Introduction

The 2019 novel coronavirus (COVID-19) pandemic is the greatest public health crisis of this century, with both the case rate and death toll continuing to rise.¹ The pandemic has strained healthcare systems and exacerbated known healthcare disparities related to race, sex, and underlying co-morbidity status.^2,3 In addition, men are more likely to be infected and die from COVID-19 than women.³ These sex disparities may be related to different rates of underlying pre-existing disease, variable behaviors, and biological differences particularly related to angiotensin-converting enzyme 2 (ACE2) receptors.⁴ COVID-19 also disproportionately affects patients with underlying health problems. A national study found that 90% of patients hospitalized with COVID-19 have at least one underlying co-morbidity.⁵ It is important for healthcare providers, and the healthcare system at large, to be aware of the incommensurate impact of the pandemic on these high-risk populations in order to provide optimal care as the pandemic continues. 

In addition to bringing increased visibility to longstanding healthcare disparities, the COVID-19 pandemic has greatly impacted healthcare delivery across the world. Many hospitals and health systems cancelled non-urgent procedures and closed clinics, and governments messaged to the public to stay home and avoid going to hospitals for non-urgent care. While hospitalization rates related to COVID-19 infection have surged, there is clear evidence that patients in the United States and around the world have less commonly sought medical attention for a number medical emergencies such as acute myocardial infarction (AMI) than they were prior to the pandemic.⁶ The characteristics of patients most affected by this phenomenon and its impact on complication rates and patient outcomes are yet to be elucidated.

Results

In order to examine the impact of the epidemic on patients with AMI, Dr. Gluckman and colleagues evaluated case rates and in-hospital outcomes for patients presenting with AMI to any of the 49 hospitals in the Providence St. Joseph Health (PSJH) system spread across six states (Alaska, California, Montana, Oregon, Texas, and Washington).⁷ The analysis divided AMI hospital admissions at PSJH into three time periods: before COVID-19 (December 30, 2018 to February 22, 2020), an early period in the pandemic (February 23, 2020 to March 28, 2020), and a later period in the pandemic (March 28, 2020 to May 16, 2020).

This study evaluated over 15,000 hospitalizations involving more than 14,700 patients and confirmed the concerning trends of prior studies in AMI hospitalization: case rates of AMI hospitalization across PSJH decreased during the period early in the pandemic at a rate of -19.0 (95% CI, -29.0 to -9.0) cases per week, with increasing cases at a rate of +10.5 (95% CI, +4.6 to +16.5) during the period later in the pandemic. However, case rates had not returned to baseline by the last week of the study period.

Additionally, the study found that patients with AMI who were hospitalized early and later in the pandemic were generally younger, more likely to be Asian or native American, had a shorter length of stay, and were more likely to be discharged to home. After adjusting for patient characteristics (demographics and co-morbidities), patients with ST-elevation MI (STEMI) had increased risk of mortality during the period later in the pandemic (OR 1.52; 95% CI, 1.02 to 2.26). Based on the PSJH all-cause inpatient mortality risk model, the observed/expected (O/E) ratio for mortality related to all AMI (STEMI and non-STEMI) was significantly increased in both the early period of the pandemic at 1.27 (95% CI, 1.0 to 1.48) and the later period of the pandemic at 1.23 (95% CI, 0.98 to 1.47).

Other Studies

These findings build upon what has been reported from other regions of the world, and they provide evidence of the indirect impact of COVID-19 on other disease processes. A study examining hospitalizations for acute coronary syndrome (ACS) in England found that weekly hospital admissions for ACS (both STEMI and non-STEMI) decreased by 40% between mid-February and the end of March 2020, with moderate increases in ACS hospitalization during April and May.⁸ Fewer percutaneous coronary intervention (PCI) procedures for patients with both STEMI and non-STEMI were performed during this time as well, and median length of stay decreased.

Similarly, an Italian study found a decrease in AMI admissions across 54 hospitals in March 2020 compared to March 2019.⁹ In addition, the case fatality rate during the week of March 12-19, 2020 was significantly higher compared to March 12-19, 2019 (13% vs. 4.1%; RR, 3.3; 95% CI, 1.7-6.6; p < 0.001). Furthermore, the time from symptom onset to coronary angiography, as well as the time from first medical contact to coronary revascularization, were both increased in 2020 compared to 2019 (39.2% and 31.5%, respectively).

Discussion

The studies described above establish that early decreases in AMI case rates during the pandemic have been associated with an increased AMI mortality and collectively contribute to the burden of all deaths related to COVID-19.¹⁰ It is concerning the rates of AMI admissions in the later period of the pandemic were still not equivalent to the pre-COVID-19 levels, suggesting there are still patients who are not receiving timely healthcare.

The cause of the increased morbidity and mortality among hospitalized AMI patients is still not completely known at this time and is likely multifactorial. In part, it may be related to delays in the field, with longer emergency medical services (EMS) response times, given the safety precautions and changes to standard procedure. In-hospital delays may also be playing a role, as evaluation in the emergency department and treatment in the cardiac catheterization laboratory is subject to potential delays from donning of personal protective equipment (PPE).

Additionally, there is great concern that many patients may be more reticent to present to the hospital with symptoms due to fear of contracting COVID-19 or straining a healthcare system perceived as overburdened caring for COVID patients. As a result, patients may be presenting to the emergency room later in their disease course, resulting in worse outcomes. The lower age of patients hospitalized with AMI during COVID-19 suggests that perhaps older individuals are more concerned with this possibility and may be less likely to present to the hospital.

