Reference
De Filippo O, D’Ascenzo F, Angelini F, et al, Reduced Rate of Hospital Admissions for ACS during Covid-19 Outbreak in Northern Italy, NEJM 2020 Apr 28; DOI: 10.1056/NEJMc2009166
At a glance
The study shows a significant decrease in the number of patients admitted to the Emergency Departments for acute coronary syndrome (ACS) during the SARS-CoV-2 pandemic. The fear of contagion, the distrust in hospital protocols to prevent the infection spread, together with emotional reactions of anxiety, depression and social isolation due to outbreak can explain these results.
What is already known
The study refers to the period of the SARS-CoV-2 pandemic, when, following the first case diagnosed in Codogno on February 19, 2020, there was a rapid and intense viral diffusion in Italy. This led to the national lockdown measures decreed on March 8, 2020 to prevent the contagions through social isolation and restriction of various work activities. In this context, the study assessed whether, during the SARS-CoV-2 pandemic in Italy (i.e. mainly after the limitation of inter-individual contacts, when the prevailing message was “stay at home to stay safe”), there was a variation in the number of presentations to the Emergency Departments for ACS.
Design and method
The study retrospectively considered the number of patients with ACS (unstable angina, myocardial infarction without ST-segment elevation -NSTEMI, or myocardial infarction with ST-segment elevation -STEMI) admitted to the Emergency Departments in 15 Hospitals, mainly in Northern Italy, during the COVID-19 period (from February 20 to March 31, 2020). This number was compared with the number of patients with the same diagnosis, hospitalized in the same hospitals, in the same time span of 2019 (from February 20 to March 31, 2019, “inter-year” control) and in the period immediately preceding the epidemic (from January 1 to February 19, 2020, “intra-year” control).
Main results
A total of 2,202 patients with ACS were included in the analysis. The study showed during the COVID-19 period a 30% reduction in the admissions for ACS compared to “inter-year” control (13.3 vs. 18.9 hospitalizations per day) and a 26% reduction compared to “intra-year” control (13.3 vs 18.0 hospitalizations per day). Such reduction was prevalent in patients with NSTEMI (44% and 41% decrease, respectively), was lower, but significant, in those with STEMI (25% and 23% decrease, respectively) and was not observed in patients with unstable angina. Within the COVID-19 period, the number of admissions for ACS after the national lockdown (from March 8 to March 31, 2020) was 20% lower compared to those in the pre-lockdown phase (from February 20 to March 7, 2020).
Limitations
A limitation is the retrospective nature of the protocol. Moreover, the study did not allow to specifically assess the impact of changes in habits due to lockdown measures (reduction of physical activity, nutritional changes, emotional stress) on the incidence of ACS.
What’s new
The study indicates that, despite severe symptoms, COVID-19 outbreak has negatively affected the population presentation to Emergency Departments for myocardial infarctions requiring urgent interventions. Healthcare institutions, scientific societies and mass-media should worldwide promote campaigns addressing that even in the COVID-19 era: patients with symptoms suggestive of acute heart diseases anyway must access the Emergency Departments for a prompt diagnosis and potentially lifesaving treatments; hospitals are able to perform urgent cardiac interventions with adequate and specific protocols able to prevent viral diffusion. Accordingly, an analysis from Northern Italy reported an increase in the number of cases of out-of-hospital cardiac arrest and death over the time course of the COVID-19 outbreak 19 (Baldi E, Sechi GM, Mare C, et al. Out-of-Hospital Cardiac Arrest during the Covid-19 Outbreak in Italy. N Engl J Med. 2020 Apr 29). Thus, available evidence could provide healthcare systems with pivotal epidemiological data which may help them assist an expected higher number of people coming to the hospitals for severe cardiological issues in the next few months related to undiagnosed and untreated infarctions during the COVID-19 outbreak.
By Giuseppe Patti