|Year : 2021 | Volume
| Issue : 3 | Page : 219-224
COVID-19 and its impact on the management of patients with acute coronary syndrome during the first COVID wave – A questionnaire-based survey among interventional cardiologists from Southern India
Thoddi Ramamurthy Muralidharan1, Balakrishnan Vinod Kumar1, Preetam Krishnamurthy2, Nagendra Boopathy Senguttuvan3, Jayanthy Venkata Balasubramaniyan2, Shanmugasundaram Sadhanandham2, Jebaraj Rathinasamy2, Ramesh Sankaran2, Manokar Panchanatham2, Jayanthy Sathyanarayana Murthy2, Thanikachalam Sadagopan2
1 Department of Cardiology, Sri Ramachandra Institute of Higher Education and Research (Deemed to be University); C3 Research Foundation, Chennai, Tamil Nadu, India
2 Department of Cardiology, Sri Ramachandra Institute of Higher Education and Research (Deemed to be University), Chennai, Tamil Nadu, India
3 Department of Cardiology, Sri Ramachandra Institute of Higher Education and Research (Deemed to be University); C3 Research Foundation; Adjunct Faculty, Indian Institute of Technology Madras, Chennai, Tamil Nadu, India
|Date of Submission||14-Jun-2021|
|Date of Decision||13-Jul-2021|
|Date of Acceptance||13-Jul-2021|
|Date of Web Publication||14-Dec-2021|
Nagendra Boopathy Senguttuvan
Department of Cardiology, Sri Ramachandra Institute of Higher Education and Research (Deemed to be University), Porur, Chennai - 600 116, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: The COVID-19 pandemic has transformed the medical society in many ways. With significant drain on the resources and altered healthcare priorities, there is a greater need for redeployment of the resources from noncommunicable diseases to COVID-19-related healthcare services. To understand the impact of the COVID-19 pandemic on the management of acute coronary syndrome (ACS) in Tamil Nadu, a survey was administered across cardiologists in Tamil Nadu. Methods: A survey was done using an electronic questionnaire administered regarding the change of patterns of acute coronary syndromes during the COVID through Google Forms with responses collected in excel format. Results: Among 256 cardiologists contacted, 101 responded to the survey. Among cardiologists who responded, all were interventional cardiologists– with most of them performing primary percutaneous coronary intervention (PCI) (95%) regularly during pre-COVID times. Most of them have noticed a significant reduction in the number of patients with ACS seeking health care (94%) and another 61% of respondents felt that there was a reduction in the number of patients with acute coronary syndrome. There was a significant delay in ST-segment elevation myocardial infarction presentation to the hospital (88%) and significant reduction in the number of primary PCI (47%). Only 19% of respondents did primary PCI for COVID-positive patients. Conclusions: COVID pandemic has emerged as a big challenge to the global health care system. Optimal acute coronary care could not be delivered in a timely manner due to multiple social, patient, and physician-related factors. The emerging techniques in rapid diagnosis of COVID-19 and protective measures of COVID infection are expected to improve the situation. Trial Registration: Clinical Trials Registry – India (CTRI), CTRI/2020/09/027517, Registered September 1, 2020 http://CTRI. nic. In/Clinicaltrials/pmaindet2. php? trialid = 47025 and EncHid = and user Name =.
Keywords: Acute coronary syndrome, COVID-19, primary percutaneous coronary intervention, revascularization
|How to cite this article:|
Muralidharan TR, Kumar BV, Krishnamurthy P, Senguttuvan NB, Balasubramaniyan JV, Sadhanandham S, Rathinasamy J, Sankaran R, Panchanatham M, Murthy JS, Sadagopan T. COVID-19 and its impact on the management of patients with acute coronary syndrome during the first COVID wave – A questionnaire-based survey among interventional cardiologists from Southern India. J Pract Cardiovasc Sci 2021;7:219-24
|How to cite this URL:|
Muralidharan TR, Kumar BV, Krishnamurthy P, Senguttuvan NB, Balasubramaniyan JV, Sadhanandham S, Rathinasamy J, Sankaran R, Panchanatham M, Murthy JS, Sadagopan T. COVID-19 and its impact on the management of patients with acute coronary syndrome during the first COVID wave – A questionnaire-based survey among interventional cardiologists from Southern India. J Pract Cardiovasc Sci [serial online] 2021 [cited 2022 Jun 27];7:219-24. Available from: https://www.j-pcs.org/text.asp?2021/7/3/219/332489
| Introduction|| |
The COVID-19 disease has a severe impact on the global health care system. Management of patients with acute coronary syndrome (ACS) is challenging during the COVID-19 pandemic. There was significant disruption in normal life with many countries imposing strict lockdown to prevent transmission of the disease. The lockdown resulted in major impediments for patients (both having COVID and other non-COVID patients) to access healthcare. Both emergency and elective procedures were disrupted globally. Although major international societies and cardiological society of India have proposed guidelines regarding the management of such patients, a significant social, personal, and institutional variations in adherence exist in real-world practice.,,,, The overwhelming of the system created new challenges in the management of resources. We sought to know the impact of the COVID-19 pandemic on the management of ACS among interventional cardiologists from Tamil Nadu, southern India.
