Clinical and procedural characteristics of COVID-19 patients treated with percutaneous coronary interventions

Do two operators improve outcomes in left main percutaneous coronary intervention? Insights from the ORPKI Registry

BACKGROUND

Significant left main coronary artery (LMCA) disease is prevalent in 7% of patients undergoing angiography. Limited data exists on the impact of double scrubbing in LMCA PCI. We sought to assess periprocedural outcomes in two-operator LMCA percutaneous coronary intervention (PCI).

METHODS

Using data from the Polish National Registry of PCI (ORPKI), we collected data on 28,745 patients undergoing LMCA PCI from 154 centers. Patients were divided into two groups based on the number of operators performing PCI (one vs. two operators).

RESULTS

LMCA PCI was performed by a single operator in 86% of the cases and by two operators in 14% of cases. Patients treated by two operators had a greater comorbidity burden including diabetes mellitus, arterial hypertension, previous myocardial infarction, and previous revascularization. In addition, these were more likely to be treated in high-volume centers, by operators with higher volume of LMCA PCIs. The risk of periprocedural death (2.37% vs. 2.44%; P=0.78), as well as cardiac arrest, coronary artery perforation, no-reflow, and puncture site bleeding was comparable between the two groups. On multivariable analysis, we found that a two-operator strategy was an independent predictor of periprocedural death, with this effect being much more profound in an elective setting (OR=5.13 [1.37-19.26]; P=0.015), compared to an urgent (ACS) setting (OR=1.32 [1.00-1.73]; P=0.047).

CONCLUSIONS

Our study suggests that a two-operator approach is not necessarily routinely recommended for LMCA interventions, although it can be considered for more complex cases.

Atrial fibrillation ablation outcome prediction with a machine learning fusion framework incorporating cardiac computed tomography

BACKGROUND

Structural changes in the left atrium (LA) modestly predict outcomes in patients undergoing catheter ablation for atrial fibrillation (AF). Machine learning (ML) is a promising approach to personalize AF management strategies and improve predictive risk models after catheter ablation by integrating atrial geometry from cardiac computed tomography (CT) scans and patient-specific clinical data. We hypothesized that ML approaches based on a patient's specific data can identify responders to AF ablation.

METHODS

Consecutive patients undergoing AF ablation, who had preprocedural CT scans, demographics, and 1-year follow-up data, were included in the study for a retrospective analysis. The inputs of models were CT-derived morphological features from left atrial segmentation (including the shape, volume of the LA, LA appendage, and pulmonary vein ostia) along with deep features learned directly from raw CT images, and clinical data. These were merged intelligently in a framework to learn their individual importance and produce the optimal classification.

RESULTS

Three hundred twenty-one patients (64.2 ± 10.6 years, 69% male, 40% paroxysmal AF) were analyzed. Post 10-fold nested cross-validation, the model trained to intelligently merge and learn appropriate weights for clinical, morphological, and imaging data (AUC 0.821) outperformed those trained solely on clinical data (AUC 0.626), morphological (AUC 0.659), or imaging data (AUC 0.764).

CONCLUSION

Our ML approach provides an end-to-end automated technique to predict AF ablation outcomes using deep learning from CT images, derived structural properties of LA, augmented by incorporation of clinical data in a merged ML framework. This can help develop personalized strategies for patient selection in invasive management of AF.

Impact of Air Pollution and COVID-19 Infection on Periprocedural Death in Patients with Acute Coronary Syndrome

Air pollution and COVID-19 infection affect the pathogenesis of cardiovascular disease. The impact of these factors on the course of ACS treatment is not well defined. The purpose of this study was to evaluate the effects of air pollution, COVID-19 infection, and selected clinical factors on the occurrence of perioperative death in patients with acute coronary syndrome (ACS) by developing a neural network model. This retrospective study included 53,076 patients with ACS from the ORPKI registry (National Registry of Invasive Cardiology Procedures) including 2395 COVID-19 (+) patients and 34,547 COVID-19 (-) patients. The neural network model developed included 57 variables, had high performance in predicting perioperative patient death, and had an error risk of 0.03%. Based on the analysis of the effect of permutation on the variable, the variables with the greatest impact on the prediction of perioperative death were identified to be vascular access, critical stenosis of the left main coronary artery (LMCA) or left anterior descending coronary artery (LAD). Air pollutants and COVID-19 had weaker effects on end-point prediction. The neural network model developed has high performance in predicting the occurrence of perioperative death. Although COVID-19 and air pollutants affect the prediction of perioperative death, the key predictors remain vascular access and critical LMCA or LAD stenosis.

