Treatment Delays and In-Hospital Outcomes in Acute Myocardial Infarction During the COVID-19 Pandemic: A Nationwide Study

Background: Delay on admission of myocardial infarction (MI) is an important prognostic factor. In this nationwide registry, we compared treatment delays and outcomes of patients with acute MI in Covid-19 pandemic period with a recent pre-pandemic registry conducted at the same centres. Methods: A recent nationwide registry (TURKMI-1) enrolled consecutive patients with acute MI in November 1-15, 2018 in Turkey, and assessed time delay at each step from symptom-onset to treatment and outcomes. Fifty centres were selected using probability sampling. In the present study (TURKMI-2), the same information was obtained from 48 of the same 50 centres during the pandemic between April 17 and May 2, 2020. Findings: In a 2-week period, 991 patients (51·1% NSTEMI, 48·9% STEMI) were admitted to the study centres within the 48-hour of symptom-onset. Compared with the TURKMI-1, admissions decreased by 31·2% in ST-segment elevation MI (STEMI), and 56·4% in non-STEMI (NSTEMI). Median time from symptom-onset to hospital-arrival increased from 295 min to 419 min in NSTEMI, and from 150 min to 185 min in STEMI (p-values <0·001). Door-to-balloon time was similar in the two periods (37 vs. 40 min, p=0·448), however, total ischaemic time increased significantly (195 min vs 245 min, p=0·001) mainly due to patient-related delay. Percutaneous coronary intervention (PCI) was decreased especially in the NSTEMI group (60·3% vs 47·4% in NSTEMI, p<0·001; 94·8% vs 91·1% in STEMI, p=0·013). Major cardiac adverse events (MACE) defined as in-hospital death, heart failure, or cardiogenic shock were significantly higher in the pandemic period compared to non-pandemic (4·8% vs 8·9%; p <0·001). Age and sex adjusted risk of MACE was two times higher during pandemic (Odds ratio [95% confidence interval] was 1·96 [1·20-3·22] for NSTEMI, p=0·007; and 2·08 [1·38-3·13] for STEMI, p<0·001). Interpretation: Besides the overall 47·1% reduction in acute MI admissions, there was a significant patient related treatment delay during the pandemic. Although PCI was performed in a timely fashion, increase in total ischaemic time and decrease in PCI might be responsible for the increased risk of MACE in acute MI. Funding: This investigator-initiated study was funded by the Turkish Society of Cardiology, which received unrestricted grant from Astra-Zeneca Company for this project. Declaration of Interests: Dr. Kayikcioglu reports grants from Astra Zeneca, during the conduct of the study; grants from Aegerion, other from Astra Zeneca, other from Menarini, non-financial support and other from Abbott, outside the submitted work; - Dr. Aktas reports non-financial support from Astra Zeneca, during the conduct of the study - Dr. Kilickap reports grants from Astra_Zeneca, during the conduct of the study - Dr. Zeybey reports grants from Astra Zeneca, during the conduct of the study - Dr. Inci reports grants from Astra Zeneca , during the conduct of the study - Dr. Er reports grants from Astra Zeneca, during the conduct of the study - Dr. Kahraman reports grants from Astra Zeneca, during the conduct of the study - Dr. Yayla reports grants from Astra Zeneca, during the conduct of the study - Dr. Kafkas reports grants from Astra Zeneca, during the conduct of the study - Dr. Yildirim reports grants from Astra Zeneca, during the conduct of the study - Dr. can reports grants from ASTRA-ZENECA, during the conduct of the study - Dr Erol reports grands from Astra Zeneca, during the conduct of the study, - Dr. Yalcin reports grants from Astra Zeneca, during the conduct of the study - Dr. Guler reports grants from Astra Zeneca, during the conduct of the study - Dr. Arin reports grants from Astra-Zeneca, during the conduct of the study - Dr. Genc reports grants and non-financial support from Astra Zeneca, during the conduct of the study Ethics Approval Statement: The study protocol was approved by the Institutional Review Board (Ankara University Medical School; May 7, 2020; No: i4-225-20) and the Ministry of Health COVID-19 Scientific Board (May 6, 2020 No: 66175679.99.E.110223).