Changes in the investigation and management of suspected myocardial infarction and injury during COVID-19: a multi-centre study using routinely collected healthcare data

Abstract

Objective: The COVID-19 pandemic was associated with a reduction in the incidence of myocardial infarction (MI) diagnosis, in part because patients were less likely to present to hospital. Whether changes in clinical decision making with respect to the investigation and management of patients with suspected MI also contributed to this phenomenon is unknown.

Methods: Multicentre retrospective cohort study in three UK centres contributing data to the National Institute for Health Research Health Informatics Collaborative. Patients presenting to the Emergency Department (ED) of these centres between 1st January 2020 and 1st September 2020 were included. Three time epochs within this period were defined based on the course of the first wave of the COVID-19 pandemic: pre-pandemic (epoch 1), lockdown (epoch 2), post-lockdown (epoch 3).

Results: During the study period, 10,670 unique patients attended the ED with chest pain or dyspnoea, of whom 6,928 were admitted. Despite fewer total ED attendances in epoch 2, patient presentations with dyspnoea were increased (p < 0.001), with greater likelihood of troponin testing in both chest pain (p = 0.001) and dyspnoea (p < 0.001). There was a dramatic reduction in elective and emergency cardiac procedures (both p < 0.001), and greater overall mortality of patients (p < 0.001), compared to the pre-pandemic period. Positive COVID-19 and/or troponin test results were associated with increased mortality (p < 0.001), though the temporal risk profile differed.

Conclusions: The first wave of the COVID-19 pandemic was associated with significant changes not just in presentation, but also the investigation, management, and outcomes of patients presenting with suspected myocardial injury or MI.

Keywords: COVID-19; emergency department; myocardial infarction; myocardial injury; troponin.

Figure 1

Patient cohort diagram. Consort diagram indicating numbers of patients in the study.

Figure 2

Emergency department attendance, troponin testing, and troponin positivity rates during the first wave of COVID-19. Trends of (A) number of all emergency department (ED) arrivals, (B) proportion of ED arrivals stratified by primary presenting symptom/complaint, (C) proportion of ED arrivals undergoing troponin testing, and proportion with a positive troponin test, (D) proportion of patients attending ED with either chest pain or dyspnoea undergoing troponin testing, (E) primary symptom in patients undergoing troponin testing, and (F) rate of troponin test positivity stratified by primary presenting symptom/complaint. P-values reflect comparison between epoch 1 and epoch 2 in each case.

Figure 3

Cardiac procedure rates during the first wave of COVID-19. Trends in rates of (A) overall emergency and elective cardiac procedures including diagnostic cardiac catheterisation, percutaneous coronary intervention (PCI), and cardiac surgery, and (B) the individual emergency and elective cardiac procedures.

Figure 4

Patient survival by troponin, COVID-19, and cardiac procedure status. Survival of admitted patients (A) stratified by troponin status, including landmark analysis from 30 days, (B) stratified by COVID-19 status, including landmark analysis from 30 days, and (C) stratified by procedure and COVID-19 status in those with a positive troponin test.

Figure 5

Patient survival during the first wave of COVID-19. Survival of (A) patients attending the emergency department (ED) with chest pain or dyspnoea, stratified by epoch, and (B) those patients admitted from the ED after attending with chest pain or dyspnoea and with a positive troponin test, stratified by epoch.