An In-hospital Pathway for Acute Coronary Syndrome Patients During the COVID-19 Outbreak: Initial Experience Under Real-World Suboptimal Conditions

Worldwide impact of COVID-19 on hospital admissions for non-ST-elevation acute coronary syndromes (NSTACS): a systematic review with meta-analysis of 553 038 cases

BACKGROUND

How coronavirus disease 2019 (COVID-19) impacted non-ST-segment elevation acute coronary syndromes (NSTACS) is an object of controversial reports.

AIM

To systematically review studies reporting NSTACS hospitalizations during the COVID-19 pandemic, and analyse whether differences in COVID-19 epidemiology, methodology of report, or public health-related factors could contribute to discrepant findings.

METHODS

Comprehensive search (Medline, Embase, Scopus, Web of Science, Cochrane Register), of studies reporting NSTACS hospitalizations during the COVID-19 pandemic compared with a reference period, following Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. Data were independently extracted by multiple investigators and pooled using a random-effects model. Health-related metrics were from publicly available sources, and analysed through multiple meta-regression modelling.

RESULTS

We retrieved 102 articles (553 038 NSTACS cases, 40 countries). During peak COVID-19 pandemic, overall incidence rate ratio (IRR) of NSTACS hospitalizations over reference period decreased (0.70, 95% confidence interval (CI) 0.66-0.75; P < 0.00001). Significant heterogeneity was detected among studies (I2 = 98%; P < 0.00001). Importantly, wide variations were observed among, and within, countries. No significant differences were observed by study quality, whereas comparing different periods within 2020 resulted in greater decrease (IRR: 0.61; CI: 0.53-0.71) than comparing 2020 vs. previous years (IRR: 0.74; CI 0.69-0.79). Among many variables, major predictors of heterogeneity were severe acute respiratory syndrome coronavirus 2 reproduction rate/country, number of hospitals queried, and reference period length; country stringency index and socio-economical indicators did not contribute significantly.

CONCLUSIONS

During the COVID-19 pandemic, NSTACS hospitalizations decreased significantly worldwide. However, substantial heterogeneity emerged among countries, and within the same country. Factors linked to public health management, but also to methodologies to collect results may have contributed to this heterogeneity.

TRIAL REGISTRATION

The protocol was registered in the PROSPERO International Prospective Register of Systematic Reviews (ID: CRD42022308159).

The impact of COVID-19 on myocardial infarctions, strokes and out-of-hospital cardiopulmonary arrests: an observational retrospective study on time-sensitive disorders in the Friuli Venezia Giulia region (Italy)

The COVID-19 global pandemic has changed considerably the way time-sensitive disorders are treated. Home isolation, people's fear of contracting the virus and hospital reorganisation have led to a significant decrease in contacts between citizens and the healthcare system, with an expected decrease in calls to the Emergency Medical Services (EMS) of the Friuli-Venezia Giulia (FVG) region. However, mortality in clinical emergencies like acute ST-elevation myocardial infarction (STEMI), stroke and out-of-hospital cardiopulmonary arrest (OHCA) remained high. An observational retrospective cross-sectional study was carried out in FVG, taking into account the period between March 1, 2020, and May 31, 2020, the first wave of the COVID-19 pandemic, and comparing it with the same period in 2019. The flow of calls to the EMS was analysed and COVID-19 impact on time-sensitive disorders (STEMIs, ischemic strokes and OHCPAs) was measured in terms of hospitalisation, treatment and mortality. Despite a -8.01% decrease (p value ˂0.001) in emergency response, a 10.89% increase in calls to the EMS was observed. A lower number of advanced cardiopulmonary resuscitations (CPR) (75.8 vs 45.2%, p=0.000021 in April) and ROSC (39.1 vs 11.6%, p=0.0001 in April) was remarked, and survival rate dropped from 8.5 to 5%. There were less strokes (-27.5%, p value=0.002) despite a more severe onset of symptoms at hospitalisation with NHISS˃10 in 38.47% of cases. Acute myocardial infarctions decreased as well (-20%, p value=0.05), but statistical significances were not determined in the variables considered and in mortality. Despite a lower number of emergency responses, the number of calls to the EMS was considerably higher. The number of cardiac arrests treated with advanced CPR (ALS) was lower, but mortality was higher. The number of strokes decreased as well, but at the time of hospitalisation the clinical picture of the patient was more severe, thus affecting the outcome when the patient was discharged. Finally, STEMI patients decreased; however, no critical issues were observed in the variables taken into account, neither in terms of response times nor in terms of treatment times.

