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

Abstract

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.

Intraoperative ventricular septal rupture: A case report

“…15 Indeed, multiple studies have demonstrated a longer time from symptom onset to first medical contact in the setting of MI during the COVID-19 pandemic. [16][17][18] Exemplifying this fact, we were surprised to encounter a similar case report by Kok et al published in 2021. 19 The authors similarly describe a case of VSR during a CABG operation, in which the patient was managed with ECMO cannulation and delayed surgical repair.…”

“…The delayed patient presentation seen here is worth discussing in light of the ongoing impact of the COVID‐19 pandemic, as patients may be more likely to delay seeking care to avoid exposure to the virus in the healthcare setting 15 . Indeed, multiple studies have demonstrated a longer time from symptom onset to first medical contact in the setting of MI during the COVID‐19 pandemic 16–18 . Exemplifying this fact, we were surprised to encounter a similar case report by Kok et al published in 2021 19 .…”

Impact of the COVID-19 Outbreak on the Treatment of Myocardial Infarction Patients

“…However, from the patients admitted for ACS, the proportion of patients undergoing PCI was slightly increased during the first wave of the pandemic [ 20 ]. A Chinese study on the other hand showed a lower percentage of invasive strategy in patients presenting with NSTEMI early in the pandemic period as compared with NSTEMI patients presenting in the same period one year earlier [ 37 ]. It may therefore be hypothesized that the impact of the pandemic on treatment strategies was not uniform across all geographies but rather dependent on several factors including local healthcare protocols, geographical factors (rural vs. urban agglomerations), and intensity of the pandemic expressed in the number of infected and hospitalized.…”

“…This strategy however led to a lower rate of timely reperfusion with an increased rate of recurrent ischemia and a higher rate of cardiogenic shock, and more patients developed heart failure in a Chinese hospital in Beijng [ 38 ]. Another study performed in a hospital in Tianjin, China, compared treatment strategies early in the COVID-19 pandemic period (January to February 2020) with the same period one year earlier [ 37 ]. A primary PCI strategy was performed more often in the pre-COVID-19 pandemic period, while thrombolytic therapy was performed more often in the early pandemic period [ 37 ].…”

“…Another study performed in a hospital in Tianjin, China, compared treatment strategies early in the COVID-19 pandemic period (January to February 2020) with the same period one year earlier [ 37 ]. A primary PCI strategy was performed more often in the pre-COVID-19 pandemic period, while thrombolytic therapy was performed more often in the early pandemic period [ 37 ]. This did not result in differences in 30-day all-cause mortality or major cardiac adverse event rates in STEMI patients presenting during the different periods [ 37 ].…”