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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 11  |  Issue : 2  |  Page : 30-36

Impact of COVID-19 pandemic induced lockdown on management of myocardial infarction: An Indian survey report from the experiences by 1083 cardiologists


1 Department of Cardiology, P.D.Hinduja Hospital and Medical Research Centre, Mumbai, Maharashtra, India
2 Department of Cardiology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
3 Medical Services, Micro Labs Ltd, Bengaluru, Karnataka, India
4 Senior Consulant and Interventional Cardiologist, Apollo Hospitals, Chennai, Tamil Nadu, India
5 Department of Cardiology, All India Insititute of Medical Sciences, New Delhi, India
6 Department of Cardiology, Kovai Medical Centre and Hospital, Coimbatore, India
7 Chief Cardiologist, PRS Hospital, Trivandrum, India

Date of Submission20-Nov-2021
Date of Decision29-Dec-2021
Date of Acceptance31-Dec-2021
Date of Web Publication24-Jun-2022

Correspondence Address:
DM Cardiology Chandrashekar K Ponde
Department of Cardiology, P.D.Hinduja Hospital and Medical Research Centre, 724, 11th Road, Khar west, Mumbai 400 052
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcpc.jcpc_55_21

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  Abstract 

Background: COVID-19 has induced a change in the management of myocardial infarction (MI). Methods: We developed a customized technological virtual response system for mapping exercise, during August 14–28, 2020, to understand the management of MI. Prior telephonic consent was obtained, and the weblink of the questionnaire was provided on individual WhatsApp. Anonymized data were statistically analyzed by GraphPad software version 8.4.3. Results: The mean year of experience in active clinical practice was 12 years (standard deviation 10, 95% confidence interval 12–13). There were 41% (n = 445) participants who reported reduction by 25%–29% of MI patients, reporting to hospital, followed by 27.8% (n = 302) participants, reporting that <25% patients with MI approached the hospital. Sixty percent reported as the most important reason for a decrease in cases of MI patient's fear of contracting COVID-19 (n = 648), followed by limited transportation by 20.49% (n = 222) participants. There were health-care-driven reasons for a decrease in MI primary percutaneous coronary intervention activations. These included cardiologist's reluctance to do primary percutaneous cardiovascular interventions (PCI) due to COVID-19 and patients presenting late beyond the optimal window for PCI/thrombolysis by 34.71% (n = 376) and 31% (n = 341) of participants, respectively. There were 68.5% (n = 742) of respondents that were of opinion that the time component of MI care that has increased most was time between symptom onset to first medical contact, followed by time between medical contact to catheterization laboratory arrival, as opined by 20% (n = 217) of the participants. It was reported that patients undergoing no reperfusion due to delayed treatment were increased to less than 25%, as reported by 43.4% (n = 471), respondents. This was followed by 32.5% (n = 352), respondents reporting that there was 26%–50% increase in the number of patients undergoing no reperfusion due to delayed treatment. Immediate thrombolysis was preferred by 28% (n = 304) of participants from the teaching institutions. There were 75.1% (n = 814) of the participants, that tested patients for COVID-19 before shifting to the catheterization laboratory. Conclusion: This is one of the largest perception mapping exercises, limited with the absence of actual patient data, which is a cohesive reflection in line with global evidence for a remarkable decrease in cases and interventions for the management of MI. The lessons from the experiences entail that there is a need to encourage patients with symptoms suspected of MI to promptly contact emergency services to enable timely diagnosis and enable reperfusion therapy. Impact on the MI management appears to be substantial, which calls for action for change in infrastructure and policy framework to improvise MI care.

