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Will the hidden specter of acute coronary syndrome (ACS) and ST-segment elevation myocardial infarction (STEMI) emerge from the avalanche of COVID-19?

ABSTRACT: There has been a huge impact of the COVID-19 pandemic on global healthcare systems. Advisories across the world have appealed to people to stay at home and observe social distancing to slow down the pandemic. However it is important to realize as to how this is affecting acute cardiovascular care. Recent studies from Europe and USA have reported > 50% reduction in hospital admissions for ACS and declining rates of coronary interventions. The possible reasons for this noticeable reduction in patients with ACS/STEMI during the COVID-19 pandemic are multi-factorial. On one hand, it is due to change in thresholds for referring patients of ACS/STEMI for cardiac catheterization, with fibrinolysis being acceptable for many stable STEMI patients and conservative management being preferred for NSTEMI patients. Theories abound on how "staying at home" strategy may have led to an reduction in acute coronary events due to healthier lifestyle, better compliance and reduced stress. Realistically however, a more disquieting reason would be a "pseudo-reduction" ie. the incidence of ACS/STEMI is actually the same, but these patients are staying away from hospitals due to fear of contracting the infection. Lockdown restrictions have also limited transport options for patients seeking to reach hospitals in time. Healthcare systems need to be prepared for an anticipated downstream deluge of such untreated patients who may present with sequelae like heart failure, reinfarction, arrhythmias, mechanical complications etc. Scientific societies should have proactive campaigns to alleviate patient concerns, and encourage them to seek timely medical attention despite the COVID-19 pandemic.

SUBMITTER: Kapoor A

PROVIDER: S-EPMC7261094 | biostudies-literature | 2020 May - Jun

REPOSITORIES: biostudies-literature

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Will the hidden specter of acute coronary syndrome (ACS) and ST-segment elevation myocardial infarction (STEMI) emerge from the avalanche of COVID-19?

Kapoor Aditya A Yadav Rakesh R

Indian heart journal 20200530 3

There has been a huge impact of the COVID-19 pandemic on global healthcare systems. Advisories across the world have appealed to people to stay at home and observe social distancing to slow down the pandemic. However it is important to realize as to how this is affecting acute cardiovascular care. Recent studies from Europe and USA have reported > 50% reduction in hospital admissions for ACS and declining rates of coronary interventions. The possible reasons for this noticeable reduction in pati ...[more]

PMID: 32768020

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Project description:ImportanceChallenges to improving ST-segment elevation myocardial infarction (STEMI) care are formidable in low- to middle-income countries because of several system-level factors.ObjectiveTo examine access to reperfusion and percutaneous coronary intervention (PCI) during STEMI using a hub-and-spoke model.Design, setting, and participantsThis multicenter, prospective, observational study of a quality improvement program studied 2420 patients 20 years or older with symptoms or signs consistent with STEMI at primary care clinics, small hospitals, and PCI hospitals in the southern state of Tamil Nadu in India. Data were collected from the 4 clusters before implementation of the program (preimplementation data). We required a minimum of 12 weeks for the preimplementation data with the period extending from August 7, 2012, through January 5, 2013. The program was then implemented in a sequential manner across the 4 clusters, and data were collected in the same manner (postimplementation data) from June 12, 2013, through June 24, 2014, for a mean 32-week period.ExposuresCreation of an integrated, regional quality improvement program that linked the 35 spoke health care centers to the 4 large PCI hub hospitals and leveraged recent developments in public health insurance schemes, emergency medical services, and health information technology.Main outcomes and measuresPrimary outcomes focused on the proportion of patients undergoing reperfusion, timely reperfusion, and postfibrinolysis angiography and PCI. Secondary outcomes were in-hospital and 1-year mortality.ResultsA total of 2420 patients with STEMI (2034 men [84.0%] and 386 women [16.0%]; mean [SD] age, 54.7 [12.2] years) (898 in the preimplementation phase and 1522 in the postimplementation phase) were enrolled, with 1053 patients (43.5%) from the spoke health care centers. Missing data were common for systolic blood pressure (213 [8.8%]), heart rate (223 [9.2%]), and anterior MI location (279 [11.5%]). Overall reperfusion use and times to reperfusion were similar (795 [88.5%] vs 1372 [90.1%]; P = .21). Coronary angiography (314 [35.0%] vs 925 [60.8%]; P < .001) and PCI (265 [29.5%] vs 707 [46.5%]; P < .001) were more commonly performed during the postimplementation phase. In-hospital mortality was not different (52 [5.8%] vs 85 [5.6%]; P = .83), but 1-year mortality was lower in the postimplementation phase (134 [17.6%] vs 179 [14.2%]; P = .04), and this difference remained consistent after multivariable adjustment (adjusted odds ratio, 0.76; 95% CI, 0.58-0.98; P = .04).Conclusions and relevanceA hub-and-spoke model in South India improved STEMI care through greater use of PCI and may improve 1-year mortality. This model may serve as an example for developing STEMI systems of care in other low- to middle-income countries.

Project description:BackgroundST-segment elevation myocardial infarction (STEMI) is a clinically distinguishable yet lethal sequela of ischaemic heart disease (IHD). In sub-Saharan Africa (SSA), death due to acute STEMI is increasing. In South Africa, there is a paucity of data available on the clinical outcomes of acute STEMI within one year for individuals treated in the public healthcare sector. This study primarily seeks to determine the one-year all-cause mortality rate of acute STEMI. The study also assesses the value of serum cardiac biomarkers of myocardial damage and serum uric acid in predicting all-cause mortality in STEMI.MethodsThis is a single-centre observational prospective cohort of all consecutive individuals presenting with an acute STEMI to the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) in Johannesburg, South Africa. Research data will be sourced on admission through electronic medical records, blood laboratory results and coronary angiography reports, and at follow-up through periodic telephonic interviews and standardised echocardiograms. At least 355 eligible participants will be continuously followed over one year, and clinical outcomes will be measured 30 days, three months, six months and one year after the index hospitalisation.DiscussionThis study provides insights into the demographic, risk factors and clinical profiles of individuals with STEMI in South Africa. Its findings may improve the risk stratification, prognostication, and therapeutic management of STEMI patients in our setting. By comparing the clinical outcomes between the different coronary reperfusion strategies, our results may guide clinicians in providing better patient treatment, particularly in sub-Saharan Africa, where access to percutaneous coronary intervention may be limited. Furthermore, the study offers insights into the routine use of baseline serum uric acid as a potential low-cost prognostic biomarker of all-cause mortality in STEMI. Finally, this study's findings may be of public health significance to local policymakers to aid in reinforcing primary prevention strategies and developing structured referral networks for timely coronary reperfusion of acute STEMI.

Dataset Information

Will the hidden specter of acute coronary syndrome (ACS) and ST-segment elevation myocardial infarction (STEMI) emerge from the avalanche of COVID-19?

Publications

Will the hidden specter of acute coronary syndrome (ACS) and ST-segment elevation myocardial infarction (STEMI) emerge from the avalanche of COVID-19?

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