In the Journals

COVID-19 concerns may prompt patients with STEMI to delay seeking care

Since the onset of the COVID-19 pandemic in Hong Kong, patients with STEMI have been delaying first medical contact, perhaps because of reluctance to visit a hospital, according to a research letter published in Circulation: Cardiovascular Quality and Outcomes.

Chor-Cheung Frankie Tam, MBBS, associate consultant and honorary clinical assistant professor at Queen Mary Hospital, University of Hong Kong, and colleagues compared metrics between seven patients who underwent primary PCI for STEMI at Queen Mary Hospital between Jan. 25 and Feb. 10, 2020, during which Hong Kong hospitals implemented stringent infection control measures, with 108 patients who did so between Feb. 1, 2018, and Jan. 31, 2019.

Among the seven patients who presented in 2020, none had COVID-19 and six arrived during normal office hours, defined as 8 a.m. to 8 p.m. on a weekday. Among the 108 patients from 2018-2019, 48 arrived during normal office hours and 60 arrived at other times.

The mean time between symptom onset and first medical contact was 318 minutes (interquartile range [IQR], 75-458) vs. 82.5 minutes for the 2018-2019 cohort that arrived during normal office hours (IQR, 32.5-195) and 91.5 minutes for the 2018-2019 cohort that arrived during non-office hours (IQR, 35.25-232.75), the researchers wrote.

Large delays

“We found large delays in the small number of patients with STEMI seeking medical help

after institution of these infection control measures,” Tam and colleagues wrote. “It is understandable that people are reluctant to go to a hospital during the COVID-19 outbreak, which explains the potential delays in seeking care. Another concern that we are unable to evaluate is whether some patients with STEMI did not seek care at all. Delays in seeking care or not seeking care could have a detrimental impact on outcomes.”

Door-to-device time was longer in the 2020 cohort (110 minutes; IQR, 93-142) than in the 2018-2019 normal-hours cohort (84.5 minutes; IQR, 65.25-109.75), but shorter than in the 2018-2019 non-office hours cohort (129 minutes; IQR, 106-159), according to the researchers.

Cath lab arrival-to-device time was longer in the 2020 cohort than either of the 2018-2019 cohorts (2020, 33 minutes; IQR, 21-37; 2018-2019 normal hours, 20.5 minutes; IQR, 16-27.75; 2018-2019 non-office hours, 24 minutes; IQR, 18-30), the researchers found.

“Catheterization laboratories generally have positive pressure ventilation, so COVID-19 infection inside these rooms can theoretically cause widespread contamination of the surrounding environment,” Tam and colleagues wrote. “Precautions such as detailed travel and contact history, symptomatology and chest X-ray, therefore, are taken before transferring patients to the catheterization laboratory at our hospital. Although these are essential measures for containing COVID-19 infection, this could increase delays in diagnosis, staff activation and transfer if health care systems are not prepared. Similarly, even after patients arrived in the catheterization laboratory, staff may need more time to wear protective gear to prepare the patients and interventional cardiologists may not be used to performing primary PCI while in full protective gear, leading to longer treatment.”

It is possible the metrics will improve over time as clinicians get more familiar with the new protocols, the researchers wrote.

“Although we cannot make meaningful statistical [calculations], our description allows for an early examination into how public health emergencies can indirectly affect unrelated

hospital areas,” Tam and colleagues wrote.

Late presentation

The researchers acknowledge that causes for late presentation are “likely multifactorial and may include patient fear of contracting an infection from the health care system or by limited emergency medical services due to sick staff or systemic overload,” Amer K. Ardati, MD, MSc, assistant professor of medicine, interventional cardiologist and director of the UIC Critical Care Unit at the University of Illinois-Chicago, and Alfredo J. Mena Lora, MD, clinical assistant professor of medicine at the University of Illinois-Chicago and medical director of infection control at Saint Anthony Hospital, wrote in a related editorial. “Public health departments, emergency medical services and hospitals will need to maintain the highest standards of infection control to earn community trust. Additionally, mass public education efforts will need to assure patients that health care services remain operational and safe for use. Internal process delays need to be anticipated, especially since stresses on the system are likely to affect critical supply chains for essential medicines and equipment. Cardiac centers should consider the need to defer elective procedures and to carefully monitor employee health and availability for duty.” – by Erik Swain

Disclosures: The study and editorial authors report no relevant financial disclosures.

