Impact of the COVID-19 Pandemic on Acute Coronary Syndrome and Stroke Volumes in Non-Western Countries.

The Coronavirus disease 2019 (COVID-19) has profoundly disrupted healthcare services both by a massive influx of critical COVID-19 patients and through indirect effects, including medical care avoidance behaviors and the decreased efficiency of existing pathways of care [1]. The indirect impact of COVID-19 on cardiovascular and cerebrovascular care has been poorly characterized outside North America and Europe, particularly in non-Western developing countries.

We conducted a multinational retrospective survey analyzing the overall volume and the delays in presentation of acute coronary syndromes (ACS) and ischemic strokes during the COVID-19 pandemic (January 1st to April 30th, 2020), comparing with historical controls (same period in 2019). All the centers involved had access to primary percutaneous coronary intervention (PCI) and had stroke unit performing thrombolysis. Data about <12-hour ST elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI) undergoing invasive evaluation, and ischemic strokes were obtained from database managers in each participating center.

A total of 8 centers in 4 countries contributed to the survey [Russia (4), Brazil (2), Kingdom of Saudi Arabia (1), Tunisia (1)]. While the ACS volume tended to increase in January and February 2020 in comparison to the same period in 2019, in March and April 2020 the number of STEMI decreased by 17.6% and 39.2%, respectively, as well as the number of NSTEMI (by 9.6% and 26.4%, respectively) in comparison with March and April 2019. A gradual decrease in stroke cases along the first trimester was found (January −1.6%, February −3.1%, March −5.8%) when comparing 2020 to 2019, followed by 3.5% increase in April 2020 in comparison to March 2020 (Fig. 1A).

Fig. 1

STEMI, NSTEMI and ischemic strokes volumes and delays in the first quadrimesters of 2019 and 2020.

A) STEMI, NSTEMI and ischemic stroke volumes in 2019 and 2020

B) STEMI and ischemic stroke delays in 2019 and 2020

STEMI=ST elevation myocardial infarction; NSTEMI=Non ST elevation myocardial infarction.

Early STEMI presentation (≤2 h) was less often encountered in the first quadrimester of 2020 in comparison with the first quadrimester of 2019 (p < 0.001). Conversely, the delays of ischemic strokes were similar between the two periods (Fig. 1B).

Our findings showed that the number of ACS patients requiring invasive approach started to decrease in March 2020 while no significant change in ischemic stroke volume was found along the first quadrimester of 2020 in comparison with the same period of 2019.

In United States, Garcia et al. [2] reported a 38% decrease in cardiac catheterization laboratory STEMI activations. This was similar to reductions in PCI rates for ACS observed in Italy (32%), Spain (40%) and Austria (39.6%) [1,3].

In Spain, Tejada Meza et al. [4] reported that the number of stroke significantly dropped following the COVID-19 outbreak, which paralleled the number of stroke patients who received intravenous thrombolysis and/or endovascular therapy.

Several explanations could be identified. Patients are hesitant in seeking care due to concerns about possible in-hospital COVID-19 contagion. This latter fact is more relevant for ACS than for stroke, being this latter generally perceived as more worrying, which leads to emergency consultation. Second, the need to limit invasive procedures resulted in increased indication of conservative management whenever possible. Furthermore, social isolation, strict lockdown rules and the reduction in daily stressors and pollution could represent further explanations of our findings. Finally, patients could be at higher risk of dying at home from these conditions if they do not seek emergency services [1].

It can be thought that delays in seeking acute care according to benchmarks have less of an impact in developing countries as there is generally less patients awareness, less emergency medical services access, and less efficient healthcare networks. Still, we observed an increase in patients with >2 h delays in the setting of STEMI. Late presentations might be responsible for an increased incidence of previously uncommon mechanical complications of myocardial infarction [5].

The current study had some limitations. First, only tertiary centers have been included which might be against the generalization of the findings to primary and secondary healthcare centers. Second, only NSTEMI patients who underwent invasive approach were included, which likely led to underestimation. Third, no data were available regarding COVID-19 positivity in ACS and stroke patients, as this was beyond the scope of the current survey. Finally, no mortality data were available to assess the real impact of delays in seeking care during COVID-19 outbreaks. Nonetheless, to the best of our knowledge, this is the first multinational study that quantifies the impact of COVID-19 pandemic on ACS and stroke care in non-Western countries.

Declaration of competing interest

None to declare.