Acute Myocardial Infarction During the COVID-19 Pandemic: An Update on Clinical Characteristics and Outcomes

The outbreak of coronavirus disease 2019 (COVID-19) has rapidly become a worldwide pandemic. On top of respiratory complications, COVID-19 is associated with major direct and indirect cardiovascular consequences, with the latter probably being even more relevant, especially in the setting of time-dependent cardiovascular emergencies. A growing amount of data suggests a dramatic decline in hospital admissions for acute myocardial infarction (AMI) worldwide during the COVID-19 pandemic, mostly since patients did not activate emergency medical systems because hospitals were perceived as dangerous places regarding the infection risk. Moreover, during the COVID-19 pandemic, patients with AMI had a significantly higher in-hospital mortality compared to those admitted before COVID-19, potentially due to late arrival to the hospital. Finally, no consensus has been reached regarding the most adequate healthcare management pathway for AMI and shared guidance on how to handle patients with AMI during the pandemic is still needed. In this review, we will provide an update on epidemiology, clinical characteristics, and outcomes of patients with AMI during the COVID-19 pandemic, with a special focus on its collateral cardiac impact.

The Impact of the SARS-CoV-2 Pandemic on Healthcare Provision in Italy to non-COVID Patients: a Systematic Review

BACKGROUND

Italy has been one of the countries most affected by the SARS-CoV-2 pandemic, and the regional healthcare system has had to quickly adapt its organization to meet the needs of infected patients. This has led to a drastic change in the routine management of non-communicable diseases with a potential long-term impact on patient health care. Therefore, we investigated the management of non-COVID-19 patients across all medical specialities in Italy.

METHODS

A PRISMA guideline-based systematic review of the literature was performed using PubMed, Embase, and Scopus, restricting the search to the main outbreak period in Italy (from February 20 to June 25 2020). We selected articles in English or Italian that detailed changes in the Italian hospital care for non-COVID-19 patients due to the pandemic. Our keywords included all medical specialities combined with our geographical focus (Italy) and COVID-19.

RESULTS

Of the 4643 potentially eligible studies identified by the search, 247 were included. A decrease in the management of emergencies in non-COVID patients was found together with an increase in mortality. Similarly, non-deferrable conditions met a tendency toward decreased diagnosis. All specialities have been affected by the re-organization of healthcare provision in the hub-and-spoke system and have benefited from telemedicine.

CONCLUSIONS

Our work highlights the changes in the Italian public healthcare system to tackle the developing health crisis due to the COVID-19 pandemic. The findings of our review may be useful to analyse future directions for the healthcare system in the case of new pandemic scenarios.

Spillover Effects of COVID-19 on Essential Chronic Care and Ways to Foster Health System Resilience to Support Vulnerable Non-COVID Patients: A Multistakeholder Study

OBJECTIVES

Little empirical research exists on how key stakeholders involved in the provision of care for chronic conditions and policy planning perceive the indirect or "spillover" effects of the COVID-19 on non-COVID patients. This study aims to explore stakeholder experiences and perspectives of the impact of COVID-19 on the provision of care for chronic conditions, evolving modalities of care, and stakeholder suggestions for improving health system resilience to prepare for future pandemics.

DESIGN

Qualitative study design.

SETTING AND PARTICIPANTS

This study was conducted during and after the COVID-19 lockdown period in Singapore. We recruited a purposive sample of 51 stakeholders involved in care of non-COVID patients and/or policy planning for chronic disease management. They included health care professionals (micro-level), hospital management officers (meso-level), and government officials (macro-level).

