MI patients face treatment delays and worse outcomes amid COVID-19

Patients with myocardial infarction (MI) are experiencing delayed presentation to hospital, delayed treatment, and worse clinical outcomes during the coronavirus disease 2019 (COVID-19) pandemic, a study at Queen Mary Hospital (QMH) in Hong Kong has reported.

In the cross-sectional observational study, researchers compared outcomes of patients admitted for acute ST-elevation MI (STEMI) or non-ST elevation MI (NSTEMI) before (group 1) and after (group 2) 25 January 2020, when hospitals in Hong Kong launched emergency response measures to combat COVID-19. Group 1 included 85 patients admitted to QMH between 1 November 2019 and 24 January 2020, and group 2 included 64 patients admitted between 25 January and 31 March 2020. [Catheter Cardiovasc Interv 2020, doi: 10.1002/ccd.28943]

A reduction in daily Accident and Emergency Department (AED) attendance was seen during the 66-day period in group 2 (327 per day) compared with the 85-day period in group 1 (231 per day).

Among patients with STEMI, those in group 2 tended to have longer symptom-to-first medical contact time, with a higher proportion presenting out of the revascularization window (33.3 percent vs 27.8 percent in group 1).

Patients in group 2 also more commonly experienced a complicated in-hospital course and had worse outcomes. The primary composite outcome of in-hospital death, cardiogenic shock, sustained ventricular tachycardia or ventricular fibrillation, and use of mechanical circulatory support was reported in 29.7 percent of patients in group 2 vs 14.1 percent of patients in group 1 (p=0.02).

“Although severe direct cardiac damage is not dominant in COVID-19, our preliminary report showed that infectious disease outbreak can indirectly affect MI care and potentially lead to worse outcomes,” the researchers wrote.

At QMH, primary percutaneous coronary intervention continued to be provided for patients with acute STEMI after 25 January 2020, according to eligibility criteria as recommended in international guidelines. Delayed presentation of STEMI and acute NSTEMI were managed with strategies including guideline-directed medical therapy and coronary revascularization as indicated.  

“[During the study period after 25 January 2020], MI patients tried to endure their symptoms until intolerant and, eventually, when they reached the hospital, many of them had prolonged ischaemic time or were out of the window for revascularization,” the researchers pointed out.

The additional time that may be required for potential infection containing measures, such as detailed travel history taking, temperature measurement, chest X-ray and staff protective gear change, would also increase treatment delay, and might have immediately translated into an increase in adverse outcomes, they noted, adding that more MI survivors may suffer from heart failure in the long run as a result.

While these preliminary findings suggest that the COVID-19 pandemic may lead to treatment delays and potentially worse clinical outcomes in MI, the researchers suggested that patients’ and staff’s behaviour may change with time. “Hopefully, when people gain more experience, MI care system and outcome will improve with time in the midst of the COVID-19 outbreak,” they wrote.

“All hospitals not only have to prepare to fight against immediate infections. Various healthcare professionals also need to anticipate how different systems of care would be affected and act accordingly,” they concluded.