Effects of the COVID-19 pandemic on the management of ST-Segment elevation myocardial infarction in Indonesia: a cohort study

Introduction

ST-segment elevation myocardial infarction (STEMI) as one of the acute coronary syndromes is a condition of acute transmural myocardium ischemia, which causes injury or necrosis of the myocardium with a high mortality rate.¹ The management of STEMI including identification, triage, and reperfusion must be performed as soon as possible to prevent further damage to the myocardium. Reperfusion therapy as the main therapy of STEMI plays an important role to improve patients’ clinical outcomes.² Reperfusion therapy may include fibrinolytic and primary percutaneous coronary intervention (PPCI). However, PPCI is more preferably recommended since it has been proven to provide better clinical results.³

The emergence of coronavirus disease (COVID-19), which is caused by severe acute respiratory syndrome virus 2 (SARS-CoV-2), has made some impact on healthcare services. The high rate of disease transmission of SARS-CoV-2 has created changes in the algorithm of diagnosis and therapy in hospitals.^4–6 Additional screening COVID-19 tests, wearing personal protective equipment, and performing disinfection of medical equipment and wards must be done to prevent the possibility of transmission.^7,8 These conditions have potential to hamper treatment response in managing patients with emergency conditions including STEMI.^5,9 Additionally, reperfusion therapy using PPCI may need more time considering the high risk of transmission whenever the procedure should be done with the unidentified status of their COVID-19 infection.¹⁰

In response to those obstacles, some countries have changed their policy on the management of STEMI patients by prioritizing fibrinolytic therapy.^4–6,11,12 This policy has also been applied in Dr. Cipto Mangunkusumo Hospital (CMH). Therefore, this study aimed to provide knowledge about the effects of the COVID-19 pandemic on the management of STEMI patients in Indonesia.

Methods

Results

STEMI patients’ visit to the hospital during COVID-19

During the COVID-19 pandemic period, there was a reduced number of monthly hospital admission, i.e., from an average visit of 11 patients to 7 patients (p = 0.002). The percentage of STEMI patients who came with a duration of symptoms-to-hospital of <12 hours had found reduced from 68.1% to 49.2%, while symptoms-to-hospital of >12 hours increased from 31.9% to 50.8% (p < 0.001). The average symptoms to hospital time of STEMI patients before COVID-19 pandemic was 8 hours, while during the COVID-19 pandemic, it prolonged to 12 hours (p = 0.005) (Figure 1).

Figure 1. Symptoms-to-hospital before and during COVID-19.

The significantly prolonged duration of symptoms-to-hospital was found during COVID-19 pandemic compared to before COVID-19 pandemic.

Management of STEMI during COVID-19 pandemic

We found a statistically significant decrease in the use of PPCI procedure from 65.2% to 27.8% (p < 0.001) and increase in the use of fibrinolytic (1.5% vs. 9.5%, p < 0.001) and conservative therapy (28.5% vs. 55.6%, p < 0.001). However, the number of patients who underwent urgent PCI was not statistically significant (4.9% vs. 7.1%, p = 0.360) (Figure 2). The door-to-wire crossing time showed a statistically significant increase during COVID-19 pandemic (160 minutes vs. 186 minutes, p = 0.005). Furthermore, we also found the difference in door-to-diagnosis time for PPCI was statistically significant (15 minutes vs. 35 minutes, p = 0.004), but the difference in diagnosis-to-wire crossing time and ischemic time for PPCI were not statistically significant [(136 minutes vs. 134.5 minutes, p = 0.382), (521 minutes vs. 488 minutes, p = 0.421), respectively]. The duration of fibrinolytic therapy, including door-to-needle time (151 minutes vs. 158 minutes, p = 0.953), door-to-diagnosis time for fibrinolytic (16 minutes vs. 12 minutes, p = 0.571), diagnosis-to-needle time (130 minutes vs. 155 minutes, p = 0.851), and ischemic time (321.5 minutes vs. 400.5 minutes, p = 0.599) showed no statistically significant difference.