Diabetes Mellitus Is Still a Strong Predictor of Periprocedural Outcomes of Primary Percutaneous Coronary Interventions in Patients Presenting with ST-Segment Elevation Myocardial Infarction (from the ORPKI Polish National Registry)

The impact of diabetes mellitus (DM) on outcomes of patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) was confirmed by several studies. However, it is unclear whether this effect is still present in large groups of unselected patients undergoing up-to-date treatment. Thus, we sought to assess the impact of DM on periprocedural outcomes of primary PCI in STEMI using data from the Polish National Registry of PCI. Data on 150,782 STEMI patients undergoing primary PCI were collected. Of them, 26,360 (17.5%) patients had DM. Patients with DM were higher-risk individuals who experienced longer reperfusion delays and were less likely to have closed infarct-related artery at baseline (TIMI 0 + 1 flow: 73.2% vs. 72.0%; p < 0.0001) and achieve optimal reperfusion after PCI (TIMI 3 flow: 91.8% vs. 88.5%; p < 0.0001). The periprocedural mortality (1.1% vs. 1.9%; p < 0.0001) was higher in patients with DM and DM was identified as an independent predictor of periprocedural death. In conclusion, despite continuous progress in STEMI treatment, DM remains a strong predictor of periprocedural mortality. However, this detrimental effect of DM may be partially explained by the overall higher risk profile of diabetic patients.

Impact of concomitant COVID-19 on the outcome of patients with acute myocardial infarction undergoing coronary artery angiography

Background

The impact of COVID-19 on the outcome of patients with MI has not been studied widely. We aimed to evaluate the relationship between concomitant COVID-19 and the clinical course of patients admitted due to acute myocardial infarction (MI).

Methods

There was a comparison of retrospective data between patients with MI who were qualified for coronary angiography with concomitant COVID-19 and control group of patients treated for MI in the preceding year before the onset of the pandemic. In-hospital clinical data and the incidence of death from any cause on 30 days were obtained.

Results

Data of 39 MI patients with concomitant COVID-19 (COVID-19 MI) and 196 MI patients without COVID-19 in pre-pandemic era (non-COVID-19 MI) were assessed. Compared with non-COVID-19 MI, COVID-19 MI was in a more severe clinical state on admission (lower systolic blood pressure: 128.51 ± 19.76 vs. 141.11 ± 32.47 mmHg, p = 0.024), higher: respiratory rate [median (interquartile range), 16 (14–18) vs. 12 (12–14)/min, p < 0.001], GRACE score (178.50 ± 46.46 vs. 161.23 ± 49.74, p = 0.041), percentage of prolonged (>24 h) time since MI symptoms onset to coronary intervention (35.9 vs. 15.3%; p = 0.004), and cardiovascular drugs were prescribed less frequently (beta-blockers: 64.1 vs. 92.8%, p = 0.009), angiotensin-converting enzyme inhibitors/angiotensin receptor blockers: 61.5 vs. 81.1%, p < 0.001, statins: 71.8 vs. 94.4%, p < 0.001). Concomitant COVID-19 was associated with seven-fold increased risk of 30-day mortality (HR 7.117; 95% CI: 2.79–18.14; p < 0.001).

Conclusion

Patients admitted due to MI with COVID-19 have an increased 30-day mortality. Efforts should be focused on infection prevention and implementation of optimal management to improve the outcomes in those patients.

The collateral damage of COVID-19 to cardiovascular services: a meta-analysis

AIMS

The effect of the COVID-19 pandemic on care and outcomes across non-COVID-19 cardiovascular (CV) diseases is unknown. A systematic review and meta-analysis was performed to quantify the effect and investigate for variation by CV disease, geographic region, country income classification and the time course of the pandemic.

