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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 5  |  Issue : 2  |  Page : 57-61

Impact of COVID-19 pandemic on acute coronary syndrome presentation and its management in saudi arabia “a local experience”


1 Department of Adult Cardiology, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
2 Department of Adult Cardiology, King Fahad Medical City, Riyadh, Saudi Arabia
3 Department of Adult Cardiology, Prince Mohammed Ibn Abdulaziz Hospital, Riyadh, Saudi Arabia
4 Department of Cardiac Sciences, King Fahad Cardiac Center, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia

Date of Submission21-Oct-2020
Date of Decision18-Nov-2020
Date of Acceptance10-Dec-2020
Date of Web Publication25-Feb-2021

Correspondence Address:
Dr. Sondos Samargandy
Department of Adult Cardiology, Prince Sultan Cardiac Center, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/KKUJHS.KKUJHS_22_20

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  Abstract 

Background: The impact of COVID 19 pandemic on all acute coronary syndrome (ACS) presentations and its management in Saudi Arabia is still unknown. Objectives: To find furthermore in the rate of ACS presentation, including ST-segment elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), and unstable angina (UA) during this outbreak and its effect on the management. Materials and Methods: We conducted a retrospective analysis of consecutive patients presenting with ACS requiring cardiac catheterization in three primary percutaneous coronary intervention (PCI) capable centers from March to April 2020 compared to the same period from 2019. Results: We found a numeric downward shift of 62.2% in all ACS presentations, including ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), and unstable angina (UA) during the study time when compared to its equivalent period in 2019, (P = 0.329). The door-to-balloon median time in STEMIs was statistically insignificant between the two comparison groups, but more patients in 2020 had a delay in transfer with either evaluating a suspected COVID-19 case or more time to prepare the cath lab staff protected precaution (P = 0.002). We illustrated a significant delay in time to seek medical attention from onset of symptoms by patients with NSTEMI and UA in 2020, with a median of 36 h (24, 96) versus 12 h (2, 96) in 2019 (P < 0.001). Moreover, the rate of female patients with ACS cases requiring PCI yields an increase in 2020 (P < 0.001). Overall, revascularization management of ACS patients presenting before and during the pandemic showed no difference. Conclusion: ACS admissions have been reduced during the COVID-19 pandemic, with no much impact on the overall management of revascularization. Efforts should be directed to understand the underlying mechanisms of these results to improve the short and long-term outcomes of these high-risk groups in these challenging times.

Keywords: Acute coronary syndrome, COVID-19, non-ST-segment elevation myocardial infarction, onset of symptoms, SARS-CoV2, ST-segment elevation myocardial infarction


How to cite this article:
Samargandy S, AlQahtani A, Al Garni T, AlAsmari S, Alahmari M, AlShehri B, AlKaf F, AlGhamdi B, AlMoghairi A, AlHarbi W, AlAmri H. Impact of COVID-19 pandemic on acute coronary syndrome presentation and its management in saudi arabia “a local experience”. King Khalid Univ J Health Sci 2020;5:57-61

How to cite this URL:
Samargandy S, AlQahtani A, Al Garni T, AlAsmari S, Alahmari M, AlShehri B, AlKaf F, AlGhamdi B, AlMoghairi A, AlHarbi W, AlAmri H. Impact of COVID-19 pandemic on acute coronary syndrome presentation and its management in saudi arabia “a local experience”. King Khalid Univ J Health Sci [serial online] 2020 [cited 2021 Jun 12];5:57-61. Available from: https://www.kkujhs.org/text.asp?2020/5/2/57/309605


  Introduction Top


Since the World Health Organization declared (SARS-CoV-2) as a pandemic on March 11, 2020,[1] the health-care system across the globe was affected drastically. Many papers that have been published recently have noted a downward shift in the rate of acute coronary syndrome (ACS) cases as in Italy,[2] Austria,[3] and the USA[4] and deemed as collateral damage of this pandemic. Since the first case been reported in Saudi Arabia on March 2, 2020, the policymakers have implemented various measures to curb this new pandemic.[5]

Meanwhile, this phenomenon of reducing ACS admissions worldwide has fostered a concern among local cardiologists if the same will occur in Saudi Arabia.

