key: cord-1014737-1y6gvb0c
authors: Aste, Francesca; Biddau, Mattia; Marchetti, Maria Francesca; Garau, Enrica; Piga, Carlo; Ranieri, Gaetano; Boi, Giacomo; Agus, Elena; Montisci, Roberta; Meloni, Luigi
title: 653 The impact of the COVID-19 pandemic on hospitalizations for acute myocardial infarction: the experience of the Clinical Cardiology Unit, University Hospital of Cagliari
date: 2021-12-08
journal: Eur Heart J Suppl
DOI: 10.1093/eurheartj/suab140.005
sha: 9ce14cdbf98d14419628cd2641ec8505b5979656
doc_id: 1014737
cord_uid: 1y6gvb0c

AIMS: During the COVID-19 pandemic, hospitalization rates for acute myocardial infarction (AMI) decreased worldwide. The aim of the study is to evaluate the impact of the COVID-19 pandemic on the admission rate for AMI to our academic hospital, to monitor the trend during the reopening phase and to evaluate if whether changes in air pollution may have influenced hospitalization rates for AMI in Sardinia and Northern Italy. METHODS AND RESULTS: We compared the admission rate for AMI in our department and, by analysing the density of nitrogen dioxide (1/cm(2)), the state of air pollution in Sardinia and Northern Italy in different periods: the national lockdown (9 March–3 May 2020), the 8 weeks before the start of the lockdown, the 8 weeks after the end of the lockdown and the corresponding time period in 2019 (from 9 March to 3 May 2019). A marked decline in AMI admissions was observed during the lockdown period in comparison with the 8 weeks before the start of the lockdown (−47%, 95% CI: 37.5–56.7, P < 0.0001) and the corresponding period in 2019 (−52.8%, 95% CI: 43–65, P < 0.0001). There was a significant reduction in hospitalizations for NSTEMI during the lockdown period in comparison with the 8 weeks before the start of lockdown (−71.8%, 95% CI: 62.3–79.6, P < 0.0001) and the corresponding time period in 2019 (−70.5%, 95% CI: 60.9–78.5, P < 0.0001). Similar trends were seen in the group of STEMI patients, but the fall in admissions was less than that of NSTEMI patients. During the lockdown period, the hospitalizations for STEMI fell by 31.5% (95% CI: 23.2–41.4, P = 0.19) and 49% (95% CI: 39.4–58.6, 47 vs. 24 admissions, P = 0.009) in comparison to the 8 weeks before the start of lockdown and the corresponding period in 2019, respectively. We observed a rise in AMI admissions during the 8 weeks after the lockdown (+47%, 95% CI: 37.5–56.7, P < 0.0001), for both NSTEMI (+71.2%, 95% CI: 61.7–79.1, P < 0.0001) and STEMI (+33.4%, 95% CI: 24.9–43.1, P = 0.15). In Sardinia the relative change in nitrogen dioxide density during the time of lockdown was negligible with little or no impact on the environment (−19%, 95% CI: 12.5–27.7, P = 0.65), if we consider it occurred within a range of very low values of nitrogen dioxide (11.5 ± 3 e 14.1 ± 5 μmol/m(2)). In contrast, in Northern Italy during the lockdown there was a marked decrease in NO(2) concentration in comparison with the 8 weeks before the start of lockdown (−53%, 95% CI: 43–62.4, 25.1 ± 16.2 e 54.2 ± 43.5 μmol/m(2), P < 0.0001). CONCLUSIONS: Since air pollution did not change substantially in our region, the environment factor cannot explain the decline in the number of admissions for AMI we recorded during the lockdown. Fear of contagion is the most plausible reason for the drop of hospitalizations for AMI during the lockdown period.

