COVID-19 pandemic and admission rates for and management of acute coronary syndromes in England

Outcomes of Patients Presenting with Non-ST Elevation Myocardial Infarction Undergoing Surgical Revascularization

Non-ST-segment elevation myocardial infarction (NSTEMI) is a leading cause of emergency hospitalisation across Europe. This study evaluates the in-hospital and mid-term outcomes of patients undergoing coronary artery bypass grafting (CABG) following NSTEMI. A retrospective analysis of all cases undergoing isolated CABG following NSTEMI from September/2017 to September/2022 at our Centre. Patients were stratified according to in-hospital survival. Patient characteristics, operative details, and procedural complications were compared between those who survived and those who did not. Predictors of in-hospital and mid-term mortality were evaluated using logistic and Cox regression modelling. Kaplan Meier analysis was used to generate a survival curve for all alive patients at the time of discharge. Among 1011 patients (median age 64 [56 - 72] years, 852 [84.3%] male), 735 (72.7%) underwent urgent, 239 (23.6%) elective, and 37 (3.7%) emergency CABG. The in-hospital mortality was 1.5% (15/1011 patients). Those who died were more likely to be NYHA class III/IV, have LVEF <21%, severe renal impairment, peripheral vascular disease (PVD), or poor mobility. Emergency procedures, pre-operative ventilation, inotropic support, and intra-aortic balloon pump (IABP) use were also more prevalent among those who died. Logistic regression modelling revealed new postoperative stroke (OR:22.0; 95% CI:3.6-135.5; p=0.001), pre-operative IABP use (11.4; 2.4-53.7; p=0.002), new haemodialysis (9.6; 2.7-34.7; p<0.001), PVD (5.6; 1.6-20.0; p=0.008), and poor mobility (OR: 4.8; 95% CI: 1.3-18.2; p=0.022) as independent predictors of in-hospital mortality. In conclusion, new postoperative stroke, pre-operative IABP use, new haemodialysis, PVD and poor mobility are independent predictors of mortality in NSTEMI patients undergoing isolated CABG.

Colchicine in atherosclerotic cardiovascular disease

Inflammation has a direct role in the development of atherosclerotic vascular disease, and oral colchicine displays broad anti-inflammatory properties. Several large, randomised controlled trials (RCTs) have evaluated colchicine's impact on cardiovascular outcomes. Results from a meta-analysis of these trials demonstrate that colchicine reduces the risk of recurrent major adverse cardiovascular events (MACEs) by 25%, leading to its recent approval by the Food and Drug Administration for the treatment and prevention of cardiovascular disease. Despite this, colchicine has not been shown to confer any survival benefit in these trials. The non-significant reduction in cardiovascular death of 18% (95% CI: 45% decrease to 23% increase) is outweighed by a more prominent, borderline non-significant increase in the risk of non-cardiovascular death by 38% (95% CI: 1% decrease to 92% increase). Key populations including those with heart failure, those undergoing surgical revascularisation, women, elderly individuals and non-Caucasians are under-represented in completed trials, which limits generalisability. C reactive protein has been proposed as a biomarker for colchicine response and shows promise for identifying a high-risk population where the benefit on MACE reduction and specifically reduced cardiovascular death might outweigh any real increased risk of non-cardiovascular death; however, this approach is still to be validated in ongoing RCTs. In conclusion, while colchicine shows promise in reducing MACE, its net risk-benefit profile requires further elucidation before its widespread adoption into clinical practice for the secondary prevention of atherosclerotic cardiovascular disease. Much more large-scale, long-term trial data are still needed in this space.

Patterns and determinants of healthcare utilization and medication use before and during the COVID-19 crisis in Afghanistan, Bangladesh, and India

BACKGROUND

COVID-19 rapidly spread through South Asian countries and overwhelmed the health systems that were unprepared for such an outbreak. Evidence from high-income countries showed that COVID-19 impacted healthcare utilization, including medication use, but empirical evidence is lacking in South Asia. This study aimed to investigate the effect of COVID-19 on healthcare utilization and medication use in South Asia.

METHOD

The current study used longitudinal data from the 'Premise Health Service Disruption Survey' 2020 and 2021. The countries of interest were limited to Afghanistan, Bangladesh, and India. In these surveys, data related to healthcare utilization and medication use were collected for three-time points; 'Pre-COVID phase', 'Initial phase of COVID-19 outbreak', and 'One year of COVID-19 outbreak'. Generalized estimating equation (GEE) along with McNemar's test, Kruskal-Wallis test and χ2 test were applied in this study following the conceptualization of Andersen's healthcare utilization model.

RESULT

The use of healthcare and medication was unevenly impacted by the COVID-19 epidemic in Afghanistan, Bangladesh, and India. Immediately after the COVID-19 outbreak, respondents in Bangladesh reported around four times higher incomplete healthcare utilization compared to pre-COVID phase. In contrast, respondents in Afghanistan reported lower incomplete utilization of healthcare in a similar context. In the post COVID-19 outbreak, non-adherence to medication use was significantly higher in Afghanistan (OR:1.7; 95%CI:1.6,1.9) and India (OR:1.3; 95%CI:1.1,1.7) compared to pre-COVID phase. Respondents of all three countries who sought assistance to manage non-communicable diseases (NCDs) had higher odds (Afghanistan: OR:1.5; 95%CI:1.3,1.8; Bangladesh: OR: 3.7; 95%CI:1.9,7.3; India: OR: 2.3; 95% CI: 1.4,3.6) of non-adherence to medication use after the COVID-19 outbreak compared to pre-COVID phase.

CONCLUSION

The present study documented important evidence of the influence of COVID-19 epidemic on healthcare utilization and medication use in three countries of South Asia. Lessons learned from this study can feed into policy responses to the crisis and preparedness for future pandemics.

Predicting the response to acetylcholine in ischemia or infarction with non-obstructive coronary arteries: The ABCD score

BACKGROUND AND AIMS

Acetylcholine (ACh) provocation testing can detect vasomotor disorders in patients with ischemia and non-obstructed coronary arteries (INOCA) or myocardial infarction and non-obstructed coronary arteries (MINOCA). We aimed to derive and validate a simple risk score to predict a positive ACh test response.

METHODS

We prospectively enrolled consecutive INOCA and MINOCA patients undergoing ACh provocation testing. Patients were split in two cohorts (derivation and validation) according to time of enrolment. The score was derived in 386 patients (derivation cohort) and then validated in 165 patients (validation cohort).

RESULTS

551 patients were enrolled, 371 (67.3%) INOCA and 180 (32.7%) MINOCA. ACh test was positive in 288 (52.3%) patients. MINOCA, myocardial bridge (MB), C-reactive protein (CRP) and dyslipidaemia were independent predictors of a positive ACh test in the derivation cohort. The ABCD (Acute presentation, Bridge, CRP, Dyslipidaemia) score was derived: 2 points were assigned to MINOCA, 3 to MB, 1 to elevated CRP and 1 to dyslipidaemia. The ABCD score accurately identified patients with a positive ACh test response with an AUC of 0.703 (CI 95% 0.652-0.754,p < 0.001) in the derivation cohort, and 0.705 (CI 95% 0.626-0.784, p < 0.001) in the validation cohort. In the whole population, an ABCD score ≥4 portended 94.3% risk of a positive ACh test and all patients with an ABCD score ≥6 presented a positive test.

CONCLUSIONS

The ABCD score could avoid the need of ACh provocation testing in patients with a high score, reducing procedural risks, time, and costs, and allowing the implementation of a tailored treatment strategy. These results are hypothesis generating and further research involving larger cohorts and multicentre trials is needed to validate and refine the ABCD score.

Temporal trends of ambulance time intervals for suspected stroke/transient ischaemic attack (TIA) before and during the COVID-19 pandemic in Ireland: a quasi-experimental study

OBJECTIVES

Time is a fundamental component of acute stroke and transient ischaemic attack (TIA) care, thus minimising prehospital delays is a crucial part of the stroke chain of survival. COVID-19 restrictions were introduced in Ireland in response to the pandemic, which resulted in major societal changes. However, current research on the effects of the COVID-19 pandemic on prehospital care for stroke/TIA is limited to early COVID-19 waves. Thus, we aimed to investigate the effect of the COVID-19 pandemic on ambulance time intervals and suspected stroke/TIA call volume for adults with suspected stroke and TIA in Ireland, from 2018 to 2021.

DESIGN

We conducted a secondary data analysis with a quasi-experimental design.

SETTING

We used data from the National Ambulance Service in Ireland. We defined the COVID-19 period as '1 March 2020-31 December 2021' and the pre-COVID-19 period '1 January 2018-29 February 2020'.

PRIMARY AND SECONDARY OUTCOME MEASURES

We compared five ambulance time intervals: 'allocation performance', 'mobilisation performance', 'response time', 'on scene time' and 'conveyance time' between the two periods using descriptive and regression analyses. We also compared call volume for suspected stroke/TIA between the pre-COVID-19 and COVID-19 periods using interrupted time series analysis.

PARTICIPANTS

We included all suspected stroke/TIA cases ≥18 years who called the National Ambulance Service from 2018 to 2021.

RESULTS

40 004 cases were included: 19 826 in the pre-COVID-19 period and 19 731 in the COVID-19 period. All ambulance time intervals increased during the pandemic period compared with pre-COVID-19 (p<0.001). Call volume increased during the COVID-19-period compared with the pre-COVID-19 period (p<0.001).

CONCLUSIONS

A 'shock' like a pandemic has a negative impact on the prehospital phase of care for time-sensitive conditions like stroke/TIA. System evaluation and public awareness campaigns are required to ensure maintenance of prehospital stroke pathways amidst future healthcare crises. Thus, this research is relevant to routine and extraordinary prehospital service planning.

Changes in Site of Death Among Older Adults Without a COVID-19 Diagnosis During the COVID-19 Pandemic

BACKGROUND

Understanding how the coronavirus disease 2019 (COVID-19) pandemic affected site of death-an important patient-centered outcome related to end-of-life care-would inform healthcare system resiliency in future public health emergencies.

OBJECTIVE

To evaluate the changes in site of death during the COVID-19 pandemic among older adults without a COVID-19 diagnosis.

DESIGN

Using a quasi-experimental difference-in-differences method, we estimated net changes in site of death during the pandemic period (March-December 2020) from the pre-pandemic period (January-February 2020), using data on the same months in prior years (2016-2019) as the control.

PARTICIPANTS

A 20% sample of Medicare Fee-for-Service beneficiaries aged 66 years and older who died in 2016-2020. We excluded beneficiaries with a hospital diagnosis of COVID-19.

MAIN MEASURES

We assessed each of the following sites of death separately: (1) home or community; (2) acute care hospital; and (3) nursing home.

KEY RESULTS

We included 1,133,273 beneficiaries without a hospital diagnosis of COVID-19. We found that the proportion of Medicare beneficiaries who died at home or in the community setting increased (difference-in-differences [DID] estimate, + 3.1 percentage points [pp]; 95% CI, + 2.6 to + 3.6 pp; P < 0.001) and the proportion of beneficiaries who died (without COVID-19 diagnosis) in an acute care hospital decreased (- 0.8 pp; 95% CI, - 1.2 to - 0.4 pp; P < 0.001) during the pandemic. We found no evidence that the proportion of deaths in nursing homes changed during the pandemic.

