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Observational Study
. 2021 Feb;8(1):333-343.
doi: 10.1002/ehf2.13075. Epub 2020 Dec 6.

Increased mortality and worse cardiac outcome of acute myocardial infarction during the early COVID-19 pandemic

Uwe Primessnig  1   2   3 , Burkert M Pieske  1   2   3 , Mohammad Sherif  1
Affiliations
Observational Study

Increased mortality and worse cardiac outcome of acute myocardial infarction during the early COVID-19 pandemic

Uwe Primessnig et al. ESC Heart Fail. 2021 Feb.

Abstract

Aims: This study aimed to evaluate the impact of coronavirus disease 2019 (Covid-19) outbreak on admissions for acute myocardial infarction (AMI) and related mortality, severity of presentation, major cardiac complications and outcome in a tertiary-care university hospital in Berlin, Germany.

Methods and results: In a single-centre cross-sectional observational study, we included 355 patients with AMI containing ST-elevation or non-ST-elevation myocardial infarction (STEMI or NSTEMI), admitted for emergency cardiac catheterization between January and April 2020 and the equivalent time in 2019. During the early phase of the Covid-19 pandemic (e-COV) in Berlin (March and April 2020), admissions for AMI halved compared with those in the pre-Covid-19 time (January and February 2020; pre-COV) and with those in the corresponding months in 2019. However, mortality for AMI increased substantially from 5.2% pre-COV to 17.7% (P < 0.05) during e-COV. Severity of presentation for AMI was more pronounced during e-COV [increased levels of cardiac enzymes, reduced left ventricular ejection fraction (LVEF), an increase in the need of inotropic support by 25% (P < 0.01)], while patients' demographic and angiographic characteristics did not differ between pre-COV and e-COV. Time from symptom onset to first medical contact was prolonged in all AMI during e-COV (presentation > 72 h +21% in STEMI, p = 0.04 and presentation > 72 h in NSTEMI +22%, p = 0.02). Door to balloon time was similar in STEMI patients, while time from first medical contact to revascularization was significantly delayed in NSTEMI patients (p = 0.02). Major cardiac complications after AMI occurred significantly more often, and cardiac recovery was worse in e-COV than in pre-COV, demonstrated by a significantly lower LVEF (39 ± 16 vs. 46 ± 16, p < 0.05) at hospital discharge and substantially higher NTproBNP levels.

Conclusions: The Covid-19 outbreak affects hospital admissions for acute coronary syndromes. During the first phase of the pandemia, significantly less patients with AMI were admitted, but those admitted presented with a more severe phenotype and had a higher mortality, more complications, and a worse short-term outcome. Therefore, our data indicate that Covid-19 had relevant impact on non-infectious disease states, such as acute coronary syndromes.

Keywords: Acute myocardial infarction; Covid-19; NSTEMI; Percutaneous coronary intervention; SARS-CoV-2; STEMI.

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Conflict of interest statement

The authors declare no conflict of interest in relationship with manuscript content.

Figures

Figure 1
Figure 1
Hospitalization and case fatality rate for acute myocardial infarction during Covid‐19 pandemic: (A) reduced number of admissions for acute myocardial infarction (AMI) during early‐Covid‐19 (black bars: e‐COV = 1 March to 30 April) pandemic compared with the pre‐Covid‐19 time (white bars: pre‐COV = 1 January to 29 February). (B) Increased mortality rate in Covid‐19 outbreak compared with pre‐Covid‐19 time: absolute number of admissions for AMI during e‐COV (n = 51) and pre‐COV (n = 96). Data are absolute values or percentage. Statistical analysis was performed with χ 2 tests. Statistical significance was reached with a P < 0.05.
Figure 2
Figure 2
Admission for acute myocardial infarction and mortality between January and April 2020 compared with the previous year 2019: (A) There were no differences in hospitalizations for acute myocardial infarction (AMI) on January and February 2020 and 2019, while on March and April 2020, admissions for AMI halved compared with those in 2019. Absolute number of admissions. Grey bars = January to April 2019. White bars = pre‐COV (January to February 2020). Black bars = e‐COV (March to April 2020). (B) Mortality was unchanged in January and February 2020 and 2019; however, in March, mortality rate increased by 10.5% and, in April, by 11.8% in 2020 (Covid‐19 outbreak) compared with 2019. Case fatality rate among patients admitted for AMI in percentage.
Figure 3
Figure 3
Time delay in presentation with acute myocardial infarction (AMI) during COVID‐19 pandemic: a higher percentage of ST‐elevation myocardial infarction (STEMI) (A) and non‐ST‐elevation myocardial infarction (NSTEMI) (B) patients presented with a delayed time from symptom onset to first medical contact in e‐COV compared with pre‐COV. (C) Door to balloon time was not significantly changed in STEMI patients during e‐COV compared with pre‐COV. (D) Time from first medical contact to revascularization was significantly prolonged in NSTEMI patients during e‐COV. Black bars: e‐COV = 1 March to 30 April. White bars: pre‐COV = 1 January to 29 February. Data are percentage or minutes. Statistical analysis was performed with χ 2 tests or Mann–Whitney test. Statistical significance was reached with a P < 0.05.
Figure 4
Figure 4
Major cardiac complications after acute myocardial infarction (AMI) during Covid‐19 pandemic: major cardiac complications after AMI represented as a composite endpoint of cardio‐pulmonary resuscitation, cardiogenic shock, and life‐threatening arrhythmias (including ventricular tachycardia and ventricular fibrillation) were significantly higher in early‐Covid‐19 (black bars: e‐COV = 1 March to 30 April) pandemic compared with the pre‐Covid‐19 time (white bars: pre‐COV = 1 January to 29 February). Data are percentage. Statistical analysis was performed with χ 2 tests. Statistical significance was reached with a P < 0.05.
Figure 5
Figure 5
Myocardial injury and cardiac outcome of acute myocardial infarction (AMI) during Covid‐19 pandemic: (A) creatine kinase with its myocardial isoform (CK‐MB, U/L) and (B) maximum measured creatine kinase (CKmax, U/L) as a marker for total myocardial injury and damage after AMI were elevated during early‐Covid‐19 (black circles: e‐COV = 1 March to 30 April) pandemic compared with the pre‐Covid‐19 time (white circles: pre‐COV = 1 January to 29 February). (E) Significant lower left ventricular ejection fraction (LVEF,%) after AMI during hospitalization and (F) higher levels of NTproBNP (ng/L) as marker for heart failure in e‐COV. Data are mean ± SD. Statistical analysis was performed with Mann–Whitney test. Statistical significance was reached with a P < 0.05.
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