Aims: Patients who have survived acute myocardial infarction (AMI) are at higher risk of developing several cardiovascular complications during follow-up and, unfortunately, appropriate risk stratification remains a major challenge. Amyloid-b 1-40 [Ab (1-40)] has already emerged as a prognostic biomarker of cardiovascular mortality among patients with stable coronary heart disease due to its pathophysiological vascular inflammation properties. Methods and results: The relationship between plasma Ab (1-40) concentrations and follow-up outcome was examined in a large prospective cohort of patients hospitalized for AMI (NSTEMI or STEMI). Total RNA was extracted from peripheral blood mononuclear cells (PBMC) to assess the expression levels of BACE1 and BACE1-AS. A total of 894 subjects (607 patients with STEMI and 287 patients with NSTEMI) were included in this study. The median plasma Ab (1-40) concentration at admission was 96.59 (60.94-134.5) pg/ml. During the 83 month follow-up, 123 patients died and 78 patients developed HF. Higher Ab (1-40) concentrations were able to predict an increased mortality risk during follow-up. In addition, in the cohort of patients older than 67 years, the plasma concentration of Ab (1-40) strongly correlated with an unfavourable outcome, whereas in the cohort younger than 67 years did not. Conclusions: This is the largest single centre study investigating the role of plasma Ab (1-40) concentration in predicting patient outcomes after AMI both STEMI and NSTEMI. Our data show a strong correlation between plasma Ab (1-40) levels and mortality risk during follow-up. In addition, we confirmed a correlation between age and plasma Ab (1-40) concentration, noting that Ab (1-40) values are an incremental risk factor in relation to age for adverse outcomes.

483 Minoca in a young patient with elevated platelet count Stefano Alonge 1,2 , Lorenzo Acone 1,2 , Evelina Toscano 1 , and Andrea Mortara 1 1 Policlinico di Monza, Italy, and 2 Università degli Studi di Pavia, Italy

Aims: Ischaemic heart disease is rare in young women, especially in the absence of a positive family history and strong cardiovascular risk factors, such as insulindependent diabetes. However, the correct diagnosis of ischaemic heart disease in young population is mandatory, and the specific aetiology should be identified to ensure a proper treatment. Methods and results: We present the case of a 35-year-old caucasian woman who underwent ambulatory cardiological evaluation after episodes of chest pain and worsening dyspnoea (NYHA class II). The patient was asymptomatic at rest, BP was normal, heart rate was 80/minute in sinus rhythm, with no clinical signs of acute heart failure. ECG showed sinus rhythm with Q wave (lead DIII) and negative T waves (inferior leads). At echocardiographic evaluation LV was severely dilated (EDVi 105 ml/mq, EDD 66 mm) with akinesia and scar in the infero-posterior wall determining moderate reduction in ejection fraction (LVEF 40%), associated with secondary moderate mitral regurgitation; the right ventricle, the other valves and the aortic root were normal. The young lady was then admitted to Cardiology Unit for further investigations. She underwent cardiac MRI, which confirmed LV dilatation and dysfunction (EDV 198 ml/mq, LVEF 42%), associated with akinesia and infero-postero-lateral wall scar, with transmural myocardial fibrosis in the same segments, and subendocardial fibrosis on the basal segment of the anterior wall. Analysis of blood samples revealed elevated haemoglobin levels (Hb: 17.5 g/dl, n.v. 12-16 g/dl) and extremely elevated platelet count (PLT 945 000/mmc, n.v. 130 000-400 000/mmc). Cardiac troponin I (cTnI) was negative on serial determinations. All findings were suggestive for subacute infero-posterior myocardial infarction. Coronary angiography was performed via radial access: the exam was negative for significant stenosis in any coronary segment, only mild stenosis of proximal dominant left circumflex (LCX) artery was identified; moreover, there were no angiographic signs of coronary dissection. Eventually, SCAD and aortic defects were ruled out by coronary CT scan, which was negative for both coronary and aortic dissection. New blood samples examinations confirmed high values of Hb and PLT. Low levels of EPO (1.4 mU/ml) and JAK-2 mutation V617F positivity suggested the clinical diagnosis of essential thrombocythemia, later confirmed by bone marrow aspiration. Hydroxyurea was prescribed, as well as haematologic follow-up. Conclusions: This is an interesting case of ischaemic heart disease, confirmed by ECG, echocardiography, and cardiac MRI, in presence of non-obstructive coronary artery disease. The aetiology of this specific case of MINOCA is potentially to be sought in the haematologic disorder. It is possible to hypothesize that a platelet/RBC clot might have determined acute obstruction of the proximal dominant LCX artery, then followed by spontaneous recanalization. Only mild stenosis on the proximal vessel was identified, and stenting was considered not appropriate for this lesion.