CONCLUSIONS

Using national data on older adults without a COVID-19 diagnosis, we found that site of death shifted toward home or community settings during the COVID-19 pandemic. Our findings may inform clinicians and policymakers in supporting end-of-life care during future public health emergencies.

Effect of the COVID-19 pandemic on the pediatric infectious disease landscape

This narrative review aims to present an overview of the COVID-19 pandemic's effects on the landscape of pediatric infectious diseases. While COVID-19 generally results in mild symptoms and a favorable prognosis in children, the pandemic brought forth significant consequences. These included persistent symptoms among infected children ("long COVID"), a profound transformation in healthcare utilization (notably through the widespread adoption of telemedicine), and the implementation of optimization strategies within healthcare settings. Furthermore, the pandemic resulted in alterations in the circulation patterns of respiratory pathogens, including influenza, RSV, and Streptococcus pneumoniae. The possible reasons for those changes are discussed in this review. COVID-19 effect was not limited to respiratory infectious diseases, as other diseases, including urinary tract and gastrointestinal infections, have displayed decreased transmission rates, likely attributable to heightened hygiene measures and shifts in care-seeking behaviors. Finally, the disruption of routine childhood vaccination programs has resulted in reduced immunization coverage and an upsurge in vaccine hesitancy. In addition, the pandemic was associated with issues of antibiotic misuse and over-prescription.     Conclusion: In conclusion, the COVID-19 pandemic has left a profound and multifaceted impact on the landscape of pediatric infectious diseases, ranging from the emergence of "long COVID" in children to significant changes in healthcare delivery, altered circulation patterns of various pathogens, and concerning disruptions in vaccination programs and antibiotic usage. What is Known: • COVID-19 usually presents with mild symptoms in children, although severe and late manifestations are possible. • The pandemic resulted in a dramatically increased use of health care services, as well as alterations in the circulation patterns of respiratory pathogens, decreased rates of other, non-respiratory, infections, disruption of routine childhood vaccination programs, and antibiotic misuse. What is New: • Possible strategies to tackle future outbreaks are presented, including changes in health care services utilization, implementation of updated vaccine programs and antibiotic stewardship protocols. • The decline in RSV and influenza circulation during COVID-19 was probably not primarily related to NPI measures, and rather related to other, non-NPI measures implementation, including specific pathogen-host interactions on the level of the biological niche (the nasopharynx).

Multifaceted Impact of the Coronavirus Disease 2019 (COVID-19) Pandemic on ST-Elevation Myocardial Infarction (STEMI): A Literature Review of Incidence, Treatment Modalities, and Outcomes

The global repercussions of coronavirus disease 2019 (COVID-19) include substantial worldwide mortality and have brought to light existing gaps in healthcare systems. Particularly, diseases requiring time-sensitive treatment, such as ST-elevation myocardial infarction (STEMI), have faced significant challenges due to the impact and revelations of the COVID-19 pandemic on healthcare infrastructure. This review addresses the impact of the pandemic on STEMI, exploring incidence, treatment modalities, and clinical outcomes. Through a critical examination of existing literature, the intricate relationship between the pandemic and cardiovascular health, specifically STEMI, is elucidated. The COVID-19 pandemic has had a significant impact on the management of STEMI, with changes in hospitalization rates, treatment strategies, and the presentation of the disease posing significant challenges. The contradictory results of COVID-19 and post-vaccine myocardial infarction, as well as gender differences in reported cases, highlight the need for further research to clarify these relationships.

Allopurinol and cardiovascular outcomes in patients with ischaemic heart disease: the ALL-HEART RCT and economic evaluation

Background

Allopurinol is a xanthine oxidase inhibitor that lowers serum uric acid and is used to prevent acute gout flares in patients with gout. Observational and small interventional studies have suggested beneficial cardiovascular effects of allopurinol.

Objective

To determine whether allopurinol improves major cardiovascular outcomes in patients with ischaemic heart disease.

Design

Prospective, randomised, open-label, blinded endpoint multicentre clinical trial.

Setting

Four hundred and twenty-four UK primary care practices.

Participants

Aged 60 years and over with ischaemic heart disease but no gout.

Interventions

Participants were randomised (1 : 1) using a central web-based randomisation system to receive allopurinol up to 600 mg daily that was added to usual care or to continue usual care.

Main outcome measures

The primary outcome was the composite of non-fatal myocardial infarction, non-fatal stroke or cardiovascular death. Secondary outcomes were non-fatal myocardial infarction, non-fatal stroke, cardiovascular death, all-cause mortality, hospitalisation for heart failure, hospitalisation for acute coronary syndrome, coronary revascularisation, hospitalisation for acute coronary syndrome or coronary revascularisation, all cardiovascular hospitalisations, quality of life and cost-effectiveness. The hazard ratio (allopurinol vs. usual care) in a Cox proportional hazards model was assessed for superiority in a modified intention-to-treat analysis.

Results

From 7 February 2014 to 2 October 2017, 5937 participants were enrolled and randomised to the allopurinol arm (n = 2979) or the usual care arm (n = 2958). A total of 5721 randomised participants (2853 allopurinol; 2868 usual care) were included in the modified intention-to-treat analysis population (mean age 72.0 years; 75.5% male). There was no difference between the allopurinol and usual care arms in the primary endpoint, 314 (11.0%) participants in the allopurinol arm (2.47 events per 100 patient-years) and 325 (11.3%) in the usual care arm (2.37 events per 100 patient-years), hazard ratio 1.04 (95% confidence interval 0.89 to 1.21); p = 0.65. Two hundred and eighty-eight (10.1%) participants in the allopurinol arm and 303 (10.6%) participants in the usual care arm died, hazard ratio 1.02 (95% confidence interval 0.87 to 1.20); p = 0.77. The pre-specified health economic analysis plan was to perform a 'within trial' cost-utility analysis if there was no statistically significant difference in the primary endpoint, so NHS costs and quality-adjusted life-years were estimated over a 5-year period. The difference in costs between treatment arms was +£115 higher for allopurinol (95% confidence interval £17 to £210) with no difference in quality-adjusted life-years (95% confidence interval -0.061 to +0.060). We conclude that there is no evidence that allopurinol used in line with the study protocol is cost-effective.

Limitations

The results may not be generalisable to younger populations, other ethnic groups or patients with more acute ischaemic heart disease. One thousand six hundred and thirty-seven participants (57.4%) in the allopurinol arm withdrew from randomised treatment, but an on-treatment analysis gave similar results to the main analysis.

Conclusions

The ALL-HEART study showed that treatment with allopurinol 600 mg daily did not improve cardiovascular outcomes compared to usual care in patients with ischaemic heart disease. We conclude that allopurinol should not be recommended for the secondary prevention of cardiovascular events in patients with ischaemic heart disease but no gout.

Future work

The effects of allopurinol on cardiovascular outcomes in patients with ischaemic heart disease and co-existing hyperuricaemia or clinical gout could be explored in future studies.

Trial registration

This trial is registered as EU Clinical Trials Register (EudraCT 2013-003559-39) and ISRCTN (ISRCTN 32017426).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 11/36/41) and is published in full in Health Technology Assessment; Vol. 28, No. 18. See the NIHR Funding and Awards website for further award information.

Impact of the COVID-19 pandemic on provision of interventional cardiology and cardiac surgery services in Australia: a review of Medicare claims data

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has significantly impacted healthcare service provision worldwide. There is limited information on changes in invasive cardiovascular services during the pandemic, particularly in Australia.

AIM

We sought to assess temporal trends on the use of interventional cardiology and cardiac surgery services before and following the COVID-19 pandemic in Australia.

METHODS

Medicare Benefits Schedule items data from the Australian Government Services Australia on outpatient and private hospital interventional cardiology procedures (coronary angiogram, percutaneous coronary intervention and transcatheter aortic valve implantation) and cardiac surgery procedures (coronary artery bypass grafting [CABG] and surgical valve replacement, repair and annuloplasty) were analysed from March 2019 to 2021. This was superimposed on monthly COVID-19 case data obtained from the Australian Department of Health and Aged Care epidemiology reports.

RESULTS

A sustained reduction in CABG (-10.1%) and surgical valve intervention (-11.1%) was appreciated from March 2019-2020 to March 2020-2021, in the first year of the COVID-19 pandemic. During this period, an overall increase (+25.9%) in the use of transcatheter aortic valve implantation was observed. Following the initial period of mandated isolation in March-April 2020, a reduction in coronary angiography (-29.1%) and percutaneous coronary intervention (-19.5%) was observed in comparison to March-April 2019; however, this was largely attenuated over time.

CONCLUSIONS

The COVID-19 pandemic has resulted in reductions in the use of interventional cardiology and cardiac surgery services, with cardiac surgery most affected. However, an increase in uptake of transcatheter aortic valve implantation has been observed during the pandemic. This may have implications for future planning and resource allocation in the aftermath of the pandemic.

Prognostic Implications of the Timing of ST-Elevation Myocardial Infarction Development in Relation to COVID-19 Infection

Background: Patients with ST-segment elevation myocardial infarction (STEMI) and COVID-19 infection have a worse clinical course and prognosis. The prognostic significance of the timing of STEMI in relation to COVID-19 infection was not investigated. Objectives: To assess whether the time of STEMI development in relation to COVID-19 infection (concurrent or following the infection) influenced the short-term prognosis. Methods: This was an observational study of consecutive COVID-19 patients with STEMI admitted to the COVID-hospital Batajnica (February 2021-March 2022). The patients were divided into the "STEMI first" group: patients with STEMI and a positive polymerase chain reaction test for COVID-19, and the "COVID-19 first" group: patients who developed STEMI during COVID-19 treatment. All patients underwent coronary angiography. The primary endpoint was in-hospital all-cause mortality. Results: The study included 87 patients with STEMI and COVID-19 (Mage, 66.7 years, 66% male). The "STEMI first" group comprised 54 (62.1%) patients, and the "COVID-19 first" group included 33 (37.9%) patients. Both groups shared a comparatively high burden of comorbidities, similar angiographic and procedural characteristics, and high percentages of performed percutaneous coronary interventions with stent implantation (90.7% vs. 87.9%). In-hospital mortality was significantly higher in the "COVID-19 first" group compared to the "STEMI first" group (51.5% vs. 27.8%). Following adjustment, the "COVID-19 first" group had a hazard ratio of 3.22 (95% confidence interval, 1.18-8.75, p = .022) for in-hospital all-cause death, compared with the "STEMI first" group (reference). Conclusion: Clinical presentation with COVID-19 infection, followed by STEMI ("COVID-19 first"), was associated with greater short-term mortality compared to patients presenting with STEMI and testing positive for COVID-19 ("STEMI first").

Impact of the COVID-19 Pandemic on Global TAVR Activity: The COVID-TAVI Study

BACKGROUND

The COVID-19 pandemic adversely affected health care systems. Patients in need of transcatheter aortic valve replacement (TAVR) are especially susceptible to treatment delays.

OBJECTIVES

This study sought to evaluate the impact of the COVID-19 pandemic on global TAVR activity.

