Out-of-hospital cardiac arrest during the COVID-19 pandemic in Paris, France: a population-based, observational study

Impact of the COVID-19 pandemic on pediatric out-of-hospital cardiac arrest outcomes in Japan

This study investigates the impact of the COVID-19 pandemic on pediatric out-of-hospital cardiac arrest (OHCA) outcomes in Japan, aiming to address a critical research gap. Analyzing data from the All-Japan Utstein registry covering pediatric OHCA cases from 2018 to 2021, the study observed no significant changes in one-month survival, neurological outcomes, or overall performance when comparing the pre-pandemic (2018-2019) and pandemic (2020-2021) periods among 6765 cases. However, a notable reduction in pre-hospital return of spontaneous circulation (ROSC) during the pandemic (15.1-13.1%, p = .020) was identified. Bystander-initiated chest compressions and rescue breaths declined (71.1-65.8%, 22.3-13.0%, respectively; both p < .001), while bystander-initiated automated external defibrillator (AED) use increased (3.7-4.9%, p = .029). Multivariate logistic regression analyses identified factors associated with reduced pre-hospital ROSC during the pandemic. Post-pandemic, there was no noticeable change in the one-month survival rate. The lack of significant change in survival may be attributed to the negative effects of reduced chest compressions and ventilation being offset by the positive impact of widespread AED availability in Japan. These findings underscore the importance of innovative tools and systems for safe bystander cardiopulmonary resuscitation during a pandemic, providing insights to optimize pediatric OHCA care.

Impact of Coronavirus Disease 2019 Pandemic on Cardiac Arrest and Emergency Care

The incidence of both out-of-hospital and in-hospital cardiac arrest increased during the coronavirus disease 2019 (COVID-19) pandemic. Patient survival and neurologic outcome after both out-of-hospital and in-hospital cardiac arrest were reduced. Direct effects of the COVID-19 illness combined with indirect effects of the pandemic on patient's behavior and health care systems contributed to these changes. Understanding the potential factors offers the opportunity to improve future response and save lives.

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.

Post-discharge all-cause mortality in COVID-19 recovered patients hospitalized in 2020: the impact of chronic kidney disease

In Brazil, the COVID-19 burden was substantial, and risk factors associated with higher in-hospital mortality rates have been extensively studied. However, information on short-term all-cause mortality and the factors associated with death in patients who survived the hospitalization period of acute SARS-CoV-2 infection is limited. We analyzed the six-month post-hospitalization mortality rate and possible risk factors of COVID-19 patients in a single center in Brazil. This is a retrospective cohort study focused on a six-month follow-up. The exclusion criteria were death during hospitalization, transference to another hospital, and age under 18. We collected data from the charts of all hospitalized patients from March 2020 to December 2020 with a positive RT-PCR test for SARS-CoV-2, resulting in a sample size of 106 patients. The main outcome was death after hospitalization, whereas comorbidities and demographics were evaluated as risk factors. The crude post-hospitalization death rate was 16%. The first 30 days of follow-up had the highest mortality rate. In a Cox regression model for post-hospitalization mortality, previous chronic kidney disease (HR, 4.06, 95%CI 1.46 - 11.30) and longer hospital stay (HR 1.01, 95%CI 1.00 - 1.02) were the only factors statistically associated with death. In conclusion, a high six-month all-cause mortality was observed. Within the six-month follow-up, a higher risk of death was observed for patients who had prior CKD and longer hospital stay. These findings highlight the importance of more intensive medical surveillance during this period.

Out-of-Hospital Cardiac Arrest Following the COVID-19 Pandemic

Importance

Out-of-hospital cardiac arrest (OHCA) health care provision may be a good indicator of the recovery of the health care system involved in OHCA care following the COVID-19 pandemic. There is a lack of data regarding outcomes capable of verifying this recovery.

Objective

To determine whether return to spontaneous circulation, overall survival, and survival with good neurological outcome increased in patients with OHCA since the COVID-19 pandemic was brought under control in 2022 compared with prepandemic and pandemic levels.

Design, Setting, and Participants

This observational cohort study was conducted to examine health care response and survival with good neurological outcome at hospital discharge in patients treated following OHCA. A 3-month period, including the first wave of the pandemic (February 1 to April 30, 2020), was compared with 2 periods before (April 1, 2017, to March 31, 2018) and after (January 1 to December 31, 2022) the pandemic. Data analysis was performed in July 2023. Emergency medical services (EMS) serving a population of more than 28 million inhabitants across 10 Spanish regions participated. Patients with OHCA were included if participating EMS initiated resuscitation or continued resuscitation initiated by a first responder.

Exposure

The pandemic was considered to be under control following the official declaration that infection with SARS-CoV-2 was to be considered another acute respiratory infection.

Main Outcome and Measures

The main outcomes were return of spontaneous circulation, overall survival, and survival at hospital discharge with good neurological outcome, expressed as unimpaired or minimally impaired cerebral performance.

Results

A total of 14 732 patients (mean [SD] age, 64.2 [17.2] years; 10 451 [71.2%] male) were included, with 6372 OHCAs occurring during the prepandemic period, 1409 OHCAs during the pandemic period, and 6951 OHCAs during the postpandemic period. There was a higher incidence of OHCAs with a resuscitation attempt in the postpandemic period compared with the pandemic period (rate ratio, 4.93; 95% CI, 4.66-5.22; P < .001), with lower incidence of futile resuscitation for OHCAs (2.1 per 100 000 person-years vs 1.3 per 100 000 person-years; rate ratio, 0.81; 95% CI, 0.71-0.92; P < .001). Recovery of spontaneous circulation at hospital admission increased from 20.5% in the pandemic period to 30.5% in the postpandemic period (relative risk [RR], 1.08; 95% CI, 1.06-1.10; P < .001). In the same way, overall survival at discharge increased from 7.6% to 11.2% (RR, 1.45; 95% CI, 1.21-1.75; P < .001), with 6.6% of patients being discharged with good neurological status (Cerebral Performance Category Scale categories 1-2) in the pandemic period compared with 9.6% of patients in the postpandemic period (RR, 1.07; 95% CI, 1.04-1.10; P < .001).

Conclusions and Relevance

In this cohort study, survival with good neurological outcome at hospital discharge following OHCA increased significantly after the COVID-19 pandemic.

OHCA in Bosnia and Herzegovina: Before and During the COVID-19 Pandemic

Background

Out-of-hospital cardiac arrest (OHCA) refers to the cessation of mechanical cardiac activity outside healthcare facilities which requires prompt intervention and intensive resuscitative efforts. The COVID-19 pandemic has caused significant disruptions to OHCA systems-of-care, adversely affecting every component of the chain of survival.

Objective

The objective of this study was to examine the potential impacts of the COVID-19 pandemic on OHCA events, to draw comparisons between the period before and during the COVID-19 pandemic.

Methods

This cross-sectional study encompassed data pertaining to all OHCA incidents attended to by the Emergency Medical Service of Canton Sarajevo, covering the period from January 2017 to December 2022, before and during the COVID-19 pandemic.

Results

During observed period, a total of 1418 [796 (56.1%) before and 622 (43.9%) during COVID-19 pandemic] OHCA events have occurred in Canton Sarajevo of which 297 (20.9 %) [180 (12.7%) before and 117 (8.2%) during COVID-19 pandemic] obtained ROSC. After a 30-day period following the ROSC) it was observed that the predominant outcome, accounting for 181 (12.7%) [106 (7.4%) before and 75 (5.2%) during COVID-19 pandemic] of cases, was a complete recovery. An examination before and during COVID-19 pandemic revealed a decline in OHCA during the year 2021 and 2022 when COVID-19 pandemic was at its highest in the country Being younger, quicker EMT response time and individuals with the initial rhythm of VF or VT were significantly associated with obtaining ROSC (p<0.05). Only 48 (3.3%) of 1418 OHCA events were assisted by bystanders There was no report of AED usage.

Conclusion

In conclusion, our investigation highlights the impact of the COVID-19 pandemic on OHCA events in Canton Sarajevo, revealing a decrease in OHCA incidence and a reduction in cases achieving ROSC. Notably, EMT response time was shorter during the pandemic.