METHODS AND RESULTS

From January 2019 to December 2021, Medline and Embase databases were searched for observational studies comparing a pandemic and pre-pandemic period with relation to CV disease hospitalisations, diagnostic and interventional procedures, outpatient consultations, and mortality. Observational data were synthesised by incidence rate ratios (IRR) and risk ratios (RR) for binary outcomes and weighted mean differences for continuous outcomes with 95% confidence intervals. The study was registered with PROSPERO (CRD42021265930). A total of 158 studies, covering 49 countries and 6 continents, were used for quantitative synthesis. Most studies (80%) reported information for high-income countries (HICs). Across all CV disease and geographies there were fewer hospitalisations, diagnostic and interventional procedures, and outpatient consultations during the pandemic. By meta-regression, in low-middle income countries (LMICs) compared to HICs the decline in ST-segment elevation myocardial infarction (STEMI) hospitalisations (RR 0.79, 95% confidence interval [CI] 0.66-0.94) and revascularisation (RR 0.73, 95% CI 0.62-0.87) was more severe. In LMICs, but not HICs, in-hospital mortality increased for STEMI (RR 1.22, 95% CI 1.10-1.37) and heart failure (RR 1.08, 95% CI 1.04-1.12). The magnitude of decline in hospitalisations for CV diseases did not differ between the first and second wave.

CONCLUSIONS

There was substantial global collateral CV damage during the COVID-19 pandemic with disparity in severity by country income classification.

Impact of SARS-CoV-2 Outbreak on Emergency Department Presentation and Prognosis of Patients with Acute Myocardial Infarction: A Systematic Review and Updated Meta-Analysis

We performed an updated meta-analysis to robustly quantify admission trends of patients with ST-segment elevation MI (STEMI) and non-ST-segment elevation MI (NSTEMI) during the first wave of the pandemic and to characterize on a large basis the risk profile and early prognosis. Studies having the same observation period for the comparison between SARS-CoV-2 outbreak in 2020 versus control period in 2019 were included. Primary endpoints were the relative variation of hospital admissions, the difference of in-hospital mortality for STEMI and NSTEMI. Secondary were: mortality according to countries, income levels and data quality; cardiogenic shock, mechanical complications, door-to-balloon time, time from symptom onset to first medical contact, left ventricular ejection fraction (LVEF) and troponin. In total, 61 observational studies with 125,346 patients were included. Compared with 2019, during the pandemic for STEMI were observed: a 24% reduction of hospitalizations with an impact on early survival (OR = 1.33 in-hospital mortality); the time from symptom onset to first medical contact was 91.31 min longer, whereas door-to-balloon time was increased (+5.44 min); after STEMI, the rate of cardiogenic shock was 33% higher; LVEF at discharge was decreased (−3.46); elevated high-sensitivity troponin levels (1.52) on admission. For NSTEMI, in the COVID-19 period, we observed a 31% reduction of hospitalizations and higher in-hospital deaths (OR = 1.34). The highest mortality rates among countries were: Italy OR = 3.71 (high income), Serbia OR = 2.15 (upper middle) and Pakistan OR = 1.69 (lower middle). Later hospital presentation was associated with larger infarctions, as well as with increased cardiogenic shock and in-hospital mortality.

Comparison of the Characteristics, Management, and Outcomes of STEMI Patients Presenting With vs. Those of Patients Presenting Without COVID-19 Infection: A Systematic Review and Meta-Analysis

Objectives

This study aimed to investigate the differences in the characteristics, management, and clinical outcomes of patients with and that of those without coronavirus disease 2019 (COVID-19) infection who had ST-segment elevation myocardial infarction (STEMI).

Methods

Databases including Web of Science, PubMed, Cochrane Library, and Embase were searched up to July 2021. Observational studies that reported on the characteristics, management, or clinical outcomes and those published as full-text articles were included. The Newcastle-Ottawa Scale (NOS) was used to assess the quality of all included studies.

