Impact of SARS-CoV-2 Outbreak on Emergency Department Presentation and Prognosis of Patients with Acute Myocardial Infarction: A Systematic Review and Updated Meta-Analysis

Abstract

We performed an updated meta-analysis to robustly quantify admission trends of patients with ST-segment elevation MI (STEMI) and non-ST-segment elevation MI (NSTEMI) during the first wave of the pandemic and to characterize on a large basis the risk profile and early prognosis. Studies having the same observation period for the comparison between SARS-CoV-2 outbreak in 2020 versus control period in 2019 were included. Primary endpoints were the relative variation of hospital admissions, the difference of in-hospital mortality for STEMI and NSTEMI. Secondary were: mortality according to countries, income levels and data quality; cardiogenic shock, mechanical complications, door-to-balloon time, time from symptom onset to first medical contact, left ventricular ejection fraction (LVEF) and troponin. In total, 61 observational studies with 125,346 patients were included. Compared with 2019, during the pandemic for STEMI were observed: a 24% reduction of hospitalizations with an impact on early survival (OR = 1.33 in-hospital mortality); the time from symptom onset to first medical contact was 91.31 min longer, whereas door-to-balloon time was increased (+5.44 min); after STEMI, the rate of cardiogenic shock was 33% higher; LVEF at discharge was decreased (−3.46); elevated high-sensitivity troponin levels (1.52) on admission. For NSTEMI, in the COVID-19 period, we observed a 31% reduction of hospitalizations and higher in-hospital deaths (OR = 1.34). The highest mortality rates among countries were: Italy OR = 3.71 (high income), Serbia OR = 2.15 (upper middle) and Pakistan OR = 1.69 (lower middle). Later hospital presentation was associated with larger infarctions, as well as with increased cardiogenic shock and in-hospital mortality.