Recently, a significant reduction in ST-elevation myocardial infarction (STEMI) admission was reported from the United States and Europe where the coronavirus disease (COVID-19) caused a public health crisis.1 , 2 The door-to-device time of primary percutaneous coronary intervention (PPCI) was also delayed.3 The COVID-19 pandemic has a much less impact in Taiwan because early actions to prevent community outbreak were taken from January 2020 when mystery pneumonia in Wuhan, China was found.4 As to May 2020, there were only 443 confirmed cases in 23 million population in Taiwan and most patients were imported cases from February to April, 2020. The public health response in Taiwan became a role model to flatten the infection curve of COVID-19.
We conducted a multicenter, observational, nationwide survey to collect data of STEMI cases from February 1 to April 30, 2020 (COVID-19 pandemic period) and compared the data with the same period in 2019. The following data were collected: (1) the number of patients admitted for STEMI, (2) symptom onset-to-door time, (3) door-to-device time of PPCI, and (4) use of fibrinolytic therapy. Symptom onset-to-door time is defined as the time between first patient- or family-reported symptom onset and patients' arrival at the hospitals. Door-to-device time is defined as the time between patients’ arrival at the hospitals and successful wire crossing or balloon inflation during PPCI. Data were presented with mean ± standard deviation for average case number or medians and interquartile ranges for times. Comparisons were performed by paired Student t test for case number and Wilcoxon rank sum test for times. Overall, 42 major hospitals with 24-hour primary PCI service participated the survey and 40 (95.2%) provided the data for analysis. Compared with February to April, 2019 (n = 1,092), there was no significant reduction of admission for STEMI in 2020 (n = 1,038) with COVID-19 pandemic (average case number per hospital, 27.3 ± 18.4 vs 26.0 ± 16.7, p = 0.27). The door-to-device time was similar between 2019 and 2020, but there was a significant increase of symptom onset-to-door time in 2020 (142 [75 to 338] vs 180 [84 to 460] min, p <0.01; Table 1 ). In 2020 with COVID-19 pandemic, none of the hospitals used fibrinolytic therapy and 9 out of 40 (22.5%) hospitals had experiences of wearing personal protective equipment to perform PCI for suspected cases with COVID-19.
Table 1.
The case number and primary PCI for STEMI before and after COVID-19 outbreak in Taiwan
| 2019 (Feb to Apr) (n = 1,092) | 2020 (Feb to Apr) (n = 1,038) | p value | |
|---|---|---|---|
| STEMI case number/hospital | 27.3 ± 18.4 | 26.0 ± 16.7 | 0.27 |
| Symptom onset-to-door time (min) | 142 (75-338) | 180 (84-460) | <0.01 |
| Door-to-device time (min) | 65 (50-81) | 66 (52-81) | 0.20 |
COVID-19 = coronavirus disease 2019; PCI = percutaneous coronary intervention; STEMI = ST-segment elevation myocardial infarction.
In Taiwan, adequate public health strategy diminished the impact of COVID-19 pandemic on healthcare system. There was no significant influence on admission and care quality of STEMI. Registry data in Taiwan showed the median door-to-device time was 96 minutes in 2010 and 71 minutes in 2015.5 The time was continuously decreased to 66 minutes in 2020 even in the COVID-19 pandemic. However, there was a significant delay of seeking medical help. The symptom onset-to-door time increased by 27% in 2020 compared with the equivalent months in 2019. There were no in-hospital transmission and healthcare personnel infection of COVID-19 in Taiwan. It is likely that the impression of virus spread from hospitalized patients with COVID-19 made patients reluctant to go to hospitals and delay in seeking care. In Italy, a similar reduction of STEMI admission was found in central and south parts where there were less cases of COVID-19 compared with the most affected north part.1 The risk of mortality and complications of STEMI also increased significantly.1 Further study is needed to evaluate whether delay in treatment also cause worse prognosis of STEMI in Taiwan. In conclusion, although there was no reduction of STEMI admission in Taiwan, a significant delay for medical help was found during the COVID-19 pandemic. Further actions are necessary to avoid the negative impact of COVID-19 pandemic on care of STEMI.
Disclosures
The authors have no conflicts of interest to disclose.
Footnotes
Dr. Li and Huang contributed equally to this work.
References
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