METHODS

This international registry reported monthly TAVR case volume in participating institutions prior to and during the COVID-19 pandemic (January 2018 to December 2021). Hospital-level information on public vs private, urban vs rural, and TAVR volume was collected, as was country-level information on socioeconomic status, COVID-19 incidence, and governmental public health responses.

RESULTS

We included 130 centers from 61 countries, including 65,980 TAVR procedures. The first and second pandemic waves were associated with a significant reduction of 15% (P < 0.001) and 7% (P < 0.001) in monthly TAVR case volume, respectively, compared with the prepandemic period. The third pandemic wave was not associated with reduced TAVR activity. A greater reduction in TAVR activity was observed in Africa (-52%; P = 0.001), Central-South America (-33%; P < 0.001), and Asia (-29%; P < 0.001). Private hospitals (P = 0.005), urban areas (P = 0.011), low-volume centers (P = 0.002), countries with lower development (P < 0.001) and economic status (P < 0.001), higher COVID-19 incidence (P < 0.001), and more stringent public health restrictions (P < 0.001) experienced a greater reduction in TAVR activity.

CONCLUSIONS

TAVR procedural volume declined substantially during the first and second waves of the COVID-19 pandemic, especially in Africa, Central-South America, and Asia. National socioeconomic status, COVID-19 incidence, and public health responses were associated with treatment delays. This information should inform public health policy in case of future global health crises.

Non-COVID-19 hospitalization and mortality during the COVID-19 pandemic in Iran: a longitudinal assessment of 41 million people in 2019-2022

BACKGROUND

During a COVID-19 pandemic, it is imperative to investigate the outcomes of all non-COVID-19 diseases. This study determines hospital admissions and mortality rates related to non-COVID-19 diseases during the COVID-19 pandemic among 41 million Iranians.

METHOD

This nationwide retrospective study used data from the Iran Health Insurance Organization. From September 23, 2019, to Feb 19, 2022, there were four study periods: pre-pandemic (Sept 23-Feb 19, 2020), first peak (Mar 20-Apr 19, 2020), first year (Feb 20, 2020-Feb 18, 2021), and the second year (Feb 19, 2021-Feb 19, 2022) following the pandemic. Cause-specific hospital admission and in-hospital mortality are the main outcomes analyzed based on age and sex. Negative binomial regression was used to estimate the monthly adjusted Incidence Rate Ratio (IRR) to compare hospital admission rates in aggregated data. A logistic regression was used to estimate the monthly adjusted in-hospital mortality Odds Ratio (OR) for different pandemic periods.

RESULTS

During the study there were 6,522,114 non-COVID-19 hospital admissions and 139,679 deaths. Prior to the COVID-19 outbreak, the standardized hospital admission rate per million person-month was 7115.19, which decreased to 2856.35 during the first peak (IRR 0.40, [0.25-0.64]). In-hospital mortality also increased from 20.20 to 31.99 (OR 2.05, [1.97-2.13]). All age and sex groups had decreased admission rates, except for females at productive ages. Two years after the COVID-19 outbreak, the non-COVID-19 hospital admission rate (IRR 1.25, [1.13-1.40]) and mortality rate (OR 1.05, [1.04-1.07]) increased compared to the rates before the pandemic. The respiratory disease admission rate decreased in the first (IRR 0.23, [0.17-0.31]) and second years (IRR 0.35, [0.26-0.47] compared to the rate before the pandemic. There was a significant reduction in hospitalizations for pneumonia (IRR 0.30, [0.21-0.42]), influenza (IRR 0.04, [0.03-0.06]) and COPD (IRR 0.39, [0.23-0.65]) during the second year. There was a significant and continuous rise in the hematological admission rate during the study, reaching 186.99 per million person-month in the second year, reflecting an IRR of 2.84 [2.42-3.33] compared to the pre-pandemic period. The mortality rates of mental disorders (OR 2.15, [1.65-2.78]) and musculoskeletal (OR 1.48, [1.20-1.82), nervous system (OR 1.42, [1.26-1.60]), metabolic (OR 1.99, [1.80-2.19]) and circulatory diseases (OR 1.35, [1.31-1.39]) increased in the second year compare to pre-pandemic. Myocardial infarction (OR 1.33, [1.19-1.49]), heart failure (OR 1.59, [1.35-1.87]) and stroke (OR 1.35, [1.24-1.47]) showed an increase in mortality rates without changes in hospitalization.

CONCLUSIONS

In the era of COVID-19, the changes seem to have had a long-term effect on non-COVID-19 diseases. Countries should prepare for similar crises in the future to ensure medical services are not suspended.

Changes in diagnostic patterns and resource utilisation in Swiss adult ICUs during the first two COVID-19 waves: an exploratory study

BACKGROUND AND AIM

The coronavirus disease 2019 (COVID-19) outbreak deeply affected intensive care units (ICUs). We aimed to explore the main changes in the distribution and characteristics of Swiss ICU patients during the first two COVID-19 waves and to relate these figures with those of the preceding two years.

METHODS

Using the national ICU registry, we conducted an exploratory study to assess the number of ICU admissions in Switzerland and their changes over time, characteristics of the admissions, the length of stay (LOS) and its trend over time, ICU mortality and changes in therapeutic nursing workload and hospital resources in 2020 and compare them with the average figures in 2018 and 2019.

RESULTS

After analysing 242,935 patient records from all 84 certified Swiss ICUs, we found a significant decrease in admissions (-9.6%, corresponding to -8005 patients) in 2020 compared to 2018/2019, with an increase in the proportion of men admitted (61.3% vs 59.6%; p <0.001). This reduction occurred in all Swiss regions except Ticino. Planned admissions decreased from 25,020 to 22,021 in 2020 and mainly affected the neurological/neurosurgical (-14.9%), gastrointestinal (-13.9%) and cardiovascular (-9.3%) pathologies. Unplanned admissions due to respiratory diagnoses increased by 1971 (+25.2%), and those of patients with acute respiratory distress syndrome (ARDS) requiring isolation reached 9973 (+109.9%). The LOS increased by 20.8% from 2.55 ± 4.92 days (median 1.05) in 2018/2019 to 3.08 ± 5.87 days (median 1.11 days; p <0.001), resulting in an additional 19,753 inpatient days. The nine equivalents of nursing manpower use score (NEMS) of the first nursing shift (21.6 ± 9.0 vs 20.8 ± 9.4; p <0.001), the total NEMS per patient (251.0 ± 526.8 vs 198.9 ± 413.8; p <0.01) and mortality (5.7% vs 4.7%; p <0.001) increased in 2020. The number of ICU beds increased from 979 to 1012 (+3.4%), as did the number of beds equipped with mechanical ventilators (from 773 to 821; +6.2%).

CONCLUSIONS

Based on a comprehensive national data set, our report describes the profound changes triggered by COVID-19 over one year in Swiss ICUs. We observed an overall decrease in admissions and a shift in admission types, with fewer planned hospitalisations, suggesting the loss of approximately 3000 elective interventions. We found a substantial increase in unplanned admissions due to respiratory diagnoses, a doubling of ARDS cases requiring isolation, an increase in ICU LOS associated with substantial nationwide growth in ICU days, an augmented need for life-sustaining therapies and specific therapeutic resources and worse outcomes.

Association Between History of Polymerase Chain Reaction-verified COVID-19 Infection and Outcomes of Subsequent ST-Elevation Myocardial Infarction

While the acute phase of coronavirus disease 2019 (COVID-19) is associated with worsening cardiac outcomes, it is unclear whether it affects the outcome of patients with ST-segment elevation myocardial infarction (STEMI) after the acute phase. In addition, while many studies compared the course of STEMI during the COVID-19 pandemic with the years before the outbreak, we evaluated the course of STEMI during the pandemic according to whether or not patients had history of COVID-19. Patients diagnosed with STEMI during the ongoing COVID-19 pandemic were included in the study. The Ministry of Health database was analyzed retrospectively, and patients with (n = 191) and without (n = 127) a history of polymerase chain reaction (PCR) confirmed COVID-19 infection were divided into groups. Clinical and angiographic characteristics were assessed. The rates of in-hospital major adverse cardiac events (MACE) were higher in those who had a history of PCR-verified COVID-19 infection. Angiographic and procedural findings indicating successful reperfusion were better in patients without a history of COVID-19. A history of COVID-19 infection (odds ratio 1.40, 95% confidence interval 1.25-1.60, P < .01) independently predicted MACE. A history of COVID-19 infection is a predictor of worse outcomes following coronary intervention and in-hospital MACE among patients with STEMI.

Dapagliflozin in Myocardial Infarction without Diabetes or Heart Failure

Dapagliflozin in Myocardial InfarctionA total of 4017 patients with acute myocardial infarction, but no diabetes or chronic heart failure, were randomly assigned 10 mg of dapagliflozin or placebo. The primary outcome was a composite of death, hospitalization for heart failure, and five cardiometabolic outcomes analyzed using the win ratio method. There were significantly more wins for dapagliflozin than for placebo (win ratio, 1.34; 95% confidence interval, 1.20 to 1.50), which was driven by the cardiometabolic outcomes. The composite of time to cardiovascular death/hospitalization for heart failure was not different between the two groups.

Correlates of the Veterans Visiting Emergency Departments in Taiwan: A Comparison Before and After the Coronavirus Disease 2019 Pandemic

BACKGROUND

Taiwan has a substantial number of veterans, but knowledge regarding their emergency department (ED) visits during the coronavirus disease 2019 (COVID-19) pandemic remains limited. This study examined the characteristics of veterans' ED visits during Taiwan's COVID-19 epidemic.

METHODS

This was a cross-sectional study conducted at the ED of a large veteran medical center located in Taipei, Taiwan, from May 2018 to October 2021. We analyzed the numbers and features of visits in summer and autumn according to the first wave of the COVID-19 epidemic in Taiwan in 2021.

RESULTS

Medical institutions were positively associated with veteran status. Emergency department complaints of trauma (adjusted odds ratio [AOR] = 1.15, 95% CI: 1.06-1.25; summer P < .01) and chest pain/tightness (AOR = 1.65, 95% CI: 1.45-1.87; summer P < .01; AOR = 1.4, 95% CI: 1.26-1.55; P < .01) were associated with increased odds of being a veteran. Triage levels above 2 were positively associated with veteran status in the autumn model (AOR = 1.14, 95% CI: 1.07-1.22; P < .01). Patients hospitalized after ED visits were associated with reduced odds of veteran status (P < .01). Those who spent a long time in the ED were more likely to be veterans than those who spent a shorter time in the ED (P < .01). Veterans were less likely to visit the ED regardless of the time frame of the study period (P < .01), except during the COVID-19 outbreak in the autumn (2019-2020).

CONCLUSIONS

The distinctions in ED visits highlighted the individuality of veterans' medical needs. Our findings suggest that the veteran medical system can add to the focus on improving senior-friendly care, fall prevention, quality of life of institutionalized veterans, access for homeless veterans, and care for ambulatory care-sensitive conditions.