The impact of COVID-19 pandemic on out-of-hospital cardiac arrest: An individual patient data meta-analysis

AIM

Prior studies have reported increased out-of-hospital cardiac arrests (OHCA) incidence and lower survival during the COVID-19 pandemic. We evaluated how the COVID-19 pandemic affected OHCA incidence, bystander CPR rate and patients' outcomes, accounting for regional COVID-19 incidence and OHCA characteristics.

METHODS

Individual patient data meta-analysis of studies which provided a comparison of OHCA incidence during the first pandemic wave (COVID-period) with a reference period of the previous year(s) (pre-COVID period). We computed COVID-19 incidence per 100,000 inhabitants in each of 97 regions per each week and divided it into its quartiles.

RESULTS

We considered a total of 49,882 patients in 10 studies. OHCA incidence increased significantly compared to previous years in regions where weekly COVID-19 incidence was in the fourth quartile (>136/100,000/week), and patients in these regions had a lower odds of bystander CPR (OR 0.49, 95%CI 0.29-0.81, p = 0.005). Overall, the COVID-period was associated with an increase in medical etiology (89.2% vs 87.5%, p < 0.001) and OHCAs at home (74.7% vs 67.4%, p < 0.001), and a decrease in shockable initial rhythm (16.5% vs 20.3%, p < 0.001). The COVID-period was independently associated with pre-hospital death (OR 1.73, 95%CI 1.55-1.93, p < 0.001) and negatively associated with survival to hospital admission (OR 0.68, 95%CI 0.64-0.72, p < 0.001) and survival to discharge (OR 0.50, 95%CI 0.46-0.54, p < 0.001).

CONCLUSIONS

During the first COVID-19 pandemic wave, there was higher OHCA incidence and lower bystander CPR rate in regions with a high-burden of COVID-19. COVID-19 was also associated with a change in patient characteristics and lower survival independently of COVID-19 incidence in the region where OHCA occurred.

Out-of-hospital cardiac arrest patients during the coronavirus disease 2019 pandemic

The coronavirus disease 2019 (COVID-19) pandemic had severe impact on the outcome of out-of-hospital cardiac arrest (OHCA) patients and the possibility of bystander cardiopulmonary resuscitation (CPR). Previous studies focused only on the short periods of the pandemic and reported a significant increase in the number of infections. In a retrospective cohort study we aimed to compare the outcomes of OHCA patients 1 year before and 1 year after the onset of COVID-19. Data of 519 OHCA patients during the pre-pandemic (January-December 2019; 262 patients) and intra-pandemic (April 2020-March 2021; 257 patients) periods in Yokohama Municipal Hospital, Japan were collected and analysed retrospectively. The study outcomes were the return of spontaneous circulation (ROSC), admission to hospital, survival to discharge, and cerebral performance category at discharge. The intra-pandemic period was associated with decreased bystander CPR (P = 0.004), prolonged transport time (P < 0.001), delayed first adrenaline administration (P < 0.001), and decrease in ROSC (P = 0.023). Logistic regression analysis revealed that the following factors were significantly associated with ROSC: "pandemic", "shockable initial waveform", and "witness presence".

Simultaneous Double-Vessel Coronary Thrombosis with Sudden Cardiac Arrest as the First Manifestation of COVID-19

The relationship between coronavirus disease 2019 (COVID-19) and myocardial injury was established at the onset of the COVID-19 pandemic. An increase in the incidence of out-of-hospital cardiac arrest was also observed. This case report aims to point to the prothrombotic and proinflammatory nature of coronavirus infection, leading to simultaneous coronary vessel thrombosis and subsequently to out-of-hospital cardiac arrest. During the COVID-19 pandemic, a 46-year-old male patient with no comorbidities suffered out-of-hospital cardiac arrest (OHCA) with ventricular fibrillation as the first recorded rhythm. The applied cardiopulmonary resuscitation (CPR) measures initiated by bystanders and continued by emergency medical service (EMS) resulted in the return of spontaneous circulation. The stabilized patient was transferred to the tertiary university center. Electrocardiogram (ECG) revealed "lambda-like" ST-segment elevation in DI and aVL leads, necessitating an immediate coronary angiography, which demonstrated simultaneous occlusion of the left anterior descending (LAD) and right coronary artery (RCA). Primary percutaneous coronary intervention (PCI) with the implantation of one drug-eluting stent (DES) in LAD and two DES in RCA was done. Due to the presence of cardiogenic shock (SCAI C), an intra-aortic balloon pump (IABP) was implanted during the procedure, and due to the comatose state and shockable cardiac arrest, targeted temperature management was initiated. The baseline chest X-ray revealed bilateral interstitial infiltrates, followed by increased proinflammatory markers and a positive polymerase chain reaction (PCR) test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) demasking underlying COVID-19-related pneumonia. Within the following 48 h, the patient was hemodynamically stable, which enabled weaning from IABP and vasopressor discontinuation. However, due to the worsening of COVID-19 pneumonia, prolonged mechanical ventilation, together with antibiotics and other supportive measures, was needed. The applied therapy resulted in clinical improvement, and the patient was extubated and finally discharged on Day 26, with no neurological sequelae and with mildly reduced left ventricle ejection fraction.

Lack of temporal correlations between COVID pandemic waves and the occurrence of malignant ventricular arrhythmias

AIMS

Correlations between malignant ventricular arrhythmias and the COVID waves have never been investigated.

METHODS AND RESULTS

Prevalence of malignant ventricular arrhythmias/sudden cardiac death has been correlated to the four COVID waves between the onset of pandemic and end 2021. No significant correlation was present in the temporal evolution of both COVID patients/positive tests and incidence of malignant ventricular arrhythmias, which tended to decrease after vaccination onset.

CONCLUSION

We present evidence of complex higher-order periodicities and the co-existence of such regions with stable non-chaotic areas in ex vivo human hearts. We infer that the oscillation of the calcium cycling machinery is the primary mechanism of higher-order dynamics. These higher-order regions may act as niduses of instability and may provide targets for substrate-based ablation of VF.

Updated trends in the outcomes of out-of-hospital cardiac arrest from 2017-2021: Prior to and during the coronavirus disease (COVID-19) pandemic

Objective

This study aims to describe out-of-hospital cardiac arrest (OHCA) characteristics and trends before and during the coronavirus disease-2019 (COVID-19) pandemic in Taiwan.

Methods

We conducted a retrospective cohort study using a 5-year interrupted time series analysis. Eligible adults with non-traumatic OHCAs from January 2017 to December 2021 in 3 hospitals (university medical center, urban second-tier hospital, and rural second-tier hospital) were retrospectively enrolled. Variables were extracted from the emergency medical service reports and medical records. The years 2020 and 2021 were defined as the COVID-19 pandemic period. Outcomes included survival to admission after a sustained return of spontaneous circulation, survival to hospital discharge, and good neurological outcomes (cerebral performance category score 1 or 2).

Results

We analyzed 2819 OHCA, including 1227 from a university medical center, 617 from an urban second-tier hospital, and 975 from a rural second-tier hospital. The mean age was 71 years old, and 60% of patients were males. During the COVID-19 pandemic period, video-assisted endotracheal tube intubation replaced the traditional direct laryngoscopy intubation. The trends of outcomes in the pre-pandemic and pandemic periods varied among different hospitals. Compared with the pre-pandemic period, the outcomes at the university medical center during the COVID-19 pandemic were significantly poorer in several respects. The survival rate on admission dropped from 44.6% to 39.4% (P = 0.037), and the survival rate to hospital discharge fell from 17.5% to 14.9% (P = 0.042). Additionally, there was a notable decrease in patients' good neurological outcomes, declining from 13.2% to 9.7% (P = 0.048). In contrast, the outcomes in urban and rural second-tier hospitals during the COVID-19 pandemic did not significantly differ from those in the pre-pandemic period.

Conclusions

COVID-19 may alter some resuscitation management in OHCAs. There were no overall significant differences in outcomes before and during COVID-19 pandemic, but there were significant differences in outcomes when stratified by hospital types.

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.

Ventricular arrhythmia burden in ICD patients during the second wave of the COVID-19 pandemic

AIM

COVID-19 has been associated with cardiovascular complications including ventricular arrhythmias (VA) and an increased number of out-of-hospital cardiac arrests. Nevertheless, several authors described a decrease of VA burden in patients with an implantable defibrillator (ICD) during the first wave of the COVID-19 pandemic. The objective of this study was to determine if these observations could be transferred to later periods of the pandemic as well.

