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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 10  |  Issue : 2  |  Page : 39-44

Admissions and management strategies for acute coronary syndromes during COVID-19


1 Senior Interventional Cardiologist, Little Flower Hospital & Research Institute, Angamaly, Kochi, Kerala, India
2 Senior Consultant Interventional Cardiologist, Medical Trust Hospital, MG Road, Kochi, India
3 Senior Consultant Interventional Cardiologist, Samaritan Heart Institute, Pazhanganad, Kochi, India
4 Senior Consultant Cardiologist, MOSC Medical College Hospital, Kolenchery, Ernakulam, India
5 Senior Consultant and Interventional Cardiologist, Rajagiri Hospital, Chunangamvely, Aluva, India
6 Senior Consultant Interventional Cardiologist, Lourdes Hospital, Ernakulam, India
7 Consultant, Department of Cardiology, General Hospital, Ernakulam, India
8 Senior Consultant & Electrophysiologist, Amrita Institute of Medical sciences, Ponekkara, Kochi, India

Date of Web Publication14-Feb-2022

Correspondence Address:
Dr. Sajan Narayanan
Department of Cardiology, Little Flower Hospital & Research Centre, Angamaly, Kochi 683572, Kerala.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/khj.khj_4_21

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  Abstract 

Background and Objectives: Severe respiratory syndrome caused by coronavirus 2 (SARS COVID-19) was declared a pandemic by the World Health Organization (WHO) on March 12, 2020. In India, the central government declared lockdown on March 25, 2020. We report the trends in admissions for acute coronary syndromes (ACS) at cardiac care units (CCUs) during lockdown and impact on reperfusion strategies adopted during this time period in comparison with the previous year. Materials and Methods: We conducted a multicenter retrospective observational survey on admissions for ACS at CCUs of Ernakulam district in Kerala from January to May 15, 2020. Records were analyzed for admissions during equivalent period of 2019. Trends in admissions during lockdown phases were analyzed separately. Results: We observed an 18.2% reduction in admissions for ACS during lockdown. A significant reduction in number of patients presenting with ST elevation myocardial infarction (STEMI) (186 vs. 169 and 130 vs. 82) was observed when compared to 2019 (P = 0.0047). Decrease in number of primary angioplasties was noted during lockdown phase (302 vs. 244. P = 0.049). There was an increase in adoption of thrombolysis as reperfusion modality at tertiary care centers during lockdown period (27.1% vs. 40.8%). We did not observe an increase in number of patients who presented late during this phase and there was no heterogenicity in admission pattern according to hospital location. Conclusion: Study confirms a significant reduction in admissions for ACS during lockdown period and change in reperfusion strategies adopted during lockdown.

Keywords: Acute coronary syndromes, cardiac care units, lockdown, SARS-COVID-19, STEMI, thrombolysis


How to cite this article:
Narayanan S, Varma MR, Subramanian S, Punnoose E, Nayak R, Thomas J, Biju Mon P R, Natarajan K. Admissions and management strategies for acute coronary syndromes during COVID-19. KERALA HEART J 2021;10:39-44

How to cite this URL:
Narayanan S, Varma MR, Subramanian S, Punnoose E, Nayak R, Thomas J, Biju Mon P R, Natarajan K. Admissions and management strategies for acute coronary syndromes during COVID-19. KERALA HEART J [serial online] 2021 [cited 2022 Jul 4];10:39-44. Available from: http://www.csikhj.com/text.asp?2021/10/2/39/337621




  Introduction Top


Severe respiratory syndrome caused by coronavirus 2 (SARS COVID-19) infection was first reported in India on January 30, 2020. No significant spread of cases was reported in February, but 22 new infections were diagnosed on March 4. The World Health Organization (WHO) declared coronavirus disease-2019 (COVID-19) as a pandemic on March 12, 2020. Since then there has been a steady rise in the number of cases. Central and state governments imposed lockdown (LD) from March 25––initially in three phases, during which there was curb on public movement and establishment went for total shut down. Public were strictly instructed to remain indoors to limit the spread of viral illness. Diagnosis and treatment of other medical illnesses like acute coronary syndromes (ACS) suffer during such periods due to limitations for prompt hospital visits. According to the National Interventional Council Registry, a total of 3,87,416 percutaneous coronary intervention (PCI) procedures were performed all over India and percutaneous intervention (PCI) for non-ST-elevation myocardial infarction (NSTEMI) comprise about 25.8%.[1] Primary percutaneous intervention (PPCI) for ST-elevation myocardial infarction (STEMI) accounted for 13.7% of interventions in 2017.[1] There were press reports that ACS admissions had fallen drastically during LD when compared to previous year from various parts of the country.[2] These were primarily from tertiary care centers located within metropolitan cities. On the contrary, there were social media reports that peripheral centers located in semiurban and rural areas recorded a spike in the number of ACS admissions.