Results

A total of 27,742 patients from 13 studies were included in this meta-analysis. Significant delay in symptom onset to first medical contact (SO-to-FMC) time (mean difference = 23.42 min; 95% CI: 5.85–40.99 min; p = 0.009) and door-to-balloon (D2B) time (mean difference = 12.27 min; 95% CI: 5.77–18.78 min; p = 0.0002) was observed in COVID-19 patients. Compared to COVID-19 negative patients, those who are positive patients had significantly higher levels of C-reactive protein, D-dimer, and thrombus grade (p < 0.05) and showed more frequent use of thrombus aspiration and glycoprotein IIbIIIa (Gp2b3a) inhibitor (p < 0.05). COVID-19 positive patients also had higher rates of in-hospital mortality (OR = 5.98, 95% CI: 4.78–7.48, p < 0.0001), cardiogenic shock (OR = 2.75, 95% CI: 2.02–3.76, p < 0.0001), and stent thrombosis (OR = 5.65, 95% CI: 2.41–13.23, p < 0.0001). They were also more likely to be admitted to the intensive care unit (ICU) (OR = 4.26, 95% CI: 2.51–7.22, p < 0.0001) and had a longer length of stay (mean difference = 4.63 days; 95% CI: 2.56–6.69 days; p < 0.0001).

Conclusions

This study revealed that COVID-19 infection had an impact on the time of initial medical intervention for patients with STEMI after symptom onset and showed that COVID-19 patients with STEMI were more likely to have thrombosis and had poorer outcomes.

Care management and 90-day post discharge mortality in patients hospitalized for myocardial infarction and COVID-19: A French nationwide observational study

BACKGROUND

Concomitant or cured coronavirus disease 2019 (COVID-19) in patients with myocardial infarction (MI) may lead to difficulties in acute care management and impair prognosis.

AIMS

To describe and compare the characteristics, care management and 90-day post discharge outcomes of patients hospitalized for MI who did not have COVID-19 with those of patients with concomitant or previous hospital-diagnosed COVID-19.

METHODS

This population-based French study included all patients hospitalized for MI in France (30 December 2019 to 04 October 2020) from the French National Health Data System. Outcomes were described for each COVID-19 group and compared using adjusted logistic regression analysis.

RESULTS

Among 55,524 patients hospitalized for MI, 135 had previous hospital-diagnosed COVID-19 and 329 had concomitant COVID-19. Patients with previous hospital-diagnosed COVID-19 had more personal history of cardiovascular diseases than those without concomitant/previous confirmed COVID-19. In-hospital and 90-day post discharge mortality rates of patients with previous COVID-19 were 8.1% and 4.0%, respectively, compared with 3.5% and 3.0% in patients without concomitant/previous confirmed COVID-19 (odds ratio [OR]_{adjin-hospital} 1.83, 95% confidence interval [CI] 0.97-3.46; OR_{adjpostdischarge} 0.77, 95% CI 0.28-2.13). Patients with concomitant COVID-19 had more personal history of cardiovascular diseases, but also a poorer prognosis than their no concomitant/no previous confirmed COVID-19 counterparts; they presented excess cardiac complications during hospitalization (OR_adj 1.62, 95% CI 1.29-2.04), in-hospital mortality (OR_adj 3.31, 95% CI 2.32-4.72) and 90-day post discharge mortality (OR_adj 2.09, 95% CI 1.24-3.51).

CONCLUSIONS

In-hospital and 90-day post discharge mortality of patients hospitalized for MI who had previous hospital-diagnosed COVID-19 did not seem to differ from those hospitalized for MI alone. Conversely, concomitant COVID-19 and MI carried a poorer prognosis extending beyond the hospital stay. Special attention should be given to patients with simultaneous COVID-19 and MI, in terms of acute care and secondary prevention.

