key: cord-0721770-f2wj0u6t
authors: Xiang, Dingcheng; Xiang, Xin; Zhang, Wei; Yi, Shaodong; Zhang, Jinxia; Gu, Xiaolong; Xu, Yawei; Huang, Kai; Su, Xi; Yu, Bo; Wang, Yan; Fang, Weiyi; Huo, Yong; Ge, Junbo
title: Management and Outcomes of Patients With STEMI During the COVID-19 Pandemic in China
date: 2020-08-19
journal: J Am Coll Cardiol
DOI: 10.1016/j.jacc.2020.06.039
sha: 10552125b8bfb2261ea55c54cca6c235b5b3e553
doc_id: 721770
cord_uid: f2wj0u6t

BACKGROUND: ST-segment elevation myocardial infarction (STEMI) is a fatal cardiovascular emergency requiring rapid reperfusion treatment. During the coronavirus disease-2019 (COVID-19) pandemic, medical professionals need to strike a balance between providing timely treatment for STEMI patients and implementing infection control procedures to prevent nosocomial spread of COVID-19 among health care workers and other vulnerable cardiovascular patients. OBJECTIVES: This study evaluates 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. METHODS: Based on the data of 28,189 STEMI patients admitted to 1,372 Chest Pain Centers in China between December 27, 2019 and February 20, 2020, the study analyzed how the COVID-19 outbreak and China Chest Pain Center’s modified STEMI protocol influenced the number of admitted STEMI cases, reperfusion strategy, key treatment time points, and in-hospital mortality and heart failure for STEMI patients. RESULTS: The COVID-19 outbreak reduced the number of STEMI cases reported to China Chest Pain Centers. Consistent with China Chest Pain Center’s modified STEMI protocol, the percentage of patients undergoing primary percutaneous coronary intervention declined while the percentage of patients undergoing thrombolysis increased. With an average delay of approximately 20 min for reperfusion therapy, the rate of in-hospital mortality and in-hospital heart failure increased during the outbreak, but the rate of in-hospital hemorrhage remained stable. CONCLUSIONS: There were reductions in STEMI patients’ access to care, delays in treatment timelines, changes in reperfusion strategies, and an increase of in-hospital mortality and heart failure during the COVID-19 pandemic in China.

. On the other hand, the screening and infectious control procedures required to reduce the nosocomial spread of COVID-19 may substantially delay primary PCI and negatively impact patient prognosis (8, 9) . The scarcity of personal protective equipment and rapid testing for COVID-19 further exacerbates the problem, as most medical facilities could not afford to engage full personal protective equipment for all STEMI patients with confirmed COVID-19 status.

As a result, medical professionals across the globe have been debating about the extent to which to initiate COVID-19 screening protocols for STEMI patients and to adjust treatment procedures to prevent nosocomial infection. Organizations or experts in the United States, Italy, Australia, and New Zealand have mostly recommended continuing with existing primary PCI protocols for STEMI patients except for confirmed COVID-19 patients and persons under investigation or cases in which primary PCI could not be performed within required time frames (10) (11) (12) (13) . In contrast, experts in China, Iran, Palestine, and Jordan recommended prioritizing thrombolytic treatment for most patients with unconfirmed COVID-19 status (14) (15) (16) .

However, there is no empirical study evaluating the impact of the COVID-19 pandemic and these different protocols on the prognosis of STEMI patients by the time of the writing of this paper, apart from 2 observational studies reporting 38% to 40% reduction in cardiac catheterization laboratory STEMI activities in Spain and United States and 1 small sample study reporting significant primary PCI delays in Hong Kong (8, 17, 18 Table 1 ). There were also statistically significant differences in key time points, proportion of effective reperfusion and timely reperfusion, and patient prognosis, which will be analyzed in the following 4 sections. Table 1) . Regression analysis ( Table 2) confirmed the negative and significant effect of the p < 0.001), but the interaction term between the COVID-19 outbreak period and Hubei province was not statistically significant ( Table 2) . Last, but not least, the analysis presented in this paper did not account for the influence of the spring festival holiday, a major 2-week festival that coincided with the first 2 weeks of the COVID-19 outbreak period. The spring festival significantly influences patient behavior, public transportation, and hospital operation. Because this study did not include a spring 

Protocol of the China ST-segment elevation myocardial infarction (STEMI) Care Project (CSCAP): a 10-year project to improve quality of care by building up a regional STEMI care network

Chest pain centers in China: Current status and prospects

ESC Guidelines for the management of acute myocardial infarction in patients presenting with STsegment elevation

STEMI care during COVID-19: losing sight of the forest for the trees

Cardiovascular considerations for patients, health care workers, and health systems during the coronavirus disease 2019 (COVID-19) pandemic

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Be prepared

Impact of coronavirus disease 2019 (COVID-19) outbreak on ST-segment-elevation myocardial infarction care in Hong Kong

Reperfusion of STEMI in the COVID-19 era -business as usual?

Considerations for cardiac catheterization laboratory procedures during the COVID-19 pandemic

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Management of acute myocardial infarction during the COVID-19 pandemic

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Expert consensus on operating procedures at chest pain centers in China during the coronavirus infectious disease-19 epidemic

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Reduction in ST-segment elevation cardiac catheterization laboratory activations in the United States during COVID-19 pandemic

The impact of the COVID-19 pandemic on healthcare activities in interventional cardiology units in Spain