Medical and cardio-vascular emergency department visits during the COVID-19 pandemic in 2020: is there a collateral damage? A retrospective routine data analysis

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Abstract

Background

In this retrospective routine data analysis, we investigate the number of emergency department (ED) consultations during the COVID-19 pandemic of 2020 in Germany compared to the previous year with a special focus on numbers of myocardial infarction and acute heart failure.

Methods

Aggregated case numbers for the two consecutive years 2019 and 2020 were obtained from 24 university hospitals and 9 non-university hospitals in Germany and assessed by age, gender, triage scores, disposition, care level and by ICD-10 codes including the tracer diagnoses myocardial infarction (I21) and heart failure (I50).

Results

A total of 2,216,627 ED consultations were analyzed, of which 1,178,470 occurred in 2019 and 1,038,157 in 2020. The median deviation in case numbers between 2019 and 2020 was − 14% [CI (− 11)–(− 16)]. After a marked drop in all cases in the first COVID-19 wave in spring 2020, case numbers normalized during the summer. Thereafter starting in calendar week 39 case numbers constantly declined until the end of the year 2020. The decline in case numbers predominantly concerned younger [− 16%; CI (− 13)–(− 19)], less urgent [− 18%; CI (− 12)–(− 22)] and non-admitted cases [− 17%; CI (− 13)–(− 20)] in particular during the second wave. During the entire observation period admissions for chest pain [− 13%; CI (− 21)–2], myocardial infarction [− 2%; CI (− 9)–11] and heart failure [− 2%; CI (− 10)–6] were less affected and remained comparable to the previous year.

Conclusions

ED visits were noticeably reduced during both SARS-CoV-2 pandemic waves in Germany but cardiovascular diagnoses were less affected and no refractory increase was noted. However, long-term effects cannot be ruled out and need to be analysed in future studies.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s00392-022-02074-3.

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Reduction of hospitalizations for myocardial infarction in Italy in the COVID-19 era

Salvatore De Rosa, Carmen Spaccarotella, Cristina Basso … (2020)

Abstract Aims To evaluate the impact of the COVID-19 pandemic on patient admissions to Italian cardiac care units (CCUs). Methods and Results We conducted a multicentre, observational, nationwide survey to collect data on admissions for acute myocardial infarction (AMI) at Italian CCUs throughout a 1 week period during the COVID-19 outbreak, compared with the equivalent week in 2019. We observed a 48.4% reduction in admissions for AMI compared with the equivalent week in 2019 (P < 0.001). The reduction was significant for both ST-segment elevation myocardial infarction [STEMI; 26.5%, 95% confidence interval (CI) 21.7–32.3; P = 0.009] and non-STEMI (NSTEMI; 65.1%, 95% CI 60.3–70.3; P < 0.001). Among STEMIs, the reduction was higher for women (41.2%; P = 0.011) than men (17.8%; P = 0.191). A similar reduction in AMI admissions was registered in North Italy (52.1%), Central Italy (59.3%), and South Italy (52.1%). The STEMI case fatality rate during the pandemic was substantially increased compared with 2019 [risk ratio (RR) = 3.3, 95% CI 1.7–6.6; P < 0.001]. A parallel increase in complications was also registered (RR = 1.8, 95% CI 1.1–2.8; P = 0.009). Conclusion Admissions for AMI were significantly reduced during the COVID-19 pandemic across Italy, with a parallel increase in fatality and complication rates. This constitutes a serious social issue, demanding attention by the scientific and healthcare communities and public regulatory agencies.

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COVID-19 pandemic and admission rates for and management of acute coronary syndromes in England

Marion Mafham, Enti Spata, Raphael Goldacre … (2020)

Summary Background Several countries affected by the COVID-19 pandemic have reported a substantial drop in the number of patients attending the emergency department with acute coronary syndromes and a reduced number of cardiac procedures. We aimed to understand the scale, nature, and duration of changes to admissions for different types of acute coronary syndrome in England and to evaluate whether in-hospital management of patients has been affected as a result of the COVID-19 pandemic. Methods We analysed data on hospital admissions in England for types of acute coronary syndrome from Jan 1, 2019, to May 24, 2020, that were recorded in the Secondary Uses Service Admitted Patient Care database. Admissions were classified as ST-elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), myocardial infarction of unknown type, or other acute coronary syndromes (including unstable angina). We identified revascularisation procedures undertaken during these admissions (ie, coronary angiography without percutaneous coronary intervention [PCI], PCI, and coronary artery bypass graft surgery). We calculated the numbers of weekly admissions and procedures undertaken; percentage reductions in weekly admissions and across subgroups were also calculated, with 95% CIs. Findings Hospital admissions for acute coronary syndrome declined from mid-February, 2020, falling from a 2019 baseline rate of 3017 admissions per week to 1813 per week by the end of March, 2020, a reduction of 40% (95% CI 37–43). This decline was partly reversed during April and May, 2020, such that by the last week of May, 2020, there were 2522 admissions, representing a 16% (95% CI 13–20) reduction from baseline. During the period of declining admissions, there were reductions in the numbers of admissions for all types of acute coronary syndrome, including both STEMI and NSTEMI, but relative and absolute reductions were larger for NSTEMI, with 1267 admissions per week in 2019 and 733 per week by the end of March, 2020, a percent reduction of 42% (95% CI 38–46). In parallel, reductions were recorded 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%, 95% CI 12–29) and NSTEMI (383 PCI procedures per week in 2019 vs 240 by the end of March, 2020; percent reduction 37%, 29–45). The median length of stay among patients with acute coronary syndrome fell from 4 days (IQR 2–9) in 2019 to 3 days (1–5) by the end of March, 2020. Interpretation Compared with the weekly average in 2019, there was a substantial reduction in the weekly numbers of patients with acute coronary syndrome who were admitted to hospital in England by the end of March, 2020, which had been partly reversed by the end of May, 2020. The reduced number of admissions during this period is likely to have resulted in increases in out-of-hospital deaths and long-term complications of myocardial infarction and missed opportunities to offer secondary prevention treatment for patients with coronary heart disease. The full extent of the effect of COVID-19 on the management of patients with acute coronary syndrome will continue to be assessed by updating these analyses. Funding UK Medical Research Council, British Heart Foundation, Public Health England, Health Data Research UK, and the National Institute for Health Research Oxford Biomedical Research Centre.