Keywords: COVID, STEMI, survey


How to cite this article:
Ponde CK, Jain D, Suresh M, Gunasekaran S, Mishra S, Alexander T, Nair T. Impact of COVID-19 pandemic induced lockdown on management of myocardial infarction: An Indian survey report from the experiences by 1083 cardiologists. J Clin Prev Cardiol 2022;11:30-6

How to cite this URL:
Ponde CK, Jain D, Suresh M, Gunasekaran S, Mishra S, Alexander T, Nair T. Impact of COVID-19 pandemic induced lockdown on management of myocardial infarction: An Indian survey report from the experiences by 1083 cardiologists. J Clin Prev Cardiol [serial online] 2022 [cited 2022 Nov 28];11:30-6. Available from: https://www.jcpconline.org/text.asp?2022/11/2/30/348084


  Introduction Top


The number of myocardial infarction (MI) patients treated during the current COVID-19 outbreak has reported to be decreased with the increase in the median time from symptom onset to reperfusion.[1] The ST elevation MI (STEMI) revascularization time targets (<120 min) even otherwise have been difficult to achieve in normal times, and now almost impossible to achieve in periods of lockdown because of the several obstacles.[2] The proportion of patients treated with thrombolytic therapy has been documented to increase during the lockdown period as compared to the pre-COVID period.[3]

During the lockdown period, patients appear to have been reluctant to present to hospitals which has led to delays in patients seeking care for cardiac problems.[4]

The European Association of Percutaneous Cardiovascular Interventions and the Acute Cardiovascular Care Association released a position statement on invasive management of acute coronary syndromes (ACSs) during the COVID-19 pandemic. These addressed the need for re-organization of ACS networks, with redistribution of hub-and-spoke hospitals, as well as for in-hospital reorganization of emergency rooms and cardiac units. This also provides the guidance to reorganization of catheterization laboratories and guides for the measures for the protection of health-care providers involved with invasive procedures.[5]

Objective

Ever since the outbreak of the COVID-19 pandemic, there is varied literature, which documents the changing presentation of MI, with several challenges for the patients to approach the hospital and the clinical perspectives which make the management of MI difficult. Therefore, we realized the need for a consensus, for the lessons from the experiences, through a uniform perception mapping exercise within a defined time span from the Indian medical fraternity. This would enable to prepare for better management of MI, especially during the ever-evolving dynamic situations during the COVID-19 era. The objective was defined to plan a survey report through virtual participation to understand the management of MI based on the knowledge, information, and the practical experiences of the Indian cardiologists and to manage MI during an ongoing pandemic that has translated into a health crisis.


  Methods Top


We made up an eminent specialist cardiologists' panel who are leaders in cardiology care across various regions of India. The expert group reviewed the contemporary literature in the management of MI during COVID-19 era and brainstormed through a series of meeting to plan, validate, and cascade a structured questionnaire targeted towards the Indian cardiologists. This eventually led to a sub-expert nationwide panel comprising 1083 experts that responded with adequate representation across the geography of India.

The execution processes

We developed a customized technological platform (https://stemisurvey.typeform.com/to/qzF9YTbO) specifically for the virtual response system. This helped to record the unbiased and high opinion perspectives based on the rich experiences of the medical fraternity. Prior telephonic consent was obtained, and the weblink of the questionnaire was provided on individual WhatsApp. An auto acknowledgment e-mail was sent to the respondent for the confirmation of the completion of the questionnaire. This also enabled the source document validation. The responses were captured prospectively from August 14, 2020, to August 28, 2020, in the time duration of 15 days.

Statistical analysis

Anonymized data were statistically analyzed by GraphPad software version 8.4.3.(GraphPad Software Inc, California, USA).

The responses from the participants were collated and collectively termed as the responses from the subexpert group and analyzed for corroboration with the contemporary literature and specific comments were suggested by the core expert group. Results on continuous measurements were presented as mean ± standard deviation (SD) and results on categorical measurements were presented in number (%). Normality of data was tested by Shapiro–Wilk test. Paired t-test was used to find the significance of study parameters within groups measured on two occasions.


