key: cord-0742692-l1yqzgoe authors: Natarajan, Madhu K.; Wijeysundera, Harindra C.; Oakes, Garth; Cantor, Warren J.; Miner, Steven E.S.; Welsford, Michelle; Cheskes, Sheldon; Le May, Michel R.; Jeffrey, Jana; Ko, Dennis T. title: Early Observations during COVID-19 pandemic in cardiac catheterization procedures for ST Elevation Myocardial Infarctions (STEMI) across Ontario date: 2020-07-23 journal: CJC Open DOI: 10.1016/j.cjco.2020.07.015 sha: e7c1d4ea87ef4b807c68d41ce90d8a1347e1439d doc_id: 742692 cord_uid: l1yqzgoe In response to the COVID-19 pandemic, Ontario issued a declaration of emergency, implementing public health interventions on March 16, 2020. We compared cardiac catheterization procedures for STEMI between January 1 and May 10, 2020 to the same timeframe in 2019. From March 16 to May 10, 2020, after implementation of provincial directives, STEMI cases significantly decreased by up to 25%. The proportion of patients achieving guideline targets for FMC-balloon for PPCI decreased substantially to 28% (Median 101 min) for patients presenting directly to a PCI-site and to 37% (Median 149 min) for patients transferred from a non-PCI site, compared to 2019. STEMI cases across Ontario have been substantially impacted during the COVID-19 pandemic. In response to the COVID-19 pandemic, Ontario issued a declaration of emergency, implementing public health interventions on March 16, 2020. We compared cardiac catheterization procedures for STEMI between January 1 and May 10, 2020 to the same timeframe in 2019. From March 16 to May 10, 2020, after implementation of provincial directives, STEMI cases significantly decreased by up to 25%. The proportion of patients achieving guideline targets for FMC-balloon for PPCI decreased substantially to 28% (Median 101 min) for patients presenting directly to a PCI-site and to 37% (Median 149 min) for patients transferred from a non-PCI site, compared to 2019. STEMI cases across Ontario have been substantially impacted during the COVID-19 pandemic. The COVID-19 pandemic prompted Ontario to implement emergency public health measures. During the following 8 weeks from March 16 to May 10, 2020 we observed substantial decreases in the number of emergency cardiac catheterization lab procedures for STEMI as well as increases in treatment times. STEMI cases in Ontario have been substantially impacted by COVID-19. In response to the COVID-19 pandemic, the Province of Ontario declared a state of emergency on March 16, 2020 and many public health interventions were implemented including social distancing, halting of non-essential businesses and cancelling of elective health procedures and surgeries (1) . Although STEMI management requires emergent intervention and was not directly halted by these measures, the indirect effects of the pandemic on cardiac health and management may be important. Whether these interventions have impacted the number of patients presenting with STEMI and their treatment times is unknown. Outcomes in patients presenting with STEMI are sensitive to both the timeliness of presentation (symptoms to first medical contact (FMC)) as well as the promptness of treatment (first medical contact to first balloon/device (FMC-balloon)). Ontario has a well-developed STEMI System of Care with designated care pathways (Ontario STEMI Bypass Protocol for patients calling 911 and Ontario Emergency Department (ED) STEMI Protocol for patients presenting to an ED) and regional partnerships for both primary percutaneous coronary interventions (PPCI) and pharmaco-invasive PCI performed by 17 cardiac centres. CorHealth Ontario routinely monitors STEMI activity and provides productivity reports quarterly. In response to the changing landscape, and in consultation with provincial STEMI stakeholders and national societies, CorHealth developed a STEMI guidance document aiming to preserve the established regional practices of PPCI or pharmacoinvasive PCI during the COVID-19 pandemic, while maintaining the safety of patients and health care workers (2, 3) . Brief reports from other jurisdictions affected by the COVID-19 pandemic show a substantial decrease in the number of patients presenting to hospital with STEMI, delayed patient presentations, and potential delays in treatment times due to a limited capacity for regional transfers or availability of front-line health care workers (4) (5) (6) . These studies were based on a selected number of centres and none reported treatment times. Herein we report our observations for STEMI care during the initial few weeks following declaration of an emergency and the subsequent public health measures advising the public to stay home. Data maintained in the CorHealth Ontario Cardiac Registry were used for this analysis. The data elements are collected on a standardized STEMI Case Report Form completed by a coordinator performing chart review at each STEMI hospital and consolidated monthly. Inclusion criteria for the reports are cases with STEMI diagnosis on referral where a coronary angiogram is performed at a hospital with PPCI capabilities as the initial procedure. Variables included in this analysis include age, sex, diabetes, hypertension, hyperlipidemia, prior MI > 30 days, prior heart failure, prior PCI, prior coronary artery bypass surgery (CABG), chronic obstructive pulmonary disease (COPD), mode of presentation (EMS vs self), location of first presentation (Direct to PCI site, Transferred from non-PCI site), reperfusion type (PPCI, pharmaco-invasive PCI, rescue PCI, Late PCI > 24 hrs) and FMC-balloon