What Impact Has COVID-19 Had on ACS Presentations?

This transcript has been edited for clarity.

Welcome to Medscape UK. My name is Mamas Mamas. I'm professor of cardiology based at Keele  University.

Globally over the past couple of months, we've experienced an explosion of COVID-19-related mortality, both in the UK and elsewhere.

However, this is not the only story. Early data from Italy suggests that non-COVID-related mortality has also substantially increased compared to this time last year.

This is not unexpected. Our medical services have been overwhelmed by acute presentations of patients with COVID-19. This will impact on our ability to deliver acute and elective care to patients with chronic diseases, such as cardiovascular diseases.

People from the UK and the United States have noticed a marked reduction in acute admissions of patients with acute coronary syndromes, of heart failure, and so forth. However, this is all anecdotal and during these times, we need hard facts. This is data from Spain, reported by my colleague Dr Oriol Rodriguez.

Spanish Data

Hi, my name is Dr Oriol Rodriguez-Leor. I am an interventional cardiologist based in Barcelona, Spain. And during the next couple of minutes, I'm going to briefly comment on the results of a study performed by the Spanish Interventional Cardiology Association regarding activity reduction in cath[eter] labs during the current COVID-19 outbreak.

We collected information in 71 hospitals that are part of the STEMI [ST-elevation myocardial infarction] care network in Spain. We found an important reduction in cath lab activity that can be summarised as:

• A reduction of 57% in diagnostic procedures
• A reduction of 48% in elective PCI [percutaneous coronary intervention]
• A reduction of 81% in structural interventions
• And finally, a reduction of 40% in patients treated with primary PCI for a STEMI

We have also found a slight increase in the use of thrombolysis, mainly due to problems within the hospital transport times, or less frequently, in cases of patients with a confirmed COVID-19 diagnosis.

We have also found that up to 5% of interventional cardiologists in Spain presented with COVID-19 during the third week of March.

With respect to the reduction of patients with a STEMI that came to our hospitals during the outbreak, there are some possible explanations.

We have evidence on the effect of air pollution on STEMI occurrence. So this could explain, at least in part, a reduction in the incidence of STEMI. But our data strongly suggests that there is a large number of symptomatic STEMI patients who stay at home and don't ask for care, being afraid of going to hospitals.

An increase in short and long-term mortality is expected, with many patients who will present with sudden out-of-hospital death, and with long evolution times in those who consult, with a consequent increase in heart failure, cardiogenic shock, and mechanical complications.

Scientific societies and health authorities must carry out specific strategies and vigorous actions to alleviate, as much as possible, this excess of morbidity and mortality expected in STEMI patients during the current outbreak.

COI: None reported.

REC: Interventional Cardiology. Impacto de la pandemia de COVID-19 sobre la actividad asistencial en cardiología intervencionista en España. DOI: https://doi.org/10.24875/RECIC.M20000120

Potential Mechanisms

This reduction in cath lab activity by 50% in patients with acute coronary syndrome reported by the Spanish data is interesting. But what are the potential mechanisms?

Firstly, there may be a change in threshold for referring these patients for cardiac catheterisation. And certainly this may be a possibility in non-ST elevation myocardial infarction [NSTEMI].

Certainly, both in our cath labs and others, there has been a move towards managing low-risk N-STEMI cases medically, to reduce their risk of COVID-19.

This, however, does not explain the reduction in primary PCI.

Another possibility may be that in this time of lockdown, there's reduced stress activity, with reduced physical activity, and this may in itself reduce incidence of myocardial infarction.

And certainly we know that these factors are precipitants in AMI [acute myocardial infarction].

Thirdly, and most worryingly, the incidence of myocardial infarction may be the same or may have even increased, but patients are less likely to seek medical attention.

Certainly this is what many of my colleagues are hearing. Patients that do come with myocardial infarction have told us that they have tried to keep away and tried to ignore the pain, because of the worry of catching COVID-19.

I think during this time, it's very important that national societies have media campaigns to remind patients that just because there is an ongoing COVID-19 pandemic, if they have experience of myocardial infarction [symptoms], and so forth, that they should seek medical attention. Otherwise, we're going to see marked increases in sudden cardiac death, or future presentations with heart failure because of missed myocardial infarction and the failure to deliver coronary revascularisation.

Worrying Data

Finally, and worryingly, data from Spain suggests that up to 5% of interventional cardiologists may be COVID-19 positive. This is particularly worrying because it highlights the risks that healthcare professionals have in delivering acute care to patients that's run well.

What should we do? Well, unfortunately, there is no way to test for COVID-19 in the acutely unwell patient, the test results will at best take several hours. Therefore, we have to assume that all patients presenting with an acute coronary syndrome, particularly [those needing] primary PCI, are COVID-19 positive and therefore we have to take the appropriate protection.

What does this involve? Well, patients [needing] primary PCI can be unstable, and may have cardiac arrest, and therefore primary PCI should be considered to have the potential to be an aerosol-generating procedure.

Therefore, appropriate PPE [personal protective equipment] involves full gowns, double gloves, visors, FFP3 masks and hats.

It is only by protecting our workforce that we will be able to deliver a primary PCI and an ACS [acute coronary syndrome] service.

If our workforce become unwell with COVID-19 then we will no longer be able to deliver these services and we will need to go back to medical management, or thrombolysis, which we know are less effective than the current gold standard.

I'd like to thank you for joining me on Medscape UK and thank you to my guest, Dr Oriol Rodriguez. Stay safe.

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