Table 3.
Management, patient- and system-related delays and outcomes.
| Author, year of publication | Management | Patient- and system-related delays | Reasons for delays in seeking medical care | Length of stay | Outcomes related to management |
|---|---|---|---|---|---|
| Araiza-Garaygordobil, 2021 | Significant reduction of patients undergoing pPCI was observed (81.8% pre-pandemic vs. 76.2% pandemic, difference: −5.6%, p = 0.041). | The proportion of patients who developed any mechanical complication during the pandemic period was higher when compared with the pre-pandemic period (1.98% [23/1161] vs. 0.98% [41/4143], p = 0.006) and compared to the historical control (1.98% [23/1161] vs. 1.17% [30/2547], p = 0.057) | |||
| Mafham, 2020 | There were reductions in the number of PCI procedures for patients with both STEMI (438 PCI procedures per week in 2019 vs 346 by the end of March, 2020; percent reduction 21%) and NSTEMI (383 PCI procedures per week in 2019 vs 240 by the end of March, 2020; percent reduction 37%). | The median length of stay among patients with ACS fell from 4 days (IQR 2–9) in 2019 to 3 days (1–5) by the end of March, 2020. | No apparent change in in-hospital mortality among patients admitted with ACS in the period | ||
| Perrin, 2020 | Delay from symptom onset to first medical contact was longer among patients suffering from STEMI in the COVID-19 period compared with the control period (112 min vs 60 min, p = 0.049). Delayed presentations were reported in 18.2% and 9% of patients in the COVID-19 and control periods, respectively (p = 0.3) | ACS patients delayed their call to the emergency services mainly because of fear of contracting or spreading COVID-19 following hospital admission, as well as of adding burden to the healthcare system | Hospital length of stay was significantly shorter for the COVID-19 period as compared to the control period (6 vs 7 days, p = 0.03). | ||
| Tam, 2020 | Delay from symptom onset to first medical contact was longer among patients suffering from STEMI in the COVID-19 period compared with the pre-pandemic period. The proportion of patients who presented out of the revasculrization window during the pandemic period was higher when compared with the pre-pandemic period (33% vs 27.8%) | The primary composite outcome of in-hospital death, cardiogenic shock, sustained ventricular tachycardia or fibrillation and use of mechanical circulatory support was significantly higher during the pandemic period compared to pre-pandemic period (29.7% vs 14.1%, p = 0.02) | |||
| Toniolo, 2020 | |||||
| Huet, 2020 | |||||
| Kwok, 2020b | Compared with 2017–2019, patients admitted with primary PCI for STEMI in the month of April 2020 were more likely to have longer time from symptom-to-hospital (median 135 min vs 153 min, p = 0.004) and they also had a longer door-to-balloon time (48 (21–112) vs 37 (16–94) min, p < 0.001). | There was a shorter median length of stay postlockdown compared to prelockdown: 2 (1–3) days vs 3 (2−4) days, p < 0.001). | No significant differences in in-hospital death and MACE were observed overall | ||
| Boukhris, 2020 | There was increase in patients with >2 h delays in the setting of STEMI in the pandemic period compared to the same period in 2019. Delays in ischemic strokes were similar between the two periods | ||||
| Braiteh, 2020 | In NSTEMI patients, 36.4% presented late (>24 h of symptoms) during the COVID-19 pandemic in comparison with 2019 (27.1%, p = .033). | ||||
| Butt, 2020 | Overall length of stay was shorter during the pandemic period compared to March 2019. | Deaths - Compared to March 2019 (179), there was 19% increase in in-hospital deaths in March 2020 (221) (p = 0.05) | |||
| De Filippo, 2020 | |||||
| De Rosa, 2020 | Both patient- and system-related declared delays were substantially increased during the COVID-19 outbreak. Time from symptom onset to coronary angiography was increased by 39.2% in 2020 compared with the equivalent week in 2019, while the time from first medical contact to coronary revascularization was increased by 31.5%. | Case fatality rate during the pandemic was increased compared with 2019. | |||