time. Key performance indicators were percentage of STEMI cases presenting directly to a PCI-site achieving time < 90 minutes from FMC-balloon and percentage of STEMI cases transferred from a Non-PCI site achieving time < 120 minutes from FMC-balloon. For this analysis, STEMI activity across the province was compared between January 1 to May 10, 2020 and the same time period in 2019. Baseline characteristics were statistically compared across all timeframes for cardiac catheterization procedures for STEMIs between January 1 and May 10, 2020 to the same timeframe in 2019, and, after the implementation of provincial directives, from March 16 to May 10, 2020 using a Chi-Square test for categorical variables and ANOVA for continuous variables. Any differences among the 3-way timeframe comparisons were further examined by performing pairwise comparisons ( Table 1 ). The rate of the number of STEMI cases reported in bi-weekly periods in 2019 and 2020 were compared using a Poisson model ( Figure 1 ). In addition, FMC-balloon times for PPCI were assessed on a bi-weekly basis, coordinating with Monday to Sunday calendar weeks ( Figure 2 ). Times are displayed in minutes as median and 10 th and 90 th percentiles. The median times reported in bi-weekly periods in 2019 and 2020 were compared using a 2-sided Wilcoxon Two-Sample Test. Between January 1 and May 10, 2020, there were 2221 STEMI cases reported to CorHealth, compared to 2513 cases during the same timeframe in 2019 (Table 1 ). There were no differences observed in baseline characteristics of age and sex. Compared to 2019 or first 3 months of 2020 there were less patients with hyperlipidemia, prior MI and COPD and an approximate 8% increase in patients presenting by EMS after March 16, 2020. There were no changes observed in proportion of patients referred for cardiac catheterization presenting greater than 12 hours after symptom onset. The majority (more than 70%) of STEMI cases continued to be treated with PPCI. A sustained and significant reduction in STEMI cases of up to 25% was observed after March 16, 2020 ( Figure 1 ). The decrease in STEMI volumes also correlated with an increase in reported active COVID-19 cases (Figure 1 ). Starting in the week of March 16, 2020, the proportion of patients achieving FMC-balloon benchmarks for PPCI decreased substantially to 28% (FMC-balloon < 90 min) for patients presenting directly to a PCI-site and to 37% (FMCballoon <120 min) for patients transferred from a non-PCI site ( Figure 2 ). The corresponding biweekly median times significantly increased to 101 min for direct to PCI-site group and nonsignificantly increased to 149 min for patients transferred from a non-PCI site, compared to 2019. Our early observations for STEMI care during COVID-19 across Ontario show a substantial and sustained decrease in cardiac catheterization procedures for STEMI over several weeks starting mid-March, 2020. This coincided temporally with the Ontario government directed public health interventions and direction to stay home. Although the majority of STEMI patients continued to receive primary PCI, a decrease in key performance metrics was noted especially in patients being transferred from non-PCI sites. An increase in cardiac catheterization lab procedures for patients with symptom onset to FMC greater than 12 hours was not observed. It is an area of ongoing analysis to determine if there were a greater number of out-of-hospital cardiac deaths potentially due to untreated STEMI and if the short-term outcomes for treated STEMI patients were affected due to delays in presentation. CorHealth data only includes STEMI patients who have a cardiac catheterization procedure. Therefore, we could not determine the number of STEMI patients who present to non-PCI hospitals and did not get referred for cardiac catheterization. The increase in treatment times from first medical contact for patients receiving PPCI is concerning but not unexpected. Meeting performance indicators for timely reperfusion in STEMI is highly dependent on tight alignments of rapid diagnosis and rapid transfers between STEMI providers. In a well-organized STEMI system, longer treatment times for PPCI are generally associated with ambiguity in patient clinical presentation (e.g. atypical symptoms) or diagnostic findings (e.g. complex ECG). Timely availability of transport services and healthcare personnel on both the sending and receiving hospitals may have been an issue. It is possible that safety measures aimed to protect both the patient and health care workers may have negatively affected timely delivery of PPCI. These safety measures including newly implemented screening protocols at every step of the patient encounter as well as donning of personal protective equipment by health care workers. In addition, symptoms of dyspnea and chest pain related to possible presence of COVID-19 may have further delayed definitive STEMI diagnosis and activation. Most concerning is that the lower proportion of patients achieving performance indices are noted in the setting of reduced STEMI volumes. This suggests, that although the province of Ontario did not experience a significant limitation in intensive care unit beds due to COVID-19 (between March and May 2020) and hospital systems were not directed to limit essential activity, there was an observed reduction in the performance of the Ontario STEMI system to provide timely care (7) . Whether this is a temporary phenomenon related to initial challenges of implementation and accommodation to