Aim

The aim of this study was to detect the impact of LD on admissions with a diagnosis of ACS to cardiac care units (CCUs) of Ernakulam district of Kerala.


  Materials and methods Top


We conducted a multicenter, retrospective observational survey involving CCUs of Ernakulam district. Cochin Cardiology forum invited all affiliated hospitals to participate in the survey. Data were collected from January 1 to May 15, 2020. Same data were also collected for equivalent period of 2019. All consecutive ACS patients were analyzed. Diagnosis of ACS was as per individual institution protocols that generally involve a combination of ECG criteria and elevation of biomarkers according to fourth universal definition of myocardial infarction (MI). ACS patients were further analyzed for two prespecified subgroups: (1) STEMI and (2) NSTEMI/unstable angina. We analyzed reperfusion strategies adopted for STEMI presentation and compared them with practice pattern for equivalent period in 2019. Data during LD periods (divided into three phases: LD phase 1––from March 25 to April 15, phase 2––from April 16 to 30, and phase 3––from May 1 to 15) were analyzed separately.

To detect any heterogenicity in admission rates among hospitals at different locations, centers were divided into central hospitals (those located within Kochi Corporation Limits) and peripheral centers (located outside Kochi Corporation).

Statistical analysis

Descriptive statistics were used for the baseline characteristics of the data. The significance of monthwise admissions of LD periods in yearwise and hospital-wise analyses were done using chi-square test for trends. A value of P < 0.05 was considered statistically significant. All data were analyzed using the SPSS software program, version 20.0.


  Results Top


A total of 13 centers participated in the study. Seven centers were located within Kochi Corporation Limits and six centers were in peripheral locations. All centers had CCU managed by dedicated cardiology specialists. All centers had catheterization labs, whereas 11 of 13 centers have onsite cardiac surgery support.

[Figure 1] shows trend for ACS admissions from January to May. In the year 2020, there was a reducing trend of admissions with a diagnosis of ACS from February. When compared with equivalent period of 2019, this decrease in numbers was statistically significant (P = 0.0006).
Figure 1: Trends for ACS admissions from January to May

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During LD period, there was a reduction in the number of ACS admissions––this was contributed by a decrease in both STEMI (417 vs. 364) and NSTEMI (938 vs. 764) cases [Figure 2].
Figure 2: ACS admissions during lockdown phases 1 to 3

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A total of 364 STEMI cases were registered during LD phases 1 to 3. When compared to 2019 for the same timeline, there was a 12.7% reduction in the number of STEMI cases. When we analyzed STEMI admissions during individual LD periods [Figure 3], the decrease in the number of patients presenting with STEMI was significantly less during phases 1 and 2 compared to corresponding time in 2019 (186 vs. 169 during LD phase 1 and 130 vs. 82 during LD phase 2; P = 0.0047). The decreasing trend which was more pronounced during phase 2 was noted equally at central and peripheral locations [Figure 4]A and B.
Figure 3: STEMI admissions that were less during lockdown phases 1 and 2 when compared to 2019

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Figure 4: (A and B) STEMI admissions according to hospital location during lockdown (LD): Decreasing trends in STEMI admissions were noted in hospitals at both central (left ) and peripheral (right) locations

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A reduction in the number of PPCI was seen during all three phases of LD which was more apparent during the initial two phases [Figure 5]. Total number of patients who underwent PPCI during LD phase was 302 (2019) vs. 244 (2020).(P = 0.0491). Decrease in PPCI numbers was evident at both central and peripheral hospitals [Figure 6]A and B.
Figure 5: Trends in PPCIs during lockdown (LD). Initial two phases of lockdown witnessed significant fall in number of PPCIs

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Figure 6: (A and B) PPCI according to hospital location. Both central (left) and peripheral (right) hospitals recorded a reduction in number of primary angioplasties during lockdown period

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A difference in reperfusion strategies adopted for STEMI was seen in hospitals at central location. In 2019, 63.5% of patients with STEMI received PPCI, whereas proportion of patients receiving PPCI in 2020 was 55.2%.An increase in utilization of thrombolysis as reperfusion strategy was noted in 2020 (27.1% vs. 40.8%; P = 0.018) compared with equivalent period in 2019 [Figure 7]A and B. PPCI trends remained stable in hospitals located at periphery during the LD time (173 vs. 162). (P = 0.093) [Figure 8]. There was no increase in patients who presented late and hence ineligible for any form of reperfusion treatment (19 vs. 7 at central hospitals and 9 vs. 13 at peripheral centers).
Figure 7: (A and B) Reperfusion strategies for STEMI at central hospitals. There was an increase in number of patients receiving thrombolysis during lockdown phase in 2020 (27.1% vs. 40.8% P = 0.018)

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Figure 8: (A and B) Reperfusion strategies for STEMI at peripheral hospitals