METHODS

In-depth semi-structured interviews were conducted. All interviews were digitally recorded, transcribed verbatim, and thematically analyzed.

RESULTS

Optimal provision of care for chronic diseases may be compromised through the following processes: lack of "direct" communication between colleagues on clinical cases resulting in rescheduling of patient visits; uncertainty in diagnostic decisions due to protocol revision and lab closure; and limited preparedness to handle non-COVID patients' emotional reactions. Although various digital innovations enhanced access to care, a digital divide exists due to uneven digital literacy and perceived data security risks, thereby hampering wider implementation. To build health system resilience, stakeholders suggested the need to integrate digital care into the information technology ecosystem, develop strategic public-private partnerships for chronic disease management, and give equal attention to the provision of holistic psychosocial and community support for vulnerable non-COVID patients.

CONCLUSIONS AND IMPLICATIONS

Findings highlight that strategies to deliver quality chronic care for non-COVID patients in times of public health crisis should include innovative care practices and institutional reconfiguration within the broader health system context.

COVID-19 pandemic and waiting times in outpatient specialist care in Germany: an empirical analysis

Background

International healthcare systems face the challenge that waiting times may create barriers to accessing medical care, and that those barriers are unequally distributed between different patient groups. The disruption of healthcare systems caused by the COVID-19 pandemic could exacerbate this already strained demand situation. Using the German healthcare system as an example, this study aims to analyze potential effects of the COVID-19 pandemic on waiting times for outpatient specialist care and to evaluate differences between individual patient groups based on their respective insurance status and the level of supply.

Methods

We conducted an experiment in which we requested appointments by telephone for different insurance statuses in regions with varying levels of supply from 908 outpatient specialist practices in Germany before and during the COVID-19 pandemic. Data from 589 collected appointments were analyzed using a linear mixed effect model.

Results

The data analysis revealed two main counteracting effects. First, the average waiting time has decreased for both patients with statutory (mandatory public health insurance) and private health insurance. Inequalities in access to healthcare, however, remained and were based on patients’ insurance status and the regional level of supply. Second, the probability of not receiving an appointment at all significantly increased during the pandemic.

Conclusions

Patient uncertainty due to the fear of a potential COVID-19 infection may have freed up capacities in physicians’ practices, resulting in a reduction of waiting times. At the same time, the exceptional situation caused by the pandemic may have led to uncertainty among physicians, who might thus have allocated appointments less frequently. To avoid worse health outcomes in the long term due to a lack of physician visits, policymakers and healthcare providers should focus more on regular care in the current COVID-19 pandemic.

Impact of the COVID-19 Pandemic on the Management of Acute Myocardial Infarction

Aim

The coronavirus (COVID-19) outbreak in 2019 has negatively impacted the care of patients with other life-threatening diseases, including acute myocardial infarction (AMI). However, there is little published information concerning the depth of the impact on the clinical management and outcome following AMI.

Methods

We enrolled patients with AMI who received urgent primary percutaneous coronary intervention at the Beijing Tiantan Hospital (Beijing, China) between December 1, 2019 and April 10, 2020. Patients were divided into 2 cohorts, the pre-COVID-19 group (from December 1, 2019 to January 31, 2020) and during-COVID-19 group (from February 1, 2020 to April 10, 2020) for analysis. The door-to-balloon (D to B) time, total hospitalization stay (days) and coronary care unit (CCU) hospitalization days were calculated. New York Heart Association heart functional class (NYHA class), re-hospitalization and death ratio in patients were assessed between the two cohorts.

Results

A total of 148 AMI patients were enrolled in this study comprising 53 patients pre-COVID-19 group and 95 patients during-COVID-19 group. Patients with AMI during-COVID-19 group had longer symptom onset to hospital time (4.5 [2.0–9.3] vs 3.0 [2.0–5.0] hours, p = 0.013) and D to B time (96 [74–119] vs 67 [52–81] minutes, p <0.001); the D to B time shortened during the study period. The two cohorts did not have significantly different number of hospitalization days, re-hospitalization rates, peak cTnI, BNP or death rates. For the one-year follow-up, the patients in the during-COVID-19 group were classified as NYHA class III–IV more frequently (9 [9.7%] vs 0 [0%], p=0.004).