new processes that will improve over time remains to be seen. Despite increasing COVID-19 activity across the province more than 70% of STEMI procedures across Ontario were for PPCI. Some groups have proposed a move to a routine fibrinolyticbased reperfusion strategy during the pandemic (8, 9) . A pharmacoinvasive strategy as reported in the Strategic Reperfusion Early after Myocardial Infarction (STREAM) study, may be an alternative to PPCI when timeline metrics cannot be met, especially during COVID-19 (10). While increased risks of intracranial bleed have been a concern with this strategy, recent realworld data from the Vital Heart Response Strategy Alberta, Canada has shown that a pharmacoinvasive strategy was associated with improved clinical outcomes (including core lab ST-segment resolution) compared to PPCI with similar intracranial and major bleeding rates, when incorporating half-dose in elderly patients (11) . Fibrinolysis time of thirty minutes may be a more achievable mode of reperfusion with less personnel and allows more time for further evaluation of patient status and testing for COVID-19. Additionally, transfer for a less emergent cardiac catheterization procedure further protects cardiac catheterization laboratory staff from inadvertent exposure and risks. In addition to the STEMI guidance document (2), CorHealth informed Provincial Emergency Departments of the need to be adequately prepared including consideration of a pharmacoinvasive approach during this pandemic and future waves of COVID-19 (12) . However, challenges of routine fibrinolysis administration include ability to rapidly ramp-up local supplies, ability of emergency departments to rapidly switch practice, and ongoing need for rescue PCI. Additionally, specific concerns related to administration of fibrinolysis during COVID-19 include atypical STEMI presentations and reports of a myocarditis-like syndrome that mimics STEMI and possible increased risks of fibrinolysis (13). Infarction (NACMI) registry will provide further insights into these clinical presentations and outcomes (14) . Previous observational studies have demonstrated that every 10-minute treatment delay in PPCI leads to an additional 3.3 deaths among 100 PPCI-treated patients for FMC-to-balloon times ranging from 60 to 180 minutes (15). Although the proportion of patients receiving PPCI within 90 min decreased substantially in the direct to PCI-centre group, the actual increase in median times was less than ten minutes. However, the increase in median FMC-to-balloon time for the transferred patients increased by more than 20 minutes. Ongoing surveillance and monitoring are needed as it is not clear at this time that the processes that contributed to increased FMC-to-balloon time would not also adversely affect door-to-needle time. Nevertheless, a pharmacoinvasive strategy may need to be reconsidered regardless of COVID-19 prevalence, for patients who present at hospitals across Ontario without PPCI where substantial treatment delays with PPCI are expected (16). CorHealth relies on cardiac hospitals to provide timely data for reporting purposes. During COVID-19 many hospitals reported reduction of staff as well as reallocation to essential services. While it is possible that data entry may be delayed, surveys of hospitals did not highlight any concerns with workload for data entry for this analysis. We did not observe changes in proportion of STEMI patients presenting late after symptom onset. This may be related to several factors including uncertainty and inconsistencies in defining symptom onset (i.e. when symptoms started versus when they were severe enough to seek medical attention), differences in coding of patients as STEMI or NSTEMI on the referral form and patients not being referred for cardiac catheterization. However, the coding practices have remained unchanged over the last several years. Mortality data was not available for this cohort but will be the focus of further analysis. The COVID-19 pandemic and corresponding public health measures have had a significant impact on STEMI care across Ontario. Cardiac catheterization lab procedures for STEMI have been reduced. The proportion of patients meeting reperfusion treatment goals for PPCI has decreased. Long-term consequences of these observations should be considered. Precautions and Procedures for Coronary and Structural Cardiac Interventions During the COVID-19 Pandemic: Guidance from Canadian Association of Interventional Cardiology Impact of Coronavirus Disease 2019 (COVID-19) Outbreak on ST-Segment-Elevation Myocardial Infarction Care in Hong Kong Reduction in ST-Segment Elevation Cardiac Catheterization Laboratory Activations in the United States during COVID-19 Pandemic Reduced Rate of Hospital Admissions for ACS during Covid-19 Outbreak in Northern Italy Era -Business as Usual? STEMI Care and COVID-19: The Value Proposition of Pharmacoinvasive Therapy Fibrinolysis or primary PCI in ST-segment elevation myocardial infarction Pharmacoinvasive Strategy Versus Primary Percutaneous Coronary Intervention in ST-Elevation Myocardial Infarction in Clinical Practice: Insights From the Vital Heart Response Registry Figure 2 : Trends in STEMI Metrics in two-week intervals between January and May 2020 are displayed using medians (with 10 th and 90 th percentiles). a) FMC-Balloon for Patients Presenting to PCI Sites; b) FMC-Balloon for Patients Transferred from non-PCI sites. Number of cases and percentage of patients meeting target FMC-balloon are listed below each plot.