Trends in the Incidence of Cardiovascular Diagnoses and Procedures over the Years 2012-2021 in Israel: The Impact of the COVID-19 Pandemic

Prior studies found reduced incidences of cardiovascular diagnoses and treatments in the initial phase of the COVID-19 pandemic. However, these studies included a limited number of outcomes and did not consider pre-pandemic trends. This study aimed to describe trends in the incidence of cardiovascular diagnoses and treatments over the years 2012-2021 in Israel and to compare the two years of the COVID-19 period with the preceding 8 years. In this retrospective, population-based study, carried out within Clalit Health Services, the incidence rates of cardiovascular outcomes were calculated for individuals aged ≥ 25 (~2.7 million adults per year) during the first (Y1, 3/2020-2/2021) and second (Y2, 3/2021-2/2022) years of COVID-19 and the 8 years prior (3/2012-2/2020). Declines were observed in Y1 compared to 2019 in all diagnoses and treatments: STEMI (-16.3%; 95% CI: -16.6, -16.1), non-STEMI (-16.4%; -16.6, -16.2), AF (-14.1%; -14.2, -14.0), CHF (-7.8%; -7.9, -7.7), CVA (-5.0%; -5.0, -4.9), catheterization (-64.7%; -65.2, -64.2), CABG (-77.7%; -79.2, -76.2), ablation (-21.2%; -22.0, -20.4), pacemaker implantation (-39.3%; -40.7, -37.9), and defibrillator insertion (-12.5%; -13.1, -12.0). Compared with expected rates based on pre-pandemic trends, observed rates were within expected ranges (CHF, CVA, and ablation), less than expected (STEMI, non-STEMI, AF, catheterization, CABG, and pacemaker insertion), or more than expected (defibrillator insertion). In Y2, STEMI, catheterization, and CABG returned to expected rates; non-STEMI and AF were lower than expected; and CHF, CVA, ablation, and pacemaker and defibrillator implantations were higher than expected. Several cardiovascular diagnoses and treatment trends were interrupted by COVID-19. The long-term consequences of these changes should be considered by health policymakers.

Predicted clinical and economic burden associated with reduction in access to acute coronary interventional care during the COVID-19 lockdown in two European countries

AIMS

As a consequence of untimely or missed revascularization of ST-elevation myocardial infarction (STEMI) patients during the COVID-19 pandemic, many patients died at home or survived with serious sequelae, resulting in potential long-term worse prognosis and related health-economic implications.This analysis sought to predict long-term health outcomes [survival and quality-adjusted life-years (QALYs)] and cost of reduced treatment of STEMIs occurring during the first COVID-19 lockdown.

METHODS AND RESULTS

Using a Markov decision-analytic model, we incorporated probability of hospitalization, timeliness of PCI, and projected long-term survival and cost (including societal costs) of mortality and morbidity, for STEMI occurring during the first UK and Spanish lockdowns, comparing them with expected pre-lockdown outcomes for an equivalent patient group.STEMI patients during the first UK lockdown were predicted to lose an average of 1.55 life-years and 1.17 QALYs compared with patients presenting with a STEMI pre-pandemic. Based on an annual STEMI incidence of 49 332 cases, the total additional lifetime costs calculated at the population level were £36.6 million (€41.3 million), mainly driven by costs of work absenteeism. Similarly in Spain, STEMI patients during the lockdown were expected to survive 2.03 years less than pre-pandemic patients, with a corresponding reduction in projected QALYs (-1.63). At the population level, reduced PCI access would lead to additional costs of €88.6 million.

CONCLUSION

The effect of a 1-month lockdown on STEMI treatment led to a reduction in survival and QALYs compared to the pre-pandemic era. Moreover, in working-age patients, untimely revascularization led to adverse prognosis, affecting societal productivity and therefore considerably increasing societal costs.

Nationwide time trends in patients hospitalized for acute coronary syndrome: a worrying generational and social effect among women

AIMS

To estimate the time trends in the annual incidence of patients hospitalized for acute coronary syndrome (ACS) in France from 2009 to 2021 and to analyse the current sex and social differences in ACS, management, and prognosis.

METHODS AND RESULTS

All patients hospitalized for ACS in France were selected from the comprehensive National Health Insurance database. Age-standardized rates were computed overall and according to age group (over or under 65 years), sex, proxy of socioeconomic status, and ACS subtype [ST-segment elevation (STSE) and non-ST-segment elevation]. Patient characteristics and outcomes were described for patients hospitalized in 2019. Differences in management (coronarography, revascularization), and prognosis were analysed by sex, adjusting for cofonders. In 2019, 143,670 patients were hospitalized for ACS, including 53,227 STSE-ACS (mean age = 68.8 years; 32% women). Higher standardized incidence rates among the most socially deprived people were observed. Women were less likely to receive coronarography and revascularization but had a higher excess in-hospital mortality. In 2019, the age-standardized rate for hospitalized ACS patients reached 210 per 100 000 person-year. Between 2009 and 2019, these rates decreased by 11.4% (men: -11.2%; women: -14.0%). Differences in trends of age-standardized incidence rate have been observed according to sex, age, and social status. Middle aged women (45-64 years) showing more unfavourable trends than in other age classes or in men. In addition, among women the temporal trends were more unfavourable as social deprivation increased.

CONCLUSION

Despite encouraging overall trends in patients hospitalized for ACS rates, the increasing trends observed among middle-aged women, especially socially deprived women, is worrying. Targeted cardiovascular prevention and close surveillance of this population should be encouraged.

Novel Cardiovascular and Pulmonary Findings in the Noninvasive Ischemic Assessment of Patients With Coronavirus 2019 (COVID-19)

In the past several years, the coronavirus pandemic has introduced multiple medical disciplines to various new forms of disease previously unknown and has shown us a unique presentation of already existing diseases. We continue to understand the long-term effects of the pandemic on the population's health and continue to find new unique features previously unknown. This paper presents the unique feature of lung uptake abnormalities discovered on nuclear stress testing for cardiac perfusion defects, a consistent finding in multiple individuals with recent COVID-19 or ongoing infection.

The effect of COVID-19 and COVID-19 vaccination on serum anti-Mullerian hormone: A systematic review and meta-analysis

OBJECTIVE

The current study aims to evaluate the impact of COVID-19 infection and vaccination on ovarian reserve by detecting the anti-Mullerian hormone (AMH) level.

METHOD

PubMed, Embase, Web of Science, and Scopus has been searched for studies assessing the effect of COVID-19 infection and/or vaccination on AMH levels up to February 27, 2023. Based on PRISMA 2020 statement criteria, a systematic review and meta-analysis of included studies were performed. The studies' quality was assessed by the National Institute of Health (NIH) quality assessment tool. The standardized mean difference (MD) of the AMH level was used and the quantitative values of each study were pooled separately by using a random effect model.

RESULTS

Out of 246 studies screened, 18 were included in the systematic review and 14 in the meta-analysis. Included studies were published between 2021 and 2022 and were conducted in different countries, including the USA (n = 3), China (n = 2), Russia (n = 2), Turkey (n = 5), Israel (n = 3), Czech (n = 2), and Spain (n = 1). Eight studies investigated the effect of SARS-CoV-2 infection on AMH levels, and ten studies investigated the possible effect of COVID-19 vaccination on AMH levels. The pooled analysis showed a statistically significant decrease in AMH levels after COVID-19 infection (SMD: -0.24; 95% CI: -0.36 to -0.11; I2 = 0%; p = .0003). Vaccination analysis showed a nonstatistically significant change in AMH levels after COVID-19 vaccination (SMD: -0.11; 95% CI: -0.25 to 0.04; I2 = 35%; p = .14).

CONCLUSION

COVID-19 infection can result in ovarian reserve injury by reducing the AMH level but getting vaccinated against COVID-19 has no impact on the AMH level.

Impact of the COVID-19 Pandemic on the Long-Term Prognosis of Acute Myocardial Infarction in Japan

Background During the early phase of the coronavirus disease 2019 (COVID-19) pandemic, a global reduction in hospitalizations for acute myocardial infarction (AMI) was observed. Generally, patients experienced increased severity of AMI with delays in time from symptom onset to treatment during the pandemic. However, the impact of the COVID-19 pandemic on in-hospital mortality among patients with AMI remains unclear. This study aimed to compare the long-term prognosis of patients with AMI during the COVID-19 pandemic to that observed in the pre-pandemic period and to evaluate the influence of the COVID-19 pandemic on the prognosis of patients with AMI. Methods We reviewed the data of patients admitted to our hospital for AMI treatment between April 1, 2018, and March 31, 2021. The time from admission to major adverse cardiac events (MACE), as well as the time from admission to all-cause death, were examined between the pandemic period (April 1, 2020, to March 31, 2021) and the pre-pandemic period (April 1, 2018, to March 31, 2020). Results Eighty patients were included in the study, and those admitted during the pandemic exhibited a higher likelihood of advanced age, lower levels of LDL-cholesterol, and a reduced prevalence of hypertension. The 2.5-year MACE-free survival and overall survival rates between the patients during the pre-pandemic and pandemic periods were not significantly different. Conclusion The long-term prognosis of patients with AMI during the COVID-19 pandemic remains unclear. In this study, we reported that the 2.5-year MACE-free survival and overall survival rates of the patients with AMI admitted during the COVID-19 pandemic were not significantly different from those during the pre-pandemic period. The impact of the COVID-19 pandemic on the prognosis of patients with AMI appears to vary according to the study population.

COVID-19, deaths at home and end-of-life cancer care

During the COVID-19 pandemic there was a period of high excess deaths from cancer at home as opposed to in hospitals or in care homes. In this paper we aim to explore whether healthcare utilisation trajectories of cancer patients in the final months of life during the COVID-19 pandemic reveal any potential unmet healthcare need. We use English hospital records linked to data on all deaths in and out of hospital which identifies the cause and location of death. Our analysis shows that during the periods of peak COVID-19 caseload, patients dying of cancer experienced up to 42% less hospital treatment in their final month of life compared to historical controls. We find reductions in end-of-life hospital care for cancer patients dying in hospitals, care homes/hospices and at home, however the effect is amplified by the shift to more patients dying at home. Through the first year of the pandemic in England, we estimate the number of inpatient bed-days for end-of-life cancer patients in their final month reduced by approximately 282,282, or 25%. For outpatient appointments in the final month of life we find a reduction in face-to-face appointments and an increase in remote appointments which persists through the pandemic year and is not confined only to the periods of peak COVID-19 caseload. Our results suggest reductions in care provision during the COVID-19 pandemic may have led to unmet need, and future emergency reorganisations of health care systems must ensure consistent care provision for vulnerable groups such as cancer patients.

Economic burden of cardiovascular diseases in the European Union: a population-based cost study

BACKGROUND AND AIMS

Cardiovascular disease (CVD) impacts significantly health and social care systems as well as society through premature mortality and disability, with patients requiring care from relatives. Previous pan-European estimates of the economic burden of CVD are now outdated. This study aims to provide novel, up-to-date evidence on the economic burden across the 27 European Union (EU) countries in 2021.

METHODS

Aggregate country-specific resource use data on morbidity, mortality, and health, social and informal care were obtained from international sources, such as the Statistical Office of the European Communities, enhanced by data from the European Society of Cardiology Atlas programme and patient-level data from the Survey of Health, Ageing and Retirement in Europe. Country-specific unit costs were used, with cost estimates reported on a per capita basis, after adjustment for price differentials.