Conclusion

The COVID-19 pandemic significantly affected one measure of critical care of patients with AMI, NYHA classification, which may have resulted in increased medical expenses.

Reduction of Inhospital Mortality of Patient Admissions to Cardiac Intensive Care Units During the COVID-19 Pandemic in Hunan, China

This study aims to evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on patient admissions to Hunan's cardiac intensive care units (CCUs).We conducted a retrospective, single-center study. Data were collected from patients who were confirmed to have critical cardiovascular disease and admitted to the CCU of the Second Xiangya Hospital of Central South University, Hunan, from January 23 to April 23, 2020. Compared with the same period in 2019, the results show that the number of hospitalization decreased by 19.6%; the inhospital mortality rate of CCU was decreased (28.57% versus 16.67%; odds ratio (OR), 0.50; 95% confidence interval (CI), 0.251-0.996; P = 0.047); hospital stay was decreased (7.97 versus 12.36, P < 0.001); hospital emergency percutaneous coronary intervention (PCI) rate in patients with acute coronary syndromes (ACS) significantly decreased (76.00% versus 39.00%, P < 0.001); among this, the PCI rate of patients with ST-segment elevation myocardial infarction (STEMI) decreased (76.32% versus 55.17%, P = 0.028) as well. In addition, the number of patients transferred from other hospitals significantly decreased (76.79% versus 56.67%, P = 0.002), and the number of patients transferred from other cities also decreased by 10.75%.During the outbreak of the COVID-19 epidemic in Hunan Province, the number of patients admitted to CCU decreased, as well as the mortality rate; fewer patients with severe cardiovascular disease can be transported to better hospitals from remote rural areas. In addition to epidemic prevention and control, experts in China should focus on improved emergency transport medical services to reduce this impact.

Perceived Effectiveness, Restrictiveness, and Compliance with Containment Measures against the Covid-19 Pandemic: An International Comparative Study in 11 Countries

National governments took action to delay the transmission of the coronavirus (SARS-CoV-2) by implementing different containment measures. We developed an online survey that included 44 different containment measures. We aimed to assess how effective citizens perceive these measures, which measures are perceived as violation of citizens' personal freedoms, which opinions and demographic factors have an effect on compliance with the measures, and what governments can do to most effectively improve citizens' compliance. The survey was disseminated in 11 countries: UK, Belgium, Netherlands, Bulgaria, Czech Republic, Finland, India, Latvia, Poland, Romania, and Sweden. We acquired 9543 unique responses. Our findings show significant differences across countries in perceived effectiveness, restrictiveness, and compliance. Governments that suffer low levels of trust should put more effort into persuading citizens, especially men, in the effectiveness of the proposed measures. They should provide financial compensation to citizens who have lost their job or income due to the containment measures to improve measure compliance. Policymakers should implement the least restrictive and most effective public health measures first during pandemic emergencies instead of implementing a combination of many restrictive measures, which has the opposite effect on citizens' adherence and undermines human rights.

The Effects of the Health System Response to the COVID-19 Pandemic on Chronic Disease Management: A Narrative Review

BACKGROUND

Individuals with chronic conditions require ongoing disease management to reduce risks of adverse health outcomes. During the COVID-19 pandemic, health care for non-COVID-19 cases was affected due to the reallocation of resources towards urgent care for COVID-19 patients, resulting in inadequate ongoing care for chronic conditions.

METHODS

A keyword search was conducted in PubMed, Google Scholar, Science Direct, and Scopus for English language articles published between January 2020 and January 2021.

