Key result
COVID-19 pandemic response linked to fewer ACS admissions and resulting cardiac collateral damage.
Why the study?
The impact of the COVID-19 outbreak and related public health measures on the diagnosis and treatment of acute coronary syndrome in Austria was unclear.
Observational (n=725)
Yes
Effect estimate: 39.4% relative reduction
The COVID-19 pandemic and associated public health measures were associated with a nearly 40% decline in ACS admissions in Austria, raising concerns for untreated cardiac collateral damage.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Lots of reports have shown that there have been fewer heart attacks in hospitals since 2020—but something seems to be missing from that data. We now show that if you account for deaths at home, cardiac deaths are going up and have stayed up for years. Today there are a lot more people having cardiac deaths at home, which also raises the concern that people with heart disease haven't been getting the care they need since the pandemic.”
“What most likely happened is that patients and population in general was not getting the care, being in isolation, because of the pandemic, social distancing, et cetera. A lot of patients that had bad diabetes or high blood pressure or chronic kidney disease didn't seek care with their doctors and specialists and their conditions essentially got worse. And those same risk factors then led to them having congestive heart failure, hence the rise in the number of deaths.”
“The repercussions of the Covid-19 pandemic on cardiovascular care and outcomes will be with us for a long while yet. There is little doubt that there will continue to be deaths and illness that would not have otherwise occurred. Urgent action is needed to address the burden of cardiovascular disease left in the wake of the pandemic.”
Urges vigilance for missed ACS during crises; leaves open generalizability and causal strategies beyond this Austrian cohort.
We conducted a nationwide retrospective survey on the impact of COVID-19 on the diagnosis and treatment of acute cornary syndrome (ACS) from 2 to 29 March in Austria. Of the 19 public primary percutaneous coronary (PCI) centres contacted, 17 (90%) provided the number of admitted patients. During the study period, we observed a significant decline in the number of patients admitted to hospital due to ACS (Figure 1). Comparing the first and last calendar week, there was a relative reduction of 39.4% in admissions for ACS. In detail, from calendar week 10 to calendar week 13, the number of ST-segment elevation myocardial infarction (STEMI) patients admitted to all hospitals was 94, 101, 89, and 70, respectively. The number of non-STEMI patients declined even more markedly from 132 to 110, to 62, and to 67. Decline of acute coronary syndrome admissions in Austria since the outbreak of COVID-19. The absolute numbers of all ACS (blue bars), STEMI (orange bars), and NSTEMI (grey bars) admissions in Austria from calendar week 10 to calendar week 13 are shown. Abbreviations: STEMI, ST-segment elevation myocardial infarction; NSTEMI, non-ST-segment elevation myocardial infarction. The main finding of our retrospective observational study is an unexpected major decline in hospital admissions and thus treatment for all subtypes of ACS with the beginning of the COVID-19 outbreak in Austria and subsequent large-scale public health measures such as social distancing, self-isolation, and quarantining. Several factors might explain this important observation. The rigorous public health measures, which are undoubtedly critical for controlling the COVID-19 pandemic, may unintentionally affect established integrated care systems. Amongst others, patient-related factors could mean that infarct-related symptoms such as chest discomfort and dyspnoea could be misinterpreted as being related to an acute respiratory infection. Moreover, the strict instructions to stay at home as well as the fear of infection in a medical facility may have further prevented patients with an ACS from going to a hospital. Irrespective of the causes, the lower rate of admitted and therefore treated patients with ACS is worrisome and we are concerned that this might be accompanied by a substantial increase in early and late infarct-related morbidity and mortality. Our study does not provide data on mortality; however, considering the annual incidence of ACS in Austria (200/100 000/year = 17 600/year in 8.8 million habitants)1 and taking into consideration sudden cardiac deaths and silent infarctions (one-third), there will remain ∼1000 ACS cases a month. The difference between the assumed number of ACS patients and the observed number in our study, i.e. 725 ACS patients in calendar weeks 10–13 is 275. According to these assumptions, 275 patients were not treated in March 2020. Based on data showing that the cardiovascular mortality of untreated ACS patients might be as high as 40% (as it was in the 1950s),2 we can theoretically estimate 110 ACS deaths during this time frame. The number of deaths associated with this unintentional undersupply of guideline-directed ACS management is very alarming, particularly when considering that the official number of COVID-related deaths in Austria was 86 on 29 March. In conclusion, it seems likely that the COVID-19 outbreak is associated with a significantly lower rate of hospital admissions and thus, albeit unintended, treatment of ACS patients, which is most likely explained by several patient- and system-related factors. Every effort should be undertaken by the cardiology community to minimize the possible cardiac collateral damage caused by COVID-19.
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Metzler et al. (2020) conducted an observational in Acute coronary syndrome (ACS) (n=725). COVID-19 outbreak and public health measures vs. Pre-outbreak period (calendar week 10) was evaluated on Hospital admissions for ACS (39.4% relative reduction). The COVID-19 outbreak and public health measures were associated with a 39.4% relative reduction in hospital admissions for acute coronary syndrome in Austria.
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