Worldwide differences of hospitalization for ST-segment elevation myocardial infarction during COVID-19: A systematic review and meta-analysis

Abstract

Background: Discrepant data were reported about hospital admissions for ST-segment elevation myocardial infarction (STEMI) during COVID-19 pandemic. We reviewed studies reporting STEMI hospitalizations during COVID-19 pandemic, investigating whether differences in COVID-19 epidemiology or public health-related factors could explain discrepant findings in different countries.

Methods: Search through MedLine, Embase, Scopus, Web-of-Science, Cochrane Register of Controlled Trials, of studies comparing STEMI admissions during COVID-19 pandemic with a reference period, without language restrictions, as registered in PROSPERO International Prospective Register of Systematic Reviews. Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed. Data independently extracted by multiple investigators were pooled using a random-effects model. Health-related metrics were from publicly-available sources.

Results: We included 79 articles (111,557 STEMI cases, from 57 countries). During peak COVID-19 pandemic, overall incidence rate-ratio (IRR) of STEMI hospitalizations over reference period decreased (0.80; 95% CI 0.76-0.84; p < 0.05). Although wide variations and significant heterogeneity were detected among studies (I² = 89%; p < 0.0001), no significant differences were observed by report methodology (survey vs registry), or observation/reference period. However, large differences emerged at country level not explained by COVID-related epidemiological data, nor by public health strategies. Instead, IRRs for STEMI admissions were inversely related to hospital bed availability in each country (p < 0.05).

Conclusions: During COVID-19 pandemic hospitalization for STEMI significantly decreased, although to a smaller extent than initially reported. Large variability emerged across countries, unrelated to COVID-related epidemiology or social containment measures. Disparities in healthcare organization likely contributed, indicating that proper organization of emergency medicine should be preserved during pandemics.

Keywords: Acute coronary syndromes; COVID-19; Healthcare organization; Myocardial infarction; STEMI; Sars-Cov-2.

Fig. 1

Geographical distribution of papers reporting STEMI admission data during COVID-19 pandemic. World map highlighting (in red) all 57 countries for which STEMI admission data during COVID-19 pandemic peak were reported and utilized for this meta-analysis. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 2

Meta-analysis of all papers reporting STEMI admission data during COVID-19 pandemic, grouped by geographic areas. Each panel shows Forest plot of studies reporting STEMI hospitalizations during the COVID-19 peak compared to the control period in: European countries (2a); Asia-Pacific and Middle East (2b); North-Central-South America (NCSA) (2c). Note: a) variability of results within the same geographical area; b) marked differences among different countries.

Fig. 3

Impact of hospital bed availability per country on STEMI hospitalizations during COVID-19 pandemic. Meta-regression of number of hospital beds/1000 inhabitants (X-axis) vs incidence rate ratio (IRR) of STEMI hospitalizations in each country during peak COVID-19 pandemic, relative to reference period (Y-axis). Circles represent individual studies; diameter is proportional to the inverse of the variance of the IRRs (p < 0.017). See Table 2 for details. Note the inverse relationship between bed availability and STEMI hospitalization, which stayed around historical levels in countries with greater bed availability, while it sharply decreased along with bed availability, suggesting an important role of health organization.