  Results Top


The mean year of experience in the active clinical practice was 12 years (SD 10, 95% confidence interval 12–13, minimum 0 years, and maximum 55 years). The distribution of the years of experience is graphically represented in the violin graph [Figure 1]
Figure 1: Experience years of the participants

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The participants predominantly, with approximately one in three, were each from private nonteaching (n = 352) and teaching hospitals (n = 332). This was followed by 28.2% (306) from public teaching hospitals. The participants from the exclusive outpatient or day-care practice and public nonteaching hospitals had minimal representation, with each 4.4% (n = 48) and 4.1% (n = 45), respectively [Table 1].
Table 1: Practice setting of the participants

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About 45.9% of the participants reported that their place of practice has not been ever under the containment zone, followed by one-third (n = 366) of the participants reported that their setups were under the containment zone at least at one point of time and one in five (n = 219) reported to be under partial containment zone at least at one point of time [Table 2].
Table 2: Locality ever been or is currently in the containment zone

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Zonal containment (e.g., most shops and restaurants are closed, people work from home as much as possible) at different point times would have been a challenge for the patients to access the health-care facilities.

Lower incidence of MI during lockdown has been reported by several studies. Four out of every ten participants (n = 445) reported the reduction of patients reporting to hospital with MI by approximately 25%–29% which was followed by 27.8% (n = 302) of participants reporting reduction of <25% for the decrease in the number of patients with MI. Less than 10% (94) did not report for the decrease in the number of cases of MI approaching hospital [Table 3].
Table 3: Decrease in the number of ST elevation myocardial infarctions patients reporting to hospital

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The most important patient-driven reasons for the decrease in STEMI primary percutaneous coronary intervention activations were evaluated. Patient's fear of contracting COVID-19 was rated as the most important reason for the decrease in cases of MI by approximately 60% (n = 648) of participants, followed by limited and lack of transportation by every fifth participant (n = 222) [Table 4].
Table 4: Most important patient-driven reasons for a decrease in myocardial infarctions primary percutaneous coronary intervention activations

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The two most important health-care-driven reasons for the decrease in MI primary percutaneous coronary intervention activations were the cardiologist's reluctance to perform primary PCI because of COVID-19 and patients presenting late beyond the optimal window for PCI/thrombolysis by over one-third (n = 376) and by 31% (n = 341), respectively [Table 5].
Table 5: Most important health-care-driven reasons for a decrease in myocardial infarctions primary percutaneous coronary intervention activations

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Approximately 4 out of 10 participants (n = 420) reported that 26%–50% of patients with MI present later than usual during COVID-19 pandemic, followed by approximately one-fourth (n = 282) of the participants reported that <25% of patients present late beyond the optimal window for PCI/thrombolysis [Table 6].
Table 6: Do myocardial infarctions patients present later than usual during COVID-19 pandemic (i.e., beyond the optimal window for percutaneous cardiovascular interventions/thrombolysis)

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A vast majority of approximately 7 out of 10 participants (742) were of the opinion that the time component of MI care that has increased the most was the time between the symptom onset to first medical contact followed by the time between the medical contact to catheterization laboratory arrival opined by 20% (n = 217) [Table 7].
Table 7: Time component of myocardial infarctions care has increased the most during COVID-19 pandemic

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In the current practice scenario, the most preferred treatment strategy to manage a patient with MI presenting within 3 h of symptoms onset has been immediate thrombolysis by 43% (n = 466) of participants. Immediate primary PCI with full safety precautions has been the next chosen approach by almost one-third (n = 306). Surprisingly, 19% (n = 206) prefer clinical evaluation for the possibility of COVID-19 and then select for reperfusion therapy accordingly. Conducting rapid antigen assay for COVID-19 followed by primary PCI is the least preferred modality (n = 105) [Table 8].
Table 8: Preferred treatment strategy to manage a patient with myocardial infarctions presenting within 3 h of symptoms onset

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In the current practice scenario, the most preferred treatment strategy to manage a patient with MI presenting within 3–6 h of symptoms onset has been immediate thrombolysis by 33.24% (360) of participants. Immediate primary PCI with full safety precautions has been the next chosen approach by almost one-third (n = 325). About 1 in 4 (n = 250) prefer clinical evaluation for the possibility of COVID-19 and then select for reperfusion therapy accordingly. Conducting rapid antigen assay for COVID-19 followed by primary PCI is the least preferred modality (n = 148) [Table 9].
Table 9: Preferred treatment strategy to manage a patient with myocardial infarctions presenting within 3-6 h of symptoms onset

