“Missing” acute coronary syndrome hospitalizations during the COVID‐19 era in Greece: Medical care avoidance combined with a true reduction in incidence?
Abstract:Background: Reports from countries severely hit by the COVID-19 pandemic suggest a decline in acute coronary syndrome (ACS)-related hospitalizations. The generalizability of this observation on ACS admissions and possible related causes in countries with low COVID-19 incidence are not known.
“… Figure 4 Summary of reports in literature demonstrating the drop in STEMI volume and relative prevalence of COVID-19. 1 , 2 , 6 , 7 , 11 , 13 , 14 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 . For each country, the total number of COVID-19 cases, the cases per million, the drop in STEMI volume by percentages and the size of the study are shown.…”
Background: Management of ST-elevated myocardial infarction (STEMI) necessitates rapid reperfusion. Delays prolong myocardial ischemia and increase the risk of complications, including death. The COVID-19 pandemic may have affected management of STEMI. We evaluated the relative volume of hospitalizations and clinical time intervals within a regional STEMI system. Methods: Four hundred ninety-four patients with STEMI were grouped into prelockdown, lockdown, and reopening cohorts. Clinical, temporal, and outcome data were collected and compared among groups for
R ESUM EContexte : La prise en charge de l'infarctus du myocarde avec el evation du segment ST (STEMI) n ecessite une reperfusion rapide. Tout retard de reperfusion prolonge l'isch emie myocardique et augmente le risque de complications, y compris le risque de d ecès. Il est possible que la pand emie de COVID-19 ait nui à la prise en charge du STEMI. Nous avons donc evalu e le nombre relatif d'hospitalisations et le temps ecoul e avant la reperfusion au sein d'un système r egional de traitement des STEMI. M ethodologie : Au total, 494 patients ayant pr esent e un STEMI ont et e divis es en trois cohortes : pr econfinement, confinement et During the COVID-19 pandemic, a reduction in patients presenting with ST-elevated myocardial infarction (STEMI) has been reported. 1,2 These studies lacked data on important areas including impact of the COVID-19 lockdown on STEMI care in regions with low incidence of disease, granular details regarding reperfusion management during lockdown, effect of the pandemic on STEMI care in rural regions, and patterns of STEMI volume posteCOVID-19 lockdown. It is imperative to study the effects of COVID-19 comprehensively, so that lessons can be learned for a potential second wave or future pandemics.From March 11, 2020, to August 16, 2020, the Ottawa regions recorded 2761 cases of In response to the initial outbreak, the Ontario Ministry of Health declared a state of emergency and instituted lockdown measures on March 17, 2020. 4 Various restrictions were imposed including closure of nonessential businesses, limits on social gatherings, and cancellation of elective medical procedures. 4 These interventions were successful in limiting the spread of COVID-19; however, concerns regarding an unintended impact on STEMI care were raised. 3,
“… Figure 4 Summary of reports in literature demonstrating the drop in STEMI volume and relative prevalence of COVID-19. 1 , 2 , 6 , 7 , 11 , 13 , 14 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 . For each country, the total number of COVID-19 cases, the cases per million, the drop in STEMI volume by percentages and the size of the study are shown.…”
Background: Management of ST-elevated myocardial infarction (STEMI) necessitates rapid reperfusion. Delays prolong myocardial ischemia and increase the risk of complications, including death. The COVID-19 pandemic may have affected management of STEMI. We evaluated the relative volume of hospitalizations and clinical time intervals within a regional STEMI system. Methods: Four hundred ninety-four patients with STEMI were grouped into prelockdown, lockdown, and reopening cohorts. Clinical, temporal, and outcome data were collected and compared among groups for
R ESUM EContexte : La prise en charge de l'infarctus du myocarde avec el evation du segment ST (STEMI) n ecessite une reperfusion rapide. Tout retard de reperfusion prolonge l'isch emie myocardique et augmente le risque de complications, y compris le risque de d ecès. Il est possible que la pand emie de COVID-19 ait nui à la prise en charge du STEMI. Nous avons donc evalu e le nombre relatif d'hospitalisations et le temps ecoul e avant la reperfusion au sein d'un système r egional de traitement des STEMI. M ethodologie : Au total, 494 patients ayant pr esent e un STEMI ont et e divis es en trois cohortes : pr econfinement, confinement et During the COVID-19 pandemic, a reduction in patients presenting with ST-elevated myocardial infarction (STEMI) has been reported. 1,2 These studies lacked data on important areas including impact of the COVID-19 lockdown on STEMI care in regions with low incidence of disease, granular details regarding reperfusion management during lockdown, effect of the pandemic on STEMI care in rural regions, and patterns of STEMI volume posteCOVID-19 lockdown. It is imperative to study the effects of COVID-19 comprehensively, so that lessons can be learned for a potential second wave or future pandemics.From March 11, 2020, to August 16, 2020, the Ottawa regions recorded 2761 cases of In response to the initial outbreak, the Ontario Ministry of Health declared a state of emergency and instituted lockdown measures on March 17, 2020. 4 Various restrictions were imposed including closure of nonessential businesses, limits on social gatherings, and cancellation of elective medical procedures. 4 These interventions were successful in limiting the spread of COVID-19; however, concerns regarding an unintended impact on STEMI care were raised. 3,