FINDINGS

During the COVID-19 pandemic, in-person care for individuals with chronic conditions have decreased due to government restriction of elective and non-urgent healthcare visits, greater instilled fear over potential COVID-19 exposure during in-person visits, and higher utilization rates of telemedicine compared to the pre-COVID-19 period. Potential benefits of a virtual-care framework during the pandemic include more effective routine disease monitoring, improved patient satisfaction, and increased treatment compliance and follow-up rates. However, more needs to be done to ensure timely and effective access to telemedicine, particularly for individuals with lower digital literacy. Capitation primary care models have been proposed as a more financially-robust approach during the COVID-19 pandemic than fee-for-service primary care models; however, the interplay between different primary models and the health outcomes is still poorly understood and warrants further investigation. Shortages of medication used to manage chronic conditions were also observed at the beginning of the COVID-19 pandemic due to global supply chain disruptions. Finally, patients with chronic conditions faced lifestyle disruptions due to the COVID-19 pandemic, specifically in physical activity, sleep, stress, and mental health, which need to be better addressed.

INTERPRETATION

Overall, this review elucidates the disproportionately greater barriers to primary and specialty care that patients with chronic diseases face during the COVID-19 pandemic and emphasizes the urgent need for better chronic disease management strategies moving forward.

Modified Strategies for Invasive Management of Acute Coronary Syndrome during the COVID-19 Pandemic

The COVID-19 pandemic presents several challenges for managing patients with acute coronary syndrome (ACS). Modified treatment algorithms have been proposed for the pandemic. We assessed new algorithms proposed by The European Association of Percutaneous Cardiovascular Interventions (EAPCI) and the Acute Cardiovascular Care Association (ACCA) on patients with ACS admitted to the hospital during the COVID-19 pandemic. The COVID-19 period group (CPG) consisted of patients admitted into a high-volume centre in Prague between 1 February 2020 and 30 May 2020 (n = 181). The reference group (RG) included patients who had been admitted between 1 October 2018 and 31 January 2020 (n = 834). The proportions of patients with different types of ACS admitted before and during the pandemic did not differ significantly: in all ACS patients, KILLIP III-IV class was present in 13.9% in RG and in 9.4% of patients in CPG (p = 0.082). In NSTE-ACS patients, the ejection fraction was lower in the CPG than in the RG (44.7% vs. 50.7%, respectively; p < 0.001). The time from symptom onset to first medical contact did not differ between CPG and RG patients in the respective NSTE-ACS and STEMI groups. The time to early invasive treatment in NSTE-ACS patients and the time to reperfusion in STEMI patients were not significantly different between the RG and the CPG. In-hospital mortality did not differ between the groups in NSTE-ACS patients (odds ratio in the CPG 0.853, 95% confidence interval (CI) 0.247 to 2.951; p = 0.960) nor in STEMI patients (odds ratio in CPG 1.248, 95% CI 0.566 to 2.749; p = 0.735). Modified treatment strategies for ACS during the COVID-19 pandemic did not cause treatment delays. Hospital mortality did not differ.

Management of Acute Coronary Syndromes During the Coronavirus Disease 2019 Pandemic: Deviations from Guidelines and Pragmatic Considerations for Patients and Healthcare Workers

Coronavirus disease 2019 (COVID-19) is forcing cardiology departments to rapidly adapt existing clinical guidelines to a new reality and this is especially the case for acute coronary syndrome pathways. In this focused review, the authors discuss how COVID-19 is affecting acute cardiology care and propose pragmatic guideline modifications for the diagnosis and management of acute coronary syndrome patients, particularly around the appropriateness of invasive strategies as well as length of hospital stay. The authors also discuss the use of personal protective equipment for healthcare workers in cardiology. Based on shared global experiences and growing peer-reviewed literature, it is possible to put in place modified acute coronary syndrome treatment pathways to offer safe pragmatic decisions to patients and staff.