Methods and results: We compared the admission rate for AMI in our department and, by analysing the density of nitrogen dioxide (1/cm 2 ), the state of air pollution in Sardinia and Northern Italy in different periods: the national lockdown (9 March-3 May 2020), the 8 weeks before the start of the lockdown, the 8 weeks after the end of the lockdown and the corresponding time period in 2019 (from 9 March to 3 May 2019). A marked decline in AMI admissions was observed during the lockdown period in comparison with the 8 weeks before the start of the lockdown (À47%, 95% CI: 37.5-56.7, P < 0.0001) and the corresponding period in 2019 (À52.8%, 95% CI: 43-65, P < 0.0001). There was a significant reduction in hospitalizations for NSTEMI during the lockdown period in comparison with the 8 weeks before the start of lockdown (À71.8%, 95% CI: 62.3-79.6, P < 0.0001) and the corresponding time period in 2019 (À70.5%, 95% CI: 60.9-78.5, P < 0.0001). Similar trends were seen in the group of STEMI patients, but the fall in admissions was less than that of NSTEMI patients. During the lockdown period, the hospitalizations for STEMI fell by 31.5% (95% CI: 23.2-41.4, P ¼ 0.19) and 49% (95% CI: 39.4-58.6, 47 vs. 24 admissions, P ¼ 0.009) in comparison to the 8 weeks before the start of lockdown and the corresponding period in 2019, respectively. We observed a rise in AMI admissions during the 8 weeks after the lockdown (þ47%, 95% CI: 37.5-56.7, P < 0.0001), for both NSTEMI (þ71.2%, 95% CI: 61.7-79.1, P < 0.0001) and STEMI (þ33.4%, 95% CI: 24.9-43.1, P ¼ 0.15). In Sardinia the relative change in nitrogen dioxide density during the time of lockdown was negligible with little or no impact on the environment (À19%, 95% CI: 12.5-27.7, P ¼ 0.65), if we consider it occurred within a range of very low values of nitrogen dioxide (11.5 6 3 e 14.1 6 5 lmol/m 2 ). In contrast, in Northern Italy during the lockdown there was a marked decrease in NO 2 concentration in comparison with the 8 weeks before the start of lockdown (À53%, 95% CI: 43-62.4, 25.1 6 16.2 e 54.2 6 43.5 lmol/m 2 , P < 0.0001). Conclusions: Since air pollution did not change substantially in our region, the environment factor cannot explain the decline in the number of admissions for AMI we recorded during the lockdown. Fear of contagion is the most plausible reason for the drop of hospitalizations for AMI during the lockdown period. Aims: The no reflow phenomenon is a not rare complication that occurs in up to 30% of patients with acute coronary syndrome undergoing myocardial reperfusion by percutaneous coronary intervention. The use of coronary artery thrombus aspiration or distal embolization protection systems has reduced the risk of distal embolization and no-reflow phenomenon. Methods and results: We describe the case of a 77 year old female suffering from hypertension presented at our emergency department for inferior STEMI. An urgent coronary angiography was performed, showing a three-vessel coronary artery disease with right coronary artery sub-occluded in the middle segment (culprit lesion), with a voluminous endoluminal minus image, as intracoronary thrombosis. Before performing the coronary angioplasty, a Spider FX3 filter was placed on the distal segment of the right coronary artery; thrombus aspiration was performed, which was ineffective, then angioplasty and Zotarolimus eluting stent implantation in the mid segment of the right coronary artery. After stent implantation, an image of minus was highlighted inside the basket of the filter, as a migrated and incarcerated thrombotic formation; then, the filter was removed. During the removal of the filter, longitudinal crush of the distal portion of the stent is caused, with limitation of the downstream flow, in the absence of haemodynamic instability. The stent was recrossed with Fielder XT guidewire supported by Turnpike LP Microcatheter. Multiple dilations werenperformed with semi-compliant and non-compliant increasing-caliber balloons and then Zotarolimus eluting stent implantation, in partial overlap with the distal portion of the previously implanted stent, with TIMI flow 3. The echocardiogram showed a normal global systolic function, with alterations in regional kinetics. On the 6th day, angioplasty and Zotarolimus eluting stent implantation was performed on the mid-proximal segment of the left anterior descending artery. During the hospitalization the patient was stable and has been discharged in good condition on the ninth day. Conclusions: The interest of this case is the evidence of a rare complication related to the use of distal embolization protection system, probably due to an incomplete closure of the filter before removal, due to the high amount of thrombotic material inside it. The rapid recrossing of the stent after the longitudinal crush, the angioplasty and the second stent implantation, led to a quick flow restoration, without haemodynamic and clinical consequences on the patient's outcome. 580 Percutaneous coronary intervention or medical therapy as initial management strategy of patients with spontaneous coronary artery dissections: insight from the multicentre, international dissezioni spontanee coronariche (disco) registry Orbassano, Turin, Italy, and 26 Interventional Cardiology Unit, Rivoli Infermi Hospital, Rivoli, Turin, Italy

