COVID-19 pandemic and admission rates for and management of acute coronary syndromes in England

Abstract

Background: Several countries affected by the COVID-19 pandemic have reported a substantial drop in the number of patients attending the emergency department with acute coronary syndromes and a reduced number of cardiac procedures. We aimed to understand the scale, nature, and duration of changes to admissions for different types of acute coronary syndrome in England and to evaluate whether in-hospital management of patients has been affected as a result of the COVID-19 pandemic.

Methods: We analysed data on hospital admissions in England for types of acute coronary syndrome from Jan 1, 2019, to May 24, 2020, that were recorded in the Secondary Uses Service Admitted Patient Care database. Admissions were classified as ST-elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), myocardial infarction of unknown type, or other acute coronary syndromes (including unstable angina). We identified revascularisation procedures undertaken during these admissions (ie, coronary angiography without percutaneous coronary intervention [PCI], PCI, and coronary artery bypass graft surgery). We calculated the numbers of weekly admissions and procedures undertaken; percentage reductions in weekly admissions and across subgroups were also calculated, with 95% CIs.

Findings: Hospital admissions for acute coronary syndrome declined from mid-February, 2020, falling from a 2019 baseline rate of 3017 admissions per week to 1813 per week by the end of March, 2020, a reduction of 40% (95% CI 37-43). This decline was partly reversed during April and May, 2020, such that by the last week of May, 2020, there were 2522 admissions, representing a 16% (95% CI 13-20) reduction from baseline. During the period of declining admissions, there were reductions in the numbers of admissions for all types of acute coronary syndrome, including both STEMI and NSTEMI, but relative and absolute reductions were larger for NSTEMI, with 1267 admissions per week in 2019 and 733 per week by the end of March, 2020, a percent reduction of 42% (95% CI 38-46). In parallel, reductions were recorded in the number of PCI procedures for patients with both STEMI (438 PCI procedures per week in 2019 vs 346 by the end of March, 2020; percent reduction 21%, 95% CI 12-29) and NSTEMI (383 PCI procedures per week in 2019 vs 240 by the end of March, 2020; percent reduction 37%, 29-45). The median length of stay among patients with acute coronary syndrome fell from 4 days (IQR 2-9) in 2019 to 3 days (1-5) by the end of March, 2020.

Interpretation: Compared with the weekly average in 2019, there was a substantial reduction in the weekly numbers of patients with acute coronary syndrome who were admitted to hospital in England by the end of March, 2020, which had been partly reversed by the end of May, 2020. The reduced number of admissions during this period is likely to have resulted in increases in out-of-hospital deaths and long-term complications of myocardial infarction and missed opportunities to offer secondary prevention treatment for patients with coronary heart disease. The full extent of the effect of COVID-19 on the management of patients with acute coronary syndrome will continue to be assessed by updating these analyses.

Funding: UK Medical Research Council, British Heart Foundation, Public Health England, Health Data Research UK, and the National Institute for Health Research Oxford Biomedical Research Centre.

Figure 1

Weekly admissions to acute National Health Service hospital trusts in England with an acute coronary syndrome, by type For weekly admissions in 2019, boxplots show the median and IQR, with whiskers extending (up to) 1·5 times the IQR above the upper quartile and below the lower quartile, with any weekly counts beyond those ranges indicated by x. For 2020, a locally estimated scatterplot smoothing spline is fitted through the weekly reported counts, with datapoints and SEs plotted. The date of the UK COVID-19 lockdown (March 23, 2020) is shown with a vertical dotted line. STEMI=ST-elevation myocardial infarction. NSTEMI=non-ST-elevation myocardial infarction.

Figure 2

Weekly admissions to acute National Health Service hospital trusts in England with an acute coronary syndrome receiving PCI on the day of admission For weekly admissions in 2019, boxplots show the median and IQR, with whiskers extending (up to) 1·5 times the IQR above the upper quartile and below the lower quartile, with any weekly counts beyond those ranges indicated by x. For 2020, a locally estimated scatterplot smoothing spline is fitted through the weekly reported counts or proportions. Vertical lines represent 1 SD for weekly counts or proportions. The date of the UK COVID-19 lockdown (March 23, 2020) is shown with a vertical dotted line. STEMI=ST-elevation myocardial infarction. NSTEMI=non-ST-elevation myocardial infarction. PCI=percutaneous coronary intervention.

Figure 3

Weekly admissions to acute National Health Service hospital trusts in England with an acute coronary syndrome receiving a coronary procedure For weekly admissions in 2019, boxplots (coloured according to type of procedure) show the median and IQR, with whiskers extending (up to) 1·5 times the IQR above the upper quartile and below the lower quartile, with any weekly counts beyond those ranges indicated by x. For 2020, a locally estimated scatterplot smoothing spline is fitted through the weekly reported counts, with datapoints and SEs plotted. The date of the UK COVID-19 lockdown (March 23, 2020) is shown with a vertical dotted line. CABG=coronary artery bypass graft. STEMI=ST-elevation myocardial infarction. NSTEMI=non-ST-elevation myocardial infarction. PCI=percutaneous coronary intervention.