The Coronavirus disease 2019 (COVID-19) pandemic has changed the way patients seek medical attention and how medical services are provided. We sought to compare characteristics, clinical course, and outcomes of patients presenting with acute myocardial infarction (AMI) during the pandemic compared with before it. This is a multicenter, retrospective cohort study of consecutive COVID-19 negative patients with AMI in Lithuania from March 11, 2020 to April 20, 2020 compared with patients admitted with the same diagnosis during the same period in 2019. All patients underwent angiography. Six-month follow-up was obtained for all patients. A total of 269 patients were included in this study, 107 (40.8%) of whom presented during the pandemic. Median pain-to-door times were significantly longer (858 [quartile 1=360, quartile 3 = 2,600] vs 385.5 [200, 745] minutes, p <0.0001) and post-revascularization ejection fractions were significantly lower (35 [30, 45] vs 45 [40, 50], p <0.0001) for patients presenting during vs. prior to the pandemic. While the in-hospital mortality rate did not differ, we observed a higher rate of six-month major adverse cardiovascular events for patients who presented during versus prior to the pandemic (30.8% vs 13.6%, p = 0.0006). In conclusion, 34% fewer patients with AMI presented to the hospital during the COVID-19 pandemic, and those who did waited longer to present and experienced more 6-month major adverse cardiovascular events compared with patients admitted before the pandemic.
Coronavirus disease 2019 (COVID-19) has been a matter of international concern since it was first reported in December 2019. As the World Health Organization (WHO) declared COVID-19 a pandemic on March 11, 2020, European governments responded with strict “stay at home” policies in attempts to slow the spread of the virus. Beginning March 11, 2020, the Lithuanian government imposed some of the most restrictive measures compared with countries with similar infection levels. Though these protocols aided in slowing the growth of the pandemic in Lithuania, they also had immediate negative impacts on the treatment of other important diseases, such as acute myocardial infarction (AMI). As the repercussions of the pandemic are still evolving, it is the purpose of this paper to examine the 6-month outcomes of the COVID-19 pandemic lockdown in terms of major cardiovascular adverse events (MACE) among noninfected AMI patients.
Methods
This is a multicenter, retrospective cohort study including 6 out of 10 administrative regions in the republic of Lithuania. The study involved consecutive patients with AMI (NSTEMI or STEMI) who received a negative test result for COVID-19 infection from March 11, 2020 to April 20, 2020 and underwent invasive angiography at the Hospital of the Lithuanian University of Health Sciences Kaunas Clinics or the Republican Hospital of Panevezys. The data were compared with patients admitted with the same diagnosis during the same period in 2019. Patients with AMI and a COVID-19 positive test were excluded from the study (there were 5 instances of this). Patients were followed until whichever occurred first: death or 6 months following hospital discharge. This study received approval from the Research Ethics Committee of the region of Kaunas and Panevezys.
Data collected included patient demographics, co-morbidities, medications, cardiac catheterization procedural characteristics, echocardiography results, and clinical course (length of stay, ischemic or hemorrhagic stroke, cardiopulmonary resuscitation, hypotensive shock, endotracheal intubation). We considered a composite primary end point of MACE within 6 months of hospital discharge, and also examined its individual components, as well as all-cause mortality. MACE was defined as follows: cardiovascular death, nonfatal myocardial infarction, target vessel revascularization, recurrent hospitalization due to decompensated heart failure, and stroke (ischemic or hemorrhagic).
STEMI and NSTEMI were defined according to fourth universal definition of myocardial infarction. Cardiogenic shock was defined as persistent hypotension (systolic blood pressure < 90 mm Hg or a mean arterial pressure 30 mm Hg below baseline) with evidence of decreased organ perfusion caused by severe right, left or biventricular dysfunction despite adequate fluid administration. Successful PCI was defined as the reduction of coronary artery lesion stenosis to <20%. Dyslipidemia was defined as fasting low density lipoprotein cholesterol ≥100 mg/dl. Pain-to-door time was defined as the duration (in minutes) from onset of symptoms to first medical contact at the PCI center. Door-to-wire time was defined as the time (in minutes) from first medical contact at the facility to crossing the culprit lesion with a coronary wire. Post-reperfusion left ventricular ejection fraction was assessed via echocardiography imaging within 24 hours after coronary reperfusion using Simpson’s biplane method. Six-month follow-up information was obtained via telephone interview or a visit at a participating outpatient clinic.