| Fileti, 2020 | Among those admitted for ACS, 57 (79.1%) were treated with PCI in 2020, and 67 (71.2%) in 2019, with an overall 14.9% reduction. | Among STEMI patients, the rate of those with a time delay presentation from symptoms onset longer than 180 min was significantly higher during the pandemic period compared to 2019 | PCI procedural success and in-hospital mortality were not significantly different between the two periods | ||
| Folino, 2020 | |||||
| Haddad, 2020 | Longer delays between symptom onset and first medical contact were noted during the pandemic compared to pre-pandemic and control period | There were worse in-hospital outcomes (MACE, mechanical complications, death, other cardiac complications) during the pandemic compared to pre-pandemic and control period | |||
| Hauguel-Moreau, 2020 | Median symptom-onset-to-first medical contact time was significantly higher in 2020 than in the two previous years (600 min [298–632] versus 121 min [55–291], p < 0.001). There was also a delay in STEMI management (3-fold increase in ischemic time) | ||||
| Holy, 2020 | |||||
| Metzler, 2020 | |||||
| Montagnon, 2021 | For patients with ACS, the average time interval between the first symptoms and the consultation was shorter in 2020. However, the average time lapse between the consultation and subsequent cerebral imaging increased in 2020 compared with 2019. | ||||
| Showkathali, 2020 | The symptom to door time was prolonged in 2020 compared to 2019 | The duration of hospital stay was longer in 2020 compared to previous years | There was no difference in in-hospital mortality between the two study periods of 2020 and 2019 respectively | ||
| Sokolski, 2020 | The mean length of stay was significantly shorter in 2020 (4.9 days) in comparison to 2019 (5.9 days) | There was no statistically significant difference in death rates between studied periods: 107 (3.6%) in 2020 versus 175 (3.9%) deaths in 2019 | |||
| Solomon, 2020 | |||||
| Vacanti, 2020 | The total number of coronary angiographies and PCIs were lower in 2020 compared to 2019 and 2019 | ||||
| Yalamanchi, 2020 | The in-hospital mortality of patients was also similar in all 3 years | ||||
| Tsioufis, 2020 | |||||
| Gasior, 2020 | |||||
| Dreger, 2020 | Number of PCI in AMI patients also fell. | ||||
| Anderson, 2020 | |||||
| Gluckman, 2020 | Median length of stay for patients with AMI was shorter in the early COVID-19 period by 7 h and in the later COVID-19 period by 6 h compared with the before period. Similar trends were observed for STEMI and NSTEMI | Patients with STEMI had a statistically greater risk of mortality during the later COVID-19 period | |||
| Mohammad, 2020 | PCI was equally performed during the two periods | Time from symptom onset to PCI was shorter during the pandemic compared to the control period | No differences in all-cause mortality rates between the two periods | ||
| Piccolo, 2020 | |||||
| Secco, 2020 | Longer door-to-balloon and symptoms to PCI times in 2020 compared to 2019 | No difference in in-hospital mortality between the two periods. However, in 2020, patients had a lower discharged residual left ventricular function and an increased predicted late cardiovascular mortality | |||
| Ayad, 2021 | Time from first medical contact to needle was longer during the pandemic period. | Hospital length of stay was longer during the pandemic | In-hospital mortality, incidence of re-infarction and need for revascularization were higher during the pandemic period. Incidence of HF, stroke and bleeding was not different between the periods | ||
| Bhatt, 2020 | Hospital length of stay was shorter in March 2020: 4.8 (2.4−8.3) days compared with March 2019: 6.0 (3.1−9.6) days | In-hospital mortality was not significantly different between the two periods | |||
| Daoulah, 2021 | Timing from the onset of symptoms to the balloon of more than 12 h was higher during 2020 comparing to pre-COVID 19 | No differences in length of hospital stay | There were no differences with respect to in-hospital events (mortality, thrombosis, bleeding etc) | ||
| Desai, 2020 | Number of patients undergoing endovascular thrombectomy remained constant | ||||
| Diegoli, 2020 | No differences in number of patients provided with reperfusion therapies | No differences in time from onset to admission. | |||
| Gitt, 2020 | |||||