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It was reported that patients undergoing no reperfusion due to delayed treatment were increased to less than 25%, as reported by 43.4% (n = 471), respondents. This was followed by 32.5% (n = 352), respondents reporting that there was 26%–50% increase in the number of patients undergoing no reperfusion due to delayed [Table 10].
Table 10: Has the percentage of no reperfusion because of delayed treatment increased during the current COVID-19 pandemic

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The responses varied little across the number of COVD-19 patients treated in the same hospital with the provision of management of patients with STEMI [Table 11].
Table 11: Percentage of the patients currently admitted to your hospital because of COVID-19

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The majority (75%) reported that they evaluated patients for COVID 19 before shifting to catheterization laboratory [Table 12].
Table 12: Do you test all patients (immunological/radiological test) prior to shifting to the catheterization laboratory?

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This reflects the contagious nature of the virus which is health hazard to the cardiologists [Table 13].
Table 13: Percentage of patients who were managed for myocardial infarctions tested positive for COVID-19?

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  Discussion Top


An important strength of this perception mapping exercise was that it represented a wide distribution of the participants across the practice settings. Therefore, this consensus exercise is representative for not only the numbers but also the range of the spread of the participants. An important revelation was that, during the first major lockdown, half of the participants were partially or completely affected by the lockdown, hence that translated the practice setups to come under containment zone.

There has been a reduction in the number of cases reporting with myocardial infarction

In concurrence with other evidence, there was a decrease in the number of cases reporting with MI. This was like the results reported in a study from Italy that showed a 23.4% reduction in ACS admissions during 2020, with a decrease for both STEMI (−5.6%) and non-STEMI (−34.5%).[6] In a study from France, admissions for acute MI and STEMI decreased by 30% and 24%, respectively.[7] It has been reported from Northern Europe for a 32% decrease in STEMI[8] and a 27.6% decrease has been reported in Spain.[1] The drop in STEMI cases has been significant to up to 25% from Canada.[9] New Zealand reported 53% reductions in the inpatient angiograms and percutaneous intervention procedures.[10]

High loads drive fear of contracting COVID-19 and delays approach to hospital for management of myocardial infarction

There has been a report for the reduction of STEMI patients by 51.4% from China.[11] There is evidence that shows that the patients have concern for the fear of contracting COVID-19, which may drive patients for self-triage, especially in regions where the caseloads are noted to be high.[12],[13],[14],[15],[16] Significantly longer delays between symptom onset and first medical contact have been reported.[4],[13] It has been reported in the studies from the other parts of the world that the patients with STEMI during COVID-19 era have reported later than the usual beyond the optimal window for PCI/thrombolysis.[15] The enhanced time from the symptom onset of STEMI to first medical contact was the most prominent response. Significant time lags between symptom onset in STEMI and first medical contact have been reported.[4],[17]

Restructuring of cardiology setups driven by COVID-19 limits cardiac care

Less than 1 in 5 cardiology setups were reported to be not restructured due to COVID-19 [Table 14]. This shows that the cardiology care would have been compromised in majority of the centers. The vast majority, 78.2%, either agree or strongly agree with the risk of future complications because of MI. This highlights the need to address the current gaps that lead to inadequate management of MI. Our results are similar to the survey conducted by the European Society of Cardiology, across 141 countries across 6 continents, to evaluate, through the 3101 responses, the impact of COVID-19 on the admission of patients with STEMI.[18] Our results are in line with the survey conducted by STEMI Working Group of Stent-Save a Life from Latin America.[19] As A majority 80.2% (80.2) has been using full personal protective equipment [Table 15] 651 (60.1%) agreed that Late presentations might be a sign for an increase in future complications of MI [Table 16]. 431 (39.7%) opined that it would take six months to normalise the cardiology practice [Table 17].
Table 14: Has your ward/unit/department been restructured because of the COVID-19 pandemic?

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Table 15: Do you use full personal protective equipment in your catheterization laboratory/coronary care unit/cardiac procedure/diagnostic procedures?

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Table 16: Do you agree that the decrease in hospital acute coronary syndromes admissions and late presentations might be a sign for an increase in future complications of myocardial infarctions?