The Most Relevant Factors Affecting the Perioperative Death Rate in Patients with Acute Coronary Syndrome and COVID-19, Based on Annual Follow-Up in the ORPKI Registry

Background: The COVID-19 pandemic is significantly affecting the functioning of the entire healthcare system. The disease itself may be associated with thromboembolic complications. The purpose of this study is to compare patients with acute coronary syndrome (ACS) and patients with ACS who were diagnosed with COVID-19 in terms of their clinical profile, management, treatment complications, and prognosis. Methods: We analyzed 47,940 cases of patients treated for ACS in 2020, including 44,952 patients (93.8%) who were not diagnosed with COVID-19 and 2988 patients (6.2%) who tested positive for COVID-19. Results: Patients with COVID-19 were significantly more likely to experience out-of-hospital sudden cardiac arrest (7.9 vs. 1.1%; p < 0.0001) and be transported directly to a catheterization laboratory (21.3% vs. 8.1%; p < 0.0001). Mortality was significantly higher in this group (0.9% vs. 0.4%; p < 0.0001). The risk of perioperative death was increased by age over 65 years, use of glycoprotein IIb/IIIa inhibitors (GPI IIb/IIIa), femoral access, critical left main stem coronary artery (LMCA) vascular lesions, ST elevation myocardial infarction (STEMI), and no-reflow phenomenon. Conclusions: Despite the pandemic, patients with COVID-19 were treated equally to healthy patients. Efficient organization of the healthcare system allowed the prompt transportation of patients to catheterization laboratories. The study group was characterized by a worse prognosis that was affected by multiple factors.

The Global Effect of the COVID-19 Pandemic on STEMI Care: A Systematic Review and Meta-analysis

BACKGROUND

The COVID-19 pandemic has affected patients with ST-segment elevation myocardial infarction (STEMI) requiring primary percutaneous coronary intervention (PCI) worldwide. In this review we examine the global effect of the COVID-19 pandemic on incidence of STEMI admissions, and relationship between the pandemic and door to balloon time (D2B), all-cause mortality, and other secondary STEMI outcomes.

METHODS

We performed a systematic review and meta-analysis to primarily compare D2B time and in-hospital mortality of STEMI patients who underwent primary PCI during and before the pandemic. Subgroup analyses were performed to investigate the influence of geographical region and income status of a country on STEMI care. An online database search included studies that compared the aforementioned outcomes of STEMI patients during and before the pandemic.

RESULTS

In total, 32 articles were analyzed. Overall, 19,140 and 68,662 STEMI patients underwent primary PCI during and before the pandemic, respectively. Significant delay in D2B was observed during the pandemic (weighted mean difference, 8.10 minutes; 95% confidence interval [CI], 3.90-12.30 minutes; P = 0.0002; I2 = 90%). In-hospital mortality was higher during the pandemic (odds ratio [OR], 1.27; 95% CI, 1.09-1.49; P = 0.002; I2 = 36%), however this varied with factors such as geographical location and income status of a country. Subgroup analysis showed that low-middle-income countries observed a higher rate of mortality during the pandemic (OR, 1.52; 95% CI, 1.13-2.05; P = 0.006), with a similar but insignificant trend seen among the high income countries (OR, 1.17; 95% CI, 0.95-1.44; P = 0.13).

CONCLUSIONS

The COVID-19 pandemic is associated with worse STEMI performance metrics and clinical outcome, particularly in the Eastern low-middle-income status countries. Better strategies are needed to address these global trends in STEMI care during the pandemic.

Review of Irish patients meeting ST elevation criteria during the COVID-19 pandemic

Introduction

The COVID-19 pandemic has seen the introduction of important public health measures to minimise the spread of the virus. We aim to identify the impact government restrictions and hospital-based infection control procedures on ST elevation myocardial infarction (STEMI) care during the COVID-19 pandemic.

Methods

Patients meeting ST elevation criteria and undergoing primary percutaneous coronary intervention from 27 March 2020, the day initial national lockdown measures were announced in Ireland, were included in the study. Patients presenting after the lockdown period, from 18 May to 31 June 2020, were also examined. Time from symptom onset to first medical contact (FMC), transfer time and time of wire cross was noted. Additionally, patient characteristics, left ventricular ejection fraction, mortality and biochemical parameters were documented. Outcomes and characteristics were compared against a control group of patients meeting ST elevation criteria during the month of January.