| Hammad, 2020 | Door-to-balloon time were not significantly different | (i) Fear of contracting COVID-19 (27%); (ii) Symptoms were COVID-19 related (18%); (iii) Did not want to burden the emergency dept (9%) | Shorter ICU duration and length of stay during the pandemic period: 2.3 vs 3.6 days | ||
| Kerleroux, 2020 | There was a significant increase in delays between imaging and groin puncture during the pandemic period | No difference in outcomes (successful reperfusion and in-hospital mortality) | |||
| Montaner, 2020 | Time from symptoms onset to arrival at hospital was delayed during the pandemic period. Door-to-needle time was delayed during the pandemic. However, mean times of arrival to thrombectomy reference center from symptoms onset improved during the pandemic | ||||
| Neves Briard, 2020 | Time from symptom onset to hospital presentation was longer during the pandemic period. Door-to-needle and door-to-recanalization metrics were also longer during the pandemic. A significantly smaller proportion of ischemic stroke patients was treated with thrombolysis or thrombectomy during the pandemic | ||||
| Pop, 2020 | There were 33.3% fewer acute revascularization treatments, 40.9% less intravenous thrombolysis and 27.6% less mechanical thrombectomy in 2020 | No significant differences in patient- and system-related delays. | |||
| Popovic, 2020 | Delayed hospital presentation in the pandemic period compared to control period | Higher in-hospital mortality in the pandemic period | |||
| Range, 2020 | Time from symptom onset to first medical contact was longer for lockdown group | Length of hospital stay was similar in both periods | There were higher rates of in-hospital MACE and mortality in the lockdown group but the differences were not significant. | ||
| Reinstadler, 2020 | Door-to-balloon times were constant during the period. Total ischemic times increased from 164 min (calendar week 9/10) to 237 min (calendar week 11/12) and to 275 min (calendar week 13/14) (p = 0.006). | Rates of in-hospital death and re-infarction were similar between groups | |||
| Sarfo, 2020 | Case fatality rate during the pandemic was increased compared with 2019. | ||||
| Teo, 2020 | Stroke onset-to-door arrival time was longer during the pandemic. There were no significant differences in the ambulance scene arrival to hospital arrival time, proportion of patients receiving reperfusion therapy, door-to-needle time, and mechanical thrombectomy procedural times during the 2 periods | ||||
| Toner, 2020 | Symptom-to-door time was longer during the COVID-19 period (4-fold increase). Proportion of patients presenting late was also higher during the pandemic period. | ||||
| Abdelaziz, 2020 | Delay in symptom-to-first medical contact during pandemic vs pre-COVID era. The door-to-balloon time was similar between both groups. | ||||
| Agarwal, 2020 | The time from symptom onset to presentation was not significantly different the two groups. There were longer median door to head CT and door to groin puncture times during the pandemic compared to pre-pandemic times. Time to alteplase administration, door to reperfusion times and defect-free care were similar in the pandemic and pre-pandemic groups | There was no difference in the length of hospital stay between the pandemic and pre-pandemic cohorts | Successful recanalization rates were similar between the two groups. Pandemic patients had increased discharge mortality in multivariable analysis compared to pre-pandemic patients | ||
| Burgos, 2020 | |||||
| Aldujeli, 2020 | NSTEMI: The median pain-to-door time was longer during the pandemic compared to pre-pandemic era. There was a significant delay in door-to-reperfusion time during the pandemic. There were 24 (80%) and 25 (42%) patients who presented after 12 h of pain onset in pandemic and pre-pandemic eras, respectively (p = 0.0006). STEMI: The median pain-to-door time during the pandemic was longer than that of the pre-pandemic. There were 22 (47%) and 14 (24%) patients who presented after 12 h of pain onset in the pandemic and prepandemic eras, respectively (p = 0.0127). There was no difference in delay in door-to-reperfusion time. | There were no differences in length of hospitalization between pandemic and pre-pandemic eras. | There were no differences in in-hospital death, or stroke between pandemic and pre-pandemic eras. | ||