This brought the investigators of this paper to combine efforts and look furthermore in the rate of ACS presentation, including ST-segment elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), and unstable angina (UA) during this outbreak and its effect on the management.[6]

As known, restoring blood flow as quickly as possible in an occluded infarcted artery is of high impact on survival.[7] We reviewed the available literature and found limited data on the effect of this pandemic on patients' presentation time and the door-to-balloon time (DTB) in STEMI cases. Hence, we analyze those points starting with DTB time and factors affecting it during the pandemic. The DTB time delay was defined as more than 90 min from the first medical encounter to the balloon.

Furthermore, the potency of an early invasive strategy in NSTEMI and UA may be limited by the delay in delivery,[8],[9] which subsequently could impact the outcome; therefore, we evaluated the time taken by patients to seek medical attention from onset of their symptoms in 2020 and 2019 in hours.


  Materials and Methods Top


This is a multicenter observational retrospective analysis study of consecutive patients presenting with ACS requiring cardiac catheterization at three primary percutaneous coronary intervention (PPCI) capable centers in Riyadh, Saudi Arabia, from March to April 2020. The same data were collected for equivalent months in 2019, comparing ACS incidents and their management before and during the COVID-19 pandemic. The three centers that participated in the study all have more than 100 STEMI activation/year. It is worth mentioning that one hospital out of the three that participated in this study has a designated COVID-19 catheterization lab, and the other two have instilled a high-efficiency particular air filter in their laboratories for suspected or confirmed COVID-19 cases.

Regarding DTB time, which is a continuous variable, we analyzed the time of delay in minutes and took the median. Furthermore, we looked into the transfer delay grounds, which are categorical variables that impacted the DTB time.

Data were collected at each center from the catheterization lab databases, procedure logbooks, and institutional records using case report forms provided by the coordinating team. Patient information was cross-checked against catheterization laboratories and COVID-19 records of the same institution. After data collection, participating centers submitted completed case report forms to the coordinating center. After data have been analyzed, the patients were divided into two groups: cases done during 2019 (Group 1) consisted of 393 patients and cases done during 2020 (Group 2) consisted of 147 patients.

Research and Ethics Committee approval was obtained initially at the coordinating center [BLINDED FOR PEER REVIEW] with approval number R20010 and similarly at the other participating centers. The study was conducted per the Declaration of Helsinki and applicable local regulations.

Continuous variables were tested for normality distribution by the Shapiro–Wilk test and were reported as means ± standard deviation if normally distributed or as median with the 25th and 75th percentile in skewed data. Categorical variables were expressed as counts and percentages. A comparison using independent-samples Student's t-test between the two groups was made by for normally distributed data or independent samples Mann–Whitney U-test in case of nonnormally distributed continuous variables. Categorical data were compared using the Pearson's Chi-square test or Fisher's exact test as appropriate. IBM-SPSS (IBM Corp., Armonk, NY, USA) version 25 was used for all statistical analyses. P < 0.05 was considered to be statistically significant.


  Results Top


A total of 540 patients' data have been collected. 393 patients' data were collected in 2019 and 147 patients' data for equivalent months in 2020. Patients' characteristics are shown in [Table 1].
Table 1: Demographic and clinical characteristics of patients presenting with acute coronary syndrome admitted at three primary percutaneous coronary intervention centers in Saudi Arabia

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In comparison to the same period in 2019, there was a numeric reduction of 62.6% in all ACS presentations in 2020 (P = 0.329). More detailed results are shown in [Figure 1] and [Table 2].
Figure 1: Number of patients per acute coronary syndrome presentation before and during the COVID-19 pandemic

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Table 2: Admission diagnosis

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The patient's background showed no difference in the mean age of patients in 2019 compared to 2020 (P = 0.069).

Analysis of ACS categories, STEMI, showed a reduction in 2020 of 55.3% in comparison to 2019 but not statistically significant. Among STEMI patients who have been included in the study, none was diagnosed with COVID-19.

We appraised the DTB time and evaluated the reasons for the delay. DTB time delay was defined as more than 90 min from the first medical encounter to the balloon. Our study yields the median DTB in STEMI which was not significantly different between the two groups (P = 0.810), DTB median time in 2019 was 89 min (60,104), and in 2020, it was 80 min (59,275). However, more patients in 2020 experience a delay in transferee compared to 2019, 15% versus 4% (P = 0.002). The main reasons for the delay in 2020 were driven by either evaluating a suspected COVID-19 case by the first medical encounter team, which represented 5.6% of the cases in 2020, or more time to conduct COVID-19 screen including nasopharyngeal swap and prepare the catheterization staff with personal protective equipment, which represented 13.9% of the cases in 2020 [Table 3].
Table 3: Reasons for door-to-balloon time delay in ST-segment elevation myocardial infarction

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Analysis of NSTEMI demonstrated a 67% reduction in admission rate between pandemic and nonpandemic period.