RESULTS

CVD is estimated to cost the EU €282 billion annually, with health and long-term care accounting for €155 billion (55%), equalling 11% of EU-health expenditure. Productivity losses accounted for 17% (€48 billion), whereas informal care costs were €79 billion (28%). CVD represented a cost of €630 per person, ranging from €381 in Cyprus to €903 in Germany. Coronary heart disease accounted for 27% (€77 billion) and cerebrovascular diseases for 27% (€76 billion) of CVD costs.

CONCLUSIONS

This study provides contemporary estimates of the wide-ranging impact of CVD on all aspects of the economy. The data help inform evidence-based policies to reduce the impact of CVD, promoting care access and better health outcomes and economic sustainability.

Epidemiological, clinical, and economic burden of myocardial infarction patients in Iran during the COVID-19 pandemic

Background

To define changes in AMI case rates, patient demographics, cardiovascular comorbidities, treatment approaches, in-hospital outcomes, and the economic burden of COVID-19 during the pandemic.

Methods

We conducted a multicenter, observational survey with selected hospitals from three medical universities in Tehran city. A data collection tool consisting of three parts. The first part included socio-demographic information, and the second part included clinical information, major complications, and in-hospital mortality. Finally, the third part was related to the direct medical costs generated by AMI in COVID-19 and non-COVID-19 patients. The study cohort comprised 4,560 hospitalizations for AMI (2,935 for STEMI [64%] and 1,625 for NSTEMI [36%]).

Results

Of those hospitalized for AMI, 1,864 (76.6 %) and 1,659 (78 %) were male before the COVID-19 outbreak and during the COVID-19 era, respectively. The length of stay (LOS), was significantly lower during the COVID-19 pandemic era (4.27 ± 3.63 vs 5.24 ± 5.17, p = 0.00). Results showed that there were no significant differences in terms of patient risk factors across periods. A total of 2,126 AMIs were registered during the COVID-19 era, with a 12.65 % reduction (95 % CI 1.5-25.1) compared with the equivalent time in 2019 (P = 0.179). The risk of in-hospital mortality rate for AMI patients increased from 4.9 % in 2019 to 7.0 % in the COVID-19 era (OR = 1.42; 95 % CI 1.11-1.82; P = 0.004). Major complications were registered in 9.7 % of cases in 2020, which is higher than the rate of 6.6 % reported in 2019 (OR = 1.46, 95 % CI 1.11-1.82; P = 0.000). Total costs in hospitalized AMI-COVID patients averaged $188 more than in AMI patients (P = 0.020).

Conclusion

This cross-sectional study found important changes in AMI hospitalization rates, worse outcomes, and higher costs during the COVID-19 periods. Future studies are recommended to examine the long-term outcomes of hospitalized AMI patients during the COVID-19 era.

The impact of the COVID-19 pandemic on delayed care of cardiovascular diseases in Europe: a systematic review

AIMS

Cardiovascular diseases (CVD) are the leading cause of death worldwide. The coronavirus disease 2019 (COVID-19) pandemic has disrupted healthcare systems, causing delays in essential medical services, and potentially impacting CVD treatment. This study aims to estimate the impact of the pandemic on delayed CVD care in Europe by providing a systematic overview of the available evidence.

METHODS AND RESULTS

PubMed, Embase, and Web of Science were searched until mid-September 2022 for studies focused on the impact of delayed CVD care due to the pandemic in Europe among adult patients. Outcomes were changes in hospital admissions, mortality rates, delays in seeking medical help after symptom onset, delays in treatment initiation, and change in the number of treatment procedures. We included 132 studies, of which all were observational retrospective. Results were presented in five disease groups: ischaemic heart diseases (IHD), cerebrovascular accidents (CVA), cardiac arrests (CA), heart failures (HF), and others, including broader CVD groups. There were significant decreases in hospital admissions for IHD, CVA, HF and urgent and elective cardiac procedures, and significant increases for CA. Mortality rates were higher for IHD and CVA.

CONCLUSION

The pandemic led to reduced acute CVD hospital admissions and increased mortality rates. Delays in seeking medical help were observed, while urgent and elective cardiac procedures decreased. Adequate resource allocation, clear guidelines on how to handle care during health crises, reduced delays, and healthy lifestyle promotion should be implemented. The long-term impact of pandemics on delayed CVD care, and the health-economic impact of COVID-19 should be further evaluated.

Impact of the COVID-19 pandemic on acute coronary syndrome hospital admission and management in Slovenia

AIMS

We evaluated the effects of the COVID-19 pandemic on hospital admission and quality of care for acute coronary syndrome.

METHODS AND RESULTS

Data for all patients admitted to hospital care for acute coronary syndromes in Slovenia (nationwide cohort) between 2014 and 2021 were obtained by merging the national hospital database, national medicines reimbursement database and population mortality registry using unique identifying numbers. Using interrupted time series analysis, we assessed the impact of the COVID-19 pandemic on hospital admission rates and quality of care (in-hospital and 30-day mortality, reperfusion and secondary preventive medication uptake). Data were fitted to segmented regression models with March 2020 as the breakpoint. Data on 21 001 patients were included (7057 ST-elevation myocardial infarction (STEMI), 7649 non-ST elevation myocardial infarction (NSTEMI) and 6295 unstable angina). Hospital admissions for STEMI remained stable (92 patients; +1 patient per month, p=0.783), whereas the pandemic was associated with a significant reduction in NSTEMI (81 patients; -21 patients per month, p=0.015) and unstable angina admissions (47 patients; -28 patients per month, p=0.025). In patients with STEMI, the pandemic did not affect reperfusion rates (0.29%, (95% CI) -1.5% to 2.1%, p=0.755) or in-hospital mortality (0.1%, (95% CI) -0.9% to 1.1%, p=0.815), but was associated with a significant negative trend for secondary preventive medication uptake (-0.12%, (95% CI) -0.23% to -0.01%, p=0.034).

CONCLUSION

In Slovenia, hospital admissions for STEMI remained stable throughout the COVID-19 pandemic, but NSTEMI and unstable angina admissions dropped significantly. While mortality and reperfusion rates were not affected, the pandemic was associated with a continual negative time trend for the uptake of secondary preventive medication.

Cardiorenal multimorbidity in hospitalized cardiology patients: The Hellenic Cardiorenal Morbidity Snapshot (HECMOS) study

PURPOSE

Cardiovascular disease is commonly accompanied by renal dysfunction. Multimorbidity in hospitalized patients impacts unfavorably on prognosis and hospital stay. We aimed to illustrate the contemporary burden of cardiorenal morbidity across inpatient cardiology care in Greece.

METHODS

The Hellenic Cardiorenal Morbidity Snapshot (HECMOS) used an electronic platform to collect demographic and clinically relevant information about all patients hospitalized on March 3, 2022, in Greece. The participating institutions covered all levels of inpatient cardiology care and most of the country's territories to collect a real-world, nation representative sample.

RESULTS

A total of 923 patients (men 68.4%, median age 73 ± 14.8 years) were admitted to 55 different cardiology departments. 57.7% of the participants were aged >70 years. Hypertension was highly prevalent and present in 66% of the cases. History of chronic HF, diabetes mellitus, atrial fibrillation, and chronic kidney disease was present in 38%, 31.8%, 30%, and 26%, respectively. Furthermore, 64.1% of the sample exhibited at least one of these 4 entities. Accordingly, a combination of ≥2 of these morbid conditions was recorded in 38.7%, of ≥3 in 18.2%, whereas 4.3% of the sample combined all 4 in their medical history. The most common combination was the coexistence of heart failure-atrial fibrillation accounting for 20.6% of the sample. Nine of 10 nonelectively admitted patients were hospitalized due to acute HF (39.9%), acute coronary syndrome (33.5%), or tachyarrhythmias (13.2%).

CONCLUSION

HECMOS participants carried a remarkable burden of cardio-reno-metabolic disease. HF in conjunction with atrial fibrillation was found to be the most prevalent combination among the studied cardiorenal nexus of morbidities in the whole study population.

Optical Coherence Tomography-Guided versus Angiography-Guided PCI

BACKGROUND

Data regarding clinical outcomes after optical coherence tomography (OCT)-guided percutaneous coronary intervention (PCI) as compared with angiography-guided PCI are limited.

METHODS

In this prospective, randomized, single-blind trial, we randomly assigned patients with medication-treated diabetes or complex coronary-artery lesions to undergo OCT-guided PCI or angiography-guided PCI. A final blinded OCT procedure was performed in patients in the angiography group. The two primary efficacy end points were the minimum stent area after PCI as assessed with OCT and target-vessel failure at 2 years, defined as a composite of death from cardiac causes, target-vessel myocardial infarction, or ischemia-driven target-vessel revascularization. Safety was also assessed.

RESULTS

The trial was conducted at 80 sites in 18 countries. A total of 2487 patients underwent randomization: 1233 patients were assigned to undergo OCT-guided PCI, and 1254 to undergo angiography-guided PCI. The minimum stent area after PCI was 5.72±2.04 mm2 in the OCT group and 5.36±1.87 mm2 in the angiography group (mean difference, 0.36 mm2; 95% confidence interval [CI], 0.21 to 0.51; P<0.001). Target-vessel failure within 2 years occurred in 88 patients in the OCT group and in 99 patients in the angiography group (Kaplan-Meier estimates, 7.4% and 8.2%, respectively; hazard ratio, 0.90; 95% CI, 0.67 to 1.19; P = 0.45). OCT-related adverse events occurred in 1 patient in the OCT group and in 2 patients in the angiography group. Stent thrombosis within 2 years occurred in 6 patients (0.5%) in the OCT group and in 17 patients (1.4%) in the angiography group.

CONCLUSIONS

Among patients undergoing PCI, OCT guidance resulted in a larger minimum stent area than angiography guidance, but there was no apparent between-group difference in the percentage of patients with target-vessel failure at 2 years. (Funded by Abbott; ILUMIEN IV: OPTIMAL PCI ClinicalTrials.gov number, NCT03507777.).

Acute SARS-CoV-2 Infection and Incidence and Outcomes of Out-of-Hospital Cardiac Arrest

Importance

Little is known about how COVID-19 affects the incidence or outcomes of out-of-hospital cardiac arrest (OHCA), and it is possible that more generalized factors beyond SARS-CoV-2 infection are primarily responsible for changes in OHCA incidence and outcome.

Objective

To assess whether COVID-19 is associated with OHCA incidence and outcomes.

Design, Setting, and Participants

This retrospective cohort study was conducted in Seattle and King County, Washington. Participants included persons aged 18 years or older with nontraumatic OHCA attended by emergency medical services (EMS) between January 1, 2018, and December 31, 2021. Data analysis was performed from November 2022 to March 2023.

Exposures

Prepandemic (2018-2019) and pandemic (2020-2021) periods and SARS-CoV-2 infection.

Main Outcomes and Measures

The primary outcomes were OHCA incidence and patient outcomes (ie, survival to hospital discharge). Mediation analysis was used to determine the percentage change in OHCA incidence and outcomes between prepandemic and pandemic periods that was attributable to acute SARS-CoV-2 infection vs conventional Utstein elements related to OHCA circumstances (ie, witness status and OHCA location) and resuscitation care (ie, bystander cardiopulmonary resuscitation, early defibrillation, and EMS response intervals).

