Evidence-Based Medicine
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Cardiol. Apr 26, 2021; 13(4): 76-81
Published online Apr 26, 2021. doi: 10.4330/wjc.v13.i4.76
Challenges in managing ST elevation myocardial infarction during the COVID-19 pandemic
Megan Smith, Aniruddha Singh, Douglas McElroy, Shilpi Mittal, Richard Pham
Megan Smith, Aniruddha Singh, Richard Pham, Department ofCardiology, University of Kentucky College of Medicine, Bowling Green, KY 42101, United States
Aniruddha Singh, Department of Cardiology, Western Kentucky Heart and Lung Research Foundation, Bowling Green, KY 42101, United States
Aniruddha Singh, Department of Cardiology, The Medical Center, Bowling Green, KY 42101, United States
Douglas McElroy, Department of Biology, Western Kentucky University, Bowling Green, KY 42101, United States
Shilpi Mittal, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN 37232, United States
Author contributions: Singh A and Smith M contributed equally to this work; Singh A, Smith M, Mittal S, McElroy D and Pham R designed the study and contributed to the manuscript; Smith M and Pham R performed data extraction; McElroy D performed statistics and wrote the methods and results section; all authors have read the original and revised copy of the manuscript and approve the final version.
Conflict-of-interest statement: All the authors of this study report no potential conflict of interest related to any aspect of the study.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Aniruddha Singh, FACC, MBBS, Assistant Professor, Department of Cardiology, University of Kentucky College of Medicine, 399 US 31W Bypass, Bowling Green, KY 42101, United States. aniruddha.singh@uky.edu
Received: October 20, 2020
Peer-review started: October 20, 2020
First decision: December 24, 2020
Revised: January 4, 2021
Accepted: March 7, 2021
Article in press: March 7, 2021
Published online: April 26, 2021
ARTICLE HIGHLIGHTS
Research background

Treatment of time sensitive medical conditions like ST elevation myocardial infarction (STEMI) could have been adversely affected during the coronavirus disease 2019 (COVID-19) pandemic. This could be due to fear of contracting COVID-19 in the hospital setting, along with healthcare challenges such as lack of personal protective equipment and shifting policies on rapid COVID-19 testing in these acutely sick patients. All of these factors could prolong symptom onset to first medical contact (FMC) and FMC to balloon times. Prolonged time to coronary reperfusion has been shown to be related to increased mechanical complications and worse outcomes.

Research motivation

Currently no data from an academic United States institute exist on STEMI performance measures such as time to electrocardiogram, FMC to balloon, etc. during the current pandemic. There is also lack of STEMI outcomes data during the pandemic which could have been adversely affected.

Research objectives

We evaluated STEMI performance benchmarks and clinical outcomes of all patients who presented to our facility during the COVID-19 pandemic. These were compared to the same time cohort from 2019. Knowing, whether these standards are preserved currently during the pandemic is critical as it allows us to further investigate the mechanistic aspect of it and offer solution.

Research methods

All patients who presented to our facility with STEMI during the pandemic were compared to a matched cohort from 2019. STEMI with unknown time of symptom onset and inpatient STEMI patients were excluded. Primary outcome was major adverse cardiac events (MACE) in-hospital and up to 14 d after STEMI, including death, myocardial infarction, cardiac arrest, or stroke. Significant differences among groups for continuous variables were tested through ANOVA, using SYSTAT, version 13. Chi-square tests of association were used to compare patient characteristics among groups using SYSTAT. Relative risk scores and associated tests for significance were calculated for discrete variables using MedCalc (MedCalc Software, Ostend, Belgium).

Research results

Symptom onset to FMC time interval was significantly longer in the COVID-19 group (P < 0.02) when compared to 2019 cohort. Time to first electrocardiogram, door-to-balloon time, and FMC to balloon time were not significantly affected. The right coronary artery was the most common culprit for STEMI in both the cohorts. Over 60% of patients had one or more obstructive (> 50%) lesion(s) remote from the culprit site. In-hospital and 14 d MACE were more prevalent in the COVID-19 group (P < 0.01 and P < 0.001).

Research conclusions

This single academic center study conducted in the United States during the current pandemic reports longer time interval from symptom onset to first medical contact in patients presenting with STEMI. This is likely resulting in worse MACE outcomes when compared to the pre-COVID era as reflected from this report.

Research perspectives

Although a ‘randomized control study’ to assess the potential adverse impact on STEMI outcomes during the pandemic is not practical, our study provides observations from a teaching center during the ‘natural experiment’ conditions created by the current pandemic. Our findings suggest a need for data from bigger studies to confirm our study’s pattern and outcomes.