Impact of SARS-CoV-2 on Provided Healthcare. Evidence From the Emergency Phase in Italy

The SARS-CoV-2 (COVID-19) pandemic led to an emergency scenario within all aspects of health care, determining reduction in resources for the treatment of other diseases. A literature review was conducted to identify published evidence, from 1 March to 1 June 2020, regarding the impact of COVID-19 on the care provided to patients affected by other diseases. The research is limited to the Italian NHS. The aim is to provide a snapshot of the COVID-19 impact on the NHS and collect useful elements to improve Italian response models. Data available for oncology and cardiology are reported. National surveys, retrospective analyses, and single-hospital evidence are available. We summarized evidence, keeping in mind the entire clinical pathway, from clinical need to access to care to outcomes. Since the beginning, the COVID-19 pandemic was associated with a reduced access to inpatient (-48% for IMA) and outpatient services, with a lower volume of elective surgical procedures (in oncology, from 3.8 to 2.6 median number of procedures/week). Telehealth may plays a key role in this, particularly in oncology. While, for cardiology, evidence on health outcome is already available, in terms of increased fatality rates (for STEMI: 13.7 vs. 4.1%). To better understand the impact of COVID-19 on the health of the population, a broader perspective should be taken. Reasons for reduced access to care must be investigated. Patients fears, misleading communication campaigns, re-arranged clinical pathways could had played a role. In addition, impact on other the status of other patients should be mitigated.

Establishing a New Normal for Hospital Care: A Whole of Hospital Approach to COVID-19

Singapore’s hospitals had prepared operations to receive patients (potentially) infected with SARS-CoV-2, planning various scenarios and levels of surge with a policy of isolating all confirmed cases as inpatients. The National University Hospital, adopted a whole of hospital approach to COVID-19 with three primary goals: zero hospital-acquired COVID-19, all patients receive timely necessary care, and maintenance of staff morale. These goals to date have been met. A large influx of COVID-19 cases emerged requiring a significant transformation of clinical and operational processes. Isolation room numbers almost tripled and dedicated COVID-19 cohort wards were established, elective care was postponed and Intensive Care Units were augmented with equipment and manpower. In the wake of the surge establishing a new normal for hospital care requires a considered balance of maintaining vigilance to detect endemic COVID-19, establishing contingency plans to ramp up in case of another surge, while returning to business as usual.

Assessing the impact of COVID-19 on the management of patients with liver diseases: A national survey by the Italian association for the study of the Liver

BACKGROUND

The COVID-19 pandemic had a huge impact on national and regional health systems. The impact of SARS-CoV-2 on the quality of care for patients with liver disease is still unknown.

AIMS

The Italian Association for the Study of the Liver (AISF) conducted a survey to assess the impact of SARS-CoV-2 on hepatology units activities in Italy.

METHODS

A prospective web-based survey was proposed to all AISF active members. The survey was available online from April 8 2020, to May 3 2020, (lockdown phase in Italy).

RESULTS

194 AISF members answered the questionnaire, most of whom were specialists in Gastroenterology (41%) or Internal Medicine (28%), and worked in Northern Italy (51%). 26% of hepatology wards had been converted into COVID-19 wards, and 33% had bed reductions. All hepatological activities, including the management of patients with decompensated liver disease, liver transplant and HCC had been significantly reduced/stopped. The number of physicians answering that their practices had not been modified ranged between 0.6% (for chronic hepatitis) to 47% (for the execution of paracentesis). The recorded answers were consistent among different regions, and did not show any north-south gradient CONCLUSION: COVID-19 outbreak significantly impacted on hepatological clinical activity. This survey can serve as a basis to compare the impact of future measures aimed at delivering an acceptable level of liver care during a national pandemic or crisis.

Hospital attendance and admission trends for cardiac diseases during the COVID-19 outbreak and lockdown in Greece

Objectives

The coronavirus disease 2019 (COVID-19) outbreak, along with implementation of lockdown and strict public movement restrictions, in Greece has affected hospital visits and admissions. We aimed to investigate trends of cardiac disease admissions during the outbreak of the pandemic and possible associations with the applied restrictive measures.

Study design

This is a retrospective observational study.