Since the onset of the COVID-19 pandemic in Hong Kong, patients with STEMI have been delaying first medical contact, perhaps because of reluctance to visit a hospital, according to a research letter published in Circulation: Cardiovascular Quality and Outcomes.

Chor-Cheung Frankie Tam, MBBS, associate consultant and honorary clinical assistant professor at Queen Mary Hospital, University of Hong Kong, and colleagues compared metrics between seven patients who underwent primary PCI for STEMI at Queen Mary Hospital between Jan. 25 and Feb. 10, 2020, during which Hong Kong hospitals implemented stringent infection control measures, with 108 patients who did so between Feb. 1, 2018, and Jan. 31, 2019.

Among the seven patients who presented in 2020, none had COVID-19 and six arrived during normal office hours, defined as 8 a.m. to 8 p.m. on a weekday. Among the 108 patients from 2018-2019, 48 arrived during normal office hours and 60 arrived at other times.

The mean time between symptom onset and first medical contact was 318 minutes (interquartile range [IQR], 75-458) vs. 82.5 minutes for the 2018-2019 cohort that arrived during normal office hours (IQR, 32.5-195) and 91.5 minutes for the 2018-2019 cohort that arrived during non-office hours (IQR, 35.25-232.75), the researchers wrote.

Large delays

“We found large delays in the small number of patients with STEMI seeking medical help

after institution of these infection control measures,” Tam and colleagues wrote. “It is understandable that people are reluctant to go to a hospital during the COVID-19 outbreak, which explains the potential delays in seeking care. Another concern that we are unable to evaluate is whether some patients with STEMI did not seek care at all. Delays in seeking care or not seeking care could have a detrimental impact on outcomes.”

Door-to-device time was longer in the 2020 cohort (110 minutes; IQR, 93-142) than in the 2018-2019 normal-hours cohort (84.5 minutes; IQR, 65.25-109.75), but shorter than in the 2018-2019 non-office hours cohort (129 minutes; IQR, 106-159), according to the researchers.

Cath lab arrival-to-device time was longer in the 2020 cohort than either of the 2018-2019 cohorts (2020, 33 minutes; IQR, 21-37; 2018-2019 normal hours, 20.5 minutes; IQR, 16-27.75; 2018-2019 non-office hours, 24 minutes; IQR, 18-30), the researchers found.

“Catheterization laboratories generally have positive pressure ventilation, so COVID-19 infection inside these rooms can theoretically cause widespread contamination of the surrounding environment,” Tam and colleagues wrote. “Precautions such as detailed travel and contact history, symptomatology and chest X-ray, therefore, are taken before transferring patients to the catheterization laboratory at our hospital. Although these are essential measures for containing COVID-19 infection, this could increase delays in diagnosis, staff activation and transfer if health care systems are not prepared. Similarly, even after patients arrived in the catheterization laboratory, staff may need more time to wear protective gear to prepare the patients and interventional cardiologists may not be used to performing primary PCI while in full protective gear, leading to longer treatment.”

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It is possible the metrics will improve over time as clinicians get more familiar with the new protocols, the researchers wrote.

“Although we cannot make meaningful statistical [calculations], our description allows for an early examination into how public health emergencies can indirectly affect unrelated

hospital areas,” Tam and colleagues wrote.

Late presentation

The researchers acknowledge that causes for late presentation are “likely multifactorial and may include patient fear of contracting an infection from the health care system or by limited emergency medical services due to sick staff or systemic overload,” Amer K. Ardati, MD, MSc, assistant professor of medicine, interventional cardiologist and director of the UIC Critical Care Unit at the University of Illinois-Chicago, and Alfredo J. Mena Lora, MD, clinical assistant professor of medicine at the University of Illinois-Chicago and medical director of infection control at Saint Anthony Hospital, wrote in a related editorial. “Public health departments, emergency medical services and hospitals will need to maintain the highest standards of infection control to earn community trust. Additionally, mass public education efforts will need to assure patients that health care services remain operational and safe for use. Internal process delays need to be anticipated, especially since stresses on the system are likely to affect critical supply chains for essential medicines and equipment. Cardiac centers should consider the need to defer elective procedures and to carefully monitor employee health and availability for duty.” – by Erik Swain

Disclosures: The study and editorial authors report no relevant financial disclosures.

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