“…First, the reduction in hospitalizations may also be attributed to the mitigation of other lifestyle and environmental risk factors during quarantine, such as reduced exposure to traffic, air pollution, other respiratory infections (eg, influenza), as well as reduced energy expenditure. 35 , 51 This is supported by a decline in hospitalizations and ED visits for chronic obstructive pulmonary disease (COPD)/asthma and pneumonia during the COVID-19 pandemic, which shares many of these risk factors. 37 , 52 , 53 Another possible explanation is that the effective shift into telemedicine, coupled with the absence of prior distractions (eg, work, travel, etc.…”
Section: Healthcare Characteristics and Utilization By Individuals Wimentioning
Background
Individuals with chronic conditions require ongoing disease management to reduce risks of adverse health outcomes. During the COVID-19 pandemic, health care for non-COVID-19 cases was affected due to the reallocation of resources towards urgent care for COVID-19 patients, resulting in inadequate ongoing care for chronic conditions.
Methods
A keyword search was conducted in PubMed, Google Scholar, Science Direct, and Scopus for English language articles published between January 2020 and January 2021.
Findings
During the COVID-19 pandemic, in-person care for individuals with chronic conditions have decreased due to government restriction of elective and non-urgent healthcare visits, greater instilled fear over potential COVID-19 exposure during in-person visits, and higher utilization rates of telemedicine compared to the pre-COVID-19 period. Potential benefits of a virtual-care framework during the pandemic include more effective routine disease monitoring, improved patient satisfaction, and increased treatment compliance and follow-up rates. However, more needs to be done to ensure timely and effective access to telemedicine, particularly for individuals with lower digital literacy. Capitation primary care models have been proposed as a more financially-robust approach during the COVID-19 pandemic than fee-for-service primary care models; however, the interplay between different primary models and the health outcomes is still poorly understood and warrants further investigation. Shortages of medication used to manage chronic conditions were also observed at the beginning of the COVID-19 pandemic due to global supply chain disruptions. Finally, patients with chronic conditions faced lifestyle disruptions due to the COVID-19 pandemic, specifically in physical activity, sleep, stress, and mental health, which need to be better addressed.
Interpretation
Overall, this review elucidates the disproportionately greater barriers to primary and specialty care that patients with chronic diseases face during the COVID-19 pandemic and emphasizes the urgent need for better chronic disease management strategies moving forward.
“…Hospital admissions for acute coronary syndromes were decreased by approximately 40% in one study during the COVID-19 pandemic, likely reflecting patient preferences to remain home when experiencing symptoms given the risk of transmission of virus in the healthcare setting. 20 Other studies have confirmed this decline in ACS admissions, 21 , 22 raising the concern that large numbers of patients may emerge from the pandemic with the sequelae of untreated acute coronary syndrome, such as heart failure. 23 …”
Background: Thrombotic complications of COVID-19 infection have become increasingly apparent as the disease has infected a growing number of individuals. Although less common than upper respiratory symptoms, thrombotic complications are not infrequent and may result in severe and long-term sequelae. Common thrombotic complications include pulmonary embolism, cerebral infarction, or venous thromboembolism; less commonly seen are acute myocardial injury, renal artery thrombosis, and mesenteric ischemia. Several case reports and case series have described acute myocardial injury in patients with COVID-19 characterized by elevations in serum biomarkers. Case report: Here, we report the first case to our knowledge of a patient with acute coronary syndrome confirmed on catheter angiography and cardiac MRI. This patient was found to additionally have a left ventricular thrombus and ultimately suffered an acute cerebral infarction. Recognition of thrombotic complications in the setting of COVID-19 infection is essential for initiating appropriate therapy. Conclusions: In acute myocardial injury, given the different treatment strategies for myocarditis versus acute myocardial infarction secondary to coronary artery thrombus, imaging can play a key role in clinical decision making for patients.
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