Impact of COVID-19 pandemic on ST-elevation myocardial infarction in a non-COVID-19 epicenter

Abstract

Objectives: We sought to study the impact of COVID-19 pandemic on the presentation delay, severity, patterns of care, and reasons for delay among patients with ST-elevation myocardial infarction (STEMI) in a non-hot-spot region.

Background: COVID-19 pandemic has significantly reduced the activations for STEMI in epicenters like Spain.

Methods: From January 1, 2020, to April 15, 2020, 143 STEMIs were identified across our integrated 18-hospital system. Pre- and post-COVID-19 cohorts were based on March 23rd, 2020, whenstay-at-home orders were initiated in Ohio. We used presenting heart rate, blood pressure, troponin, new Q-wave, and left ventricle ejection fraction (LVEF) to assess severity. Duration of intensive care unit stay, total length of stay, door-to-balloon (D2B) time, and radial versus femoral access were used to assess patterns of care.

Results: Post-COVID-19 presentation was associated with a lower admission LVEF (45 vs. 50%, p = .015), new Q-wave, and higher initial troponin; however, these did not reach statistical significance. Among post-COVID-19 patients, those with >12-hr delay in presentation 31(%) had a longer average D2B time (88 vs. 53 min, p = .033) and higher peak troponin (58 vs. 8.5 ng/ml, p = .03). Of these, 27% avoided the hospital due to fear of COVID-19, 18% believed symptoms were COVID-19 related, and 9% did not want to burden the hospital during the pandemic.

Conclusions: COVID-19 has remarkably affected STEMI presentation and care. Patients' fear and confusion about symptoms are integral parts of this emerging public health crisis.

Keywords: coronavirus; delayed presentation; door-to-balloon; length of stay; troponin.

FIGURE 1

ST‐ elevation myocardial infraction presentation in the pre‐ and post‐COVID‐19 periods. (a) Incidence of late presentation was consistently higher in the post‐COVID‐19 cohort regardless which cutoff was used to define late presentation; similarly, the proportion of patients with (b) new Q‐waves and (c) average initial troponin was consistently higher; and (d) the average initial LVEF was consistently lower [Color figure can be viewed at wileyonlinelibrary.com]

FIGURE 2

Clinical course of 11 patients with >12 hr delay in the post‐COVID‐19 period. About 50% of patients who presented greater than 12 hr after symptom onset in the post‐COVID‐19 period cited a COVID‐19 related apprehension. Although these patients presented late and with greater severity, they had a shorter average total length‐of‐stay (<3 days) [Color figure can be viewed at wileyonlinelibrary.com]

FIGURE 3

Door‐to‐balloon (D2B) times and peak troponin levels with and without presentation delay in the pre‐ and‐post‐COVID‐19 cohorts. D2B times and peak troponin levels were not different between the pre‐ and post‐COVID‐19 cohorts. However, when comparing patients with and without >12‐hr presentation delay within these two cohorts, we found that (b) the D2B times and (d) peak troponin levels were significantly higher in the patients who presented greater than 12 hr after symptom onset in the post‐COVID‐19 cohort [Color figure can be viewed at wileyonlinelibrary.com]