Continuous variables were skewed and are presented as median [quartile 1, quartile 3]. Categorical variables are presented as frequency and percentage. Differences in patient and clinical characteristics between those admitted in the pandemic period versus the prepandemic period were assessed via the Wilcoxon Rank Sum Test and Chi-Square or Fisher’s Exact Test, as appropriate. We examined the association between pain-to-door time and after-revascularization ejection fraction using Spearman’s correlation coefficient. Differences in the primary outcome of MACE, its individual components, and all-cause mortality between study periods were assessed via Chi-Square or Fisher’s Exact Test, as appropriate. We utilized multivariable logistic regression only for the composite outcome of MACE because the small number of events that occurred in this study largely prohibited statistical adjustment for other outcomes. Factors identified as having a significant association with study period ( Table 1 and Table 2 ) were considered for use in the multivariable model. We utilized stepwise selection in order to identify jointly significant factors while preserving the degrees of freedom, due to the small number of events. We considered an interaction term between study period (pandemic/pre-pandemic) and AMI type (NSTEMI/STEMI).
| Overall | NSTEMI | STEMI | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Variable | Pandemic (n = 107) | Prepandemic (n = 162) | p-value | Pandemic (n = 40) | Prepandemic (n = 76) | p-value | Pandemic (n = 67) | Prepandemic (n =86) | P-value |
| Men | 71 (66.4%) | 108 (66.7%) | 0.9577 | 27 (67.5%) | 47 (61.8%) | 0.5467 | 44 (65.7%) | 61 (70.9%) | 0.4868 |
| Age (years) | 68 [61, 76] | 67 [59, 80] | 0.7499 | 69.5 [64, 80] | 70 [61, 80.5] | 0.8932 | 67 [59, 76] | 66 [59, 80] | 0.7953 |
| Obesity | 47 (43.9%) | 61 (37.7%) | 0.3045 | 20 (50.0%) | 32 (42.1%) | 0.4164 | 27 (40.3%) | 29 (33.7%) | 0.4021 |
| Killip Score | 0.0654 | 0.0691 | |||||||
| 1 | 38 (35.5%) | 70 (43.2%) | 15 (37.5%) | 35 (46.1%) | 23 (34.3%) | 35 (40.7%) | |||
| 2 | 60 (56.1%) | 66 (40.7%) | 22 (55%) | 31 (40.8%) | 38 (56.7%) | 35 (40.7%) | |||
| 3 | 4 (3.7%) | 15 (9.3%) | 3 (7.5%) | 6 (7.9%) | 1 (1.5%) | 9 (10.5%) | |||
| 4 | 5 (4.7%) | 10 (6.2%) | 0 (0%) | 3 (3.9%) | 5 (7.5%) | 7 (8.1%) | |||
| Dyslipidemia | 93 (86.9%) | 132 (81.5%) | 0.2382 | 37 (92.5%) | 67 (88.2%) | 0.5403 | 56 (83.6%) | 65 (75.6%) | 0.2273 |
| Hypertension | 95 (88.8%) | 146 (90.1%) | 0.725 | 38 (95%) | 71 (93.4%) | 1 | 57 (85.1%) | 75 (87.2%) | 0.7034 |
| Smoker | 21 (19.6%) | 33 (20.4%) | 0.8814 | 7 (17.5%) | 14 (18.4%) | 0.9025 | 14 (20.9%) | 19 (22.1%) | 0.8582 |
| Diabetes mellitus | 27 (25.2%) | 33 (20.4%) | 0.3484 | 11 (27.5%) | 19 (25%) | 0.7701 | 16 (23.9%) | 14 (16.3%) | 0.24 |
| Coronary artery disease | 45 (42.1%) | 53 (32.7%) | 0.1192 | 21 (52.5%) | 29 (38.2%) | 0.1382 | 24 (35.8%) | 24 (27.9%) | 0.2953 |
| Prior CABG | 13 (12.1%) | 5 (3.1%) | 0.0036 | 9 (22.5%) | 3 (3.9%) | 0.0032 | 4 (6%) | 2 (2.3%) | 0.2492 |
| COPD | 1 (0.9%) | 5 (3.1%) | 0.4074 | 0 (0%) | 3 (3.9%) | 0.5502 | 1 (1.5%) | 2 (2.3%) | 1 |
| Peripheral arterial disease | 4 (3.7%) | 3 (1.9%) | 0.4414 | 3 (7.5%) | 1 (1.3%) | 0.1176 | 1 (1.5%) | 2 (2.3%) | 1 |
| Cerebrovascular disease | 9 (8.4%) | 12 (7.4%) | 0.7639 | 4 (10%) | 6 (7.9%) | 0.7352 | 5 (7.5%) | 6 (7%) | 1 |