| Andersson, 2020 | Mortality was similar before and after the national lockdown for the population with HF | ||||
| Ball, 2020 | |||||
| Boeddinghaus, 2020 | 220/398 PCIs (55.3%) PCIs were performed before versus 178/398 PCIs (44.7%) after the outbreak. | Time from chest pain onset to ED presentation, postinfarction LVEF, and median door-to-balloon time remained unchanged. | |||
| Bromage, 2020 | There were no differences in inpatient management, including place of care and pharmacological management of heart failure with reduced ejection fraction | In-hospital mortality rates were low in both periods | |||
| Bryndza, 2021 | There was a significant increase (90.7%) in the number of patients who experienced pain longer than 12 h prior to presentation to the hospital | There was a 100% increase in mechanical complications during pandemic period compared to control period | |||
| Cammalleri, 2020 | In March 2020, there was longer median time in symptom-to-first medical contact, spoke-to-hub, and the cumulative symptom-to-wire delay compared to March 2019 | Length of hospitalization was longer in 2020 | Procedural data and in-hospital outcomes were similar between the 2 groups. Patients in 2020 had a worse left ventricular ejection fraction at discharge. | ||
| Candelaresi, 2021 | Compared to the pre-lockdown, there was a significant reduction in the number of acute reperfusion treatments for stroke. | The time to reach medical attention was significantly longer in the lockdown phase. For patients who underwent acute reperfusion treatment, there was a significantly longer time-to-imaging and a trend to longer time-to-needle (75 versus 90 min P 0.23), but not time-to-groin. | Discharge neurological status was not significantly different between the periods | ||
| Chew, 2021 | Fewer patients in the pandemic group achieved door-to-baloon time <90 min compared with the pre-pandemic group. | There was no difference in hospital admission duration between groups. | In-hospital mortality was similar between groups. The 30-day readmission rate was lower in the pandemic group compared with the pre-pandemic group. The rates of sepsis and acute mitral regurgitation were higher in the pandemic group compared with the pre-pandemic group. | ||
| Choudhary, 2020 | Percentage of STEMI patients undergoing emergent catheterisation was lower in the lockdown and pre-lockdown period compared to pre-COVID period. Percentage of STEMI patients having thrombolysis was higher in the lockdown and pre-lockdown period compared to pre-COVID period. | The percentage of STEMI patients who presented outside the window period (presentation after 12 h of symptom onset) was 6.1% in the pre-COVID period, 17.4% during the pre-lockdown period and 25.0% during the lockdown period. | In-hospital mortality was 7.3%, 3.5% and 2.7%, in the lockdown, pre-lockdown, and pre-COVID periods, respectively. | ||
| Çinier, 2020 | Prolonged ischemic time, longer pain-to-balloon and door-to-balloon time during the pandemic. | ||||
| Colivicchi, 2020 | In-hospital all-cause mortality was 17.2% in 2020 and 6.3% in 2019 | ||||
| Cummings, 2020 | There was a higher percentage of patients receiving intravenous tPA during the pandemic, and the number of thrombectomies per week was lower during the pandemic | No differences in door-to-needle and door-in-door-out times | No differences in in-hospital mortality | ||
| Del Pinto, 2020 | Less daily cardiovascular procedures performed in 2020 than in 2019 | More in-hospital cardiovascular deaths occurred in 2020 compared with 2019. Less in-hospital all-cause mortality occurred in 2020 than 2019 | |||
| Enache, 2020 | |||||
| Erol, 2020 | There was a significant reduction in the overall frequency of coronary angiography during the pandemic period compared to the pre-pandemic period. Frequency of PCI decreased during the pandemic. | EMS transport significantly increased during the pandemic period. Median time from symptom-onset to hospital-arrival was increased during the pandemic. The total ischemic time for patients with STEMI who were treated with PCI was significantly longer during the pandemic period compared with the pre-pandemic period. Door-to-balloon time was similar in the two periods. | In-hospital major adverse cardiac events were significantly increased during the pandemic period | ||