| Methods|| |
Our study was a cross-sectional study using electronic questionnaire-based survey (Supplementary appendix) that was conducted in September 2020. Members of the Tamil Nadu Interventional Council who are active in the society's Whatsapp group were contacted individually for participation in the study. The survey focused on the change of patterns of acute coronary syndromes during the COVID pandemic, COVID-19 screening protocols, and changes in the management of non-COVID patients with heart ailments. The survey was administered in English. The study was approved by Medstar Multispeciality Hospital's Ethics committee. All participants gave their consent for participation in this study, and the study was registered in the clinical trials registry of India (Clinical Trials Registry – India/2020/09/027517). The study was conceptualized by the first author and successfully executed by the second, third, and fourth authors. This study was funded by C3RF, a not-for-profit organization.
| Results|| |
Of 256 participants, 101 (39%) responded to the survey. Almost all respondents but one was male (N = 100). We classified the locality of respondents based on tiers of cities as designated by the Government of India. Among the responders, 56% were from Tier 1 cities, 32% from Tier 2 cities, and 12% from Tier 3 cities. All were interventional cardiologists with majority of them performing around 10–20 percutaneous coronary intervention (PCI) per month (33.7%) with 95% of them being primary PCI operators before the COVID pandemic [Table 1].
During the COVID pandemic, 94% of respondents noted a significant reduction in the number of patients seeking medical attention to the hospital, and 61% felt that there was also a reduction in the admission of patients with the acute coronary syndrome. Importantly, participants (88%) felt that patients with ST-segment elevation myocardial infarction (STEMI) presented late to the hospital reducing the benefits of revascularization. Primary PCI as a modality of revascularization was performed by less than half of the participants compared with pre-COVID (95% vs. 47%) [Figure 1]. Despite the perception that testing for COVID before intervention resulted in the delay in primary PCI (81%), majority (62%) wanted to test for COVID-19 disease before Primary PCI. The interventional cardiologists preferred reverse transcription-polymerase chain reaction (RT-PCR) (86.1%) over screening chest computer tomography (CT) (58.4%); 44% wanted screening by both RT-PCR and chest CT. Only 17% of respondents performed primary PCI for COVID-positive patients. During primary PCI in the COVID era, 54.5% encountered higher thrombus burden in the culprit vessels compared with pre-COVID times. Though there was increase in thrombus burden, fewer respondents (36.6%) felt the need for glycoprotein 2b3a inhibitors. Tenecteplase was the commonly used thrombolytic agent (68.3%). More than one-third of the participants (36.6%) performed rescue PCI during the COVID pandemic. Elective coronary evaluation in patients with ACS was done preferably within 2 days of presentation by most operators (91.1%). Incidence of MINOCA was more frequently observed (51.5%) compared with the pre-COVID times. However, none of the operators observed any increase in the incidence of stent thrombosis. Most respondents (80%) managed patients with cardiogenic shock; However, left ventricular assist devices were used in <25% of patients with intra-aortic balloon counterpulsation being the preferred modality (87%). Only 27% of respondents felt that there was increase in mechanical complications with increased use of thrombolysis during the COVID pandemic. Among centers which were earlier performing coronary artery bypass graft (CABG), 59.4% did not perform CABG during the COVID Pandemic. Despite initial conflicting reports on angiotensinogen-converting enzyme (ACEi) and angiotensin receptor blockers (ARBs), most respondents (98%) continued usage of these medications. Most respondents felt that it was safe to initiate ACEi and ARB (98%) in appropriate patients with indications.
|Figure 1: A brief summary of the results of the study among the interventional cardiologists regarding their practices in acute coronary syndrome during COVID era.|
Click here to view
| Discussion|| |
Acute coronary syndrome is a major cause of mortality and morbidity across the world. The burden of cardiovascular disease, despite great advances, has not seen significant changes as reported in a multicentric prospective cohort study over the period from 1990 to 2015. In our study to understand the impact of COVID on contemporary cardiology practice, we found that the participants observed a reduction in the number of patients seeking medical attention to the hospital, decrease in the admission of patients with ACS, significant delay in the diagnosis and management of the patients with ACS who received medical treatment.
COVID infection and ACS share a lot of similarities in terms of presentation. Libby et al. has proposed that COVID-19 is an endothelial disease, and hence pathophysiologically may be similar to ACS. Reports about the presence of inflammatory pathophysiological mechanisms, triggering plaque disruption and generating a prothrombotic milieu supported an anticipated increase in the number of patients presenting with ACS during the COVID-19 pandemic.,, Activation of pro-inflammatory interleukins pathway is the proposed mechanism of cytokine storm observed in patients with ACS and COVID-19. Similar to previous viral pandemics, hypotension, cardiomegaly, and arrhythmia are recognized as harbingers of acute heart failure in COVID-19 too. Heart failure is a recognized vulnerable state during respiratory viral infections for increased adverse events. The subtle compensated state of heart failure can easily be tilted toward decompensation state due to COVID-19 leading to arrhythmic and ischemic risk in patients with heart failure.