Methods

Data for 4970 patients admitted via the cardiology emergency department (ED) across 3 large-volume urban hospitals in Athens and 2 regional/rural hospitals from February 3, 2020, up to April 12 were recorded. Data from the equivalent (for the COVID-19 outbreak) time period of 2019 and from the postlockdown time period were also collected.

Results

A falling trend of cardiology ED visits and hospital admissions was observed starting from the week when the restrictive measures due to COVID-19 were implemented. Compared with the pre–COVID-19 outbreak time period, acute coronary syndrome (ACS) [145 (29/week) vs. 60 (12/week), −59%, P < 0.001], ST elevation myocardial infarction [46 (9.2/week) vs. 21 (4.2/week), −54%, P = 0.002], and non-ST elevation ACS [99 cases (19.8/week) vs. 39 (7.8/week), −60% P < 0.001] were reduced at the COVID-19 outbreak time period. Reductions were also noted for heart failure worsening and arrhythmias. The ED visits in the postlockdown period were significantly higher than in the COVID-19 outbreak time period (1511 vs 660; P < 0.05).

Conclusion

Our data show significant drops in cardiology visits and admissions during the COVID-19 outbreak time period. Whether this results from restrictive measures or depicts a true reduction of cardiac disease cases warrants further investigation.

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The coronavirus disease 2019 (COVID-19) outbreak has led to an unprecedented health system overload.

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The restrictive measures in Greece resulted in a low number of COVID-19 cases.

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Hospital visits and cardiovascular events have diminished after implementation of restrictive measures.

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Acute coronary syndromes reduced by approximately 55%, despite limited incidence of COVID-19.

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The multifactorial etiology of this finding should be thoroughly investigated.

Treat all COVID 19-positive patients, but do not forget those negative with chronic diseases

The outbreak of coronavirus disease 2019 (COVID-19) has distressed our working practice. Infectious disease specialists, pneumologists and intensivists were not enough to face the enormous amount of patients that needed hospital care; therefore, many doctors have been recruited from other medical specialties trying to take care of as many patients as possible. The 'call to duty' of such doctors for urgent COVID-19 cases, however, diverted the attention from the care of patients with chronic conditions, which might have been neglected or undervalued. In this extremely difficult time, the standard of care of chronic patients has been reduced and this might have determined an increased rate of complications secondary to undermanagement. Thousands of patients with acute and chronic non-COVID-19 conditions have not accessed specialist care in the last weeks in Italy. Moreover, even those patients who have had scheduled an outpatient visit did not attend it for fear of leaving their home or due to the inability to go. During the pandemic, there was a drastic reduction in the number of hospital admissions for any medical conditions different from COVID-19. Self-presentation to the emergency department (ED) has been discouraged and the patients' own fear of being infected by going to the hospital led to also a significant decrease in ED access. During the lockdown, in San Giuseppe Hospital MultiMedica IRCCS, Milan, the ED admissions dropped from the mean of 2361/month in December 2019-February 2020 to 1102 (- 53%) and 861 (- 63%) in March and April 2020, respectively. For all the above-mentioned reasons, it is possible that some clinical conditions will further progress with a significant increase in morbidity and mortality. To prevent this, it is essential that patients with chronic conditions should be at least monitored and managed with telephone or online health consultation, identifying those who need urgent access to care, prioritizing outpatient visits based on disease severity. Patients with mild conditions could be managed outside the hospital by implementing telemedicine and creating networks of general practitioners who can consult with in-hospital specialists.

