Fall in hospitalisations for acute coronary syndrome seen during COVID-19

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A rise in the number of out-of-hospital cardiac arrests (OHCAs) correlated with a fall in the number of acute coronary syndrome hospitalisations during the COVID-19 surge in the New York metropolitan area, according to a research letter published in the Journal of the American College of Cardiology (JACC).

In the research letter, Stavros E Mountantonakis (Northwell Health, New York, USA) et al, compared data from 20 March to 22 April 2019, to the same time period in 2020, examining the number of daily OHCAs and the number of pronounced deaths on the scene (DOS) from the Fire Department of the City of New York (FDNY). Researchers also examined data on the number of admissions for acute coronary syndrome at 13 Northwell Health hospitals from the same time periods.

From 20 March to 22 April , 2019, researchers found there were 2,242 OHCAs, of which 861 (38%) were DOS. During the same period of 2020, there were 7,249 OHCAs, of which 5,139 (71%) were DOS. This represents a 4.97-fold increase in OHCAs and an almost doubling of DOS, they suggest.

From 20 March to 22 April , 2019, there were 2,084 Northwell Health hospital admissions with a primary diagnosis of ACS, compared with 911 hospital admissions due to ACS for this time frame in 2020—representing a 56.3% reduction.

“During the peak of the COVID-19 outbreak in New York, a marked increase in OHCAs reported by the FDNY paralleled a more than halving in ACS hospitalisations across a large [healthcare] network,” write the authors of the research letter.

“While it is impossible to make a direct relationship between the two findings, challenges in access to, and fear of seeking, care may, in part, explain the observed results. Patients need to be educated and encouraged to seek care for emergent conditions despite the COVID-19 pandemic.”

Similarly, research published in The Lancet this week has also assessed the number of admissions to hospitals in England for acute coronary syndrome, noting a decline from mid-February, 2020, falling from a 2019 baseline rate of 3,017 admissions per week to 1,813 per week by the end of March 2020, a reduction of 40% (95% CI 37–43). This decline was partly reversed during April and May 2020, they reported, such that by the last week of May there were 2,522 admissions, representing a 16% (95% CI 13–20) reduction from baseline.

Writing in The Lancet Marion Mafham (University of Oxford, Oxford, UK) et al report that reductions were recorded in numbers of admissions for acute myocardial infarction, ST-elevation myocardial infarction (STEMI), and non-STEMI (NSTEMI) from the average for 2019 to the end of March 2020, they note, reporting that the percentage reduction in admissions for all acute myocardial infarctions was 35% (95% CI 32–39), with an average of 2,061 admissions per week in 2019, falling to 1,335 per week by the end of March 2020.

For STEMI, there were 621 admissions per week in 2019 and 477 per week by the end of March 2020 (percentage reduction in admissions 23%, 95% CI 16–30), they report. The percentage reduction in admissions for NSTEMI was 42% (95% CI 38–46), with 1,267 admissions per week in 2019 and 733 per week by the end of March 2020. Admissions for both STEMI and NSTEMI rose through April and May 2020, such that, by the last week of May, 2020, admissions were 10% lower than the 2019 baseline for STEMI (95% CI 2–17; 561 admissions per week) and 24% lower for NSTEMI (95% CI 19–28; 966 admissions per week) the researchers reported.

 

Discussing the findings, Mafham et al write: “Taken together, the substantial reduction in admissions for acute coronary syndrome during the COVID-19 pandemic is a serious concern, because patients with symptoms indicative of acute myocardial ischaemia benefit from rapid in-hospital assessment, with the gain being greatest among those with STEMI. Among such patients, there is a substantial risk of out-of-hospital cardiac arrest, and the failure of patients with STEMI to be admitted to hospital so they can receive early reperfusion therapy and other appropriate treatments is likely to have resulted in avoidable deaths and complications, such as fatal arrhythmias and disabling heart failure.

“Although no overall increase in in-hospital mortality was seen among patients admitted for acute coronary syndrome, a direct comparison between mortality rates before and after mid-March, 2020, is likely to be confounded by differences in underlying risk of admitted patients and by the duration of hospital stay. Moreover, it is not possible to assess directly the deaths and disability that probably occurred among those patients with acute coronary syndrome who were not admitted to hospital because of COVID-19 and, therefore, did not receive treatment that is known to be effective.”


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