There was a significant delay in time to seek medical attention from onset of symptoms in NSTEMI and UA in 2020 with median time of 36 h (24, 96) versus 12 h (2, 96) in 2019, (P < 0.001).

Evaluating the overall management of ACS patients presenting before and during the pandemic showed no difference [Table 4]. On another note, the incidence rate of female patients among ACS cases requiring percutaneous coronary intervention yielded an increase in 2020 pandemic group with 25% in 2020 and 15.8% in 2019 (P < 0.001) [Figure 2].
Table 4: Management of acute coronary syndrome patients presenting before and during COVID-19 pandemic

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Figure 2: (a) Distribution of percutaneous coronary intervention by gender from March to April 2020 and the same period in 2019. (b) Distribution of acute coronary syndrome cases by gender

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  Discussion Top


Since the dynamic emergence of COVID-19 global pandemic, health-care establishments around the world have been under significant strain from receiving highly contagious and critically ill patients and diverting resources to the right places to face and curb this crisis. Yet, it is a matter of great concern the observational reduction in rate of admission for ACS cases all over the world. This raises many hypotheses and speculations about the probable mechanism behind this phenomenon, especially that the decline is not in line with the prepandemic period; in fact, it is more in line with the local Saudi Red Crescent authority published contributions in April 2020, which showed more calls to the main call center with 1,400,292 calls in 2020 versus 222,747 calls in 2019, in addition to it, more emergency transferred cases to urgent hospital care in 2020 with 54,324 versus 29,949 in 2019.[10],[11] This sends a signal of concern if we are losing patients before reaching the hospital as a complication of missed or late ACS cases?

You would have anticipated an increase in ACS and STEMI cases driven by the frightening COVID-19 pandemic and its consequences of elevation of psychological stress by the lockdown and financial difficulties that faced many people during this unprecedented time,[12] or even the possibility of STEMI induced by the viral illness, like the influenza.[13] Thus far, this is not the case in our study or even in other countries.[2],[3],[4]

The present study observed a reduction in the number of hospitalizations for ACS during the first 2 months after declaring COVID-19 as a pandemic by the WHO in compared to a similar time frame of last year. In fact, admissions for STEMI were halved during the pandemic compared with the previous year's equivalent period, although it was not statistically significant, but this could be due to the small number of patients included in the study and not powered enough to show the difference.

We looked into factors that might contribute to this reduction in ACS admissions. The rigorous measures that have been taking by the policymakers,[5] though are crucial in controlling the pandemic. Yet, may be unintended, it affected the integrated establishments as it might have led to the restriction of patients' transportation and their willingness to leave their homes, for example, limitation of public transit, grounding domestic flights, or implementation of 24 h curfew. This also came as a possible factor of why there was a delay in patients' presentations before seeking medical attention. In addition to it, patients' reluctance to visit the emergency department or even come to the hospital in fear of contracting SARS-CoV-2 infection is genuine. This comes with the media's daily reports that possibly infuse fear and anxiety among the general population.

Moreover, with the relatively limited knowledge that we have on this novel virus and spectrum of its presentations, the patients with suspected ACS who attend the emergency department could be misinterpreted as if they have COVID-19 until proven otherwise. Therefore, another factor impacting the DTB time where physicians need more time to evaluate the situation and apply a scoring system to decide which pathway the patients should go for. This brings us to another point, which is the growing approach of pharmacological reperfusion in STEMI cases or even noninvasive medical approaches among ACS cases, which has been applied by different establishments.[14] Finally, with implemented social distancing and lockdown, we anticipated a decrease in the physical activities of the population with a paired reduction in air pollution,[15],[16] which we think that it might lead to a reduction of triggers for ACS. Some data supported the notion of a decrease in the physical activity with remote monitoring of the patients during this pandemic, but further studies are needed to validate these hypotheses.