METHODS

We retrospectively analyzed a total of 1674 patients with an ICD presenting in our outpatient clinic during the second wave of the COVID-19 pandemic and during a control period for the occurrence of VA requiring ICD interventions.

RESULTS

Seven hundred ninety-five patients with an ICD had a device interrogation in our ambulatory clinic during the second wave of the COVID-19 pandemic compared to eight hundred seventy-nine patients in the control period. There was significant higher amount of adequate ICD therapies in the course of the COVID-19 period. Thirty-six patients (4.5%) received in total eighty-five appropriate ICD interventions during COVID-19, whereas only sixteen patients (1.8%) had sustained VA in the control period (p = 0.01).

CONCLUSION

In contrast to the first wave of COVID-19, which was characterized by a decrease or least stable number of ICD therapies in several centers, we found a significant increase of VA in ICD patients during the second wave of COVID-19. Possible explanations for this observation include higher infectious rates, potential cardiac side effects of the vaccination as well as personal behavioral changes, or reduced utilization of medical services.

Association of atmospheric temperature with out-of-hospital natural deaths occurrence before and during the COVID-19 pandemic in Osaka, Japan

In this study, we aimed to investigate the relationship between out-of-hospital natural death (OHND) and ambient temperature and examine the seriousness of the impact of the coronavirus disease-2019 (COVID-19) pandemic on this relationship. We used data from the Osaka Prefectural Office of Medical Examiners between 2018 and 2022 and performed a retrospective observational study. A Poisson regression model was applied to examine the relationship between OHND and temperature in Osaka City. The relative risk of OHND at 5 °C and 32 °C compared to the minimum mortality temperature increased from 1.81 in the pre-COVID-19 period to 2.03 in the post-COVID-19 period at 5 °C and from 1.29 in the pre-COVID-19 period to 1.60 in the post-COVID-19 period at 32 °C. The increase in relative risk per 1 °C increase from the pre- to post-COVID-19 period was 1.0551 (rate ratio [RR], p = 0.003) in the hot environment and 1.0233 (RR, p = 0.013) in the cold environment, which was larger than that in the hot environment. Although the risk of OHND increased at both temperatures, the change in OHND risk during post-COVID-19 was larger in the hot environment than in the cold environment, implicating the effect of pandemics in the current scenario of global warming.

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.

The Lancet Commission to reduce the global burden of sudden cardiac death: a call for multidisciplinary action

Despite major advancements in cardiovascular medicine, sudden cardiac death (SCD) continues to be an enormous medical and societal challenge, claiming millions of lives every year. Efforts to prevent SCD are hampered by imperfect risk prediction and inadequate solutions to specifically address arrhythmogenesis. Although resuscitation strategies have witnessed substantial evolution, there is a need to strengthen the organisation of community interventions and emergency medical systems across varied locations and health-care structures. With all the technological and medical advances of the 21st century, the fact that survival from sudden cardiac arrest (SCA) remains lower than 10% in most parts of the world is unacceptable. Recognising this urgent need, the Lancet Commission on SCD was constituted, bringing together 30 international experts in varied disciplines. Consistent progress in tackling SCD will require a completely revamped approach to SCD prevention, with wide-sweeping policy changes that will empower the development of both governmental and community-based programmes to maximise survival from SCA, and to comprehensively attend to survivors and decedents' families after the event. International collaborative efforts that maximally leverage and connect the expertise of various research organisations will need to be prioritised to properly address identified gaps. The Commission places substantial emphasis on the need to develop a multidisciplinary strategy that encompasses all aspects of SCD prevention and treatment. The Commission provides a critical assessment of the current scientific efforts in the field, and puts forth key recommendations to challenge, activate, and intensify efforts by both the scientific and global community with new directions, research, and innovation to reduce the burden of SCD worldwide.

Changes in emergency department use in British Columbia, Canada, during the first 3 years of the COVID-19 pandemic

BACKGROUND

Previous studies have shown reductions in the volume of emergency department visits early in the COVID-19 pandemic, but few have evaluated the pandemic's impact over time or stratified analyses by reason for visits. We aimed to quantify such changes in British Columbia, Canada, cumulatively and during prominent nadirs, and by reason for visit, age and acuity.

METHODS

We included data from the National Ambulatory Care Reporting System for 30 emergency departments across BC from January 2016 to December 2022. We fitted generalized additive models, accounting for seasonal and annual trends, to the monthly number of visits to estimate changes throughout the pandemic, compared with the expected number of visits in the absence of the pandemic. We determined absolute and relative differences at various times during the study period, and cumulatively since the start of the pandemic until the overall volume of emergency department visits returned to expected levels.

RESULTS

Over the first 16 months of the pandemic, the volume of emergency department visits was reduced by about 322 300 visits, or 15% (95% confidence interval 12%-18%), compared with the expected volume. A sharp drop in pediatric visits accounted for nearly one-third of the reduction. The timing of the return to baseline volume of visits differed by subgroup. The largest and most sustained decreases were in respiratory-related emergency department visits, visits among children, visits among oldest adults and non-urgent visits. Later in the pandemic, we observed increased volumes of highest-urgency visits, visits among children and visits related to ear, nose and throat.

INTERPRETATION

We have extended evidence that the impact of the COVID-19 pandemic and associated mitigation strategies on emergency department visits in Canada was substantial. Both our findings and methods are relevant in public health surveillance and capacity planning for emergency departments in pandemic and nonpandemic times.

Is hybrid cardiac rehabilitation superior to traditional cardiac rehabilitation?

BACKGROUND

The current COVID-19 pandemic imposes changes in the management of cardiac pathologies. Cardiac rehabilitation needs to define new protocols to welcome patients back. In connection with the observations of the European Association of Preventive Cardiology, the choice of cardiac tele-rehabilitation appeared to be unavoidable.

AIM

This retrospective research based on data from the Program for the Medicalisation of Information Systems (PMSI) and the electronic medical record analyzes the effect of Hybrid Cardiac Rehabilitation.

METHODS

One hundred and ninety-two patients (29 females and 163 males) with an average of 56.9 years old (±10.3) were able to benefit from a Hybrid Cardiac Rehabilitation program. The data concerning the Stress Test and the Wall Squat Test were collected.

RESULTS

We have noticed that patients had improved their cardiorespiratory capacity on the initial and final Stress Test 6.6 (±1.8) MET to 8.2 (±1.9) MET (p < 0.0001). We also found that patients improved lower limb muscle strength 75.1 (±44.8) seconds to 105.7 (±49.7) seconds (p < 0.0001).

CONCLUSIONS

Hybrid Cardiac Rehabilitation protocols can be set up in this pandemic situation. The programme effectiveness appears to be comparable to the traditional model. However, additional studies are needed to determine the effectiveness of this programme in the long term.

Racial and ethnic disparities in the provision of bystander CPR after witnessed out-of-hospital cardiac arrest in the United States

OBJECTIVE

To evaluate the association between race/ethnicity and the odds of receiving bystander cardiopulmonary resuscitation (bCPR) after witnessed out-of-hospital cardiac arrest (OHCA).

METHODS

For this cross-sectional retrospective study, data were obtained from the National Emergency Medical Services Information System database for adults (≥18 years) with a witnessed non-traumatic OHCA in the year 2021. Patients were separated into two groups including Black/Hispanic and White. The primary outcome was the odds of receiving bCPR. We excluded traumatic etiology, do-not-resuscitate orders, and arrest in a healthcare facility or wilderness location. Multiple logistic regression controlling for known covariates was utilized and analyses were stratified by public versus non-public location, median household income, and rural, suburban, or urban setting.

RESULTS

A total of 64,007 witnessed OHCAs were included. When compared to White, the Black/Hispanic group were younger (62 vs 67 years) and more often female (40% vs 33%), in neighborhoods with the lowest median household income (31% vs 13%) and in an urban setting (92% vs 80%). Overall, bystander CPR rates were 60% and 67% for the Black/Hispanic and White groups, respectively. Multiple logistic regression stratified by OHCA location found that the Black/Hispanic group had a decreased odds of receiving bCPR compared to the White group both in the home (adjusted OR [aOR] 0.77; 95% CI 0.74-0.81) and in public (aOR 0.69; 95% CI 0.64-0.76). This difference persisted throughout neighborhoods of different socioeconomic status and across the rural-urban spectrum.