Figure 2. The illustration of COVID-19 pandemic impact on STEMI patients visits and the reperfusion strategy.

Panel A shows monthly hospital admission of STEMI patients seems to have decreased during the pandemic and it was accompanied by the strategies of reperfusion. Panel B shows a decreased significantly the percentage of PPCI and fibrinolytic as well as conservative increased, meanwhile, urgent PCI was not statistically affected. Abbreviation: PPCI: percutaneous coronary intervention, urgent PCI: urgent percutaneous coronary intervention. Panel A i.e., the COVID-19 daily new cases has been reproduced with permission from Ministry of Health of the Republic of Indonesia [https://covid19.go.id/].

Discussion

This study found that during the COVID-19 pandemic, there was a significant decrease in the average number of monthly of STEMI related hospital admissions compared to before the COVID-19 pandemic period (11 patients vs. 7 patients, p = 0.002). We also found that the STEMI patients who came to the hospital were dominated by those who experienced the onset of symptoms >12 hours earlier with a median time of 12 hours. Some hypotheses can explain those findings: first, during the pandemic, STEMI patients hesitate to visit hospitals as they may be afraid of COVID-19 exposure when they come to the healthcare facilities; second, there is the large-scale social restriction or emergency public activity restriction in Indonesia, therefore, patient access to healthcare facilities becomes limited; third, the lack of cost to visit healthcare facilities and other socio-economic reasons. Although Indonesia has implemented a national health insurance system, some patients have not register to that system yet. Moreover, the cost of some aspects are not covered, such as transportation to CMH because not every patients is transported with ambulance facilities. The accommodation for the families and relatives who accompany the patients is also not covered by this insurance. In COVID-19 pandemic era, the patients could not be accompanied by other relatives due to the risk of transmission thus, the relatives often stayed outside the hospital, in local homestays provided by government and non-government organization.

The reduced number of patients who came to ED during COVID-19 has also occurred in numerous places for extremely varying reasons and these reasons are still speculative.^9,15–18 A study conducted in France has suggested that the reason for reduced patient visits to ED was that the patients were afraid to get exposed to COVID-19 when they must visit the hospital or they were worried that they would become a burden to healthcare personnel during the difficult time of fighting the pandemic.¹⁶ In addition, the factor of persuasion on “stay at home” or lockdown during a pandemic may also have a great contribution to the decrease of patient visits.¹⁶ A study in Italy has suggested some other hypotheses on the reduced number of visits, i.e. changes to a healthier lifestyle due to the policy to stay at home; therefore, the stress and air pollution levels, which are one of the triggering factors of the coronary event, become less and on the contrary, the feeling of scared being exposed to COVID-19 or misinterpretation of the “stay at home” instruction may also cause patients to not visit hospital although they experience myocardial infarct symptoms.¹⁷ Changes in hospital policy that gives a greater priority to COVID-19 patients and executes deferral for patients without any emergency may also become a reason for reduced admission of STEMI patients.¹⁹ Lack of education associated with symptoms of heart attack and COVID-19 may also become a factor that can affect the reduced number of visits of STEMI patients who came to the hospital during the COVID-19 pandemic.²⁰