Results

A total of 42 patients presented with STEMI during the lockdown period. A significant increase in total ischaemic time (TIT) was noted versus controls (8.81 hours (±16.4) vs 2.99 hours (±1.39), p=0.03), with increases driven largely by delays in seeking FMC (7.13 hours (±16.4) vs 1.98 hours (±1.46), p=0.049). TIT remained significantly elevated during the postlockdown period (6.1 hours (±5.3), p=0.05), however, an improvement in patient delays was seen versus the control group (3.99 hours (±4.5), p=0.06). There was no difference seen in transfer times and door to wire cross time during lockdown, however, a significant increase in transfer times was seen postlockdown versus controls (1.81 hours (±1.0) vs 1.1 hours (±0.87), p=0.004).

Conclusion

A significant increase in TIT was seen during the lockdown period driven mainly by patient factors highlighting the significance of public health messages on public perception. Additionally, a significant delay in transfer times to our centre was seen postlockdown.

Characteristics of patients with ST-segment elevated myocardial infarction (STEMI) at the initial stage of the COVID-19 pandemic: a systematic review and meta-analysis

BACKGROUND

The COVID-19 pandemic has become a new challenge to the medical system in various countries. The patients with ST-segment elevated myocardial infarction (STEMI) were also affected.

METHODS

We used a random-effects mode to analyze the differences of the baseline characteristics and therapeutic features between STEMI patients admitted before and after the start of the COVID-19 pandemic.

RESULTS

Thirty eight studies involving 79,753 patients were included in this analysis. The number of hospitalized STEMI patients decreased by 26% after the start of the COVID-19 pandemic. There were no differences in age, sex, prevalence of diabetes, hypertension, dyslipidemia or percutaneous coronary intervention rate between the STEMI patients before and after the start of the COVID-19 pandemic. However, the STEMI patients admitted after the start of the COVID-19 pandemic had a significantly increased time from symptom onset to first medical contact (standard mean difference: 0.51, 95% confidence interval: 0.24-0.78, p < .001) and an increased in-hospital mortality (odds ratio: 1.70, 95% confidence interval:1.14-2.56, p < .001); The in-hospital mortality of the STEMI patients with COVID-19 was 24% (95% confidence interval: 0.15-0.33); The in-hospital mortality of the STEMI patients with COVID-19 was significantly higher than that of the STEMI patients without COVID-19 at the initial stage of the COVID-19 pandemic (odds ratio: 7.28, 95% confidence interval: 2.75-19.28, p < .001).

CONCLUSION

The number of admitted STEMI patients was reduced while the in-hospital mortality and the time from symptom onset to first medical contact were increased during the COVID-19 pandemic.

Impact of COVID-19 Pandemic on Mechanical Reperfusion in ST-Segment-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention: A Multicenter Retrospective Study From a Non-epicenter Region

Objective: The COVID-19 pandemic placed heavy burdens on emergency care and posed severe challenges to ST-segment-elevation myocardial infarction (STEMI) treatment. This study aimed to investigate the impact of COVID-19 pandemic on mechanical reperfusion characteristics in STEMI undergoing primary percutaneous coronary intervention (PPCI) in a non-epicenter region. Methods: STEMI cases undergoing PPCI from January 23 to March 29 between 2019 and 2020 were retrospectively compared. PPCI parameters mainly included total ischemic time (TIT), the period from symptom onset to first medical contact (S-to-FMC), the period from FMC to wire (FMC-to-W) and the period from door to wire (D-to-W). Furthermore, the association of COVID-19 pandemic with delayed PPCI risk was further analyzed. Results: A total of 14 PPCI centers were included, with 100 and 220 STEMI cases undergoing PPCI in 2020 and 2019, respectively. As compared to 2019, significant prolongations occurred in reperfusion procedures (P < 0.001) including TIT (420 vs. 264 min), S-to-FMC (5 vs. 3 h), FMC-to-W (113 vs. 95 min) and D-to-W (83 vs. 65 min). Consistently, delayed reperfusion surged including TIT ≥ 12 h (22.0 vs.3.6%), FMC-to-W ≥ 120 min (34.0 vs. 6.8%) and D-to-W ≥ 90 min (19.0 vs. 4.1%). During the pandemic, the patients with FMC-to-W ≥ 120 min had longer durations in FMC to ECG completed (6 vs. 5 min, P = 0.007), FMC to DAPT (24 vs. 21 min, P = 0.001), catheter arrival to wire (54 vs. 43 min, P < 0.001) and D-to-W (91 vs. 78 min, P < 0.001). The pandemic was significantly associated with high risk of delayed PPCI (OR = 7.040, 95% CI 3.610-13.729, P < 0.001). Conclusions: Even in a non-epicenter region, the risk of delayed STEMI reperfusion significantly increased due to cumulative impact of multiple procedures prolongation.