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[Figure 9] shows admissions with a diagnosis of NSTEMI from January to May. There was a significant reduction in the number of patients admitted with a diagnosis of NSTEMI during the months of March, April, and May when compared with corresponding period of 2019. The difference in trends of admissions was statistically significant (P = 0.044).
Figure 9: Monthwise trends for NSTEMI

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When we examined the trends during LD phases, there was a reduction in the number of patients admitted with a diagnosis of NSTEMI when compared to 2019. At central hospitals, during LD 1, there was 42.2% decrease (206 vs. 119), 17% (124 vs. 103) and 19.4% (124 vs. 100) reduction, respectively, during phases 2 and 3 [Figure 10].
Figure 10: NSTEMI admissions to central hospitals during lockdown (LD) phases

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At peripheral centers, the reduction in admissions was noted during phases 1 and 3 (251 vs. 205 (18.3%) and 135 vs. 119 (11.9%)) [Figure 11].
Figure 11: NSTEMI admissions to peripheral hospitals during lockdown phases

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  Discussion Top


The principal findings of this study are the dramatic reduction in the number of patients admitted to centers across Ernakulam district with a diagnosis of ACS during LD phase from March 25 to May 15. The decrease was equally evident with regard to STEMI and NSTEMI. The reduction in admissions was noticed at central locations and at peripheral hospitals. There are different hypotheses that can explain the reduction in the number of admissions for ACS. First, fear of contagion could discourage patients to ignore symptoms of acute myocardial infarction (AMI) and avoid hospital visits. Second, nonavailability of transportation could have prevented hospital visits. Third hypothesis is linked to fact that most hospitals faced a shortage of health care personnel when LD was announced within a short period of time which prevented primary care physicians from seeking expert cardiology advice. Contrary to media reports, we did not find any heterogenicity in admission patterns with regard to location of hospitals.

In Spain, there was a 40% reduction in activation of PPCI services during pandemic phase from March 16 to 22.[3] Compared with before COVID-19 pandemic, incidence ratios showed weekly PPCI referrals in COVID-19 era decreased by 42.8% and STEMI presentations by 51.4% in a single center experience from united kingdom.[4] In Ireland, the number of patients who presented >24 h after onset of symptoms was higher during LD phase.[5] Reports from Bergamo in Italy showed that in March 2020, primary PCI for STEMI reduced by 37% and late presentations were increased by 25%.[6] Our study also noted a 12.7% reduction in the number of STEMI cases when compared to previous year. Pattern of reperfusion therapy adopted revealed an interesting and unique finding. Although the number of primary PCIs was lower when compared to equivalent period of 2019, this reduction was commensurate with decrease in STEMI cases. We did not find any increase in the number of patients who presented late and hence ineligible for any form of reperfusion therapy. During LD phase, there was an increase in use of fibrinolysis at central hospitals, a trend which was also reported from Madrid during pandemic phase.[2] Reasons for change in strategy are to be determined, yet most likely due to shortage of medical personnel.

Study limitations

Collecting clinical data during pandemic is challenging. Our data pertain only to the number of ACS admissions during a specific time frame. Due to challenges imposed by pandemic, we could not collect demographics and outcome data during this period which would have yielded more findings. We have left out information on performance metrics like window period, door to balloon, and door to needle times. Despite comparing with equivalent period of 2019, use of such short period for data collection still presents a source for potential bias.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sreenivas KA, Sudhir K, Ramakrishna J, Sanjeeva KE, Gokul RM The report on the Indian coronary intervention data for the year 2017: National Interventional Council. Indian Heart J 2019;71: 146-8.  Back to cited text no. 1
    
2.
Kerala Hospitals see a nearly 50% drop in heart attack cases. The Times of India2020.  Back to cited text no. 2
    
3.
Oriol R-L, Belén C-Á, Soledad O, Javier M-M, José RR, Ramón L-P, et al. Impact of the COVID-19 pandemic on interventional cardiology activity in Spain. REC Interv Cardiol 2020;2:82-9.  Back to cited text no. 3
    
4.
Simon JW, Michelle JC, Ziyad E, Claudia C, Sami F, Pitt L, et al. Effect of the COVID-19 pandemic on ST-segment–elevation myocardial ifarction presentations and in-hospital outcomes. Circ Cardiovasc Interv 2020;13:e009438.  Back to cited text no. 4
    
5.
Coughlan JJ, Chongprasertpon N, et al. COVID-19 and STEMI: A snapshot analysis of presentation patterns during a pandemic. IJC Heart Vasc https://doi.org/10.1016/j.ijcha.2020.100546.  Back to cited text no. 5
    
6.
Marco R, Giulio G, Borja I The obstacle course of reperfusion for ST segment elevation myocardial infarction in the COVID-19 pandemic. Circulation 2020;141:1951-3.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]



 

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