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Decline of acute coronary syndrome admissions in Austria since the outbreak of COVID-19: the pandemic response causes cardiac collateral damage

Bernhard Metzler, Peter Siostrzonek, Ronald Binder … (2020)

We conducted a nationwide retrospective survey on the impact of COVID-19 on the diagnosis and treatment of acute cornary syndrome (ACS) from 2 to 29 March in Austria. Of the 19 public primary percutaneous coronary (PCI) centres contacted, 17 (90%) provided the number of admitted patients. During the study period, we observed a significant decline in the number of patients admitted to hospital due to ACS (Figure 1 ). Comparing the first and last calendar week, there was a relative reduction of 39.4% in admissions for ACS. In detail, from calendar week 10 to calendar week 13, the number of ST-segment elevation myocardial infarction (STEMI) patients admitted to all hospitals was 94, 101, 89, and 70, respectively. The number of non-STEMI patients declined even more markedly from 132 to 110, to 62, and to 67. Figure 1 Decline of acute coronary syndrome admissions in Austria since the outbreak of COVID-19. The absolute numbers of all ACS (blue bars), STEMI (orange bars), and NSTEMI (grey bars) admissions in Austria from calendar week 10 to calendar week 13 are shown. Abbreviations: STEMI, ST-segment elevation myocardial infarction; NSTEMI, non-ST-segment elevation myocardial infarction. The main finding of our retrospective observational study is an unexpected major decline in hospital admissions and thus treatment for all subtypes of ACS with the beginning of the COVID-19 outbreak in Austria and subsequent large-scale public health measures such as social distancing, self-isolation, and quarantining. Several factors might explain this important observation. The rigorous public health measures, which are undoubtedly critical for controlling the COVID-19 pandemic, may unintentionally affect established integrated care systems. Amongst others, patient-related factors could mean that infarct-related symptoms such as chest discomfort and dyspnoea could be misinterpreted as being related to an acute respiratory infection. Moreover, the strict instructions to stay at home as well as the fear of infection in a medical facility may have further prevented patients with an ACS from going to a hospital. Irrespective of the causes, the lower rate of admitted and therefore treated patients with ACS is worrisome and we are concerned that this might be accompanied by a substantial increase in early and late infarct-related morbidity and mortality. Our study does not provide data on mortality; however, considering the annual incidence of ACS in Austria (200/100 000/year = 17 600/year in 8.8 million habitants) 1 and taking into consideration sudden cardiac deaths and silent infarctions (one-third), there will remain ∼1000 ACS cases a month. The difference between the assumed number of ACS patients and the observed number in our study, i.e. 725 ACS patients in calendar weeks 10–13 is 275. According to these assumptions, 275 patients were not treated in March 2020. Based on data showing that the cardiovascular mortality of untreated ACS patients might be as high as 40% (as it was in the 1950s), 2 we can theoretically estimate 110 ACS deaths during this time frame. The number of deaths associated with this unintentional undersupply of guideline-directed ACS management is very alarming, particularly when considering that the official number of COVID-related deaths in Austria was 86 on 29 March. In conclusion, it seems likely that the COVID-19 outbreak is associated with a significantly lower rate of hospital admissions and thus, albeit unintended, treatment of ACS patients, which is most likely explained by several patient- and system-related factors. Every effort should be undertaken by the cardiology community to minimize the possible cardiac collateral damage caused by COVID-19.

