key: cord-0736651-amw9k06r
authors: Calvão, João; Amador, Ana Filipa; Costa, Catarina Martins da; Araújo, Paulo Maia; Pinho, Teresa; Freitas, João; Amorim, Sandra; Macedo, Filipe
title: O impacto da pandemia COVID-19 nas Admissões por Síndrome Coronária Aguda num hospital terciário do Porto
date: 2021-03-20
journal: Rev Port Cardiol
DOI: 10.1016/j.repc.2021.01.007
sha: 3c85279bc37225f12cff8c136b19aa4d96849d43
doc_id: 736651
cord_uid: amw9k06r

Introdução e Objetivos: A pandemia pela COVID-19 colocou os sistemas de saúde em todo o mundo sob uma exigência sem precedentes. Apesar de a maioria dos doentes admitidos por síndrome coronária aguda não estarem infetados com COVID-19, as medidas de saúde pública instituídas poderão afetar este grupo de risco particularmente elevado. O objetivo desde estudo passa por avaliar o impacto que a fase inicial da pandemia COVID-19 teve na apresentação e evolução clínica de doentes admitidos por síndrome coronária aguda num hospital terciário numa das regiões de Portugal mais afetadas pela pandemia. Métodos: Este estudo retrospetivo de caso-controlo incluiu doentes admitidos com o diagnóstico de síndrome coronária aguda entre Março e Abril de 2020 (grupo pandémico) e no mesmo período em 2019 (grupo controlo). Foram recolhidos dados em relação à evolução clínica em regime de internamento e após a alta. Resultados: Durante o período de pandemia, verificou-se uma diminuição do número de admissões por síndrome coronária aguda bem como apresentações mais graves, registando-se uma maior proporção de enfartes agudos do miocárdio com supradesnivelamento do segmento ST (54,9% versus 38,8%, p= 0.047), níveis máximos de troponina I mais elevados, e maior prevalência de disfunção sistólica do ventrículo esquerdo à data de alta (58,0% versus 35,0%, p= 0,01). Apesar de não se ter atingido valores estatisticamente significativos, observou-se um aumento do intervalo de tempo entre o início de sintomas e a realização de intervenção coronária percutânea, o que poderá traduzir um atraso na procura de cuidados de saúde. Conclusão: A fase inicial da pandemia COVID-19 associou-se a um menor número e maior gravidade de admissões por síndrome coronária aguda num hospital terciário numa das regiões de Portugal mais afetadas pela pandemia. Introduction and Objectives: The coronavirus SARS-CoV-2 (COVID-19) pandemic has been an unmatched challenge to global healthcare. Although the majority of patients admitted with acute coronary syndrome (ACS) may not be infected with COVID-19, the quarantine and public health emergency measures may have affected this particular high risk group. The objective of this study is to assess the impact of the early period of the COVID-19 pandemic on ACS admissions and clinical course, in a tertiary care hospital in Portugal’s most affected region. Methods: This retrospective, case-control study included patients admitted with a diagnosis of ACS during March and April 2020 (pandemic group) and in the same period in2019 (control group). Clinical course and complications were also assessed. Results: During the pandemic, there were fewer ACS admissions but presentation was more severe, with a larger proportion of acute ST-elevation myocardial infarctions (54.9% vs. 38.8%, p= 0.047), higher maximum troponin levels and greater prevalence of left ventricular systolic dysfunction at discharge (58.0% vs. 35.0%, p= 0.01). In this population, although not statistically significant, it was observed a delay between the onset of symptoms and percutaneous coronary intervention, which may traduce a deferred search for urgent medical care during the pandemic. Conclusion: The lockdown phase of COVID-19 pandemic was associated with fewer and more severe ACS in a Tertiary Care Hospital in Portugal’s most affected region by the pandemic.

