key: cord-0768116-vyjk82gf authors: Piccolo, Raffaele; Bruzzese, Dario; Mauro, Ciro; Aloia, Antonio; Baldi, Cesare; Boccalatte, Marco; Bottiglieri, Giuseppe; Briguori, Carlo; Caiazzo, Gianluca; Calabrò, Paolo; Cappelli-Bigazzi, Maurizio; De Simone, Ciro; Di Lorenzo, Emilio; Golino, Paolo; Monda, Vittorio; Perrotta, Rocco; Quaranta, Gaetano; Russolillo, Enrico; Scherillo, Marino; Tesorio, Tullio; Tuccillo, Bernardino; Valva, Giuseppe; Villari, Bruno; Tarantini, Giuseppe; Varricchio, Attilio; Esposito, Giovanni title: Population Trends in Rates of Percutaneous Coronary Revascularization for Acute Coronary Syndromes Associated With the COVID-19 Outbreak date: 2020-04-30 journal: Circulation DOI: 10.1161/circulationaha.120.047457 sha: 5387db2a1afe9022ef17237b472bc72b0513c2d0 doc_id: 768116 cord_uid: vyjk82gf nan CORRESPONDENCE and 0.47 (95% CI, 0.45-0.49) for STEMI (Figure) . In comparison with the same period in 2019, PCI rates decreased from 190 to 120, from 107 to 66, and from 84 to 54 cases per 100 000 residents per year for ACS (IRR, 0.63), non-ST-segment-elevation acute ACS (IRR, 0.62), and STEMI (IRR, 0.64), respectively. In the third most populous region of Italy, we found evidence that the outbreak of COVID-19 was associated with a decline by 32% in the number of PCIs for ACS. In the last 2 weeks of the observational period, PCIs for ACS were reduced by 50%. In comparison with PCI volumes for the same time in 2019, the decline in PCI rates was of a similar magnitude (between 36% and 38%). Mechanisms underpinning this decrease are unknown, although several explanations might be involved. Chest pain might be underestimated or misestimated by patients because of the fear of exposure to COVID-19-affected subjects at hospital admission. This hypothesis might be supported by the stronger decline in PCI rates among women, in whom misdiagnosis and delayed revascularization are more likely to occur in an ACS setting. 3 Other explanations might be related to the unique situation of a country lockdown, potentially leading to less physical activity that might trigger an ACS, coupled with reduced air pollution. Our data indicate that the COVID-19 outbreak was associated with a remarkable decrease in the rates of PCI across the entire spectrum of ACS. Although we did not measure the hospitalization rates for ACS, PCI represents the most common revascularization modality for patients who have ACS. The Campania region has been less affected than others by the COVID-19 pandemic and, as a result, no changes occurred during the study period in the regional hub-and-spoke care system and in the management of patients with ACS. Therefore, PCI rates effectively reflect ACS rates. However, we cannot determine to what extent the observed trends reflect changes in patient or physician behavior versus incident ACS. The findings of this study might have important implications for healthcare systems and suggest that public campaigns aiming to increase awareness of ischemic symptoms should be reinforced during the COVID-19 pandemic. The lack of appropriate and timely revascularization for patients with ACS might have other important clinical consequences, not yet measured, including increased risk for heart failure or sudden cardiac death. Data sharing: The data that support the findings of this study are available from the corresponding author on reasonable request. Division of Cardiology, Ospedale San Giuseppe Moscati, Aversa, Italy (G.C.). Division of Cardiology, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli The mystery of the missing STEMIs during the COVID-19 pandemic. tctMD Analysis of Incidence Rates: Poisson Regression for Rate Ratios American Heart Association Cardiovascular Disease in Women and Special Populations Committee of the Council on Clinical Cardiology, Council on Epidemiology and Prevention, Council on Cardiovascular and Stroke Nursing, and Council on Quality of Care and Outcomes Research. Acute myocardial infarction in women: a scientific statement from the None.