ST-Segment elevation myocardial infarction in a Buenos Aires center during the current COVID-19 pandemic
A Matías Rodríguez-Granillo, Hernán Pavlovsky, Camila Correa-Sadouet, Camila Gallardo, Axel Vitale, María V Curotto, Carlos Fernández-Pereira, Juan Mieres, Ricardo Pérez de la Hoz, Alfredo E Rodríguez
Revista Argentina de Cardioangiología Intervencionista 2020;(2) | Doi: 10.30567/RACI/20202/0070-0072Material web complementario al número impreso
The COVID-19 pandemic presents an exponential growth in the number of admissions in intensive care units due to the necessity for respiratory support in this patients and a diminish in the consultation for another severe illnesses that were prevalent in years before, such as acute coronary syndromes with ST-T elevation segment. In our institution this phenomena was present with a delayed symptoms-first medical contact, with later presentations and an elevation of complications during hospitalization, including cardiogenic shock and acute heart failure.
Palabras clave: STEMI.STEACS. COVID-19. SARS-COV-2.
La pandemia COVID-19 presentó un aumento exponencial en el número de internaciones en las unidades de cuidados intensivos alrededor del mundo debido al requerimiento de asistencia ventilatoria y una disminución en la consulta de patologías graves y prevalentes en años previos, en especial de casos graves como el síndrome coronario agudo con elevación del segmento ST-T. En nuestra institución se manifestó el fenómeno con un aumento en los tiempos dolor-primer contacto médico, con presentaciones tardías, y un aumento de las complicaciones intrahospitalarias, incluyendo shock cardiogénico e insuficiencia cardíaca aguda.
Keywords: IAMCEST. SCASEST. COVID-19. SARS-COV-2.
Los autores declaran no poseer conflictos de intereses.
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Recibido 2020-05-18 | Aceptado 2020-05-23 | Publicado 2020-06-30
The highly infectious coronavirus-2 (SARS-CoV-2) that has caused the current COVID-19 pandemic has also caused the collapse of public healthcare systems of numerous countries in Asia, Europe, and America due to the need for ventilatory support in complex patients with long intensive care unit (ICU) stays1,2. At the same time, consultations due to other prevalent conditions have gone down significantly3,4. However, at the start of May 2020 the COVID-19 related infection and morality rates were lower in Argentina compared to the ones reported by other countries. Still, the consultations for conditions with a high morbimortality burden like the ST-segment elevation myocardial infarction (STEMI) have dropped compared to previous years. Similar results have been reported in other countries3,4. The objective of this manuscript is to assess the immediate impact of this findings to anticipate behavioral patterns to alleviate the possible consequences.
Material and Results
Since the World Health Organization (WHO) declared the SARS-CoV-2 pandemic back in March 11, 2020, many countries decided to implement quarantines as a way to flatten the curve of contagion. Argentina declared a mandatory quarantine back in March 20, 2020 at 00:00 hours5. Since then, 7 patients with a diagnosis of STEMI have been admitted to our center and included consecutively in this registry. The baseline, clinical, and angiographic data of all consecutive patients were analyzed and compared to the data of patients admitted the year before with the same condition. The main characteristics of both groups are shown on table 1. In the COVID-19 group the mean age was 70.8±10.4 years, 85.7% of the patients were males and they reported pain (first medical contact, 552±300 minutes). All cases underwent a primary coronary intervention. The rate of angiographic success was 100% and 1.8 stents were implanted per patient. The rate of complications was 71.4%. One patient had cardiogenic shock, 2 more patients required IV diuretics with KK class B at admission, 1 of them had cardiac tamponade and the other bleeding at the puncture site. The mean stay in the coronary unit was 9±10 days. When these results were compared to patients with ST-segment elevation from 2019 (Pre-COVID-19) significant differences were seen regarding the pain onset-to-first medical contact time (P=.001), but no differences were reported regarding the door-to-balloon time (P=.76). Cardiogenic shock, the ejection fraction measured on the color Doppler echocardiography, and the rate of bleeding that required longer hospital stays were higher in the COVID-19 group compared to patients previously admitted as shown on table 2. Figure 1 shows the pain onset-to-first medical contact time from January 2019 through May 2020. The start of the COVID-19 pandemic is shown with a red vertical line.
Yet despite its observational nature and unknown confounding factors, these findings are indicative that the impact the COVID-19 quarantine had had on our population has delayed consultation times especially in cases of ST-segment elevation myocardial infarction. This results in higher rates of complications and longer intervention times, which is especially detrimental to the patients’ state of health, in particular, and the healthcare system in general since the occupation time of beds for high-complexity care is longer. These results are similar to those reported in other countries7. In a letter sent to the editor of Solomon et al. published in the New England Journal of Medicine back in May 19th, the authors reported fewer AMI related hospitalizations in a California hospital, United States compared to previous years; these results are similar to those reported in Northern Italy7,8. In our own experience, the beginning of the pandemic was associated with fewer consultations, which gave rise to a second stage where patients started seeking medical attention a little too late. This is somehow consistent to what has been published recently7.This last stage is not over yet in our country.The consequences that these findings will have in the future are still unknown. However, based on previous data, the mortality rate could go up. The patients’ rate of heart failure and their quality of life could go down as well. We suggest active policies to raise the awareness of the population on these indirect complications due to the current COVID-19 pandemic.
Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497–506.
Grasselli G, Zangrillo A, Zanella A, et al. Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy Region, Italy. JAMA 2020; doi: 10.1001/jama.2020.5394.
Garcia S, Albaghdadi MS, Meraj PM, et al. Reduction in STsegment elevation cardiac catheterization laboratory activations in the United States during COVID-19 pandemic. J Am Coll Cardiol 2020 April 9 (Epub ahead of print).
De Filippo O, D’Ascenzo F, Angelini F, et al. Reduced rate of hospital admissions for ACS during Covid-19 outbreak in northern Italy. N Engl J Med. DOI: 10.1056/NEJMc2009166.
World Health Organization. WHO Director- General’s opening remarks at the media briefing on COVID-19—11 March 2020. Available at https://www.who.int/dg/speeches/detail/whodirector-general-s-opening-remarks-at-the-mediabriefing- on-covid-19—11-march-2020. Accessed March 12, 2020.
Cosentino N, Bartorelli NL, Marenzi G, Time to treatment still matters in ST-elevation myocardial infarction: a call to maintain treatment effectiveness during the COVID-19 pandemic, European Heart Journal - Cardiovascular Pharmacotherapy, pvaa054, https://doi.org/10.1093/ehjcvp/pvaa054
Solomon MD, McNulty EJ, Rana JS et al. The Covid-19 Pandemic and the Incidence of Acute Myocardial Infarction. N Enlg J Med. DOI: 10.1056/NEJMc2015630
De Filippo O, D’Ascenzo F, Angelini F, et al. Reduced rate ofhospital admissions for ACS during Covid-19 outbreak in northernItaly. N Engl J Med. DOI: 10.1056/NEJMc2009166.
Revista Argentina de Cardioangiología intervencionista
Web 2 | Volumen 10 | Año 2020
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