CONCLUSIONS

Racial/ethnic disparities exist for Black and Hispanic persons in the odds of receiving bCPR after a witnessed non-traumatic OHCA regardless of public or private setting, neighborhood income level, or population density.

The outcomes of cardiopulmonary resuscitation and their predictors during the coronavirus 2019 pandemic in Iran

BACKGROUND

Coronavirus disease 2019 (COVID-19) can negatively affect different healthcare-related outcomes. Nonetheless, there is limited information about its effects on different healthcare-related outcomes. This study aimed at evaluating the outcomes of cardiopulmonary resuscitation (CPR) and their predictors during the COVID-19 pandemic in Iran.

METHODS

This cross-sectional study was conducted on 1253 patients who had undergone CPR in the emergency wards of teaching hospitals in the west of Iran from the beginning of the first wave to the end of the third epidemic wave of COVID-19 in Iran, between February 20, 2020, and January 20, 2021. Data were collected using the National CPR Documentation Forms developed based on the Utstein Style and routinely used for all patients with cardiac arrest (CA). The SPSS (v. 20.0) program was used to analyze the data through the Chi-square, Fisher's exact, and Mann-Whitney U tests and logistic regression analysis.

RESULTS

Participants' age mean was 64.62 ± 17.54 years. Age mean among participants with COVID-19 was eight years more than other participants. Most participants were male (64.09%) and had at least one underlying disease (64.99%). The total rates of the return of spontaneous circulation (ROSC) and CPR-discharge survival were respectively 15.3% and 3.8% among all participants, 20.25% and 5.17% among participants without COVID-19, and 8.96% and 2.04% among participants with COVID-19. The significant predictors of ROSC were age, affliction by COVID-19, affliction by underlying diseases, baseline rhythm, delay in epinephrine administration, and epinephrine administration time interval, while the significant predictors of CPR-discharge survival were age and baseline rhythm.

CONCLUSIONS

The total rates of ROSC and CPR-discharge survival were respectively 15.3% and 3.8% among all participants. The rates of ROSC and CPR to discharge survival among patients without COVID-19 are respectively 2.26 and 2.53 times more than the rates among patients with COVID-19.

A comparative analysis of aerosol exposure and prevention strategies in bystander, pre-hospital, and inpatient cardiopulmonary resuscitation using simulation manikins

To evaluate aerosol exposure risk and prevention strategies during bystander, pre-hospital, and inpatient cardiopulmonary resuscitation (CPR). This study compared hands-only CPR, CPR with a surgical or N95 mask, and CPR with a non-rebreather mask at 15 L/min. 30:2 compression-ventilation ratio CPR was tested with face-mask ventilation (FMV), FMV with a high efficiency particulate air (HEPA) filter; supraglottic airway (SGA), SGA with a surgical mask, SGA with a HEPA filter, or SGA with both. Continuous CPR was tested with an endotracheal tube (ET), ET with a surgical mask, a HEPA filter, or both. Aerosol concentration at the head, trunk, and feet of the mannequin were measured to evaluate exposure to CPR personnel. Hands-only CPR with a surgical or N95 face mask coverings and ET tube ventilation CPR with filters showed the lowest aerosol exposure among all study groups, including CPR with NRM oxygenation, FMV, and SGA ventilation. NRM had a mask effect and reduced aerosol exposure at the head, trunk, and feet of the mannequin. FMV with filters during 30:2 CPR reduced aerosol exposure at the head and trunk, but increased at the feet of the mannequin. A tightly-sealed SGA when used with a HEPA filter, reduced aerosol exposure by 21.00-63.14% compared with a loose-fitting one. Hands-only CPR with a proper fit surgical or N95 face mask coverings is as safe as ET tube ventilation CPR with filters, compared with CPR with NRM, FMV, and SGA. FMV or tight-sealed SGA ventilation with filters prolonged the duration to achieve estimated infective dose of SARS-CoV-2 2.4-2.5 times longer than hands-on CPR only. However, a loose-fitting SGA is not protective at all to chest compressor or health workers standing at the foot side of the victim, so should be used with caution even when using with HEPA filters.

Pre-Arrival Care of the Out-of-Hospital Cardiac Arrest Victim

Lay rescuers play a pivotal role in the recognition and initial management of out-of-hospital cardiac arrest. The provision of timely pre-arrival care by lay responders, including cardiopulmonary resuscitation and the use of automated external defibrillator before emergency medical service arrival, is important link in the chain of survival and has been shown to improve outcomes from cardiac arrest. Although physicians are not directly involved in bystander response to cardiac arrest, they play a key role in emphasizing the importance of bystander interventions.

Manual Chest Compression versus Automated Chest Compression Device during Day-Time and Night-Time Resuscitation Following Out-of-Hospital Cardiac Arrest: A Retrospective Historical Control Study

OBJECTIVE

We assessed the effectiveness of automated chest compression devices depending on the time of admission based on the frequency of iatrogenic chest injuries, the duration of in-hospital resuscitation efforts, and clinical outcomes among out-of-hospital cardiac arrest (OHCA) patients.

METHODS

We conducted a retrospective historical control study of OHCA patients in Japan between 2015-2022. The patients were divided according to time of admission, where day-time was considered 07:00-22:59 and night-time 23:00-06:59. These patients were then divided into two categories based on the in-hospital cardiopulmonary resuscitation (IHCPR) device: manual chest compression (mCC) group and automatic chest compression devices (ACCD) group. We used univariate and multivariate ordered logistic regression models adjusted for pre-hospital confounders to evaluate the impact of ACCD use during IHCPR on outcomes (IHCPR duration, CPR-related chest injuries, and clinical outcomes) in the day-time and night-time groups.

RESULTS

Among 1101 patients with OHCA (day-time, 809; night-time, 292), including 215 patients who underwent ACCD during IHCPR in day-time (26.6%) and 104 patients in night-time group (35.6%), the multivariate model showed a significant association of ACCD use with the outcomes of in-hospital resuscitation and higher rates of return in spontaneous circulation, lower incidence of CPR-related chest injuries, longer in-hospital resuscitation durations, greater survival to Emergency Department and hospital discharge, and greater survival with good neurological outcome to hospital discharge, though only in the night-time group.

CONCLUSIONS

Patients who underwent ACCD during in-hospital resuscitation at night had a significantly longer duration of in-hospital resuscitation, a lower incidence of CPR-related chest injuries, and better outcomes.

Pre-Hospital Emergency Medical Services Utilization Amid COVID-19 in 2020: Descriptive Study Based on Routinely Collected Dispatch Data in Bavaria, Germany

BACKGROUND AND IMPORTANCE

The COVID-19 pandemic affected the utilization of health care services and posed organizational challenges. While many previous studies focused on the misuse of pre-hospital EMS for low-urgency health problems, the pandemic has put more emphasis on the avoidance of medically necessary calls.

OBJECTIVE

To compare the utilization of pre-hospital emergency medical services before and after specific pandemic periods.

DESIGN, SETTING AND PARTICIPANTS

This was a retrospective, descriptive analysis of routine data from 26 dispatch centers in Bavaria, Germany.

OUTCOMES MEASURE AND ANALYSIS

We investigated the number of emergencies per 100,000 population, as well as the relative change in the emergency rates and transport rates in 2020, compared to the two previous years. Boxplots showed the distributions across the Bavarian districts per calendar week. The mean rates and standard deviations as well as the relative changes were presented for the specific periods. A paired samples t-test was used to compare the rates.

MAIN RESULTS

Compared to the average of the two previous years, the emergency rates in 2020 were lower in 35 out of 52 calendar weeks. The strongest reductions were observed during the first wave, where the average emergency rate declined by 12.9% (SD 6.8, p < 0.001). There was no statistically significant difference in the overall emergency rate during the summer holidays. Lower transport rates were observed throughout the year, especially during the first wave.

CONCLUSIONS

Utilization of pre-hospital emergency medical services decreased in 2020, especially during the periods with strict measures. This could be due to the lower morbidity from the behavioral changes during the pandemic, but also to the avoidance of medical services for both less urgent and severe conditions. While a reduction in unnecessary care would be beneficial, patients must be encouraged to seek necessary urgent care, even during a pandemic.