Irrespective of the cause of ACS reduction during the outbreak of COVID-19, the ultimate objective should be directed toward developing measures, protocols, and pathways that protect patients and health-care workers from infection risk,[17] and at the same, it should be time-efficient to ensure good quality care. Furthermore, aware and educate the general population on the importance of seeking medical attention at the time of need through the media or through free phone applications.[18] Furthermore, cardiovascular mortality of untreated ACS is high; therefore, going virtual to communicate with patients is of great importance as it is a method of triaging, monitoring, and keeping the line of communication open.[19]


  Conclusion Top


There is an observational reduction in ACS cases admissions during the first 2 months after declaring COVID-19 as a pandemic, with no much impact on the overall management of revascularization. Furthermore, a significant delay in time to seek medical attention from onset of symptoms by patients with NSTEMI and UA was shown in 2020 pandemic time. Efforts should be directed to understand the underlying mechanisms of these results to improve the short and long-term outcomes of these high-risk groups in these challenging times.

The study has its limitations starting with its time frame, which is short and being observational retrospective. Furthermore, the number of patients included is small. In addition, the study was conducted only in three PPCI capable centers, and other centers in the regions did not participate, making the results difficult to be generalized.

It is a fact that collecting data during a pandemic crisis is challenging. We did our best to avoid any possible underreporting of cases with cross-checking the documentation and the available data, yet there is still some potential unyielding risk. Moreover, the study does not address mortality or complications, which are precious information that might help us understand the ramification of the downward shift in the rate of ACS admission and the consequences of delay in seeking medical attention.

Ethics approval and consent to participate

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and later revisions. Research and Ethics Committee approval was obtained initially at the coordinating center (Prince Sultan Cardiac Center) with approval number R20010 and similarly at the other participating centers. The study was conducted per the Declaration of Helsinki and applicable local regulations.

Informed written consent was obtained from the patient for being included in the study. No patient identity particulars have been disclosed.

Consent for publication

Informed consent was obtained from the patient for using the data without patient particulars for publication.

Availability of data and material

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Cucinotta D, Vanelli M. WHO declares COVID-19 a pandemic. Acta Biomed 2020;91:157-60.  Back to cited text no. 1
    
2.
De Rosa S, Spaccarotella C, Basso C, Calabrò MP, Curcio A, Filardi PP, et al. Reduction of hospitalizations for myocardial infarction in Italy in the COVID-19 era. Eur Heart J 2020;41:2083-8.  Back to cited text no. 2
    
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Metzler B, Siostrzonek P, Binder RK, Bauer A, Reinstadler SJ. Decline of acute coronary syndrome admissions in Austria since the outbreak of COVID-19: The pandemic response causes cardiac collateral damage. Eur Heart J 2020;41:1852-3.  Back to cited text no. 3
    
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Garcia S, Albaghdadi MS, Meraj PM, Schmidt C, Garberich R, Jaffer FA, et al. Reduction in ST-segment elevation cardiac catheterization laboratory activations in the United States during COVID-19 pandemic. J Am Coll Cardiol 2020;75:2871-2.  Back to cited text no. 4
    
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Saber Y, Khan A. COVID-19 social distancing in the Kingdom of Saudi Arabia: Bold measures in the face of political, economic, social and religious challenges. Travel Med Infect Dis 2020;37:101692-3.  Back to cited text no. 5
    
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Matthew D, Mauricio C, Anthony B, Kumbhani DJ. Reperfusion of STEMI in the COVID-19 Era – Business as usual? Circulation 2020;141:1948-50.  Back to cited text no. 6
    
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Kolte D, Khera S, Palaniswamy C, Mujib M, Fonarow GC, Ahmed A, et al. Early invasive versus initial conservative treatment strategies in octogenarians with UA/NSTEMI. Am J Med 2013;126:1076-83.e1.  Back to cited text no. 8
    
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Rosengren A, Hawken S, Ounpuu S, Sliwa K, Zubaid M, Almahmeed WA, et al. Association of psychosocial risk factors with risk of acute myocardial infarction in 11 119 cases and 13 648 controls from 52 countries (the INTERHEART study): A case-control study. Lancet (London, England) 2004;364:953-62.  Back to cited text no. 11
    
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Kwong JC, Schwartz KL, Campitelli MA, Chung H, Crowcroft NS, Karnauchow T, et al. Acute myocardial infarction after laboratory-confirmed influenza infection. N Engl J Med 2018;378:345-53.  Back to cited text no. 12
    
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Mahmud E, Dauerman HL, Welt FG, Messenger JC, Rao SV, Grines C, et al. Management of acute myocardial infarction during the COVID-19 pandemic. J Am Coll Cardiol 2020;76:1375-84.  Back to cited text no. 13
    
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Hemphill NM, Kuan MT, Harris KC. Reduced physical activity during COVID-19 pandemic in children with congenital heart disease. Can J Cardiol 2020;36:1130-4.  Back to cited text no. 14
    
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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