| Frisullo, 2020 | Significant reduction of the total number of thrombolysis and a non-significant increase of thrombectomy during the pandemic | Significant increase in onset-to-door time and door-to-groin time during pandemic | Significant reduction in length of hospitalization during pandemic | ||
| Giannouchos, 2021 | |||||
| Hoyer, 2020 | There was a significant drop in the thrombolysis rate by 60% and in the thrombectomy rate by 61% during the pandemic in one of the centers | ||||
| Hsiao, 2020 | Reperfusion treatments also appeared to decline by 31% and specifically thrombolysis by 33% | ||||
| JF Huang, 2020 | Recommendation for acute stroke intervention (IV-tPA and/or thrombectomy) occurred at a lower rate for our postepandemic declaration group | The last known normal/symptom onset time to telestroke activation in the ED was significantly shorter for the postepandemic declaration group | |||
| Ikenberg, 2020 | There was no difference of daily numbers of patients receiving thrombolysis and thrombectomy | ||||
| Jasne, 2020 | No difference in rate of Thrombolysis in Cerebral Infarction 2b or greater revascularization | There was no difference in time to presentation, door-to-needle and door-to-reperfusion times | No difference in median length of stay | There was no difference in discharge modified Rankin Scale. | |
| John, 2020 | Ischemic stroke: The rate of treatment with intravenous thrombolysis was similar in both years; Haemorrhagic stroke: Surgical treatment including placement of an external ventricular drain, endovascular embolization and microsurgical clipping/resection or hematoma evacuation occurred at similar rates. | Ischemic stroke: Presentation to the hospital from last known well time and door-to-needle times for intravenous thrombolysis was similar. However, door-to-groin puncture times for endovascular thrombectomy was significantly longer in 2020. | There was no difference in in-hospital mortality, discharge disposition or discharge/30-day modified Rankin Score | ||
| Kobo, 2020 | Patients admitted in 2020 had greater likelihood of door-to-balloon times> 90 min and greater likelihood of pain-to-balloon times> 12 h | Patients admitted in 2020 had longer hospital stay | Patients admitted in 2020 experienced higher rates hemodynamic instability and fewer early (<72 h) discharge | ||
| Kuitunen, 2020 | |||||
| Lauridsen, 2020 | The proportion of patients who underwent CAG, PCI, CABG, and extra corporeal membrane oxygenation (ECMO) were similar between 2015 and 2019 and 2020 during lockdown | No difference in 7-day mortality was observed between study periods. | |||
| Little, 2020 | Aspiration thrombectomy and rates of cases completed with TIMI flow less than 3 were similar between both groups | There was no significant difference in pain to first call for help or door-to-balloon. There was longer ambulance response times in 2020 than in 2019. | Length of stay was similar | There was no significant difference in ICU admission or in-hospital all-cause mortality | |
| Nagamine, 2020 | The average last known well to arrival time for stroke codes was longer in 2020 than in 2019. Mean time from patient arrival to administration of tPA (door-to-needle) was similar for both periods. Mean time from patient arrival to vessel puncture for endovascular therapy (door to puncture) was shorter in 2020 compared to 2019. | In-hospital mortality was higher in 2020 than in 2019 | |||
| Mitra, 2020 | Median time from symptom onset to presentation was shorter in 2020 compared to 2019. Proportion of patients who presented >12 h after onset of symptoms were similar in both periods. Median time to primary reperfusion intervention was longer in 2020 compared to 2019. | No differences in hospital length of stay | There were no differences in mortality at hospital discharge | ||
| Nguyen-Huynh, 2020 | The percentage of patients receiving alteplase was not significantly different. | Median door-to-needle time among noncanceled stroke alerts was unchanged. The median times from LTKW-to-needle time or alteplase treatment time were not significantly different. | Length of stay was similar | Stroke discharges decreased significantly post lockdown compared with pre-lockdown. No difference in in-hospital mortality | |