Results

There were a total of 13 081 patients with OHCA (7102 dead upon EMS arrival and 5979 EMS treated). Among EMS-treated patients, the median (IQR) age was 64.0 (51.0-75.0) years, 3864 (64.6%) were male, and 1027 (17.2%) survived to hospital discharge. The total number of patients with OHCA increased by 19.0% (from 5963 in the prepandemic period to 7118 in the pandemic period), corresponding to an incidence increase from 168.8 to 195.3 events per 100 000 person-years. Of EMS-treated patients with OHCA during the pandemic period, 194 (6.2%) were acutely infected with SARS-CoV-2 compared with 7 of 191 EMS-attended but untreated patients with OHCA (3.7%). In time-series correlation analysis, there was a positive correlation between community SARS-CoV-2 incidence and overall OHCA incidence (r = 0.27; P = .01), as well as OHCA incidence with acute SARS-CoV-2 infection (r = 0.43; P < .001). The survival rate during the pandemic period was lower than that in the prepandemic period (483 patients [15.4%] vs 544 patients [19.2%]). During the pandemic, those with OHCA and acute SARS-CoV-2 infection had lower likelihood of survival compared with those without acute infection (12 patients [6.2%] vs 471 patients [16.0%]). SARS-CoV-2 infection itself accounted for 18.5% of the pandemic survival decline, whereas Utstein elements mediated 68.2% of the survival decline.

Conclusions and Relevance

In this cohort study of COVID-19 and OHCA, a substantial proportion of the higher OHCA incidence and lower survival during the pandemic was not directly due to SARS-CoV-2 infection but indirect factors that challenged OHCA prevention and treatment.

Predictive value of ASCVD risk score for mortality and major adverse cardiovascular events in the year following a COVID-19 infection among US Veterans

BACKGROUND

Morbidity and mortality following COVID-19 infection may be influenced by baseline atherosclerotic cardiovascular disease (ASCVD) risk, yet limited data are available to identify those at highest risk. We examined the association between baseline ASCVD risk with mortality and major adverse cardiovascular events (MACE) in the year following COVID-19 infection.

METHODS

We evaluated a nationwide retrospective cohort of US Veterans free of ASCVD who were tested for COVID-19. The primary outcome was absolute risk of all-cause mortality in the year following a COVID-19 test among those hospitalized vs. not stratified by baseline VA-ASCVD risk scores. Secondarily, risk of MACE was examined.

RESULTS

There were 393,683 Veterans tested for COVID-19 and 72,840 tested positive. Mean age was 57 years, 86% were male, and 68% were white. Within 30 days following infection, hospitalized Veterans with VA-ASCVD scores >20% had an absolute risk of death of 24.6% vs. 9.7% (P ≤0.0001) for those who tested positive and negative for COVID-19 respectively. In the year following infection, risk of mortality attenuated with no difference in risk after 60 days. The absolute risk of MACE was similar for Veterans who tested positive or negative for COVID-19.

CONCLUSIONS

Veterans without clinical ASCVD experienced an increased absolute risk of death within 30 days of a COVID-19 infection compared to Veterans with the same VA-ASCVD risk score who tested negative, but this risk attenuated after 60 days. Whether cardiovascular preventive medications can lower the risk of mortality and MACE in the acute period following COVID-19 infection should be evaluated.

Bio-ethical issues in oncology during the first wave of the COVID-19 epidemic: A qualitative study in a French hospital

BACKGROUND

Using a specific bioethical theory (=global bioethics) and method (=a posteriori), we try here to identify and evaluate the bio-ethical issues raised by the COVID-19 pandemic, and possible solutions, to improve the management of cancer patients at the hospital in future pandemics, before the emergence of vaccines or scientifically validated treatments.

MATERIALS & METHODS

Our work is based primarily on the clinical experience of three oncologists from the oncology department of Foch Hospital in France, who were on the frontline during the first wave of the epidemic. We compared their perceptions with published findings, to complete or nuance their views.

RESULTS

Three bio-ethical issues were identified, and possible solutions to these problems were evaluated: (1) scientific evidence versus lack of time → the creation of emergency multidisciplinary team meetings (MTM); (2) healthcare equality versus lack of resources → the development of telemedicine; (3) individual liberties versus risk of contamination → role of cancer patients' associations, psychologists and bioethicists.

CONCLUSION

We consider the creation of an emergency MTM, in particular, in addition to a true ethics committee with real competence in bioethics, to be a first solution that would be easy to implement in hospitals in many countries.

The impact of the COVID-19 pandemic on presentations of self-harm over an 18-month period to a tertiary hospital

OBJECTIVES

To examine and compare rates and methods of self-harm presenting to a tertiary referral hospital during an 18-month period since the onset of the COVID-19 pandemic with a similar period immediately prior to the pandemic onset.

METHODS

Data from an anonymized database compared rates of self-harm presentations and methods employed between 1st March 2020 and 31st August 2021 to a similar time-frame prior to the onset of the COVID-19 pandemic.

RESULTS

A 9.1% increase in presentations with self-harm was noted since the onset of the COVID-19 pandemic. Periods of more stringent restrictions were associated with higher levels of self-harm (daily rate of 2.10 v 0.77). A higher lethality of attempt was demonstrated post-COVID-19 onset (χ2 = 15.38, p < 0.001). Fewer individuals presenting with self-harm were diagnosed with an adjustment disorder since the onset of the COVID-19 pandemic (n = 84, 11.1%, v. n = 112, 16.2%, χ2 = 7.898, p = 0.005), with no other differences pertaining to psychiatric diagnosis noted. More patients actively engaged with mental health services (MHS) presented with self-harm (n = 239 (31.7%) v. n = 137, (19.8%), χ2 = 40.798, p ≤ 0.001) since the onset of the COVID-19 pandemic.

CONCLUSIONS

Despite an initial reduction, an increase in rates of self-harm has occurred since the onset of the COVID-19 pandemic with higher rates evident during periods of higher government mandated restrictions. An increase in active patients of MHS presenting with self-harm potentially relates to reduced availability of supports and particularly group activities. The recommencement of group therapeutic interventions for individuals attending MHS in particular is warranted.

Indirect Effects of the COVID-19 Pandemic on In-Hospital Outcomes among Internal Medicine Departments: A Double-Center Retrospective Study

The coronavirus disease 19 (COVID-19) emergency led to rearrangements of healthcare systems with a significant impact on those internal medicine departments that had not been converted to COVID-19 wards. A reduced number of departments, indeed, had to cope with the same number of patients along with a lack of management of patients' chronic diseases. We conducted a retrospective study aimed at examiningthe consequences of the COVID-19 pandemic on internal medicine departments that were not directly managing COVID-19 patients. Data from 619 patients were collected: 247 subjects hospitalized in 2019 (pre-COVID-19 era), 178 in 2020 (COVID-19 outbreak era) and 194 in 2021 (COVID-19 ongoing era). We found that in 2020 in-hospital mortality was significantly higher than in 2019 (17.4% vs. 5.3%, p = 0.009) as well as length of in-hospital stay (LOS) (12.7 ± 6.8 vs. 11 ± 6.2, p = 0.04). Finally, we performed a logistic regression analysis of the major determinants of mortality in the entire study population, which highlighted an association between mortality, being bedridden (β = 1.4, p = 0.004), respiratory failure (β = 1.5, p = 0.001), glomerular filtration rate (β = -0.16, p = 0.03) and hospitalization in the COVID-19 outbreak era (β = 1.6, p = 0.005). Our study highlights how the COVID-19 epidemic may have caused an increase in mortality and LOS even in patients not directly suffering from this infection.

Opioid Injection-Associated Bacterial Infections in England, 2002-2021: A Time Series Analysis of Seasonal Variation and the Impact of Coronavirus Disease 2019

BACKGROUND

Bacterial infections cause substantial pain and disability among people who inject drugs. We described time trends in hospital admissions for injecting-related infections in England.

METHODS

We analyzed hospital admissions in England between January 2002 and December 2021. We included patients with infections commonly caused by drug injection, including cutaneous abscesses, cellulitis, endocarditis, or osteomyelitis, and a diagnosis of opioid use disorder. We used Poisson regression to estimate seasonal variation and changes associated with coronavirus disease 2019 (COVID-19) response.

RESULTS

There were 92 303 hospital admissions for injection-associated infections between 2002 and 2021. Eighty-seven percent were skin, soft-tissue, or vascular infections; 72% of patients were male; and the median age increased from 31 years in 2002 to 42 years in 2021. The rate of admissions reduced from 13.97 per day (95% confidence interval [CI], 13.59-14.36) in 2003 to 8.94 (95% CI, 8.64-9.25) in 2011, then increased to 18.91 (95% CI, 18.46-19.36) in 2019. At the introduction of COVID-19 response in March 2020, the rate of injection-associated infections reduced by 35.3% (95% CI, 32.1-38.4). Injection-associated infections were also seasonal; the rate was 1.21 (95% CI, 1.18-1.24) times higher in July than in February.

CONCLUSIONS

This incidence of opioid injection-associated infections varies within years and reduced following COVID-19 response measures. This suggests that social and structural factors such as housing and the degree of social mixing may contribute to the risk of infection, supporting investment in improved social conditions for this population as a means to reduce the burden of injecting-related infections.

Changes in incidence of hospitalization for cardiovascular diseases during the COVID-19 pandemic in The Netherlands in 2020

This population-based cohort study aimed to describe changes in incidence of cardiovascular disease (CVD) hospital diagnoses during the COVID-19 pandemic in The Netherlands compared with the pre-pandemic period. We used Dutch nationwide statistics about hospitalizations to estimate incidence rate ratios (IRR) of hospital diagnoses of CVD during the first and second COVID-19 waves in The Netherlands in 2020 versus the same periods in 2019. Compared with 2019, the incidence rate of a hospital diagnosis of ischemic stroke (IRR 0.87; 95% CI 0.79-0.95), major bleeding (IRR 0.74; 95% CI 0.68-0.82), atrial fibrillation (IRR 0.73; 95% CI 0.65-0.82), myocardial infarction (IRR 0.78; 95% CI 0.72-0.84), and heart failure (IRR 0.74; 95% CI 0.65-0.85) declined during the first wave, but returned to pre-pandemic levels throughout 2020. However, the incidence rate of a hospital diagnosis of pulmonary embolism (PE) increased during both the first and second wave in 2020 compared with 2019 (IRR 1.30; 95% CI 1.15-1.48 and IRR 1.31; 95% CI 1.19-1.44, respectively). In conclusion, we observed substantial declines in incidences of CVD during the COVID-19 pandemic in The Netherlands in 2020, especially during the first wave, with an exception for an increase in incidence of PE. This study contributes to quantifying the collateral damage of the COVID-19 pandemic.

Impacts of COVID-19 Pandemic on Three IVF Clinics of Jakarta, Indonesia: A Retrospective Qualitative and Quantitative Study

BACKGROUND

Corona virus disease-19 (COVID-19) pandemic also led to a reduction or even the suspension of elective health services. These decisions affected in vitro fertilization (IVF) programs worldwide. Therefore, it is essential to map the readiness of IVF clinics in providing safety in this situation and in the future.

