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Reduction of Hospitalizations for MI in Italy in COVID-19 Era
Quick Takes
- AMI admissions throughout Italy were reduced during a week in March 2020 as compared to 2019.
- The STEMI case fatality rate increased by three-fold in March 2020 as compared to March 2019.
- Delays in coronary angiography and revascularization were observed.
Study Questions:
What is the effect of the coronavirus disease 2019 (COVID-19) pandemic on admissions to cardiac care units (CCUs) in Italy?
Methods:
This was an observational, multicenter study. All academic and nonacademic hospitals in Italy with CCUs receiving acute myocardial infarction (AMI) patients were invited to participate. Data were collected for consecutive AMI patients during the week of March 12-19, 2020, and for the equivalent week in 2019. Prespecified subgroups were patients with ST- segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI). Major complications of AMI included cardiogenic shock, life-threatening arrhythmias, severe functional mitral regurgitation, and cardiac rupture/ventricular septal defect. Reporting on other diagnoses including heart failure (HF), atrial fibrillation (AF), and pulmonary embolism (PE) was optional.
Results:
A total of 54 hospitals participated in the study, including 28 academic centers (51.9%). Cardiac catheterization facilities were present within 51 centers (94.4%), and 32 centers (59.3%) had cardiac surgery units. During the week in 2020, 319 AMIs were registered, as compared with 618 during the week in 2019 (48.4% reduction, p < 0.001). Reductions in AMI admissions were similar in North Italy (52.1%), Central Italy (59.3%), and South Italy (52.1%). STEMI admissions were reduced from 268 to 197 (26.5% reduction, p = 0.009). The reduction in STEMI admissions was greater for women than men (41.2% reduction for women, p = 0.011 for comparison between 2019 and 2020, versus 17.8% reduction for men, p = 0.191). NSTEMI admissions were reduced from 350 in 2019 to 122 in 2020 (65.4% reduction, p < 0.001), with no difference between genders.
The STEMI case fatality rate during the week in 2020 was 13.7%, as compared with 4.1% in 2019 (relative risk [RR], 3.3; 95% confidence interval [CI], 1.7-6.6; p < 0.001). Major complications were registered in 18.8% of cases in 2020 and 10.4% in 2019 (RR, 1.8; 95% CI, 1.1-2.8; p = 0.025). The NSTEMI case fatality rate was 3.3% in 2020 and 1.7% in 2019 (RR, 1.9; 95% CI, 0.5-6.7; p = 0.309). Major complications of NSTEMI occurred in 10.7% of cases in 2020 and 5.1% in 2019 (RR, 2.1; 95% CI, 1.05-4.1; p = 0.037). Among STEMI patients, 21 (10.7%) were severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive, and the case fatality rate among these patients was 28.6%, as compared with 11.9% among all other STEMI patients during the week in 2020. Among NSTEMI patients, 9.8% were SARS-CoV-2 positive; none of these patients died.
The time from symptom onset to coronary angiography was increased by 39.2% in 2020 as compared to 2019. Time from first medical contact to coronary revascularization was increased by 31.5%. Admissions for HF and AF declined in 2020 as compared to 2019 (reductions of 46.8%; p = 0.005 and 53.4%, p = 0.017, respectively). No significant change was seen for PE admissions.
Conclusions:
AMI admissions in Italy were reduced during March 2020 as compared to March 2019, with increases in case fatality rate for STEMI and in major complications of STEMI and NSTEMI. Delays in coronary angiography and revascularization were observed.
Perspective:
Reductions in AMI admissions in Italy seem to be similar to those observed during the COVID-19 pandemic in the United States and elsewhere in Europe. Delays in AMI presentation related to fear of in-hospital COVID transmission, as well as delays in coronary angiography and revascularization, likely contributed to increased mortality and complication rates. One limitation of the study is that only 1 week worth of data were collected for each year.
Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, COVID-19 Hub, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Stable Ischemic Heart Disease, Valvular Heart Disease, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and Heart Failure, Cardiac Surgery and SIHD, Cardiac Surgery and VHD, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Imaging, CHD and Pediatrics and Interventions, Acute Heart Failure, Interventions and ACS, Interventions and Imaging, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Angiography, Nuclear Imaging, Chronic Angina, Mitral Regurgitation
Keywords: Acute Coronary Syndrome, Arrhythmias, Cardiac, Atrial Fibrillation, Coronary Angiography, Coronary Care Units, Coronavirus, COVID-19, Heart Failure, Heart Septal Defects, Ventricular, Mitral Valve Insufficiency, Myocardial Revascularization, Pulmonary Embolism, SARS Virus, Secondary Prevention, severe acute respiratory syndrome coronavirus 2, Shock, Cardiogenic, ST Elevation Myocardial Infarction
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