This would be expected to result in a much higher number of deaths, unless there has been an actual decrease in the incidence of these acute conditions. The detailed impact on mortality from acute CVD has, however, not been studied at national level.…”

Incidence and outcome of myocardial infarction treated with percutaneous coronary intervention during COVID-19 pandemic

“…2 3 Recent reports indicate that fewer patients present to hospitals with myocardial infarction (MI) while the incidence of cardiac arrest have increased in hard-hit areas, raising the question if fear of acquiring COVID-19 results in healthcare avoidance with consequent higher cardiac-related mortality. [4][5][6][7][8][9] However, most reports have either been anecdotal, survey results or geographically limited to areas with lockdowns as a mean of regressing disease transmission. We examined the incidence of MI during the ongoing COVID-19 pandemic in Sweden, which remained an open society with a different public health approach fighting COVID-19.…”