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      Decline of acute coronary syndrome admissions in Austria since the outbreak of COVID-19: the pandemic response causes cardiac collateral damage

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          Abstract

          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. Figure 1 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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          Reperfusion therapy for ST elevation acute myocardial infarction in Europe: description of the current situation in 30 countries

          Aims Patient access to reperfusion therapy and the use of primary percutaneous coronary intervention (p-PCI) or thrombolysis (TL) varies considerably between European countries. The aim of this study was to obtain a realistic contemporary picture of how patients with ST elevation myocardial infarction (STEMI) are treated in different European countries. Methods and results The chairpersons of the national working groups/societies of interventional cardiology in European countries and selected experts known to be involved in the national registries joined the writing group upon invitation. Data were collected about the country and any existing national STEMI or PCI registries, about STEMI epidemiology, and treatment in each given country and about PCI and p-PCI centres and procedures in each country. Results from the national and/or regional registries in 30 countries were included in this analysis. The annual incidence of hospital admission for any acute myocardial infarction (AMI) varied between 90–312/100 thousand/year, the incidence of STEMI alone ranging from 44 to 142. Primary PCI was the dominant reperfusion strategy in 16 countries and TL in 8 countries. The use of a p-PCI strategy varied between 5 and 92% (of all STEMI patients) and the use of TL between 0 and 55%. Any reperfusion treatment (p-PCI or TL) was used in 37–93% of STEMI patients. Significantly less reperfusion therapy was used in those countries where TL was the dominant strategy. The number of p-PCI procedures per million per year varied among countries between 20 and 970. The mean population served by a single p-PCI centre varied between 0.3 and 7.4 million inhabitants. In those countries offering p-PCI services to the majority of their STEMI patients, this population varied between 0.3 and 1.1 million per centre. In-hospital mortality of all consecutive STEMI patients varied between 4.2 and 13.5%, for patients treated by TL between 3.5 and 14% and for patients treated by p-PCI between 2.7 and 8%. The time reported from symptom onset to the first medical contact (FMC) varied between 60 and 210 min, FMC-needle time for TL between 30 and 110 min, and FMC-balloon time for p-PCI between 60 and 177 min. Conclusion Most North, West, and Central European countries used p-PCI for the majority of their STEMI patients. The lack of organized p-PCI networks was associated with fewer patients overall receiving some form of reperfusion therapy.
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              Author and article information

              Journal
              Eur Heart J
              Eur. Heart J
              eurheartj
              European Heart Journal
              Oxford University Press
              0195-668X
              1522-9645
              16 April 2020
              16 April 2020
              : ehaa314
              Affiliations
              [e1 ] University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck , Austria
              [e2 ] Department of Internal Medicine 2, Cardiology, Ordensklinikum Linz Barmherzige Schwestern , Linz, Austria
              [e3 ] Department of Internal Medicine 2, Cardiology, Intensive Care Medicine, Klinikum Wels-Grieskirchen , Wels, Austria
              Author notes
              Corresponding author. University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria. Tel: +43 512 504 81315, Fax: +43 512 504 22767, Email: Bernhard.Metzler@ 123456tirol-kliniken.at
              Author information
              http://orcid.org/0000-0002-4898-4606
              http://orcid.org/0000-0001-9985-3748
              http://orcid.org/0000-0002-7700-1357
              Article
              ehaa314
              10.1093/eurheartj/ehaa314
              7184486
              32297932
              6db08b61-eac2-450e-8de8-ce5539865c7f
              Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.

              This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model ( https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

              This article is made available via the PMC Open Access Subset for unrestricted re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the COVID-19 pandemic or until permissions are revoked in writing. Upon expiration of these permissions, PMC is granted a perpetual license to make this article available via PMC and Europe PMC, consistent with existing copyright protections.

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