Introduction
The SARS-CoV-2 pandemic has caused significant public health issues, first from direct implications of viral infection, such as pneumonitis, thrombophilia and myocarditis, and second, from staffing shortages and public fears with regard to hospital attendance.1 The respiratory manifestations of SARS-CoV-2 infection has been well documented across the literature, however, the implications of the pandemic on the cardiovascular health of a population are less well known.2
A report from Hong Kong noted a significant mean time delay in hospital presentation in patients with ST elevation myocardial infarction (STEMI) from 82.5 min at baseline to 318 min during the pandemic in a small cohort of patients. Although not reported in the paper, given the time critical nature of STEMI management, it is assumed a significant increase in patient morbidity and mortality may be incurred as a result.3 A recent paper published data from another primary percutaneous coronary intervention (PPCI) centre in the Ireland reported a significant increase in total ischaemic time (TIT), driven by patient delays in seeking medical attention, with further studies published from other centres in Europe reporting similar results.4 5 Furthermore, a British study reported startling delays in time of symptoms onset to first medical contact (FMC), with an increase in the 75 percentile from 3.4 to 13.2 hours.6 Additionally, a recent survey carried out by the European Society of Cardiology (ESC) suggested a perceived 50% reduction in STEMI presentations globally with respondents reporting 48% of patients presented later than usual during the pandemic.7 Reports from other fields of medicine, such as stroke, where time dependent treatments are also crucial mirror these unsettling findings.8
Finally, the impact of the pandemic has had significant effects on the management of chronic coronary syndrome (CCS). One multicentre study reported a 74% reduction in number of elective invasive coronary procedures performed for patients with CCS. Additionally, there was, however, a significant increase in the proportion of acute coronary syndrome (ACS) presentations versus the previous year. Significant delays from FMC to wire cross were seen in patients with COVID-19, which was attributed to catheterisation lab preparation times.9
This study was carried out in St James’ Hospital which is the largest primary PCI centre in the Ireland performing 25.8% of national cases.10 In keeping with ESC guidance, a target time from FMC to wire cross is <90 min, with increasing delays in revascularisation associated with poorer outcomes.11 12
COVID-19 cardiac catheterisation infection control procedures such as the use of personal protective equipment (PPE), using a dedicated COVID-19 lab and routine COVID-19 screening were implemented in our centre in line with international guidance.13 Given the concerning body of evidence being published internationally suggesting significant delays in STEMI management, we aimed to report on our experience in terms of STEMI management during, and after, the COVID-19 lockdown to identify important patient and system factors influencing care.