Reduction in the activation of cardiac catheterization for STEMI seems to be a worldwide phenomenon. There has been about 38% reduction in the volume of catheterization for STEMI in the United States and 48% reduction in Spain., Furthermore, similar survey among health care professionals by the European Society Cardiology showed a perception of decrease in STEMI as high as 40%. In addition, an increase in the first medical contact time i.e., symptom onset to ambulance arrival (82.5 min to 318 min) timing during the pandemic was noted from Hong Kong. Significant delays were also reported from India. There was extensive restructuring across countries in cardiology services with at least two-thirds requiring substantial change in their service setup. A study by Meenakshisundaram et al. in South India also showed similar trends toward lower incidence of ACS and STEMI. A recent registry data (Luca et al.) also showed similar trends with 19% reduction in primary PCI. Furthermore, it was observed in the registry data that there was increase in mortality in patients in the COVID pandemic (2019%–4.9%, 2020%–6.8%; odds ratio – 1.41, confidence interval – 1.15–1.71 P < 0.001), the mortality rate among COVID-19 patients were much higher compared with non-COVID-19 patients (29% vs. 5.5%). The higher mortality was attributed to the longer ischemia time associated with treatment during the challenging times.
Patients with STEMI are often breathless due to heart failure which further increases the suspicion among paramedics and emergency physicians regarding their COVID status. A case series published by Bangalore et al. showed COVID patients presented with electrocardiography suggestive of STEMI but still had normal coronaries. Cardiac enzymes are frequently elevated in COVID patients and the diagnosis of ACS is difficult. The similarity of the presentation and low sensitivity of initial diagnostic modalities to diagnose COVID-19 had led to a high degree of suspicion of COVID infection in patients presenting with ACS and heart failure. Hence, apprehensions of contracting COVID infection on visiting hospital by the public, strict enforcement of lockdown leading to nonavailability of transports and medical staffs, and stringent screening protocols followed at the emergency department of various institutions waiting for COVID results could be the possible reasons for such delay in getting appropriate treatment, especially in patients with STEMI. We perceive this as collateral damage of COVID-19 in addition to its direct impact on the health-care system. Paradoxically, patients with severe disease are more likely to face this “medical discrimination.” Protection of our health care workers is an important priority in the management of COVID-19 pandemic. However, rigorous testing for COVID has resulted in an additional delay for revascularization. As suggested by major societal guidelines, adequate personal protective equipment (PPE) for appropriate care should be used by health care workers in high-risk situations while doing procedures in patients with ACS undergoing PCI with pending COVID results.,,,, The reduction in patients with ACS and heart failure may actually be due to reduced incidence of ACS which could potentially be attributed to reduced air pollution, lower stress in daily life, increased utility of physical activities among the public, reduced intake of fast-food consumption, and positive effects of work from home by the majority of working community.
The renin-angiotensin-aldosterone system (RAAS) is an important mechanism for maintaining vascular homeostasis and plays an important role in cardiac pathophysiology of heart failure and ACS. The ACE2, an enzyme that counters the RAAS activation, has been discovered to function as a receptor to the severe acute respiratory syndrome (SARS) viruses. The interaction between the SARS virus and ACE2 was thought to be a potential factor for infectivity. There were concerns about the use of RAAS inhibition, whether it may alter ACE2 and possibly be responsible for virulence in the ongoing COVID pandemic. The initial reports suggested that ACE inhibitors and ARB increased susceptibility toward COVID infection. This led to a widespread withdrawal of the use of ACE inhibitors and ARB in the treatment of hypertension and heart failure patients. However, many studies have conclusively proven that there was no definite evidence of RAAS inhibition to alter ACE2 levels and activity in humans. ACE2 may in fact be beneficial rather than harmful in patients with lung injury. In our study, most of the respondents continued the use of these agents (98%). The international society guidelines also suggested that RAAS inhibition should not be withheld in patients with appropriate indications for the same.
| Conclusions|| |
COVID-19 has multiple collateral damages among cardiovascular care that included delay in clinical presentation, delay in receiving optimal treatment due to various reasons, and increased incidence of MI-related complications. Multipronged approach involving public education to avoid apprehension in reaching hospitals when required, novel diagnostic kits that can rapidly diagnose COVID infection, and early revascularization of patients with STEMI/high-risk ACS pending their COVID status with the usage of the utility of PPE of level-3 as recommended by major societies should be implemented.
Only 39% of the population responded to the questionnaire. As it based on the memory of the participants, it has its own limitations, especially limited to memory. There were more responses from Tier 1 and Tier 2 cities and rural areas were underrepresented in this survey which reduces its applicability in the general population.
Medstar Specialty Hospitals Ethics Committee (C3RF002) Bengaluru.
Tamil Nadu Intervention Council.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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