The number of PPCI procedures in CMH showed a significant decrease during pandemic when compared to before the COVID-19 pandemic period (65.2% vs. 27.8%, p < 0.001), while the number of patients who had fibrinolytic (1.5% vs. 9.5%, p < 0.001) and conservative therapy (28.5% vs. 55.6%, p < 0.001) increased. The illustration of COVID-19 daily new cases in Indonesia and STEMI patients with different reperfusion strategies in CMH is depicted in Figure 2. These changes in reperfusion strategies during COVID-19 in STEMI patients were influenced by new policies that were applied in CMH.²⁶ These included a recommendation for using fibrinolytic therapy as first-line treatment for STEMI patients with an onset of <12 hours without any contraindications for fibrinolytic agents and the hemodynamic is stable. The policy is established by considering the status of COVID-19 infection in STEMI patients, which is mostly unidentified before admission and it takes a long time for the COVID-19 test results to be confirmed. Three days were required to get the result of the COVID-19 test and other regions need to wait even longer (up to 8 days).²¹ Additionally, the absence of a negative-pressure catheterization room and other obstacles may occur because the process of establishing a COVID-19 diagnosis takes place before the reperfusion procedure is performed. Polymerase chain reaction (PCR) tests, the standard diagnostic tool of COVID-19, were scarce, particularly at the beginning of the pandemic in Indonesia when there were only the Ministry of Health’s Research and Development Agency and other three institutions designated as COVID-19 test referral lab.²¹ Therefore, a significant amount of time was needed to establish the diagnosis of COVID-19, and the PPCI procedure for STEMI patients can be potentially delayed. This policy has also been applied by some countries such as China, Taiwan, Palestine, Iran, and India.^4–6,11,12 Fibrinolytic therapy is considered as it can reduce the delay time that occurs in STEMI patients during COVID-19 pandemic.

In STEMI patients who underwent PPCI, it was observed that the door-to-diagnosis time and door-to-wire crossing time were significantly longer during COVID-19 pandemic (Figure 3). This can be explained by the occurrence of additional screening COVID-19 tests and procedures to prevent nosocomial infection in ED, from the patients came until the diagnosis can be established. These new procedures include using personal protective equipment, performing disinfection of equipment including electrocardiogram before its usage, and screening the status of COVID-19 infection, i.e including radiology examination, laboratory tests, and questionnaire COVID-19 screening (Figure 4). Meanwhile, the difference in door-to-needle time was found to be not statistically significant. This indicates that basic management for fibrinolytic therapy has not been changed. Patients with STEMI can receive fibrinolytic therapy without waiting for the establishment of COVID-19 status. Right after STEMI was established, patients who fulfill the criteria can receive the fibrinolytic agent. Hence, there are no differences between before and during COVID-19 period for fibrinolytic therapy. The condition of prolonged reperfusion time, both door-to-needle time and door-to-wire crossing time, during COVID-19 pandemic has been reported in previous studies.^5,9,22–24 Two studies from China have demonstrated a significantly prolonged time between before and during the pandemic.^5,9 However, other studies in Turkey, England, and Canada have suggested results that are not significantly different, before and during the pandemic.^22–24 These differences may occur since there are some differences in determining policy for reperfusion therapy and the availability of equipment, facility, and catheterization room during the COVID-19 pandemic.

Figure 3. Door-to-wire crossing time before and during COVID-19.

The prolonged duration of door-to-wire-crossing time was significantly observed during COVID-19 pandemic compared to before COVID-19 pandemic.

Figure 4. The illustration for diagnosis and therapy of STEMI patients during COVID-19 in Dr. Cipto Mangunkusumo Hospital.

According to the policy, there is an additional screening for COVID-19 status for all patients that may delay the treatment.²⁶

Another finding that we observed was the patient's clinical outcome during hospitalization. In this study, it was found that there was no significant difference in mortality and MACE in STEMI patients during the COVID-19 pandemic period. This indicates that there is no substantial difference in terms of the quality to give treatment for STEMI patients.

Our study was conducted in CMH which serves as the national referral hospital that may provide a general profile of the STEMI patient population in Indonesia during the COVID-19 pandemic.

Conclusions

In conclusion, this study found that the number of STEMI patients in CMH declined in monthly hospital admission. There were delays in symptoms-to-hospital time, changes in the type of reperfusion strategy, and delays in door-to-diagnosis time in PPCI and door-to-wire-crossing time. Meanwhile, the duration of fibrinolytic therapy and clinical outcomes were not affected. This study was a retrospective cohort study by analyzing the electronic medical records from our institution. More clinical and basic research is needed in the future to provide the assessment, risk factors, and treatment of STEMI patients during the COVID-19 pandemic.

Data availability