Effectiveness of Cardiopulmonary Resuscitation at the Workplace

BACKGROUND

Out-of-Hospital Cardiac Arrest (OHCA) is a medical emergency whose chances of survival can be increased by rapid Cardiopulmonary Resuscitation (CPR) and early use of Public Access Defibrillators (PAD). Basic Life Support (BLS) training became mandatory in Italy to spread knowledge of resuscitation maneuvers in the workplace. Basic Life Support (BLS) training became mandatory according to the DL 81/2008 law. To improve the level of cardioprotection in the workplace, the national law DL 116/2021 increased the number of places required to be provided with PADs. The study highlights the possibility of a Return to spontaneous circulation in OHCA in the workplace.

METHODS

A multivariate logistic regression model was fitted to the data to extrapolate associations between ROSC and the dependent variables. The associations' robustness was evaluated through sensitivity analysis.

RESULTS

The chance to receive CPR (OR 2.3; 95% CI:1.8-2.9), PAD (OR 7.2; 95% CI:4.9 - 10.7), and achieve Return to spontaneous circulation (ROSC) (crude OR 2.2; 95% CI:1.7-3.0, adjusted OR 1.6; 95% CI:1.2-2.2) is higher in the workplace compared to all other places.

CONCLUSION

The workplace could be considered cardioprotective, although further research is necessary to understand the causes of missed CPRs and identify the best places to increase BLS and defibrillation training to help policymakers implement correct programming on the activation of PAD projects.

Has COVID-19 changed the spectrum of arrhythmias and the incidence of sudden cardiac death?

Arrhythmic manifestations of COVID-19 include atrial arrhythmias such as atrial fibrillation or atrial flutter, sinus node dysfunction, atrioventricular conduction abnormalities, ventricular tachyarrhythmias, sudden cardiac arrest, and cardiovascular dysautonomias including the so-called long COVID syndrome. Various pathophysiological mechanisms have been implicated, such as direct viral invasion, hypoxemia, local and systemic inflammation, changes in ion channel physiology, immune activation, and autonomic dysregulation. The development of atrial or ventricular arrhythmias in hospitalized COVID-19 patients has been shown to portend a higher risk of in-hospital death. Management of these arrhythmias should be based on published evidence-based guidelines, with special consideration of the acuity of COVID-19 infection, concomitant use of antimicrobial and anti-inflammatory drugs, and the transient nature of some rhythm disorders. In view of new SARS-CoV‑2 variants that may evolve, the development and use of newer antiviral and immunomodulator drugs, and the increasing adoption of vaccination, clinicians must remain vigilant for other arrhythmic manifestations that may occur in association with this novel but potentially deadly disease.

Effects of the 2020 COVID-19 pandemic on outcomes of out-of-hospital cardiac arrest and bystander resuscitation efforts: a nationwide cohort study in Japan

Background and importance There is limited knowledge about the nationwide impact of the 2020 COVID-19 pandemic in Japan on out-of -hospital cardiac arrest (OHCA) outcomes.Objectives The aim of this study was to investigate the impact of the 2020 COVID-19 pandemic on OHCA outcomes and bystander resuscitation efforts in Japan. Design Retrospective analysis of a nationwide population-based registry of OHCA cases. Settings and participants To conduct this study, we created a comprehensive database comprising 821 665 OHCA cases by combining and reconciling the OHCA database for 835 197 OHCA cases between 2017 and 2020 with another database, including location and time records. After applying exclusion and inclusion criteria, we analysed 751 617 cases.Outcome measures and analysis The primary outcome measure for this study was survival with neurologically favourable outcome (cerebral performance category 1 or 2). We compare OHCA characteristics and outcomes between prepandemic and pandemic years, and also investigated differences in factors associated with outcomes. Results We found that survival with neurologically favourable outcome and the rates of bystander cardiopulmonary resuscitation (CPR) slightly increased in the pandemic year [2.8% vs. 2.9%; crude odds ratio (OR), 1.07; 95% confidence interval (CI), 1.03-1.10; 54.1% vs. 55.3%, 1.05 (1.04-1.06), respectively], although the incidence of public access defibrillation (PAD) slightly decreased [1.8% vs. 1.6%, 0.89 (0.86-0.93)]. Calls for hospital selection by emergency medical service (EMS) increased during the pandemic. Subgroup analysis showed that the incidence of neurologically favourable outcome increased in 2020 for OHCA cases that occurred on nonstate of emergency days, in unaffected prefectures, with noncardiac cause, nonshockable initial rhythm, and during daytime hours. Conclusions During the 2020 COVID-19 pandemic in Japan, survival with neurologically favourable outcome of OHCA patients and bystander CPR rate did not negatively change, despite the decrement in PAD incidence. However, these effects varied with the state of emergency, region, and characteristics of OHCA, suggesting an imbalance between medical demand and supply, and raising concerns about the pandemic.

Impact of the COVID-19 pandemic on prehospital characteristics and outcomes of out-of-hospital cardiac arrest among the elderly in Japan: A nationwide study

Aim

To assess the impact of the 2020 coronavirus disease (COVID-19) pandemic on the prehospital characteristics and outcomes of out-of-hospital cardiac arrest (OHCA) in the elderly.

Methods

In this population-based nationwide observational study in Japan, 563,100 emergency medical service-unwitnessed OHCAs in elderly (≥65 years) patients involving any prehospital resuscitation efforts were analysed (144,756, 140,741, 140,610, and 136,993 cases in 2020, 2019, 2018, and 2017, respectively). The epidemiology, characteristics, and outcomes associated with OHCAs in elderly patients were compared between 3 years pre-pandemic (2017-2019) and the pandemic year (2020). The primary outcome was neurologically favourable one-month survival. The secondary outcomes were the rate of bystander cardiopulmonary resuscitation (CPR), defibrillation by a bystander, dispatcher-assisted (DA)-CPR attempts, and one-month survival.

Results

During the pandemic year, the rates of neurologically favourable 1-month survival (crude odds ratio, 95% confidence interval: 1.19, 1.14-1.25), bystander CPR (1.04, 1.03-1.06), and DA-CPR attempts (1.10, 1.08-1.11) increased, whereas the incidence of public access defibrillation (0.88, 0.83-0.93) decreased. Subgroup analyses based on interaction tests showed that the increased rate of neurologically favourable survival during the pandemic year was enhanced in OHCA at care facilities (1.51, 1.36-1.68) and diminished or abolished on state-of-emergency days (0.90, 0.74-1.09), in the mainly affected prefectures (1.08, 1.01-1.15), and in cases with shockable initial rhythms (1.03, 0.96-1.12).

Conclusions

The COVID-19 pandemic increased the bystander CPR rate in association with enhanced DA-CPR attempts and improved the outcomes of elderly patients with OHCAs.

Exposure-response relationship between COVID-19 incidence rate and incidence and survival of out-of-hospital cardiac arrest (OHCA)

Aim

We aimed to report the epidemiology of OHCA, bystander CPR pattern and other Utstein factors in a region in Hong Kong during the COVID-19 pandemic. In particular, we studied the relationship between COVID-19 incidence, OHCA incidence and survival outcome.

Methods

This was a retrospective cohort study that used data from our registry to compare features of OHCA during pre-pandemic (Jan 2018 to Dec 2019), low-incidence pandemic (Jan 2020 to Dec 2021) and high-incidence pandemic (Jan to Mar 2022). We used multivariable logistic regression to identify survival predictors.

Results

Incidence of OHCA increased dramatically with surging COVID-19 incidence (65.9 vs 74.2 vs 159.2 per 100,000 population per year, p < 0.001). During the pandemic, there were more indoor OHCA (89.3% vs 92.6% vs 97.4%, p < 0.001), fewer witnessed arrest (38.5% vs 38.3% vs 29.6%, p = 0.001), and longer median time to basic life support upon receiving call (9 min vs 10 min vs 14 min, p < 0.001). There was a higher proportion of OHCA cases with bystander-CPR (26.1% vs 31.3% vs 35.3%, p < 0.001). The proportion of cases with survival to admission (STA) (30.8% vs 22.2% vs 15.4%, p < 0.001) and survival to discharge (STD) (2.2% vs 1.0% vs 0.2%, p = 0.001) were lowered. After controlling for confounders, the odds of STA was reduced by 33% and 55% during the low-incidence and high-incidence pandemic respectively.

