STEMI and COVID-19: Unmasking failures and opportunities to enhance future care.

The COVID‐19 pandemic has altered how patients perceive healthcare and the practice of medicine. These media perceptions have had consequences on patients whether they need immediate care or elective therapies. Exemplary are patients that require urgent treatment for ST‐segment elevation myocardial infarction (STEMI). Such patients may contribute to delayed care due to the fear of acquiring COVID‐19. Yet, overburdened health systems and diversion of resources towards COVID care may also be accountable for substandard outcomes. After admission, the pressure to reduce the length‐of‐stay to mitigate the potential for hospital‐acquired COVID may also truncate guideline‐based care delivery. These unwarranted consequences require consideration.

Hammad et al shed light on potential consequences by objectively affirming it in a retrospective review. They compared the pre‐ and postpandemic outcomes in STEMI care in an area that was not affected by COVID‐19 to the point of health care collapse. These authors noted that post‐COVID‐19 patients had new Q‐waves, high door‐to‐balloon times, and higher initial peak troponins, all significant predictors of mortality. STEMI patients after the COVID had a relatively reduced length‐of‐stay despite their high‐risk characteristics. Almost 1/4th of the study population avoided the emergency department (ED) for fear of contracting the virus, 18% attributed their symptoms to the virus, and 9% altruistically did not want to burden the ED during the surge. These changes occurred despite the population residing in an area where the March–April 2020 COVID‐19 surge did not overburden health care.

Whether these actions were patient‐ or system‐related, the implications suggest a grim outcome. While mortality was not studied in the present study, the findings noted are well‐known predictors of adverse outcome. A recent meta‐analysis of STEMI before and during the first part of the COVID pandemic showed longer door‐to‐balloon times during COVID; short‐term mortality remained similar with only a higher trend seen in the COVID era. Another contemporary study has shown an increase in out‐of‐hospital arrests occurring during COVID, although no study can yet define long‐term mortality. While COVID‐19 protocols may have contributed to increased door‐to‐balloon times, reports have found a numerical decrease in PCI procedures during the pandemic. Increased use of conservative medical management was sought after, especially in selected cases with presumptive COVID‐19 infection and in those with a low‐likelihood of mortality from STEMI. Media coverage and misinformation about over‐burdened health systems reported on specific situations that should not have been generalized. At our tertiary care health system, the maximum number of COVID‐19 patients during the March–April surge was far less than we anticipated. Yet, we also witnessed a significant fall‐off in inpatient care for STEMI. Public perception based on national media may have translated into personal actions taken by patients and their families that likely adversely affected their health outcomes. There needs to be public recognition that hospitals never take away life sustaining care even in a pandemic. Despite the excitement of a novel health crisis, this message must not be lost on the populations we serve.

Early on in the COVID‐19 pandemic, Bangalore et al. described a case series from New York City, one of the first wave's epicenters. Attributing the troponin elevation to a non‐acute coronary syndrome cause, apprehension regarding performing a procedure during an unforeseeable effect of the virus was among the many reasons why care was delayed. Another contributor included delayed STEMI activation due to confusion related to COVID‐19 induced myopericarditis versus other troponin release causes. It is known that myocardial injury may occur in 7–20% of cases based on a literature review; however, the extent of underlying coronary artery disease in these populations is difficult to ascertain. Delayed presentations have led to re‐emergence of rarely seen complications such as ventricular septal defect (VSD) or ventricular wall rupture. At the beginning of the pandemic, misleading or poorly vetted understanding about the modes of spread, effective personal protective equipment usage, decreased staffing, provider hesitancy, and difficulties in testing may have contributed to the delays and outcomes. As we have progressed further into the pandemic and understand the disease process's pathophysiology, we are now better equipped to perform procedures with minimal risk.

At this time, we are now experiencing the second wave or winter surge. The message at this junction focus should encourage patients to seek medical care for any or all urgent conditions, including emergent non‐COVID‐related conditions despite the pandemic. Promoting telehealth, advocating for risk‐mitigation strategies when patients present to the hospital, and training clinicians to avoid anchoring bias in the pandemic era are some strategies to decrease the adverse outcomes in STEMI care. This approach requires a multi‐disciplinary collaboration, and the need to ramp effort is now and fortunately is being recognized by our professional societies. Heart disease remains the number one cause of death in 2020; despite the pandemic, this message cannot be lost.