Aims: Whether patients with spontaneous coronary artery dissection (SCAD) should undergo an initial conservative management or immediate revascularization through percutaneous coronary intervention (PCI) remains debated. To investigate the frequency and predictors of choosing a strategy of immediate PCI for SCAD, and to compare the clinical outcomes of immediate PCI patients with those undergoing an initial strategy of medical management. Methods and results: 369 patients enrolled in the multicentre international DIssezioni Spontanee COronariche (DISCO) registry between January 2009 and December 2020 were included. The primary endpoint was major adverse cardiovascular events (MACE), a composite of cardiac death, non-fatal myocardial infarction (MI) and any PCI. 240 (65%) patients underwent initial medical management, whereas 129 (35%) had immediate PCI. PCI patients presented more frequently with ST segment-elevation myocardial infarction (STEMI) (68.2% vs. 35%, P < 0.001) and had higher frequency of proximal coronary segment SCAD (31.8% vs. 6.7%, P < 0.001), Thrombolysis in Myocardial infarction (TIMI) flow grade 0-1 (54.3% vs. 20.4%, P < 0.001) and multivessel SCAD (18.6% vs. 9.2%, P ¼ 0.015), as well as a more severe diameter stenosis [99% (100-90) vs. 90% (99-75), P < 0.001]. At multivariate logistic regression, STEMI at presentation (vs. NSTE-ACS, OR: 3.30 95% CI: 1.56-7.12, P ¼ 0.002), proximal coronary segment involvement (OR: 5.43, 95% CI: 1.98-16.45, P ¼ 0.002), TIMI flow grade 0-1 and 2 (respectively, vs. grade 3: OR: 3.22 95% CI: 1.08-9.96, P ¼ 0.038; and OR: 3.98; 95% CI: 1.38-11.80, P ¼ 0.009) and diameter stenosis (per 5% increase, OR: 1.13; 95% CI: 1.01-1.28, P ¼ 0.037) were predictors of immediate PCI, whereas the angiographic subtype 2B predicted a conservative approach (OR: 0.25; 95% CI: 0.07-0.83, P ¼ 0.026). The frequency of in-hospital major adverse cardiac events did not differ between medically and PCI-treated patients. At 2-year follow-up, there were no differences with respect to the composite of MACE (11.7% vs. 13.9%, P ¼ 0.47) and the individual components of cardiovascular death (0.4% vs. 0.7%, P ¼ 0.65), non-fatal MI (8.3% vs. 9.3%, P ¼ 0.92), and any PCI (8.7% vs. 12.4%, P ¼ 0.23). Conclusions: The choice between an immediate medical or PCI management of SCAD is mostly driven by clinical presentation and procedural aspects. In the DISCO cohort, the primary treatment approach was not associated with the risk of short-tomidterm adverse events.

Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino-IRCCS Italian Cardiovascular Network, Italy, 4 Interventional Cardiology Unit

Ospedale Umberto I

15 Interventional Cardiology Unit, Fondazione Poliambulanza Istituto Ospedaliero

21 Santa Maria della Misericordia Hospital