The risk of in-hospital death and in-hospital heart failure increased for ST-elevation myocardial infarction (STEMI) patients in China during the early stages of the COVID-19 pandemic, according to research published in the Journal of the American College of Cardiology (JACC). Hospitals also experienced a decline in the number of heart attack patients seeking treatments, delays in time to treatment and changes in treatment protocols, the paper indicates.
Lead author of the study, Dingcheng Xiang (General Hospital of Southern Theatre Command of PLA, Guangzhou, China), writes that at the start of the COVID-19 outbreak on January 23 2020, China Chest Pain Center’s Executive Committee recommended prioritising thrombolytic treatment for most patients with unconfirmed COVID-19 status in areas affected by the outbreak to ensure timely reperfusion therapy for patients and control in-hospital infection.
As the pandemic developed, experts in Iran, Palestine and Jordan recommended similar protocols, while those in the USA, Italy, Australia and New Zealand have recommended continuing with existing percutaneous coronary intervention (PCI) protocols except in special circumstances.
In JACC study, researchers evaluated the impact of the COVID-19 outbreak and China Chest Pain Center’s modified STEMI protocol on the treatment and prognosis of STEMI patients in China. Data were reviewed from 28,189 STEMI patients admitted to 1,372 chest pain centres between December 27 2019 and February 20 2020. A total of 25,150 (89.2%) of patients met the inclusion criteria.
Data show that there was around a 26% drop in weekly hospitalised STEMI cases during the outbreak nationwide, and a 62% drop in Hubei province, which was the epicentre of the outbreak in China. This suggests STEMI patients were less likely to access care during the outbreak, which is similar to trends seen worldwide.
Consistent with new protocols, the percentage of primary PCI dropped by half, while the percentage of thrombolysis increased four-fold in Hubei province. In other less affected provinces, there was a slight decrease in the percentage of primary PCI and slight increases in the percentage of thrombolysis.
Despite these changes, the percentage of STEMI patients receiving timely reperfusion therapy during the outbreak dropped from 59.4% to 51.6% in Hubei province during the COVID-19 outbreak and from 65.1% to 60.1% in other provinces. Researchers also found that the COVID-19 outbreak delayed primary PCI for about 21 minutes in Hubei province and about four minutes in other provinces; the delay for thrombolytic treatment was close to 23 minutes in Hubei province and close to five minutes in other provinces.
Overall, the rates of in-hospital mortality and in-hospital heart failure increased from 4.6% to 7.3% and from 14.2% to 18.4% in Hubei province during the outbreak period, respectively. Other provinces saw smaller increases of 4% to 4.7% for in-hospital mortality and 13.2% to 14% for in-hospital heart failure. There did not appear to be differences in in-hospital haemorrhage.
“Our findings provide much needed empirical evidence for healthcare professionals searching for a balance between optimizing timely treatment for STEMI patients and protecting health care workers and vulnerable cardiovascular patients from the risk of COVID-19 infection,” said Xiang. “Despite the inevitable delays in treatment timeline due to mandatory infection control procedures and changes in reperfusion strategies during the outbreak, the proportion of patients receiving effective reperfusion remained stable.”
Limitations of the study include that because there was little time between the start of China’s response to the COVID-19 outbreak and the release of the modified STEMI protocol, this observational study cannot fully dissociate the effects of the modified protocol from the other aspects of the COVID-19 outbreak that contribute to the deterioration of STEMI patient prognosis. Also, researchers were unable to assess the extent to which modified protocol protected healthcare workers and other vulnerable cardiovascular patients from COVID-19 infection due to the lack of complete data on nosocomial infection. However, researchers suggest the protocol was likely effective in this regard.
In a related editorial comment, Lauren S Ranard, Sahil A Parikh (New York, USA), Ajay J Kirtane, cardiologists at Columbia University Irving Medical Center/New York-Presbyterian Hospital (New York, USA) PCI should remain the preferred method of revascularization for STEMI patients, irrespective of COVID19, especially in areas with adequate PPE and timely access to PCI, and noted that bleeding risk might be higher than the study suggests.
“Widespread adaptation of [thrombolysis] as the preferred reperfusion approach may unnecessarily expose many patients to bleeding risk. The low total number of patients with bleeding events in this report, despite increasing adoption of [thrombolysis], suggests potential under-reporting of these outcomes, which are not readily ascertained as outcomes such as overall mortality,” Ranard said.
“However, this study has added to the growing evidence base that COVID-19 epicentres have had a decline in hospitalised STEMI cases, in conjunction with increases in time to reperfusion. Despite a protocol-based recommendation to change to a strategy of [thrombolysis] to attempt to reduce these delays in reperfusion, increases in mortality and heart failure were still observed. The old adage of ‘time is muscle’ therefore remains true, pandemic or not.”