To the Editor
Sutherland and colleagues recently reported a reduction in patients admitted with acute coronary syndrome (ACS) and an increase in total ischaemic time during the first and second wave of the COVID-19 outbreak in Melbourne [1]. They also observed a 20% rebound increase in ACS presentations following the relaxation of public health restrictions in November–December 2020 compared to the same period of 2019 and suggested that this could represent long-term sequelae of untreated ACS including reinfarction and heart failure. However, several additional mechanisms could play a role.
Daily Life Triggers
A trend of reduced hospitalisations for all ACS types during the pandemic has been observed worldwide [[1], [2], [3]]. Besides social distancing, stay-at-home orders, and fear of acquiring the infection, attenuated exposure to well-recognised ACS triggers, particularly reduced air pollution, and decreased physical and work activities, has been linked to this phenomenon [3,4]. The alleviation of restrictions after the pandemic waves restored the level of exposure to ACS triggers which could have contributed to a gradual increase in ACS hospitalisations [4]. Moreover, fear of lack of medical care, lockdown stress, anger, loneliness, job loss, financial stress, and binge smoking have been suggested as ACS triggers due to the ramification of the pandemic [5]. Along this line, a post-restriction increase in hospitalisations for ST-segment elevation myocardial infarction has been documented in Israel [2].
Population Vulnerability
Anti-pandemic measures favour sedentary behaviour, physical inactivity, unhealthy nutritional habits, weight gain, and increased alcohol consumption, as confirmed by recent meta-analyses [6,7]. Consequent negative effects on metabolism likely worsened the population’s cardiovascular health and, given their presence for over a year now, could have increased the number of vulnerable coronary patients [4]. Accordingly, increased population cardiovascular vulnerability coupled with enhanced exposure to ACS triggers could be important mechanisms of a rebound increase in ACS.
References
- 1.Sutherland N., Dayawansa N.H., Filipopoulos B., Vasanthakumar S., Narayan O., Ponnuthurai F.A., et al. Acute coronary syndrome in the COVID-19 pandemic: reduced cases and increased ischaemic time. Heart Lung Circ. 2022;31:69–76. doi: 10.1016/j.hlc.2021.07.023. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Fardman A., Oren D., Berkovitch A., Segev A., Levy Y., Beigel R., et al. Post Covid-19 acute myocardial infarction rebound. Can J Cardiol. 2020;36:1832.e15–1832.e16. doi: 10.1016/j.cjca.2020.08.016. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Rattka M., Dreyhaupt J., Winsauer C., Stuhler L., Baumhardt M., Thiessen K., et al. Effect of the COVID-19 pandemic on mortality of patients with STEMI: a systematic review and meta-analysis. Heart. 2021 doi: 10.1136/heartjnl-2020-318360. [DOI] [PubMed] [Google Scholar]
- 4.Čulić V., AlTurki A., Proietti R. Covid-19 pandemic and possible rebound phenomenon in incidence of acute myocardial infarction. Can J Cardiol. 2021;37(8):1294. doi: 10.1016/j.cjca.2020.11.004. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Hammoudeh A., Abu-Hantash H., Tabbalat R., Al-Mousa E., Madanat E., Al-Muhaisen R., et al. The Covid-19 pandemic and triggered acute myocardial infarction among non-infected individuals. Int J Clin Cardiol. 2020;7:185. [Google Scholar]
- 6.Bakaloudi D.R., Barazzoni R., Bischoff S.C., Breda J., Wickramasinghe K., Chourdakis M. Impact of the first COVID-19 lockdown on body weight: a combined systematic review and a meta-analysis. Clin Nutr. 2021 doi: 10.1016/j.clnu.2021.04.015. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Bakaloudi D.R., Jeyakumar D.T., Jayawardena R., Chourdakis M. The impact of COVID-19 lockdown on snacking habits, fast-food and alcohol consumption: a systematic review of the evidence. Clin Nutr. 2021 doi: 10.1016/j.clnu.2021.04.020. [DOI] [PMC free article] [PubMed] [Google Scholar]