Further, some patients are forgoing interfacing with the medical establishment entirely, and they do not derive any benefit from possible medical therapy or reperfusion intervention and are at increased risk of complications and death. This group is not represented in the above analyses, suggesting the available data likely an underestimate of the population AMI mortality rate. Notably, studies have noted an increase in out-of-hospital sudden cardiac arrests early in the pandemic,^11,12 which may be related to patients with AMI or arrhythmias who "sheltered in place" at home rather than calling EMS or presenting to a hospital.

Conclusion

The decreased case rate and increased mortality rate for patients hospitalized with AMI during the COVID-19 pandemic highlight important health care delivery considerations for health care systems, healthcare professionals, and patients. Further work needs to be done to determine which factors have contributed most to the decreased and delayed AMI presentation and increased mortality seen, particularly as COVID-19 case counts continue to rise. There must be continued efforts to reduce fear and emphasize the importance of early recognition and prompt treatment of AMI and stroke in order to reduce potentially avoidable morbidity and mortality. Dissemination of information via infographics such as those created by Cardiosmart¹³ and campaigns like Stop Medical Distancing¹⁴ and "Don't Die of Doubt"¹⁵ are important and timely. The medical community must continue to make clear to the public, "heart care can't wait."

References

1. Provisional Death Counts for Coronavirus Disease 2019 (COVID-19) (CDC website). 2020. Available at: http://www.cdc.gov/nchs/nvss/vsrr/covid19/index.htm. Accessed 08/01/2020.
2. Yancy CW. COVID-19 and African Americans. JAMA 2020;Apr 15 [Epub ahead of print].
3. Xie J, Tong Z, Guan X, Du B, Qiu H. Clinical characteristics of patients who died of coronavirus disease 2019 in China. JAMA Netw Open 2020;3:e205619.
4. Griffith DM, Sharma G, Holliday CS, et al. Men and COVID-19: a biopsychosocial approach to understanding sex differences in mortality and recommendations for practice and policy interventions. Prev Chronic Dis 2020;17:E63.
5. Garg S, Kim L, Whitaker M, et al. Hospitalization rates and characteristics of patients hospitalized with laboratory-confirmed coronavirus disease 2019 - COVID-NET, 14 States, March 1-30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:458-464.
6. Krumholz HM. Where Have All the Heart Attacks Gone (New York Times website)? 2020. Available at: https://www.nytimes.com/2020/04/06/well/live/coronavirus-doctors-hospitals-emergency-care-heart-attack-stroke.html. Accessed 08/01/2020.
7. Gluckman TJ, Wilson MA, Chiu ST, et al. Case rates, treatment approaches, and outcomes in acute myocardial infarction during the coronavirus disease 2019 pandemic. JAMA Cardiol 2020;Aug 07 [Epub ahead of print].
8. Mafham MM, Spata E, Goldacre R, et al. COVID-19 pandemic and admission rates for and management of acute coronary syndromes in England. Lancet 2020;396:381-9.
9. De Rosa S, Spaccarotella C, Basso C, et al. Reduction of hospitalizations for myocardial infarction in Italy in the COVID-19 era. Eur Heart J 2020;41:2083-8.
10. Weinberger DM, Chen J, Cohen T, et al. Estimation of excess deaths associated with the COVID-19 pandemic in the United States, March to May 2020. JAMA Intern Med 2020;Jul 01 [Epub ahead of print].
11. Lai PH, Lancet EA, Weiden MD, et al. Characteristics associated with out-of-hospital cardiac arrests and resuscitations during the novel coronavirus disease 2019 pandemic in New York City. JAMA Cardiol 2020;Jun 19 [Epub ahead of print].
12. Baldi E, Sechi GM, Mare C, et al. Out-of-hospital cardiac arrest during the Covid-19 outbreak in Italy. N Engl J Med 2020;383:496-8.
13. Coronavirus and your heart: don't ignore heart symptoms (Cardiosmart website) 2020. Available at: http://www.cardiosmart.org/assets/infographic/covid-19-don't-ignore-heart-symptoms. Accessed 08/01/2020.
14. Stop Medical Distancing (stopmedicaldistancing website). 2020. Available at: https://stopmedicaldistancing.org/. Accessed 08/01/2020.
15. Don't die of doubt (American Heart Association website). 2020. Available at:  http://www.heart.org/en/health-topics/dont-die-of-doubt. Accessed 08/01/2020.

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, COVID-19 Hub, Diabetes and Cardiometabolic Disease, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Stable Ischemic Heart Disease, Vascular Medicine, SCD/Ventricular Arrhythmias, Interventions and ACS, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Nuclear Imaging, Chronic Angina

Keywords: Dyslipidemias, COVID-19, Pandemics, Coronavirus, severe acute respiratory syndrome coronavirus 2, Peptidyl-Dipeptidase A, ST Elevation Myocardial Infarction, Healthcare Disparities, Inpatients, Patient Discharge, Percutaneous Coronary Intervention, Acute Coronary Syndrome, Personal Protective Equipment, Coronary Angiography, Public Health, Length of Stay, Reaction Time, Hospitalization, Emergency Service, Hospital, Out-of-Hospital Cardiac Arrest, Emergency Medical Services

< Back to Listings