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Author and article information

Contributors

Anna Slagman:

ORCID: http://orcid.org/0000-0003-2608-0347

anna.slagman@charite.de

Journal

Journal ID (nlm-ta): Clin Res Cardiol

Journal ID (iso-abbrev): Clin Res Cardiol

Title: Clinical Research in Cardiology

Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )

ISSN (Print): 1861-0684

ISSN (Electronic): 1861-0692

Publication date (Electronic): 5 August 2022

Publication date PMC-release: 5 August 2022

Pages: 1-9

Affiliations

[1 ]GRID grid.6363.0, ISNI 0000 0001 2218 4662, Health Services Research in Emergency and Acute Medicine, Emergency and Acute Medicine CVK, CCM, , Charité - Universitätsmedizin Berlin, ; Berlin, Germany

[2 ]GRID grid.6363.0, ISNI 0000 0001 2218 4662, Institute of Biometry and Clinical Epidemiology, , Charité - Universitätsmedizin Berlin, ; Berlin, Germany

[3 ]GRID grid.5807.a, ISNI 0000 0001 1018 4307, Department of Trauma Surgery, , Otto Von Guericke University Magdeburg, ; Magdeburg, Germany

[4 ]GRID grid.22937.3d, ISNI 0000 0000 9259 8492, Department of Emergency Medicine, , Medical University Vienna, ; Vienna, Austria

[5 ]GRID grid.14778.3d, ISNI 0000 0000 8922 7789, Emergency Department, , University Hospital of Düsseldorf, Heinrich-Heine-University, ; Düsseldorf, Germany

[6 ]GRID grid.412301.5, ISNI 0000 0000 8653 1507, Institute of Medical Informatics, , University Hospital Aachen, ; Aachen, Germany

[7 ]GRID grid.411984.1, ISNI 0000 0001 0482 5331, University Medical Center Göttingen, ; Göttingen, Germany

[8 ]GRID grid.411097.a, ISNI 0000 0000 8852 305X, University Hospital Cologne, ; Cologne, Germany

[9 ]GRID grid.5330.5, ISNI 0000 0001 2107 3311, Friedrich-Alexander Universität (FAU), University Hospital Erlangen, ; Erlangen, Germany

[10 ]GRID grid.6936.a, ISNI 0000000123222966, Technical University Munich, ; Munich, Germany

[11 ]GRID grid.411937.9, University Hospital Homburg-Saar, ; Homburg, Germany

[12 ]GRID grid.411339.d, ISNI 0000 0000 8517 9062, Emergency Department, , University Hospital Leipzig, ; Leipzig, Germany

[13 ]GRID grid.5963.9, Medical Center, , University Emergency Center, University of Freiburg, ; Freiburg, Germany

[14 ]GRID grid.6936.a, ISNI 0000000123222966, Technical University Munich, Hospital Right of Isar, ; Munich, Germany

[15 ]GRID grid.411095.8, ISNI 0000 0004 0477 2585, Ludwig-Maximilians University Hospital Munich, ; Munich, Germany

[16 ]GRID grid.16149.3b, ISNI 0000 0004 0551 4246, University Hospital Münster, ; Münster, Germany

[17 ]GRID grid.412469.c, ISNI 0000 0000 9116 8976, University Hospital Greifswald, ; Greifswald, Germany

[18 ]GRID grid.412301.5, ISNI 0000 0000 8653 1507, University Hospital Aachen, ; Aachen, Germany

[19 ]GRID grid.410718.b, ISNI 0000 0001 0262 7331, University Hospital Essen, ; Essen, Germany

[20 ]GRID grid.6363.0, ISNI 0000 0001 2218 4662, Emergency and Acute Medicine CBF, , Charité - Universitätsmedizin Berlin, ; Berlin, Germany

[21 ]GRID grid.412468.d, ISNI 0000 0004 0646 2097, University Hospital Kiel, ; Kiel, Germany

[22 ]GRID grid.411778.c, ISNI 0000 0001 2162 1728, University Hospital Mannheim, ; Mannheim, Germany

[23 ]GRID grid.411760.5, ISNI 0000 0001 1378 7891, Department of Internal Medicine I, , University Hospital of Würzburg, ; Würzburg, Germany

[24 ]GRID grid.412468.d, ISNI 0000 0004 0646 2097, Emergency Department, , University Hospital Lübeck, ; Lübeck, Germany

Author information

Anna Slagman http://orcid.org/0000-0003-2608-0347

Article

Publisher ID: 2074

DOI: 10.1007/s00392-022-02074-3

PMC ID: 9362706

PubMed ID: 35931896

SO-VID: e98d6703-963b-4d2b-bd8f-dabddda2816a

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

History

Date received : 25 March 2022

Date accepted : 25 July 2022

Funding

Funded by: Charité - Universitätsmedizin Berlin (3093)

Open Access :

Open Access funding enabled and organized by Projekt DEAL.

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Medical and cardio-vascular emergency department visits during the COVID-19 pandemic in 2020: is there a collateral damage? A retrospective routine data analysis

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Abstract

Background

Methods

Results

Conclusions

Graphical abstract

Supplementary Information

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Novel Coronavirus Disease COVID-19

Most cited references 31

Reduction of hospitalizations for myocardial infarction in Italy in the COVID-19 era

COVID-19 pandemic and admission rates for and management of acute coronary syndromes in England

Decline of acute coronary syndrome admissions in Austria since the outbreak of COVID-19: the pandemic response causes cardiac collateral damage

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