The Effect of the Lockdown on Patients With Myocardial Infarction During the COVID-19 Pandemic–A Systematic Review and Meta-Analysis

BACKGROUND

The phenomenon of declining numbers of patients presenting with myocardial infarction was reported from the beginning of the COVID-19 pandemic onward. It was thought that measures introduced to stem the pandemic, such as the lockdown, contributed to this development. However, the data on hospital admissions, delay times, and mortality are not consistent.

METHODS

Our systematic literature review and meta-analysis embraced studies reporting the number of hospital admissions of patients with ST-segment elevation myocardial infarction (STEMI) and/or non-ST-segment elevation myocardial infarction (NSTEMI) during lockdown episodes. We also collected data on patient- and system-related delay times and on mortality.

RESULTS

Data from 27 studies on a total of 81 163 patients were included in our meta-analysis. We found that the number of hospital admissions of patients with myocardial infarction was significantly lower during the lockdown than before the pandemic (incidence rate ratio [IRR] = 0.516 [0.403; 0.660], I2 = 98%). This was true both for patients with STEMI (IRR = 0.620 [0.514; 0.746], I2 = 96%) and for patients with NSTEMI (IRR = 0.454 [0.354; 0.584], I2 = 96%). However, we found no significant difference in the time from hospital admission to cardiac catheterization, or in mortality, in relation to the time from symptom onset to first medical contact.

CONCLUSION

In this study, we have shown that the lockdown due to COVID-19 was associated with a marked decline in the number of hospital admissions of patients with myocardial infarction. As no significant effect on delay times or mortality was observed, it seems that timely medical care continued to be delivered.

Rate of COVID-19 infection in patients with ST-segment elevation myocardial infarction

Background

The incidence of coronavirus disease 2019 (COVID-19) in patients with ST-segment elevation myocardial infarction (STEMI) has not been fully described.

Methods

All patients with STEMI undergoing primary percutaneous coronary intervention (PCI) in Ontario, Canada between March 1 and September 30, 2020 were included. Rates of positive COVID-19 tests from January 1, 2020 to the date of STEMI presentation were ascertained. For comparison, COVID-19 results were also evaluated in the adult Ontario population between January 1, 2020 and September 30, 2020, using provincial laboratory testing data.

Results

There were 3606 unique patients presenting with STEMI and receiving PCI in Ontario, Canada during the study period. Sixteen patients (0.44%) tested positive for COVID-19. The background infection rate among all 12,448,541 Ontario residents was similar, at 0.34%.

Conclusions

The results of this population-based analysis suggest that proceeding with primary PCI with appropriate infection control practices is reasonable when community infection rates are low.

Cardiovascular and Cerebrovascular Complications With COVID-19

The coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus-2 has affected the health of people across the globe. Cardiovascular diseases (CVDs) have a significant relationship with COVID-19, both as a risk factor and prognostic indicator, and as a complication of the disease itself. In addition to predisposing to CVD complications, the ongoing pandemic has severely affected the delivery of timely and appropriate care for cardiovascular conditions resulting in increased mortality. The etiology behind the cardiac injury associated with severe acute respiratory syndrome coronavirus-2 is likely varied, including coronary artery disease, microvascular thrombosis, myocarditis, and stress cardiomyopathy. Further large-scale investigations are needed to better determine the underlying mechanism of myocardial infarction and other cardiac injury in COVID-19 patients and to determine the incidence of each type of cardiac injury in this patient population. Telemedicine and remote monitoring technologies can play an important role in optimizing outcomes in patients with established CVD. In this article, we summarize the various impacts that COVID-19 has on the cardiovascular system, including myocardial infarction, myocarditis, stress cardiomyopathy, thrombosis, and stroke.