Conclusion

The increase in COVID-19 incidence had an exposure-response relationship with an increased incidence of OHCA and worsened survival outcomes.

Impact of COVID-19 epidemic on antihypertensive drug treatment disruptions: results from a nationwide interrupted time-series analysis

Background: The COVID-19 epidemic has disrupted care and access to care in many ways. It was accompanied by an excess of cardiovascular drug treatment discontinuations. We sought to investigate a deeper potential impact of the COVID-19 epidemic on antihypertensive drug treatment disruptions by assessing whether the epidemic induced some changes in the characteristics of disruptions in terms of duration, treatment outcome, and patient characteristics. Methods: From March 2018 to February 2021, a repeated cohort analysis was performed using French national health insurance databases. The impact of the epidemic on treatment discontinuations and resumption of antihypertensive medications was assessed using preformed interrupted time series analyses either on a quarterly basis. Results: Among all adult patients on antihypertensive medication, we identified 2,318,844 (18.7%) who discontinued their antihypertensive treatment during the first blocking period in France. No differences were observed between periods in the characteristics of patients who interrupted their treatment or in the duration of treatment disruptions. The COVID-19 epidemic was not accompanied by a change in the proportion of patients who fully resumed treatment after a disruption, neither in level nor in trend/slope [change in level: 2.66 (-0.11; 5.42); change in slope: -0.67 (-1.54; 0.20)]. Results were similar for the proportion of patients who permanently discontinued treatment within 1 year of disruption [level change: -0.21 (-2.08; 1.65); slope change: 0.24 (-0.40; 0.87)]. Conclusion: This study showed that, although it led to an increase in cardiovascular drug disruptions, the COVID-19 epidemic did not change the characteristics of these. First, disruptions were not prolonged, and post-disruption treatment outcomes remained unchanged. Second, patients who experienced antihypertensive drug disruptions during the COVID-19 outbreak were essentially similar to those who experienced disruptions before it.

Repurposing Drugs for the Treatment of COVID-19 and Its Cardiovascular Manifestations

COVID-19 is an infectious disease caused by SARS-CoV-2 leading to the ongoing global pandemic. Infected patients developed a range of respiratory symptoms, including respiratory failure, as well as other extrapulmonary complications. Multiple comorbidities, including hypertension, diabetes, cardiovascular diseases, and chronic kidney diseases, are associated with the severity and increased mortality of COVID-19. SARS-CoV-2 infection also causes a range of cardiovascular complications, including myocarditis, myocardial injury, heart failure, arrhythmias, acute coronary syndrome, and venous thromboembolism. Although a variety of methods have been developed and many clinical trials have been launched for drug repositioning for COVID-19, treatments that consider cardiovascular manifestations and cardiovascular disease comorbidities specifically are limited. In this review, we summarize recent advances in drug repositioning for COVID-19, including experimental drug repositioning, high-throughput drug screening, omics data-based, and network medicine-based computational drug repositioning, with particular attention on those drug treatments that consider cardiovascular manifestations of COVID-19. We discuss prospective opportunities and potential methods for repurposing drugs to treat cardiovascular complications of COVID-19.

Comparison of out-of-hospital cardiac arrests during the COVID-19 pandemic with those before the pandemic: an updated systematic review and meta-analysis

The coronavirus disease of 2019 (COVID-19) pandemic, directly and indirectly, affected the emergency medical care system and resulted in worse out-of-hospital cardiac arrest (OHCA) outcomes and epidemiological features compared with those before the pandemic. This review compares the regional and temporal features of OHCA prognosis and epidemiological characteristics. Various databases were searched to compare the OHCA outcomes and epidemiological characteristics during the COVID-19 pandemic with before the pandemic. During the COVID-19 pandemic, survival and favorable neurological outcome rates were significantly lower than before. Survival to hospitalization, return of spontaneous circulation, endotracheal intubation, and use of an automated external defibrillator (AED) decreased significantly, whereas the use of a supraglottic airway device, the incidence of cardiac arrest at home, and response time of emergency medical service (EMS) increased significantly. Bystander CPR, unwitnessed cardiac arrest, EMS transfer time, use of mechanical CPR, and in-hospital target temperature management did not differ significantly. A subgroup analysis of the studies that included only the first wave with those that included the subsequent waves revealed the overall outcomes in which the epidemiological features of OHCA exhibited similar patterns. No significant regional differences between the OHCA survival rates in Asia before and during the pandemic were observed, although other variables varied by region. The COVID-19 pandemic altered the epidemiologic characteristics, survival rates, and neurological prognosis of OHCA patients. Review registration: PROSPERO (CRD42022339435).

[Polytrauma care in air rescue in times of the COVID-19 pandemic: impact and development of case numbers]

Background

Changes in patient care occurred as a result of the SARS-CoV‑2 virus, and both intrahospital and prehospital care were profoundly affected. Public shutdowns during lockdown periods were intended to prevent overstretching existing resources, resulting in noticeable changes in medical care for both elective treatments and emergency medicine. This study now considered the impact of the COVID 19 pandemic on air ambulance services at a central air ambulance site in 2020 compared to the previous 2 years.

Methods

A retrospective evaluation of all missions of the rescue helicopter Christoph 9 in the first COVID-19 pandemic year 2020 in comparison to the years 2018 and 2019 was performed. The mission logs were evaluated for the analysis.

Results

There was a 20% reduction in the number of missions in 2020, with primarily internal medicine missions affected. Despite the lockdown periods and reduction in social life, the proportion of trauma deployments remained nearly the same. As expected, the proportion of occupational accidents decreased, and recreational activities resulted in accidents more frequently. Injury or illness severity showed no significant differences. In terms of internal diseases, there was a reduction in alerts for acute coronary syndrome and respiratory emergencies. The proportion of suicide-related injuries remained constant over the years.

Conclusion

During the COVID-19 study period, a decrease in the number of deployments and aborted deployments was observed. However, no significant differences in deployment and injury characteristics were observed for trauma-related deployments. These results highlight the importance of air ambulance services to ensure patient care even during pandemic periods.

Changes in neurological outcomes of out-of-hospital cardiac arrest during the COVID-19 pandemic in Japan: a population-based nationwide observational study

Background

There is growing interest in the indirect negative effects of coronavirus disease 2019 (COVID-19) on mortality. We aimed to assess its indirect effect on out-of-hospital cardiac arrest (OHCA) outcomes.

Methods

We analysed a prospective nationwide registry of 506,935 patients with OHCA between 2017 and 2020. The primary outcome was favourable neurological outcome (Cerebral Performance Category 1 or 2) at 30 days. The secondary outcomes were public access defibrillation (PAD) and bystander-initiated chest compression. We performed an interrupted time series (ITS) analysis to assess changes in the trends of these outcomes around the declaration of a state of emergency (April 7 - May 25, 2020). We also performed a subgroup analysis stratified by infection spread status.

Findings

We identified 21,868 patients with OHCA witnessed by a bystander who had an initial shockable heart rhythm. ITS analysis showed a drastic decline in PAD use (relative risk [RR], 0.60; 95% confidence interval [CI], 0.49-0.72; p < 0.0001) and a reduction in favourable neurological outcomes (RR, 0.79; 95% CI, 0.68-0.91; p = 0.0032) all over Japan after the state of emergency was declared when compared with the equivalent time period in previous years. The decline in favourable neurological outcomes was more pronounced in areas with COVID-19 spread than in areas without spread (RR, 0.70; 95% CI, 0.58-0.86 vs. RR, 0.87; 95% CI, 0.72-1.03; p for effect modification = 0.019).

Interpretation

COVID-19 is associated with worse neurological outcomes and less PAD use in patients with OHCA.

Funding

None.

Unmet healthcare needs among the population aged 50+ and their association with health outcomes during the COVID-19 pandemic

The COVID-19 pandemic led to unprecedented levels of subjective unmet healthcare needs (SUN). This study investigates the association between SUN in 2020 and three health outcomes in 2021-mortality, cancer, and self-assessed health (SAH), among adults aged 50 years and older, using data from the regular administration of the Survey of Health, Ageing and Retirement in Europe and from the two special waves administered in 2020 and 2021 regarding COVID-19. Three types of SUN were surveyed: care foregone due to fear of contracting COVID-19, pre-scheduled care postponed, and inability to get medical appointments or treatments demanded. We resort on the relative risk and the logistic specification to investigate the association between SUN and health outcomes. To avoid simultaneity, 1-year lagged SUN variables are used. We found a negative association between SUN and mortality. This result differs from the (scarce) previous evidence, suggesting that health systems prioritised life-threatening conditions, in the pandemic context. In line with previous studies, we obtained a positive association between SUN and worse health, in the case of cancer, though it is statistically significant only for the global measure of SUN (any reason). The higher chances of reporting cancer among those exposed to SUN might mean delayed cancer diagnosis, confirming that healthcare foregone was truly needed for a timely diagnosis. The association between SUN and poor or fair SAH is positive but not statistically significant, for the period analysed.