MATERIALS AND METHODS

This is a retrospective qualitative and quantitative research done in 2021 that involved three IVF clinics of Jakarta, Indonesia. Those three clinics were government-owned, private-owned, and educational and training center. The qualitative data of each clinic's readiness towards COVID-19 was obtained from interviews with the clinics staff. The quantitative data were collected from the clinics patients' number and demographic data from 2019-2021 as well as from COVID-19 databases. Both data sets were analysed descriptively and only for the quantitative analysis Stata version 16 was used.

RESULTS

There were changes in the domiciles and number of patients attending the three clinics. The ratio of patients from Jakarta increased while patients from outside Java Island decreased. There was a drop in annual patient numbers in 2020. However, from June 2020 to December 2021, the number of monthly IVF cycles increased significantly by 3.5 cycles per month (P=0.001). There was no association between IVF patients' attendance numbers and COVID-19 cases (P=0.785). One of the clinics had a negative pressure operating theatre, which made them more confident in treating patients with COVID-19 positive and made them even had higher IVF cycles started than the pre-pandemic period.

CONCLUSION

Those three clinics are prepared in facing COVID-19, as they complied with government regulations. As the COVID-19 pandemic progressed, the number of patients gradually returned to normal.

Barriers and shortcomings in access to cardiovascular management and prevention for familial hypercholesterolemia during the COVID-19 pandemic

Familial hypercholesterolemia (FH) is a hereditary condition caused by mutations in the lipid pathway. The goal in managing FH is to reduce circulating low-density lipoprotein cholesterol and, therefore, reduce the risk of developing atherosclerotic cardiovascular disease (ASCVD). Because FH patients were considered high risk groups due to an increased susceptible for contracting COVID-19 infection, we hypothesized whether the effects of the pandemic hindered access to cardiovascular care. In this review, we conducted a literature search in databases Pubmed/Medline and ScienceDirect. We included a comprehensive analysis of findings from articles in English related and summarized the effects of the pandemic on cardiovascular care through direct and indirect effects. During the COVID-19 pandemic, FH patients presented with worse outcomes and prognosis, especially those that have suffered from early ASCVD. This caused avoidance in seeking care due to fear of transmission. The pandemic severely impacted consultations with lipidologists and cardiologists, causing a decline in lipid profile evaluations. Low socioeconomic communities and ethnic minorities were hit the hardest with job displacements and lacked healthcare coverage respectively, leading to treatment nonadherence. Lock-down restrictions promoted sedentary lifestyles and intake of fatty meals, but it is unclear whether these factors attenuated cardiovascular risk in FH. To prevent early atherogenesis in FH patients, universal screening programs, telemedicine, and lifestyle interventions are important recommendations that could improve outcomes in FH patients. However, the need to research in depth on the disproportionate impact within different subgroups should be the forefront of FH research.

Impact of the COVID-19 pandemic on incidence and mortality of emergency cardiovascular diseases in Tokyo

BACKGROUND

The impact of the coronavirus disease 2019 (COVID-19) pandemic on the incidence and in-hospital mortality of emergency cardiovascular disease (CVD) has not been clarified in Japan.

METHODS

We compared the number of admissions and in-hospital mortality for emergency CVD during the pandemic (from January to December 2020) with those of pre-pandemic periods (from January 2018 to December 2019), using quarterly data from the Tokyo Cardiovascular Care Unit Network. The incidence rate in 2020 is compared with the average incidence rate observed in the same quarter of 2018 and 2019 and is presented as an incidence rate ratio (IRR) with 95 % confidence interval (CI).

RESULTS

The number of admissions for acute myocardial infarction during the pandemic was significantly lower than before the pandemic, with an IRR of 0.93 (95 % CI; 0.88-0.98). Similarly, the IRR for unstable angina was 0.78 (95 % CI; 0.72-0.83), for acute heart failure was 0.84 (95 % CI; 0.76-0.91), for acute aortic dissection was 0.88 (95 % CI; 0.78-0.98), and for ruptured aortic aneurysm was 0.75 (95 % CI; 0.62-0.88). In quarterly comparisons, the numbers of acute aortic diseases and emergency arrhythmia significantly decreased from July to September 2020, while those of other emergency CVDs significantly declined in the 2020 April-June period, which includes the first wave period in Japan. In-hospital mortality of emergency CVDs was unchanged from the pre-pandemic period, except for acute aortic dissection, which increased in odds ratio of 1.31 (95 % CI 1.10-1.57).

CONCLUSIONS

The COVID-19 pandemic significantly reduced the number of admissions for all emergency CVDs in all or part of the year. In-hospital mortality was unchanged from the pre-pandemic period, except for acute aortic dissection, which increased.

Patients' rights in physicians' practice during Covid-19 pandemic: a cross-sectional study in Romania

BACKGROUND

Although the Covid-19 epidemic challenged existing medical care norms and practices, it was no excuse for unlawful conduct. On the contrary, legal compliance proved essential in fighting the pandemic. Within the European legal framework for the pandemic, patients were still entitled to be treated equally, by a specialized physician, with the possibility of seeking a second medical opinion, in a confidential setting, following prior and informed consent. This study examines physicians' practices regarding patients' rights during the Covid-19 pandemic and the effects of age, experience, and specialty on physicians' behavior and preferences. Additionally, it explores the nexus of malpractice complaints, malpractice fear, and legal compliance.

METHODS

A cross-sectional study was conducted on a convenience sample of attending physicians and general practitioners to assess compliance with patients' rights regulations. Respondents were physicians practicing in private and public settings in Southwestern Romania from July 2021 to May 2022.

RESULTS

396 attending physicians and 109 general practitioners participated in the research. Attending physicians acknowledged patients' rights in 55.7% of statements, while general practitioners showed a slightly higher level of compliance at 59.9%. Emergency and Anesthesia and Intensive Care physicians showed the lowest compliance. There were no significant behavioral differences based on physicians' age, years in practice, work sector, or location. However, when faced with the question of prioritizing treatment for patients with similar medical conditions, 46.2% of attending physicians reported favoring the younger patients. This preference was common among physicians under 39. Additionally, over half of the attending physicians reported working outside their area of expertise due to staff shortages. Malpractice fear was high among physicians, although unrelated to patients' claims, legal compliance, or working outside the scope of practice. It resulted in pressure and behavioral changes.

CONCLUSION

Adherence to patients' rights was low during the Covid-19 pandemic. Physicians could benefit from educational and administrative support to ensure better legal compliance. Further research is needed to determine if this behavior persists beyond the pandemic context.

Impact of Coronavirus Disease 2019 on Hospital Admissions, Health Status, and Behavioral Changes of Patients with COPD

Introduction

Patients with chronic obstructive pulmonary disease (COPD) have an increased risk of acquiring severe coronavirus disease 2019 (COVID-19), which is why self-isolation was recommended. However, long periods of social isolation, accompanied by limited access to health care systems, might influence the outcome of patients with severe COPD negatively.

Methods

Data from COPD and pneumonia patients at Charité-Universitätsmedizin Berlin and the volume of endoscopic lung volume reduction (ELVR) surgeries from the German Lung Emphysema Registry (Lungenemphysem Register e.V.) were analyzed from pre-pandemic (2012 to 2019) to the pandemic period (2020 and 2021). In addition, 52 patients with COPD Global initiative for chronic Obstructive Lung Disease (GOLD) stage 4 status included in the lung emphysema registry received questionnaires during lockdowns from June 2020 to April 2021.

Results

Admissions and ventilation therapies administered to COPD patients significantly decreased during the COVID-19 pandemic. Likewise, there was a reduction in ELVR treatments and follow-ups registered in German emphysema centers. Mortality was slightly higher among patients hospitalized with COPD during the pandemic. Increasing proportions of COPD patients with GOLD stage 3 and GOLD stage 4 status reported behavioral changes and subjective feelings of increasing COPD symptoms the longer the lockdown lasted. However, COPD symptom questionnaires revealed stable COPD symptoms over the pandemic time period.

Summary

This study reveals reduced COPD admissions and elective treatment procedures of COPD patients during the pandemic, but a slight increase in mortality among patients hospitalized with COPD, irrespective of COVID-19. Correspondingly, patients with severe COPD reported subjective deterioration of their health status, probably caused by their very strict compliance with lockdown measures.

Identification of Low- versus High-Risk Acute Coronary Syndrome for a Selective ECG Monitoring Strategy

BACKGROUND

While admission of patients with acute coronary syndromes (ACS) in cardiology intensive care unit (CICU) is usual, in-hospital major outcomes in lower risk patients may be evaluated after early coronary angiography according to the European guidelines.

METHODS

Consecutive ACS patients were prospectively included after coronary angiography evaluation within 24 h and percutaneous coronary intervention (PCI), when required. Patients were classified as high- or low-risk according to hemodynamics, rhythmic state, ischemic and bleeding risks. Major in-hospital outcomes were assessed.

RESULTS

From January to June 2021, 277 patients were enrolled (62.8% with ST-segment elevation myocardial infarction (STEMI) (n = 174); 37.2% with non-NSTEMI (NSTEMI) (n = 103). PCI was required for 260 patients (93.9%). Seventy-four patients (26.7%) were classified as low-risk (n = 47 NSTEMI; n= 27 STEMI) and 203 patients (73.3%) as high-risk of events. All patients were monitored in CICU. While 38 patients (18.7%) from the high-risk group reached the primary endpoint, mainly related to rhythmic or conduction disorder (n = 24, 11.8%) or unstable hemodynamics (n = 17; 8.4%), only 1 patient (1.3%) in the low-risk group had one major outcome (no fatal bleeding); p < 0.01. The negative predictive value of our patient stratification for the absence of major in-hospital outcome was 100% (CI95%: 100-100%) for STEMI and 97.9% [CI95%: 93.2-100%] for NSTEMI patients.

CONCLUSIONS

Stratification of ACS patients after early coronary angiography and most of the time PCI, identify a population with very low risk of in-hospital events (1/4 of all ACS and 1/2 of NSTEMI) who may probably not require ECG monitoring and/or CICU admission. (NCT04378504).

Healthcare utilisation in patients with long-term conditions during the COVID-19 pandemic: a population-based observational study of all patients across Greater Manchester, UK

OBJECTIVES

Data on population healthcare utilisation (HCU) across both primary and secondary care during the COVID-19 pandemic are lacking. We describe primary and secondary HCU stratified by long-term conditions (LTCs) and deprivation, during the first 19 months of COVID-19 pandemic across a large urban area in the UK.

DESIGN

A retrospective, observational study.

SETTING

All primary and secondary care organisations that contributed to the Greater Manchester Care Record throughout 30 December 2019 to 1 August 2021.

PARTICIPANTS

3 225 169 patients who were registered with or attended a National Health Service primary or secondary care service during the study period.

PRIMARY OUTCOMES

Primary care HCU (incident prescribing and recording of healthcare information) and secondary care HCU (planned and unplanned admissions) were assessed.