Management of STEMI during the COVID-19 pandemic: Lessons learned in 2020 to prepare for 2021

As the prevalence of asymptomatic COVID-19 continues to increase, there is an increasing possibility that patients with COVID-19 may presen with ST-segment elevation myocardial infarction (STEMI). With social distancing and restricted access to preventive healthcare and emergency services, the management of acute cardiac emergencies such as myocardial infarction has suffered collateral damage. Thus far, global trends suggest a decrease in STEMI activations with possible worse outcomes due to delayed presentation and management. In this review, we discuss the challenges to STEMI management in the COVID-19 era and provide potential solutions for adherence to evidence-based therapies as the pandemic progresses into the year 2021.

Management of acute coronary syndromes during the COVID-19 outbreak in Lombardy: The "macro-hub" experience

Background

During the COVID-19 outbreak, healthcare Authorities of Lombardy modified the regional network concerning time-dependent emergencies. Specifically, 13 Macro-Hubs were identified to deliver timely optimal care to patients with acute coronary syndromes (ACS). Aim of this paper is to present the results of this experience.

Methods and Results

This is a multicenter, observational study. A total of 953 patients were included, presenting with STEMI in 57.7% of the cases. About 98% of patients received coronary angiography with a median since first medical contact to angiography of 79 (IQR 45–124) minutes for STEMI and 1262 (IQR 643–2481) minutes for NSTEMI.

A total of 107 patients (11.2%) had SARS-CoV2 infection, mostly with STEMI (74.8%). The time interval from first medical contact to cath-lab was significant shorter in patients with COVID-19, both in the overall population and in STEMI patients (87 (IQR 41–310) versus 160 (IQR 67–1220) minutes, P = 0.001, and 61 (IQR 23–98) versus 80 (IQR 47–126) minutes, P = 0.01, respectively). In-hospital mortality and cardiogenic shock rates were higher among patients with COVID-19 compared to patients without (32% vs 6%, P < 0.0001, and 16.8% vs 6.7%, P < 0.0003, respectively).

Conclusions

During the COVID-19 outbreak in Lombardy, the redefinition of ACS network according to enlarged Macro-Hubs allowed to continue with timely ACS management, while reserving a high number of intensive care beds for the pandemic. Patients with ACS and COVID-19 presented a worst outcome, particularly in case of STEMI.

Clinical and procedural characteristics of COVID-19 patients treated with percutaneous coronary interventions

BACKGROUND

COVID-19 pandemic has affected healthcare systems worldwide. Resources are being shifted and potentially jeopardize safety of non-COVID-19 patients with comorbidities. Our aim was to investigate the impact of national lockdown and SARS-CoV-2 pandemic on percutaneous treatment of coronary artery disease in Poland.

METHODS

Data on patients who underwent percutaneous coronary procedures (angiography and/or percutaneous coronary intervention [PCI]) were extracted for March 13-May 13, 2020 from a national PCI database (ORPKI Registry) during the first month of national lockdown and compared with analogous time period in 2019.

RESULTS

Of 163 cardiac catheterization centers in Poland, 15 (9.2%) were indefinitely or temporarily closed down due to SARS-CoV-2 pandemic. There were nine physicians (9 of 544; 1.7%) who were infected with SARS-CoV-2. There were 13,750 interventional cardiology procedures performed in Poland in the analyzed time period. In 66% of cases an acute coronary syndrome was diagnosed, and in the remaining 34% it was an elective procedure for the chronic coronary syndrome in comparison to 50% in 2019 (p < .001). There were 362 patients (2.6% of all) with COVID-19 confirmed/suspected who were treated in interventional cardiology centers and 145 with ST-Elevation Myocardial Infarction (STEMI) diagnosis (6% of all STEMIs).

CONCLUSIONS

Due to SARS-CoV-2 pandemic there was an absolute reduction in the number of interventional procedures both acute and elective in comparison to 2019 and a significant shift into acute procedures. COVID-19 confirmed/suspected patients do not differ in terms of procedural and baseline characteristics and reveal similar outcomes when treated with percutaneous coronary interventions.