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Table 17: How long would it take to normalise the cardiology practice

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Enhanced practice of thrombolysis during COVID-19 era

It has been reported from Rajasthan, India, that the proportion of patients treated with intravenous thrombolytic therapy increased from 18.4% in the pre-COVID period to 32.3% in the postlockdown period.[3] It has been reported from China the percentage of STEMI patients who received fibrinolysis in 2020 was 2–3 times higher than that in 2018 and 2019, while the volume of PPCI dropped by more than half.[11] Immediate thrombolysis is relatively less referred as compared if the presentation to hospital is within 3 h and possibility of COVID-19 is ruled out in relatively a greater number of cases as compared to the patients who arrive to the hospital within first 3 h. Significant reduction in emergent reperfusion therapy has been reported in a study from China.[20],[21]

Limitations

The present study only summarizes clinicians' perceptions and does not provide any actual data about the change in STEMI presentation and management. This is a major limitation of this study.


  Conclusion Top


This is one of the largest perception mapping exercises, for the change in the management of MI which is a cohesive reflection in line with global evidence for a remarkable decrease in cases and interventions for the management of MI. The results provide an insight, through experiences of the respondents, for the extensive adverse effects caused by COVID-19 directly for the cardiological manifestations and indirectly for the delayed treatment for STEMI. The lessons from the experiences entail that there is a need to encourage patients with symptoms suspected of MI to promptly contact emergency services to enable timely diagnosis and enable reperfusion therapy. The impact on the management of MI appears to be substantial, which calls for action for the change in the infrastructure and the policy framework to support and encourage a better management. Therefore, the lessons learned from the experiences of the participants, from the past, should enable better preparation to deliver cardiology care during the subsequent waves of COVID-19 pandemic and help mitigate the potential risk that hinders management of patients in a cardiology care setup.

Acknowledgment

We thank Micro Labs Ltd for assisting in the execution of this study by reaching out to the cardiologists. We are grateful to all the participants for their time, efforts, and the intellectual contribution to complete the survey. Micro Labs Ltd has no role in initiating, ideation, design, data analysis, interpretation, or writing of the report. The authors declare no conflict of interest.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Rodríguez-Leor O, Cid-Álvarez B, Pérez de Prado A, Rossello X, Ojeda S, Serrador A, et al. Impact of COVID-19 on ST-segment elevation myocardial infarction care. The Spanish experience. Rev Esp Cardiol (Engl Ed) 2020;73:994-1002.  Back to cited text no. 1
    
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Haddad K, Potter BJ, Matteau A, Gobeil F, Mansour S. Implications of COVID-19 on time-sensitive STEMI care: A report from a North American epicenter. Cardiovasc Revasc Med 2021;30:33-7.  Back to cited text no. 4
    
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Mesnier J, Cottin Y, Coste P, Ferrari E, Schiele F, Lemesle G, et al. Hospital admissions for acute myocardial infarction before and after lockdown according to regional prevalence of COVID-19 and patient profile in France: A registry study. Lancet Public Health 2020;5:e536-42.  Back to cited text no. 7
    
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Natarajan MK, Wijeysundera HC, Oakes G, Cantor WJ, Miner SE, Welsford M, et al. Early observations during the COVID-19 pandemic in cardiac catheterization procedures for ST-elevation myocardial infarction across Ontario. CJC Open 2020;2:678-83.  Back to cited text no. 9
    
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Mayol J, Artucio C, Batista I, Puentes A, Villegas J, Quizpe R, et al. An international survey in Latin America on the practice of interventional cardiology during the COVID-19 pandemic, with a particular focus on myocardial infarction. Neth Heart J 2020;28:424-30.  Back to cited text no. 19
    
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Song C, Liu S, Yin D, Wang Y, Zhao Y, Yang W, et al. Impact of public health emergency response to COVID-19 on management and outcome for STEMI patients in Beijing – A single-center historic control study. Curr Probl Cardiol 2021;46:100693.  Back to cited text no. 20
    
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14], [Table 15], [Table 16], [Table 17]



 

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