Acute coronary syndromes undergoing percutaneous coronary intervention in the COVID-19 era: comparable case volumes but delayed symptom onset to hospital presentation

Abstract

Timely revascularization is the standard of care for patients presenting with acute coronary syndromes (ACS). Delays in patient factors such as symptom onset to hospital presentation time or hospital factors, such as door-to-balloon time correlate with poor patient outcomes.1 While healthcare systems are being overwhelmed by the COVID-19 pandemic,2 there has been a significant reduction in rates of ACS presentations in some European countries.3 It is speculated this stems from patient avoidance of medical care due to social distancing or concerns of contracting COVID-19 from healthcare interactions. We sought to compare case volume and symptom-to-door-time (STDT) in patients presenting with ACS that underwent percutaneous coronary intervention (PCI) for a period of 1 month from the commencement of lockdown in Australia (16 March–15 April 2020; referred to herein as COVID-era) at a tertiary hospital cardiac catheterization laboratory in Melbourne with a core catchment population of 1.14 million people. These were compared with a historical cohort during the same 31-day period each year from 2014 to 2019 at our institution using prospectively collected data from the hospital PCI registry. In the event of stuttering symptoms, we restricted the coding for symptom-to-door time to 1 week as per our standardized registry data definition.4 Baseline clinical characteristics are summarized in Table 1. Mean age and risk factor profile for patients was comparable across the COVID and non-COVID eras. We included a total of 122 ACS cases that underwent PCI during the 1-month period during the COVID-era and the corresponding time over the preceding 6 years. In the COVID-era, we recorded 20 ACS cases that underwent PCI including 17 cases of non-ST-elevation ACS and 3 ST-elevation ACS. Seven additional patients presented with ACS but were not included in the analysis; three with late presentation infarcts deemed for medical management, who underwent coronary artery bypass grafting, two cases of Takotsubo cardiomyopathy, and one out-of-hospital cardiac arrest. None of these patients tested positive for COVID-19. Baseline characteristics Values presented as mean ± standard deviation or proportions. COVID-19 era refers to patients undergoing revascularization for acute coronary syndromes between 16 March and 15 April 2020. Non-COVID-19 era refers to patients undergoing revascularization for acute coronary syndromes between 16 March and 15 April between 2014 and 2019. The case volume for the number of ACS patients undergoing PCI was not significantly different in the COVID and non-COVID eras (20 vs. historical mean 18 cases/month; P = 0.20) (Fig. 1). However, median STDT was significantly higher during the COVID-era [11.1 (interquartile range 5.0–102) vs. 2.4 (1.3–6.2) h, P < 0.001]. Moreover, the proportion of patients that presented late (≥12 h post-symptom-onset) was also substantially higher during the COVID era (45% vs. 13%, P < 0.001). The main finding in this observational study is a four-fold increase in symptom-to-door-time in patients with ACS requiring percutaneous revascularization during the COVID-era. This occurred despite a comparable case volume during the same time period in the preceding 6 years. Our findings are in contrast with reports from Austria where a reduction in patient presentations with ACS have been recorded.3 Whether this may be partially explained by a flatter epidemic curve and lower rates of community transmission and deaths in Australia is unclear. The substantial increase in STDT coincides with the rigorous public health measures including physical distancing and social-isolation intended to mitigate the risk posed by the COVID-19 pandemic. This may be further accentuated by the media coverage highlighting the heightened mortality risk in older adults with pre-existing cardiovascular disease. Irrespective of the exact reason, the significant delay to hospital presentation with approximately one in two patients presenting over 12 h following symptom onset is concerning due to the risk posed by infarct related morbidity and mortality. The importance of educating the community on warning signs of a heart attack and timely medical intervention is well known and particularly relevant in the COVID-19 era.5 While social distancing is essential to limit the spread of COVID-19, this message should not deter patients from seeking prompt medical care for cardiac emergencies. Public-awareness campaigns are necessary to reinforce this message. A.N.K. is a recipient of the National Health and Medical Research Council of Australia/National Heart Foundation Post-Graduate Scholarship and Royal Australasian College of Physicians Blackburn Scholarship (1150874). (A) Median symptom-to-door time (h) for the COVID-19 era compared to the same time period in previous years, P for trend < 0.001. (B) Number of acute coronary syndrome cases undergoing percutaneous coronary intervention in the COVID-19 era compared with the same time period in previous years, P for trend = 0.21. COVID-19 era defined as 16 March–15 April 2020.

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