In order to contain the COVID-19 pandemic, there was a widespread lockdown worldwide, with restrictive home confinement and social distancing measures. 5, 6 Overwhelmed healthcare systems were also promptly restructured, expanding intensive care units and altering or cancelling non-essential procedures. 7, 8 In the meantime, many countries reported a significant reduction in hospital admissions for several acute conditions that require life-saving evidence-based emergent treatment, such as acute coronary syndrome (ACS) and stroke. [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] Moreover, patients with cardiovascular disease are at increased risk of severe COVID-19 illness, endorsing the direct and indirect consequences of delayed care of this particular group of patients. [21] [22] [23] In Portugal, the first case was reported on 2March 2020 in Porto. The mandatory national lockdown was imposed from 18March to 2 May, amounting to 25 190 cases and 1023 deaths due to COVID-19 at the end of this period. The northern region of Portugal, mainly Porto's metropolitan area, had the highest incidence of COVID-19 cases, reaching around 14 951 cases and 585 deaths. [24] [25] [26] [27] The aim of this study was to assess the impact of COVID-19 pandemic on ACS admissions 

Our study included 151 patients hospitalized with ACS in the two aforementioned periods. There were 71 ACS admissions in between March and April, 2020 (n=71), representing a reduction of 11.3% relative to the same period in 2019 (n=80).

Overall, there were no significant differences in age, gender, and cardiovascular risk factors in both groups ( Table 1 ). The pandemic group had a higher prevalence of atherosclerotic disease (defined as history of peripheral, coronary or cerebral arterial disease) (45.1% vs. 28.7%, p=0.04), although there was no difference considering previous ACS or revascularization procedures.

Three patients from the pandemic group tested positive for SARS-COV-2.

The proportion of ACS presenting as STEMI was significantly higher in the pandemic group (54.9% vs. 38.8%, p= 0.047). This was driven not only by a decrease in the number of NSTEMI and UA patients (49 vs. 32) but also by an increase in the absolute number of STEMIs (31 vs. 39).

Among STEMI admissions, although not statistically significant, there was a longer period between time from the onset of symptoms to first medical contact (FMC), during the pandemic (control vs. pandemic; median 145 ±178 min vs. 180 ±360 min, p= 0.31) ( Patients originally admitted in hospitals without the ability to perform primary PCI had no significant difference in FMC to PCI times in both groups (190 +/-632 vs. 210 +/-600, p= 0.57).

One of the patients from the pandemic group had known SARS-COV-2 infection at the time of presentation. He was admitted with inferior wall STEMI (less than one hour after symptom onset) and underwent fibrinolysis, followed by routine PCI. The decision to perform fibrinolysis was made based on a STEMI reperfusion algorithm published at the time. 30 Clinical course Both groups had a similar length of hospitalization (control vs. pandemic: 5±8 vs. 5±6 days, p= 0.377) ( Table 3 ). There was no difference regarding Killip class classification.

Maximum measured high-sensitivity Troponin I was significantly higher in the pandemic group (19439 ±70265ng/L vs. 10222 ±36870 ng/L, p= 0.03). There were also significantly more patients with LV systolic dysfunction at discharge (58.0% vs. 35.0%, p= 0.01).

Finally, there was a greater proportion of patients in the pandemic group with in-hospital complications (23.9% vs. 13.8%, p= 0.11) and in-hospital (5.6% vs. 1.3%, p= 0.15) and 30-day (7.0% vs. 2.5%, p= 0.18) mortality, although these did not reach statistical significance ( (17, 29) . Although not statistically significant, our data suggests that there was a delay between the onset of symptoms and search for medical care during the pandemic.

The non-significance of this finding may be related to the small sample size. This delay may explain the greater number of STEMIs admitted and consequently the higher prevalence of LV systolic dysfunction at the time of discharge. It is of relevance that patients during pandemic had a significantly higher prevalence of atherosclerotic disease and this may have had some impact on the differences seen in the outcomes of the two groups.

In-hospital and 30-day mortality were numerically higher in patients admitted during the pandemic, similar to those observed in other studies. 15 Our study was innovative since it also assessed complications related to ACS; the rate was overall low but a higher proportion of complications occurred during the pandemic. This may translate into higher mortality and higher morbidity in the near future. Our concern also extends to patients that did not reach out for medical care during the pandemic, which may negatively affect long-term cardiovascular health. This may partially explain the higher revascularization rates, since milder cases may not have come to medical attention. More studies should be designed to explore these events.

Importantly, there was no evidence of significant delay in the healthcare response to STEMI patients, including in cases initially admitted to hospitals without the ability to perform primary PCI. Revascularization rates were not precluded and fibrinolysis use was residual. These data may be explained since Portugal did not reach a situation in which the health care system was overwhelmed or began to collapse. 34 This analysis has some limitations. Only patients admitted to one center were included.

Additionally, acute morbidity and mortality may be underestimated, since patients who died in the pre-hospital phase/emergency room or were admitted at other intensive care units were not included. 

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