| Oseran, 2020 | |||||
| Paliwal, 2020 | Proportion of activations receiving acute recanalization therapy remained stable. | In patients undergoing acute intervention, door-to-activation and door-to-neurologist review time were longer during the lockdown compared to pre-lockdown. Symptom-to-door-time was similar | For patients that received acute recanalization therapy, early neurological outcomes in terms of change in median NIHSS at 24 h were largely similar | ||
| Papafaklis, 2020 | There was no difference in the rate of cardiac deaths between the two periods, while the rates of in-hospital repeat MI and stent thrombosis were numerically higher during the COVID-19 | ||||
| Piuhola, 2020 | |||||
| Rashid Hons, 2020 | The overall rates of invasive coronary angiography were significantly lower during COVID-19 period. The use of PCI was also lower across COVID-19 months in 2020 compared with pre–COVID-19 months in 2019. Patients admitted during the COVID-19 period were slightly less likely to be seen by a cardiologist | Increased time to reperfusion in STEMI patients during the COVID-19 period | Increased in-hospital mortality during the COVID-19 period | ||
| Richter, 2021 | IVT rate in patients with stroke was comparable, whereas mechanical thrombectomy rate was significantly higher during the pandemic | In-hospital mortality was significantly increased in patients with stroke during the pandemic period | |||
| Rodríguez-Leor, 2020 | There were no differences in reperfusion strategy (> 94% treated with primary PCI in both groups) | Patients treated with primary PCI during the COVID-19 outbreak had a longer ischemic time but showed no differences in the time from first medical contact to reperfusion. | In-hospital mortality was higher during the COVID-19 period | ||
| Ruparelia, 2020 | |||||
| Schirmer, 2020 | The mean interval from last-known-well to the presentation was significantly longer in the COVID period | ||||
| Seiffert, 2020 | The percentage of patients treated with interventional or open-surgical procedures remained similar over time | In-hospital mortality in hospitalizations for stroke increased from pre-COVID to COVID | |||
| Sharma, 2020 | There was no difference in time from symptom onset to hospital arrival. | ||||
| Siegler, 2020 | Fewer brain MRIs were performed during the COVID-19 period when compared to pre-COVID-19 | There was no significant delay from the time patients were last known well to ED arrival, arrival to computed tomography scan or to thrombolysis. | Patients treated during COVID-19 had a shorter hospital length of stay when compared to patients admitted during the pre-COVID-19 period: 2.5 (2–7) vs 4 (2−8) | No difference in in-hospital mortality | |
| Tejada Meza, 2020 | There were no differences in the proportion of patients undergoing intravenous and endovascular treatments procedures | In-hospital mortality of stroke patients increased significantly | |||
| Uchino, 2020 | Thrombolysis decreased during the COVID-19 period but thrombectomy remained unchanged | Time to presentation and time to treatment were unchanged. Door-to-needle, CT completion and puncture times were unchanged. | |||
| Vensentini, 2020 | |||||
| Wadhera, 2021 | |||||
| J Wang, 2020 | Patients admitted during the COVID-19 pandemic were more likely to undergo intravenous thrombolysis and mechanical thrombectomy | There were no differences in patients’ disposition including home, short-term, and longterm facility | |||
| Yang, 2020 | Onset to hospital arrival was not different. The time from hospital arrival to puncture and time from hospital arrival to reperfusion were significantly prolonged in the pandemic group compared with the pre-pandemic group. | The rate of successful reperfusion was not significantly different between the two groups | |||
| Zhao, 2020 | The total number of thrombolysis and thrombectomy cases dropped by 26.7% and 25.3%, respectively, in 2020 | Patients’ and their families’ fear of contracting virus in hospital (87.2%); Insufficient transportation resources (43.2%); Lack of first aid knowledge (42.3%); Lack of family support (31.7%); Insufficient ambulance resources (15.4%) | |||
| Cox, 2020 | No difference in length of stay | In-hospital mortality rate was not different between the two periods |