| Dementia | 1 (0.9%) | 1 (0.6%) | 1 | 0 (0%) | 0 (0%) | – | 1 (1.5%) | 1 (1.2%) | 1 |
| Overall | NSTEMI | STEMI | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Variable | Pandemic (n = 107) | Prepandemic (n = 162) | p-value | Pandemic (n = 40) | Prepandemic (n = 76) | p value | Pandemic (n = 67) | Prepandemic (n =86) | p value | |
| Pain to door time (mins) | 858 [360, 2600] | 385.5 [200, 745] | <.0001 | 2021 [960, 5746] | 558 [369, 882.5] | <.0001 | 582 [180, 1212] | 262 [120, 525] | 0.0003 | |
| Door to wire time (mins) | 101 [64, 273] | 94 [49, 194] | 0.137 | 302.5 [179, 600] | 200.5 [98, 434.5] | 0.0948 | 75 [53.5, 106.5] | 71 [43, 119] | 0.2257 | |
| Number of narrowed coronary arteries | 2 [1, 3] | 2 [1, 3] | 0.9455 | 2 [2, 3] | 2 [1, 3] | 0.4242 | 2 [1, 3] | 2 [1, 3] | 0.3836 | |
| Ejection fraction after PCI (%) | 35 [30, 45] | 45 [40, 50] | <.0001 | 37.5 [25, 45] | 47 [40, 50] | 0.0032 | 35 [30, 45] | 42 [35, 50] | 0.0003 | |
| Reperfusion strategy | 0.0741 | 0.0832 | ||||||||
| CABG | 4 (3.7%) | 17 (10.5%) | 2 (5%) | 14 (18.4%) | 2 (3%) | 3 (3.5%) | ||||
| PCI | 98 (91.6%) | 133 (82.1%) | 34 (85%) | 51 (67.1%) | 64 (95.5%) | 82 (95.3%) | ||||
| Medical therapy | 5 (4.7%) | 12 (7.4%) | 4 (10%) | 11 (14.5%) | 1 (1.5%) | 1 (1.2%) | ||||
| PCI access | 0.1658 | |||||||||
| Femoral | 22 (20.6%) | 24 (14.8%) | 11 (27.5%) | 9 (11.8%) | 11 (16.4%) | 15 (17.4%) | ||||
| Right radial | 79 (73.8%) | 134 (82.7%) | 23 (57.5%) | 66 (86.8%) | 56 (83.6%) | 68 (79.1%) | ||||
| Left proximal radial | 6 (5.6%) | 4 (2.5%) | 6 (15%) | 1 (1.3%) | 0 (0%) | 3 (3.5%) | ||||
| Culprit vessel 2,7,1,6,1,1 | 0.0083 | 0.2639 | 0.0092 | |||||||
| No culprit | 9 (8.4%) | 19 (11.7%) | 5 (12.5%) | 17 (22.4%) | 4 (6%) | 2 (2.3%) | ||||
| Right coronary artery | 25 (23.4%) | 38 (23.5%) | 6 (15%) | 6 (7.9%) | 19 (28.4%) | 32 (37.2%) | ||||
| Left main | 4 (3.7%) | 24 (14.8%) | 3 (7.5%) | 12 (15.8%) | 1 (1.5%) | 12 (14%) | ||||
| LAD | 49 (45.8%) | 46 (28.4%) | 14 (35%) | 19 (25%) | 35 (52.2%) | 27 (31.4%) | ||||
| Left circumflex | 18 (16.8%) | 28 (17.3%) | 11 (27.5%) | 16 (21.1%) | 7 (10.4%) | 12 (14%) | ||||
| Successful PCI 0,6,0,5,0,1 | 93 (86.9%) | 129 (79.6%) | 0.3536 | 33 (82.5%) | 52 (68.4%) | 0.2687 | 60 (89.6%) | 77 (89.5%) | 0.8316 | |
| Troponin I (µg/l) | 7.8 [2.6, 37.2] | 4.5 [1.1, 25.4] | 0.013 | 2.7 [1.5, 10.4] | 2.5 [0.6, 9.7] | 0.3248 | 25.0 [4.9, 61.8] | 9.0 [2.2, 32.5] | 0.0535 | |
| Length of stay (days) | 6 [5, 7] | 7 [5, 7] | 0.4931 | 6 [5, 7] | 6 [4, 8] | 0.4488 | 6 [5, 8] | 7 [5, 7] | 0.0755 | |
| In-hospital hemorrhagic stroke | 0 (0%) | 0 (0%) | – | 0 (0%) | 0 (0%) | – | 0 (0%) | 0 (0%) | – | |
| In-hospital ischemic stroke | 3 (2.8%) | 0 (0%) | 0.0619 | 2 (5%) | 0 (0%) | 0.1169 | 1 (1.5%) | 0 (0%) | 0.4379 | |
| In-hospital CPR | 6 (5.6%) | 9 (5.6%) | 0.9855 | 3 (7.5%) | 4 (5.3%) | 0.6306 | 3 (4.5%) | 5 (5.8%) | 1 | |
| Cardiogenic shock | 10 (9.3%) | 12 (7.4%) | 0.5702 | 5 (12.5%) | 6 (7.9%) | 0.5088 | 5 (7.5%) | 6 (7%) | 1 | |
| In-hospital re-infarction | 0 (0%) | 0 (0%) | – | 0 (0%) | 0 (0%) | – | 0 (0%) | 0 (0%) | – | |
| In-hospital death | 6 (5.6%) | 9 (5.6%) | 0.9855 | 3 (7.5%) | 4 (5.3%) | 0.6909 | 3 (4.5%) | 5 (5.8%) | 1 | |
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