Impact of diabetes on emergency care of acute myocardial infarction patients during the coronavirus disease 2019 pandemic: a nationwide population-based study

Background

Although acute myocardial infarction (AMI) requires timely intervention, limited nationwide data is available regarding the association between disruption of emergency services and outcomes of patients with AMI during the coronavirus disease 2019 (COVID-19) pandemic. Moreover, whether diabetes mellitus (DM) adversely affects disease severity in these patients has not yet been investigated.

Methods

This nationwide population-based study analyzed 45,648 patients with AMI, using data from the national registry of emergency departments (ED) in Korea. Frequency of ED visits and disease severity were compared between the COVID-19 outbreak period (year 2020) and the control period (the previous year 2019).

Results

The number of ED visits by patients with AMI decreased during the first, second, and third waves of the outbreak period compared to the corresponding time period in the control period (all p-values < 0.05). A longer duration from symptom onset to ED visit (p = 0.001) and ED stay (p = 0.001) and higher rates of resuscitation, ventilation care, and extracorporeal membrane oxygen insertion were observed during the outbreak period than during the control period (all p-values < 0.05). These findings were exacerbated in patients with comorbid DM; Compared to patients without DM, patients with DM demonstrated delayed ED visits, longer ED stays, more intensive care unit admissions (p < 0.001), longer hospitalizations (p < 0.001), and higher rates of resuscitation, intubation, and hemodialysis (all p-values < 0.05) during the outbreak period. While in-hospital mortality was similar in AMI patients with and without comorbid DM during the two periods (4.3 vs. 4.4%; p = 0.671), patients with DM who had other comorbidities such as chronic kidney disease or heart failure or were aged ≥ 80 years had higher in-hospital mortality compared with those without any of the comorbidities (3.1 vs. 6.0%; p < 0.001).

Conclusion

During the pandemic, the number of patients with AMI presenting to the ED decreased compared with that of the previous year, while the disease severity increased, particularly in patients with comorbid DM.

The impact of COVID-19 pandemic on access to medical services and its consequences on emergency surgery

Background

On March 9, 2020, the Italian Prime Minister announced the lockdown, which was officially closed on May 4. This extraordinary measure was necessary to contain the COVID-19 pandemic spread in Italy. During this phase, a significant decrease in patients' access to Emergency Department (ED) was observed. Delayed access to treatment determined a delay in the diagnosis of acute surgical conditions, as already documented in other clinical areas, with consequences on surgical outcome and survival. Aim of this study is to provide a detailed description of abdominal urgent-emergent conditions surgically treated and surgical outcomes during the lockdown in a tertiary referral Italian hospital, compared with historical data.

Methods

A retrospective review of urgent-emergent patients surgically treated in our department was conducted in order to compare patients' characteristics and surgical outcomes during the period March 9th-May 4th, 2020 with the same period of the previous year.

Results

152 patients were included in our study, 79 patients in 2020 group and 77 patients in 2019. We found no significant differences between the groups regarding ASA score, age, gender, and disease prevalence. Significant differences were found in symptom duration before ER access and abdominal pain as the main symptom in non-traumatic conditions. We also performed a sub-analysis on peritonitis which showed significant differences in: hospital length of stay, presence of colostomy vs. ileostomy, and fatal events in 2020. No differences were found in the use of laparoscopy.

Conclusions

While the overall number of ER accesses has decreased in 2020 group, the number of patients surgically treated in emergency-urgency conditions has not decreased. However, those patients waited significantly more before the hospital access. This diagnostic delay was associated with a more severe clinical condition and a consequent significantly worse prognosis.

Impact of Coronavirus Disease 2019 Pandemic on Cardiac Arrest and Emergency Care

The incidence of both out-of-hospital and in-hospital cardiac arrest increased during the coronavirus disease 2019 (COVID-19) pandemic. Patient survival and neurologic outcome after both out-of-hospital and in-hospital cardiac arrest were reduced. Direct effects of the COVID-19 illness combined with indirect effects of the pandemic on patient's behavior and health care systems contributed to these changes. Understanding the potential factors offers the opportunity to improve future response and save lives.

Impact of lockdown on cardiovascular disease hospitalizations in a Zero-COVID-19 country

OBJECTIVES

There are concerns about the potential effect of social distancing used to control COVID-19 on the incidence of cardiovascular diseases (CVD).

STUDY DESIGN

Retrospective cohort study.

METHODS

We examined the association between lockdown and CVD incidence in a Zero-COVID country, New Caledonia. Inclusion criteria were defined by a positive troponin sample during hospitalization. The study period lasted for 2 months, starting March 20, 2020 (strict lockdown: first month; loose lockdown: second month) compared with the same period of the three previous years to calculate incidence ratio (IR). Demographic characteristics and main CVD diagnoses were collected. The primary endpoint was the change in incidence of hospital admission with CVD during lockdown compared with the historical counterpart. The secondary endpoint included influence of strict lockdown, change in incidence of the primary endpoint by disease, and outcome incidences (intubation or death) analyzed with inverse probability weighting method.

RESULTS

A total of 1215 patients were included: 264 in 2020 vs 317 (average of the historical period). CVD hospitalizations were reduced during strict lockdown (IR 0.71 [0.58-0.88]), but not during loose lockdown (IR 0.94 [0.78-1.12]). The incidence of acute coronary syndromes was similar in both periods. The incidence of acute decompensated heart failure was reduced during strict lockdown (IR 0.42 [0.24-0.73]), followed by a rebound (IR 1.42 [1-1.98]). There was no association between lockdown and short-term outcomes.

CONCLUSIONS

Our study showed that lockdown was associated with a striking reduction in CVD hospitalizations, independently from viral spread, and a rebound of acute decompensated heart failure hospitalizations during looser lockdown.

Nationwide Analysis of Cardiac Arrest Outcomes During the COVID-19 Pandemic

Introduction

The coronavirus disease 2019 (COVID-19) pandemic had a significant impact on the chain of survival following cardiac arrest. However, large population-based reports of COVID-19 in patients hospitalized after cardiac arrest are limited.

Methods

The National Inpatient Sample database was queried for cardiac arrest admissions during 2020 in the United States (US). Propensity score matching was used to match patients with and without concurrent COVID-19 according to age, race, sex, and comorbidities. Multivariate logistic regression analysis was used to identify predictors of mortality.

Results

A weighted total of 267,845 hospitalizations for cardiac arrest were identified, among which 44,105 patients (16.5%) had a concomitant diagnosis of COVID-19. After propensity matching, cardiac arrest patients with concomitant COVID-19 had higher rate of acute kidney injury requiring dialysis (64.9% vs. 54.8%) mechanical ventilation > 24 hours (53.6% vs. 44.6%) and sepsis (59.4% vs. 40.4%) compared to cardiac arrest patients without COVID-19. In contrast, cardiac arrest patients with COVID-19 had lower rates of cardiogenic shock (3.2% vs. 5.4%, p < 0.001), ventricular tachycardia (9.6% vs. 11.7%, p < 0.001), and ventricular fibrillation (6.7% vs. 10.8%, p < 0.001), and a lower utilization of cardiac procedures. In-hospital mortality was higher in patients with COVID-19 (86.9% vs. 65.5%, p <0.001) and, on multivariate analysis, a diagnosis of COVID-19 was an independent predictor of mortality.

Conclusion

Among patients hospitalized following a cardiac arrest during 2020, concomitant COVID-19 infection was associated with significantly worse outcomes characterized by an increased risk of sepsis, pulmonary and renal dysfunction, and death.

Two-year prognosis of acute coronary syndrome during the first wave of the coronavirus disease 2019 pandemic

BACKGROUND

The first wave of the coronavirus disease 2019 pandemic significantly changed behaviour in terms of access to healthcare.

