Management of Acute Coronary Syndrome in the COVID Era

[A man in his sixties with dyspnoea and systolic murmur after myocardial infarction]

Background

Ventricular septal rupture (VSR) following acute myocardial infarction is rare in the modern revascularisation era. Nevertheless, clinical awareness is paramount, as presentation may vary.

Case presentation

A middle-aged male with no history of cardiovascular disease developed progressive heart failure symptoms while travelling abroad. Initial workup revealed a prominent systolic murmur, but findings were inconsistent with acute coronary syndrome. Transthoracic echocardiogram showed a small hypokinetic area in the basal septum, preserved left ventricular function and no significant valvulopathy. Despite the absence of chest pain, an invasive angiography revealed occlusion of a septal branch emerging from the left anterior descending artery, otherwise patent coronary arteries. Despite administration of diuretics, the patient remained symptomatic and presented two months later to his primary care provider with a persisting systolic murmur. He was subsequently referred to the outpatient cardiology clinic where echocardiography revealed a large VSR involving the basal anteroseptum of the left ventricle with a significant left-to-right shunt. After accurate radiological and haemodynamic assessment of the defect, he successfully underwent elective surgical repair.

Interpretation

Although traditionally associated with large transmural myocardial infarctions, VSR may arise also from minor, subclinical events. A new-onset murmur is a valuable hint for the alert clinician.

Time trends in income-related disparity in incidence of acute coronary syndrome

BACKGROUND

Higher incidence of acute coronary syndrome (ACS), among those with lower income, has been recognized in the most recent decades. Still, there is a paucity of data on temporal changes. This study aims to investigate 20-year time trends in income-related disparity in the incidence of ACS in Denmark.

METHODS

This Population-based repeated cross-sectional study included all patients with first-time ACS, aged ≥20 years, registered in the Danish National Patient Registry 1998-2017. Aggregated sociodemographic data for the Danish population was accessed from Statistics Denmark. Yearly incidence rates (IR) and incidence rate ratios (IRR), with the highest-income quartile as a reference, were standardized using cell-specific personal equivalent income according to year, sex and age group with 95% confidence intervals. Interaction analysis was executed for differences in IR of ACS between the lowest- and highest-income quartile over time.

RESULTS

A total of 220 070 patients hospitalized with ACS from 1998 to 2017 were identified. The yearly standardized ACS IRs decreased in all income quartiles. However, the IR remained higher in the lowest-income quartile compared to the highest for both men [1998: IRR 1.45 (95% confidence interval, CI 1.39-1.52) and 2017: 1.47 (1.40-1.54)] and women [1998: IRR 1.73 (1.64-1.82) and 2017: 1.76 (1.65-1.88)]. Interaction analysis showed that over the period the difference in IR between the lower- and the highest-income quartile decreased with 1-5 ACS cases per 100 000 person-year.

CONCLUSION

Income-related disparity in the incidence of ACS was present in Denmark between 1998 and 2017. Despite a marked overall decrease in the yearly ACS incidence, the extent of income-related disparity remained unchanged.

COVID-19 and Acute Coronary Syndrome: A Literature Review

The coronavirus disease 2019, also known as the COVID-19 pandemic has had a deleterious impact on daily living, with health and socioeconomic effects of a global magnitude. Acute coronary syndrome (ACS), an important cardiovascular disease with significant morbidity and mortality rates, has been frequently reported in patients with this novel virus. This review aims to discuss the potential associations between COVID-19 and ACS with the use of multiple databases, including but not limited to; PubMed, ScienceDirect, World Health Organization, and American Heart Association.

We have explored the pathophysiology of ACS, focusing on COVID-19 in particular with the use of various works of literature that highlights the pattern of viral entry and replication via the angiotensin-converting enzyme II. The review has also discussed the impact of the pandemic on hospital admissions, diagnosis, and management of ACS patients, as well as briefly highlighted a possible link between the widely available COVID-19 vaccines and possible cardiovascular complications.

The association between COVID-19 and ACS needs more in-depth studies to help establish whether there exists a direct causal and or inciting correlation between them. Understanding this association might lead to new research and treatment options for ACS patients.