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Comparative Study
. 2020 Dec 18;19(1):215.
doi: 10.1186/s12933-020-01196-0.

Impact of COVID-19 pandemic and diabetes on mechanical reperfusion in patients with STEMI: insights from the ISACS STEMI COVID 19 Registry

Giuseppe De Luca  1 , Miha Cercek  2 , Lisette Okkels Jensen  3 , Marija Vavlukis  4 , Lucian Calmac  5 , Tom Johnson  6 , Gerard Roura I Ferrer  7 , Vladimir Ganyukov  8 , Wojtek Wojakowski  9 , Clemens von Birgelen  10 , Francesco Versaci  11 , Jurrien Ten Berg  12 , Mika Laine  13 , Maurits Dirksen  14 , Gianni Casella  15 , Petr Kala  16 , José Luis Díez Gil  17 , Victor Becerra  18 , Ciro De Simone  19 , Xavier Carrill  20 , Alessandra Scoccia  21 , Arpad Lux  22 , Tomas Kovarnik  23 , Periklis Davlouros  24 , Gabriele Gabrielli  25 , Xacobe Flores Rios  26 , Nikola Bakraceski  27 , Sébastien Levesque  28 , Vincenzo Guiducci  29 , Michał Kidawa  30 , Lucia Marinucci  31 , Filippo Zilio  32 , Gennaro Galasso  33 , Enrico Fabris  34 , Maurizio Menichelli  35 , Stephane Manzo  36 , Gianluca Caiazzo  37 , Jose Moreu  38 , Juan Sanchis Forés  39 , Luca Donazzan  40 , Luigi Vignali  41 , Rui Teles  42 , Francisco Bosa Ojeda  43 , Heidi Lehtola  44 , Santiago Camacho-Freiere  45 , Adriaan Kraaijeveld  46 , Ylitalo Antti  47 , Marco Boccalatte  48 , Iñigo Lozano Martínez-Luengas  49 , Bruno Scheller  50 , Dimitrios Alexopoulos  51 , Giuseppe Uccello  52 , Benjamin Faurie  53 , Alejandro Gutierrez Barrios  54 , Bor Wilbert  12 , Giuliana Cortese  55 , Raul Moreno  56 , Guido Parodi  57 , Elvin Kedhi  58 , Monica Verdoia  59   60
Affiliations
Comparative Study

Impact of COVID-19 pandemic and diabetes on mechanical reperfusion in patients with STEMI: insights from the ISACS STEMI COVID 19 Registry

Giuseppe De Luca et al. Cardiovasc Diabetol. .

Abstract

Background: It has been suggested the COVID pandemic may have indirectly affected the treatment and outcome of STEMI patients, by avoidance or significant delays in contacting the emergency system. No data have been reported on the impact of diabetes on treatment and outcome of STEMI patients, that was therefore the aim of the current subanalysis conducted in patients included in the International Study on Acute Coronary Syndromes-ST Elevation Myocardial Infarction (ISACS-STEMI) COVID-19.

Methods: The ISACS-STEMI COVID-19 is a retrospective registry performed in European centers with an annual volume of > 120 primary percutaneous coronary intervention (PCI) and assessed STEMI patients, treated with primary PCI during the same periods of the years 2019 versus 2020 (March and April). Main outcomes are the incidences of primary PCI, delayed treatment, and in-hospital mortality.

Results: A total of 6609 patients underwent primary PCI in 77 centers, located in 18 countries. Diabetes was observed in a total of 1356 patients (20.5%), with similar proportion between 2019 and 2020. During the pandemic, there was a significant reduction in primary PCI as compared to 2019, similar in both patients with (Incidence rate ratio (IRR) 0.79 (95% CI: 0.73-0.85, p < 0.0001) and without diabetes (IRR 0.81 (95% CI: 0.78-0.85, p < 0.0001) (p int = 0.40). We observed a significant heterogeneity among centers in the population with and without diabetes (p < 0.001, respectively). The heterogeneity among centers was not related to the incidence of death due to COVID-19 in both groups of patients. Interaction was observed for Hypertension (p = 0.024) only in absence of diabetes. Furthermore, the pandemic was independently associated with a significant increase in door-to-balloon and total ischemia times only among patients without diabetes, which may have contributed to the higher mortality, during the pandemic, observed in this group of patients.

Conclusions: The COVID-19 pandemic had a significant impact on the treatment of patients with STEMI, with a similar reduction in primary PCI procedures in both patients with and without diabetes. Hypertension had a significant impact on PCI reduction only among patients without diabetes. We observed a significant increase in ischemia time and door-to-balloon time mainly in absence of diabetes, that contributed to explain the increased mortality observed in this group of patients during the pandemic.

Trial registration number: NCT04412655.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Impact of COVID 19 pandemic on primary PCI cases in patients with diabetes. a Box-and-whisker plot showing the number of STEMI patients with diabetes treated by mechanical reperfusion per million of inhabitants with diabetes/year in 2019 and 2020. Whiskers extend to the most extreme data point which is no more than 1.5 times the interquartile range from the box. IRR estimates are based on a Poisson model without covariates. b Forest plot of the incidence rate ratio on the log-scaled axis, with 95% confidence interval, across each hospital center
Fig. 2
Fig. 2
Impact of COVID 19 pandemic on primary PCI cases in patients without diabetes. a Box-and-whisker plot showing the number of STEMI patients without diabetes treated by mechanical reperfusion per million of inhabitants without diabetes/year in 2019 and 2020. Whiskers extend to the most extreme data point which is no more than 1.5 times the interquartile range from the box. IRR estimates are based on a Poisson model without covariates. b Forest plot of the incidence rate ratio on the log-scaled axis, with 95% confidence interval, across each hospital center
Fig. 3
Fig. 3
Impact of COVID-19 on PPCI procedures according to geographic area and diabetes. Box-and-whisker plot showing the number of STEMI patients treated by mechanical reperfusion per million of residents/year in 2019 and 2020 across 5 areas in patients with (left graph) and without (right graph) diabetes. A total of 5 European geographical areas were identified: Area 1: Italy; Area 2: Iberian Peninsula (Spain and Portugal); Area 3: Central Europe (France, Germany, The Netherlands, Belgium, Czech Republic); Area 4: Balkan Peninsula (Romania, Slovenia, Greece and North Macedonia); Area 5: North-East Europe (UK, Poland, Finland, Denmark, Russia). Whiskers extend to the most extreme data point which is no more than 1.5 times the interquartile range from the box. IRR estimates are based on a Poisson model without covariates
Fig. 4
Fig. 4
Impact of COVID-19 on PPCI procedures according to Diabetes and Hypertension. Box-and-whisker plot showing the number of STEMI patients treated by mechanical reperfusion per million of residents/year in 2019 and 2020 according to hypertension in patients with (left graph) and without (right graph) diabetes. Whiskers extend to the most extreme data point which is no more than 1.5 times the interquartile range from the box. IRR estimates are based on a Poisson model without covariates. A significant interaction was observed with hypertension
Fig. 5
Fig. 5
Impact of COVID-19 pandemic on time delays in according to diabetes. Bar Graphs show the association between the year of intervention with time delays (Ischemia time longer than 12 h, upper graphs; Door-to-balloon time longer that 30 min, lower graphs) in both patients with (left graphs) and without (right graphs) diabetes
Fig. 6
Fig. 6
Impact of COVID-19 pandemic on mortality according to diabetes. Bar Graphs show the association between the year of intervention and in-hospital mortality in patients with (upper graphs) and without (lower graphs) COVID positivity. The results are shown in both patients with (left graphs) and without (right graphs) diabetes
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