RESULTS

The first national lockdown was associated with reductions in all primary HCU measures, ranging from 24.7% (24.0% to 25.5%) for incident prescribing to 84.9% (84.2% to 85.5%) for cholesterol monitoring. Secondary HCU also dropped significantly for planned (47.4% (42.9% to 51.5%)) and unplanned admissions (35.3% (28.3% to 41.6%)). Only secondary care had significant reductions in HCU during the second national lockdown. Primary HCU measures had not recovered to prepandemic levels by the end of the study. The secondary admission rate ratio between multi-morbid patients and those without LTCs increased during the first lockdown by a factor of 2.40 (2.05 to 2.82; p<0.001) for planned admissions and 1.25 (1.07 to 1.47; p=0.006) for unplanned admissions. No significant changes in this ratio were observed in primary HCU.

CONCLUSION

Major changes in primary and secondary HCU were observed during the COVID-19 pandemic. Secondary HCU reduced more in those without LTCs and the ratio of utilisation between patients from the most and least deprived areas increased for the majority of HCU measures. Overall primary and secondary care HCU for some LTC groups had not returned to prepandemic levels by the end of the study.

Cardiovascular surgery during the first wave of COVID-19 pandemic

Background

In this study, we aimed to evaluate primary outcomes and main characteristics of emergency and elective/urgent cardiovascular surgeries which were performed in the first three months of the novel coronavirus disease 2019 (COVID-19) pandemic in our center.

Methods

Between March 11th, 2020 and June 11th, 2020, a total of 209 patients (44 males, 165 females; mean age: 57.3±12.8 years; range, 20 to 80 years) who underwent emergency or elective/urgent surgery with cardiovascular pathologies were retrospectively analyzed. The patients were classified as emergency and elective/urgent according to the level of necessity of the surgical procedure at the time of hospital admission. Pre-, intra-, and postoperative data of the patients were recorded.

Results

During the study period, 156 elective/urgent and 74 emergency cardiovascular surgeries were performed. Six COVID-19 (+) patients were operated emergently. The number of acute aortic dissection and peripheral vascular surgery was higher in the emergency group (p<0.05). Two patients who were COVID-19 (-) preoperatively became COVID-19 (+) in the postoperative period. In these patients, acute respiratory distress syndrome developed, and extracorporeal membrane oxygenation support was needed. Four patients who needed post-cardiotomy extracorporeal membrane oxygenation support due to low cardiac output were COVID-19 (-) both in the pre- and postoperative periods. The overall in-hospital mortality rate was 9.1%.

Conclusion

Even during pandemic such as COVID-19, referral centers with experienced personnel can provide non-pandemic healthcare with a quality close to the daily routine.

Impact of the COVID-19 Outbreak on the Treatment of Myocardial Infarction Patients

Purpose of review

The COVID-19 pandemic has led to an overburdened healthcare system. While an increased rate of ACS is expected due to the pro-thrombotic state of COVID patients, observed ACS incidence and admission rates were paradoxically decreased during the (first wave of the) pandemic. In this narrative review, we will discuss potential reasons for this decrease in ACS incidence. Furthermore, we will discuss ACS management during the COVID-19 pandemic, and we will discuss outcomes in ACS.

Recent findings

A reluctance to seek medical contact (in order not to further overburden the health system or due to fear of being infected with COVID-19 while in hospital) and unavailability of medical services seem to be important factors. This may have led to an increased symptom onset to first medical contact time and an increased rate of out-of-hospital cardiac arrests. A trend towards less invasive management was observed (less invasive coronary angiography in NSTEMI patients and more "fibrinolysis-first" in STEMI patients), although a large variation was observed with some centers having a relative increase in early invasive management. Patients with ACS and concomitant COVID-19 infection have worse outcomes compared to ACS patients without COVID-19 infection. All of the above led to worse clinical outcomes in patients presenting with ACS during the COVID-19 pandemic. Interestingly, staffing and hospital bed shortages led to experimentation with very early discharge (24 h after primary PCI) in low-risk STEMI patients which had a very good prognosis and resulted in significant shorter hospital duration.

Summary

During the COVID-19 pandemic, ACS incidence and admission rates were decreased, symptom onset to first medical contact time prolonged, and out-of-hospital rates increased. A trend towards less invasive management was observed. Patients presenting with ACS during the COVID-19 pandemic had a worse outcome. On the other hand, experimental very early discharge in low-risk patients may relieve the healthcare system. Such initiatives, and strategies to lower the reluctance of patients with ACS symptoms to seek medical help, are vital to improve prognosis in ACS patients in future pandemics.

Relationships between the COVID-19 lockdown, socioeconomic factors and acute coronary syndrome hospitalisations in France

INTRODUCTION

Worldwide, the COVID-19 pandemic has been associated with an overall drop in acute coronary syndrome (ACS) hospitalizations. Additionally, there is a well-known association between ACS and socioeconomic status. This study aims to assess the COVID-19 effect on ACS admissions in France during the first national lockdown and investigate the factors associated with its spatial heterogeneity.

MATERIALS AND METHODS

In this retrospective study, we used the French hospital discharge database (PMSI) to estimate ACS admission rates in all public and private hospitals in 2019 and 2020. A negative binomial regression explored the nationwide change in ACS admissions during lockdown compared with 2019. A multivariate analysis explored the factors associated with the ACS admission incidence rate ratio (IRR, 2020 incidence rate/2019 incidence rate) variation at the county level.

RESULTS

We found a significant but geographically heterogeneous nationwide reduction in ACS admissions during lockdown (IRR 0·70 [0·64-0·76]). After adjustment for cumulative COVID-19 admissions and the ageing index, a higher share of people on short-term working arrangements during lockdown at the county level was associated with a lower IRR, while a higher share of individuals with a high school degree and a higher density of acute care beds were associated with a higher ratio.

CONCLUSIONS

During the first national lockdown, there was an overall decrease in ACS admissions. Local provision of inpatient care and socioeconomic determinants linked to occupation were independently associated with the variation in hospitalizations.

Statistical findings and outcomes of acute coronary syndrome patients during COVID-19 pandemic: A cross sectional study

Introduction

Time to treatment of acute coronary syndrome (ACS) can be a matter of life or death considering its major contribution to cardiovascular mortality. The sudden outbreak of the Coronavirus Disease in 2019 (COVID-19) caused great uncertainty in achieving ACS time-frame goals. This study assesses ACS presentation time and outcomes before and during the COVID-19 pandemic.

Methods

A total of 1287 ACS patients were included in this cross-sectional study. We compared mortality and other outcomes during hospital admission. Before-COVID was deemed as admission between March 2018 and February 2020, while admission between March 2020 and February 2022 was deemed as during-COVID. The association of admission on outcomes was measured using regression statistics.

Results

There was a 51.2 % decline of total patients before-COVID (865 patients) to during-COVID (422 patients). While there is no difference in first medical contact (FMC) before [3 h (IQR 1-7)] compared to during the pandemic [3 h (IQR 2-9), p 0.058], we found a decrease in door to wire time < 12 h (43.41 % vs 18.98 %, p < 0.001). There was also a non-significant decrease in fibrinolysis (20.45 % vs 15.18 %, p 0.054) but an increase in those undergoing percutaneous coronary intervention (PCI) (58.36 % vs 77.04 %, p value < 0,001). We also found reduced mortality (12.52 % vs 9.69 %, p 0.151), heart failure (28.16 % vs 25.81 %, p 0.31), but more cardiogenic shock during the pandemic (9.19 % vs 13.33 %, p 0.028).

Conclusions

While the mortality seems statistically unaffected, we found less admission and prolonged door to wire time during-COVID pandemic.

Hospital admission and mortality rates for non-Covid diseases among residents of the long-term care facilities before and during the pandemic: a cohort study in two Italian regions

Aim

Long-term-care facility residents are a vulnerable population who experienced reduced healthcare access during the pandemic. This study aimed to assess the indirect impact of the COVID-19 pandemic, in terms of hospitalisation and mortality rates, among this population in two Italian Regions, Tuscany and Apulia, during 2020 in comparison with the pre-pandemic period.

Subject and methods

We conducted a retrospective cohort study on people residing in long-term-care facilities from 1 January 2018 to 31 December 2020 (baseline period: 1 January 2018-8 March 2020; pandemic period: and 9 March-31 December 2020). Hospitalisation rates were stratified by sex and major disease groups. Standardised weekly rates were estimated with a Poisson regression model. Only for Tuscany, mortality risk at 30 days after hospitalisation was calculated with the Kaplan-Meier estimator. Mortality risk ratios were calculated using Cox proportional regression models.

Results

Nineteen thousand two hundred and fifty individuals spent at least 7 days in a long-term-care facility during the study period. The overall mean non-Covid hospital admission rate per 100 000 residents/week was 144.1 and 116.2 during the baseline and pandemic periods, with a decrease to 99.7 and 77.3 during the first (March-May) and second lockdown (November-December). Hospitalisation rates decreased for all major disease groups. Thirty-day mortality risk ratios for non-Covid conditions increased during the pandemic period (1.2, 1.1 to 1.4) compared with baseline.

Conclusion

The pandemic resulted in worse non-COVID-related health outcomes for long-term-care facilities' residents. There is a need to prioritise these facilities in national pandemic preparedness plans and to ensure their full integration in national surveillance systems.

Supplementary information

The online version contains supplementary material available at 10.1007/s10389-023-01925-1.

Changes in the care of acute cerebrovascular and cardiovascular conditions during the first year of the covid-19 pandemic in 746 hospitals in the USA: retrospective analysis

Objective

To measure the impact of the covid-19 pandemic on admissions to hospital and interventions for acute ischemic stroke and acute myocardial infarction.

Design

A retrospective analysis.

Setting

746 qualifying hospitals in the USA from the Premier Healthcare Database.

Participants

Patients aged 18 years and older who were admitted to hospital with a primary diagnosis of acute ischemic stroke or acute myocardial infarction between 1 March 2019 and 28 February 2021.

Main outcome measures

Relative changes in volumes were assessed for acute ischemic stroke and acute myocardial infarction hospital admissions as well as intravenous thrombolysis, mechanical thrombectomy, and percutaneous coronary intervention (overall and for acute myocardial infarction only) across the first year of the pandemic versus the prior year. Mortality in hospital and length of stay in hospital were also compared across the first year of the pandemic versus the corresponding period the year prior. These metrics were explored across the different pandemic waves.

Results

Among 746 qualifying hospitals, admissions to hospital were significantly reduced after the covid-19 pandemic compared with before the pandemic for acute ischemic stroke (-13.59% (95% confidence interval-13.77% to -13.41%) and acute myocardial infarction (-17.20% (-17.39% to -17.01%)), as well as intravenous thrombolysis (-9.47% (-9.99% to -9.02%)), any percutaneous coronary intervention (-17.89% (-18.06% to -17.71%)), and percutaneous coronary intervention for acute myocardial infarction (-14.36% (-14.59% to -14.12%)). During the first year of the pandemic versus the previous year, the odds of mortality in hospital for acute ischemic stroke were 9.00% higher (3.51% v 3.16%; ratio of the means 1.09 (95% confidence interval (1.03 to 1.15); P=0.0013) and for acute myocardial infarction were 18.00% higher (4.81% v 4.29%; ratio of the means 1.18 (1.13 to 1.23); P<0.0001).

Conclusions

We observed substantial decreases in admissions to hospital with acute ischemic stroke and acute myocardial infarction, but an increase in mortality in hospital throughout the first year of the pandemic. Public health interventions are needed to prevent these reductions in future pandemics.