The Italian Fight Against the COVID-19 Pandemic in the Second Phase: The Renewed Opportunity of Telemedicine

Recent studies published in the Telemedicine and e-Health journal stated the reality in Italy of the importance of telemedicine promotion during the coronavirus 2019 (COVID-19) pandemic. In Italy, we gradually approached the second phase of the COVID-19 pandemic. During this phase, the activities restarted according to a temporal plan. During the second phase, "social distancing" will continue and telemedicine will continue to play a pivotal role. Now, during the second phase of the fight against the pandemic, we need: (1) to maintain social distancing; (2) to face new imminent criticalities highlighted in recent studies published in Telemedicine and e-Health; (3) to protect fragile subjects and to support disabled subjects; and (4) to still care/rehabilitate critical patients (still present even if in a decreased number). Telemedicine is still important and must also be rethought. The study, starting from the needs of chronic patients, highlighted in the recent studies published in this journal, expanded the possibilities of multiple opportunities for telemedicine integration during the second phase. An emerged categorization takes into consideration (1) the subjects with fragility, including those with rare diseases; (2) the experience gained during the emergency; (3) the new opportunities emerged for telemedicine boundaries; and (4) the new needs for telemedicine-based pulmonary rehabilitation at home.

"Celebrating old age": an obsolete expression during the COVID-19 pandemic? Medical, social, psychological, and religious consequences of home isolation and loneliness among the elderly

Since epidemiological arguments favouring self-isolation during the COVID-19 pandemic are widely recommended, the consequences of social isolation/loneliness of older people considered to be at higher risk for severe illness are neglected. We identified and described medical, social, psychological, and religious issues, indirectly generated by the COVID-19 lockdown. Mortality induced by SARS-CoV-2 and death from other "neglected" issues were put in balance. Arguments for strict lockdown from most European countries are compared with a relaxed approach, as has been applied in Sweden. Social isolation affects disproportionally the elderly, transforming it into a public health concern. One witnesses openly ageist discourse, while painful decisions to prioritising ventilation for younger patients deepens the sense of hopelessness. Fear has led to anxiety disorders and depression. Various religious practices provide resources for coping with isolation/overcoming loneliness. Higher levels of mortality/morbidity due to "COVID-19 versus non-COVID-19" polarisation oblige the healthcare community to find ways to provide proper care for its elders.

Reduction of hospitalizations for myocardial infarction in Italy in the COVID-19 era

AIMS

To evaluate the impact of the COVID-19 pandemic on patient admissions to Italian cardiac care units (CCUs).

METHODS AND RESULTS

We conducted a multicentre, observational, nationwide survey to collect data on admissions for acute myocardial infarction (AMI) at Italian CCUs throughout a 1 week period during the COVID-19 outbreak, compared with the equivalent week in 2019. We observed a 48.4% reduction in admissions for AMI compared with the equivalent week in 2019 (P < 0.001). The reduction was significant for both ST-segment elevation myocardial infarction [STEMI; 26.5%, 95% confidence interval (CI) 21.7-32.3; P = 0.009] and non-STEMI (NSTEMI; 65.1%, 95% CI 60.3-70.3; P < 0.001). Among STEMIs, the reduction was higher for women (41.2%; P = 0.011) than men (17.8%; P = 0.191). A similar reduction in AMI admissions was registered in North Italy (52.1%), Central Italy (59.3%), and South Italy (52.1%). The STEMI case fatality rate during the pandemic was substantially increased compared with 2019 [risk ratio (RR) = 3.3, 95% CI 1.7-6.6; P < 0.001]. A parallel increase in complications was also registered (RR = 1.8, 95% CI 1.1-2.8; P = 0.009).

CONCLUSION

Admissions for AMI were significantly reduced during the COVID-19 pandemic across Italy, with a parallel increase in fatality and complication rates. This constitutes a serious social issue, demanding attention by the scientific and healthcare communities and public regulatory agencies.

COVID-19: an unprecedented pandemia with a potential arrhythmic undertone

Data has shown that intense impact events such as large magnitude earthquakes and the US terrorist attacks of 11 September 2001 have shown us that unforeseen catastrophic events are followed by a significant increase of ventricular arrhythmias (VA) and sudden cardiac death (SCD). We are concerned that similarly, the recent COVID-19 pandemia that not only has dismantled our way of living, in a matter of weeks, but also has challenged all of us beyond our abilities might be also related to an increase in prevalence of VA and SCD. In addition to such provocative suggestions raise in this article we want to convey the message that we must remain vigilant long after we have silenced COVID-19.