AIM

To assess the effects of the pandemic and initial lockdown on the incidence of acute coronary syndrome and its long-term prognosis.

METHODS

Patients admitted for acute coronary syndrome from 17 March to 6 July 2020 and from 17 March to 6 July 2019 were included. The number of admissions for acute coronary syndrome, acute complication rates and 2-year rates of survival free from major adverse cardiovascular events or death from any cause were compared according to the period of hospitalization.

RESULTS

In total, 289 patients were included. We observed a 30±3% drop in acute coronary syndrome admissions during the first lockdown, which did not recover in the 2months after it was lifted. At 2years, there were no significant differences in the combined endpoint of major adverse cardiovascular events or death from any cause between the different periods (P=0.34). Being hospitalized during lockdown was not predictive of adverse events during follow-up (hazard ratio 0.87, 95% confidence interval 0.45-1.66; P=0.67).

CONCLUSIONS

We did not observe an increased risk of major cardiovascular events or death at 2years from initial hospitalization for patients hospitalized during the first lockdown, adopted in March 2020 in response to the coronavirus disease 2019 pandemic, potentially as a result of the lack of power of the study.

Sudden Cardiac Arrest During the COVID-19 Pandemic: A Two-Year Prospective Evaluation in a North American Community

BACKGROUND

Early in the COVID-19 pandemic, higher SCA incidence and lower survival rates were reported. However, ongoing effects on SCA during the evolving pandemic have not been evaluated.

OBJECTIVE

We assessed the impact of COVID-19 on SCA during two years of the pandemic.

METHODS

In a prospective study of Ventura County, CA (2020 Pop. 843,843; 44.1% Hispanic), we compared SCA incidence and outcomes during the first two years of the COVID-19 pandemic to the prior four years.

RESULTS

Of 2,222 OHCA cases identified, 907 occurred during the pandemic (March 2020 - Feb 2022) and 1315 occurred pre-pandemic (March 2016 - Feb 2020). Overall age-standardized annual SCA incidence increased from 39/100,000 [95% CI 37-41] pre-pandemic to 54/100,00 [95% CI 50 - 57, p<0.001] during the pandemic. Among Hispanics, incidence increased by 77%, from 38/100,00 [95% CI 34-43] to 68/100,00 [95% CI 60-76, p<0.001]. Among non-Hispanics, incidence increased by 26% from 39/100,000 [95% CI 37-42, p<0.001] to 50/100,00 [95% CI 46-54]. SCA incidence rates closely tracked COVID-19 infection rates. During the pandemic, SCA survival was significantly reduced (15% to 10%, p<0.001) and Hispanics were less likely than non-Hispanics to receive bystander CPR (45% vs. 55%, p=0.005) and present with shockable rhythm (15% vs. 24%, p=0.003).

CONCLUSION

Overall SCA rates remained consistently higher and survival outcomes consistently lower, with exaggerated effects during COVID infection peaks. This longer evaluation uncovered higher increases in SCA incidence among Hispanics, with worse resuscitation profiles. Potential ethnicity-specific barriers to acute SCA care warrant urgent evaluation and intervention.

The effect of the COVID-19 pandemic on the incidence and survival outcomes of EMS-witnessed out-of-hospital cardiac arrest

AIM

We sought to examine the impact of the COVID-19 pandemic on the incidence and survival outcomes of emergency medical service (EMS)-witnessed out-of-hospital cardiac arrest (OHCA) in Victoria, Australia.

METHODS

We performed an interrupted time-series analysis of adult EMS-witnessed OHCA patients of medical aetiology. Patients treated during the COVID-19 period (1st March 2020 to 31st December 2021) were compared to a historical comparator period (1st January 2012 and 28th February 2020). Multivariable poisson and logistic regression models were used to examine changes in incidence and survival outcomes during the COVID-19 pandemic, respectively.

RESULTS

We included 5,034 patients, 3,976 (79.0%) in the comparator period and 1,058 (21.0%) in the COVID-19 period. Patients in the COVID-19 period had longer EMS response times, fewer public location arrests and were significantly more likely to receive mechanical CPR and laryngeal mask airways compared to the historical period (all p < 0.05). There were no significant differences in the incidence of EMS-witnessed OHCA between the comparator and COVID-19 periods (incidence rate ratio 1.06, 95% CI: 0.97-1.17, p = 0.19). Also, there was no difference in the risk-adjusted odds of survival to hospital discharge for EMS-witnessed OHCA occurring during COVID-19 period compared to the comparator period (adjusted odd ratio 1.02, 95% CI: 0.74-1.42; p = 0.90).

CONCLUSION

Unlike the reported findings in non-EMS-witnessed OHCA populations, changes during the COVID-19 pandemic did not influence incidence or survival outcomes in EMS-witnessed OHCA. This may suggest that changes in clinical practice that sought to limit the use of aerosol generating procedures did not influence outcomes in these patients.

Did lockdown influence bystanders' willingness to perform cardiopulmonary resuscitation? A worldwide registry-based perspective

AIM

Bystander cardiopulmonary resuscitation (CPR) significantly increases the survival rate after out-of-hospital cardiac arrest. Using population-based registries, we investigated the impact of lockdown due to Covid-19 on the provision of bystander CPR, taking background changes over time into consideration.

METHODS

Using a registry network, we invited all registries capable of delivering data from 1. January 2017 to 31. December 2020 to participate in this study. We used negative binominal regression for the analysis of the overall results. We also calculated the rates for bystander CPR. For every participating registry, we analysed the incidence per 100000 inhabitants of bystander CPR and EMS-treated patients using Poisson regression, including time trends.

RESULTS

Twenty-six established OHCA registries reported 742 923 cardiac arrest patients over a four-year period covering 1.3 billion person-years. We found large variations in the reported incidence between and within continents. There was an increase in the incidence of bystander CPR of almost 5% per year. The lockdown in March/April 2020 did not impact this trend. The increase in the rate of bystander CPR was also seen when analysing data on a continental level. We found large variations in incidence of bystander CPR before and after lockdown when analysing data on a registry level.

CONCLUSION

There was a steady increase in bystander CPR from 2017 to 2020, not associated with an increase in the number of ambulance-treated cardiac arrest patients. We did not find an association between lockdown and bystanders' willingness to start CPR before ambulance arrival, but we found inconsistent patterns of changes between registries.

Age-Related Effects of COVID-19 Pandemic on Mechanical Reperfusion and 30-Day Mortality for STEMI: Results of the ISACS-STEMI COVID-19 Registry

BACKGROUND

The constraints in the management of patients with ST-segment elevation myocardial infarction (STEMI) during the COVID-19 pandemic have been suggested to have severely impacted mortality levels. The aim of the current analysis is to evaluate the age-related effects of the COVID-19 pandemic on mechanical reperfusion and 30-day mortality for STEMI within the registry ISACS-STEMI COVID-19.

METHODS

This retrospective multicenter registry was performed in high-volume PPCI centers on four continents and included STEMI patients undergoing PPCI in March-June 2019 and 2020. Patients were divided according to age (< or ≥75 years). The main outcomes were the incidence and timing of PPCI, (ischemia time longer than 12 h and door-to-balloon longer than 30 min), and in-hospital or 30-day mortality.

RESULTS

We included 16,683 patients undergoing PPCI in 109 centers. In 2020, during the pandemic, there was a significant reduction in PPCI as compared to 2019 (IRR 0.843 (95%-CI: 0.825-0.861, p < 0.0001). We found a significant age-related reduction (7%, p = 0.015), with a larger effect on elderly than on younger patients. Furthermore, we observed significantly higher 30-day mortality during the pandemic period, especially among the elderly (13.6% vs. 17.9%, adjusted HR (95% CI) = 1.55 [1.24-1.93], p < 0.001) as compared to younger patients (4.8% vs. 5.7%; adjusted HR (95% CI) = 1.25 [1.05-1.49], p = 0.013), as a potential consequence of the significantly longer ischemia time observed during the pandemic.

CONCLUSIONS

The COVID-19 pandemic had a significant impact on the treatment of patients with STEMI, with a 16% reduction in PPCI procedures, with a larger reduction and a longer delay to treatment among elderly patients, which may have contributed to increase in-hospital and 30-day mortality during the pandemic.