Impact of COVID-19 pandemic lockdown on myocardial infarction care

European Journal of Epidemiology https://doi.org/10.1007/s10654-021-00764-2 COVID-19 Impact of COVID‑19 pandemic lockdown on myocardial infarction care Timo Schmitz1,2 · Christa Meisinger1,2 · Inge Kirchberger1,2 · Christian Thilo3 · Ute Amann2 · Sebastian E. Baumeister1,2,4 · Jakob Linseisen1,2 Received: 5 January 2021 / Accepted: 19 May 2021 © The Author(s) 2021 Abstract The aim of this study was to evaluate the impact of the COVID-19 pandemic lockdown on acute myocardial infarction (AMI) care, and to identify underlying stressors in the German model region for complete AMI registration. The analysis was based on data from the population-based KORA Myocardial Infarction Registry located in the region of Augsburg, Germany. All cases of AMI (n = 210) admitted to one of four hospitals in the city of Augsburg or the county of Augsburg from February 10th, 2020, to May 19, 2020, were included. Patients were divided into three groups, namely pre-lockdown, strict lockdown, and attenuated lockdown period. An additional survey was conducted asking the patients for stress and fears in the 4 weeks prior to their AMI. The AMI rate declined by 44% in the strict lockdown period; in the attenuated lockdown period the rate was 17% lower compared to the pre-lockdown period. The downward trend in AMI rates during lockdown was seen in STEMI and NSTEMI patients, and independent of sex and age. The door-to-device time decreased by 70–80% in the lockdown-periods. In the time prior to the infarction, patients felt stressed mainly due to fear of infection with Sars-CoV-2 and less because of the restrictions and consequences of the lockdown. A strict lockdown due to the Covid-19 pandemic had a marked impact on AMI care even in a non-hot-spot region with relatively few cases of COVID-19. Fear of infection with the virus is presumably the main reason for the drop in hospitalizations due to AMI. Keywords Covid-19 · Myocardial infarction · Lockdown · Door-to-device-time · Population-based registry · Augsburg · Bavaria · Germany Introduction Since the first reported case of Covid-19 on January 27, 2020, in Bavaria, [1] Germany, the number of confirmed cases increased rapidly in early March. The exponential increase in newly confirmed cases reached a total of 67,366 positively tested cases on April 1 in whole Germany [2] and 20,178 cases in Bavaria, the German federal state most affected by Covid-19. Within Bavaria, counties were affected * Timo Schmitz 1 Chair of Epidemiology, University of Augsburg, University Hospital Augsburg, Augsburg, Germany 2 Independent Research Group Clinical Epidemiology, German Research Center for Environmental Health, Helmholtz Zentrum München, Munich, Germany 3 Department of Internal Medicine I ‑ Cardiology, University Hospital of Augsburg, Augsburg, Germany 4 University Hospital Münster, Münster, Germany to varying degrees by the pandemic; the city of Augsburg and the district of Augsburg were among the less affected counties (on April 1, 2020: 454 Covid-19-cases) [2]. On March 16, the Bavarian Government declared a state of emergency and enforced non-pharmaceutical interventions. These included physical distancing, hygiene, masks, isolation of infected people and their contacts, and lockdowns, such as closures of schools and businesses and bans on public gatherings and travel. To preserve resources, the Bavarian Government recommended deferral of elective procedures in patient care but not of care for emergency conditions such as acute myocardial infarction (AMI). Several recent studies, which were conducted in Covid-19 epicenters, reported significant reductions of hospitalizations due to AMI during the onset of the Covid-19 pandemic.[3–7] So far, investigations of heart attack events in a region with relatively low numbers of Covid-19 cases but an early and strict lockdown are missing. Because the Augsburg area is one of the districts with fewer Covid-19 cases, we evaluated AMI care before, during and post the lockdown using data from the well-established, 13 Vol.:(0123456789) T. Schmitz et al. population-based KORA Myocardial Infarction Registry in Augsburg, [8] Germany, covering all AMI events in a region of about 680,000 inhabitants. In addition, we examined possible stressors that prevented acute heart attack patients from seeking immediate inpatient treatment. Methods Study population The underlying data for this analysis was collected prospectively by the KORA Myocardial Infarction Registry. The data collection of the registry is population-based with consecutive enrollment of all cases of non-fatal AMI within the study region. The inclusion criteria are the following: the patient is older than 24 years, survived more than 24h in the hospital, and is an inhabitant of the study region of Augsburg (city of Augsburg and two adjacent counties AichachFriedberg and Augsburg). Detailed information on case identification and data collection is given elsewhere. [8, 9] For the present study, all cases of AMI admitted from February 10, 2020, to May 21, 2020, were included. Patients were divided into three groups: pre-lockdown (February 10th to March 15th, 2020), strict lockdown (March 16th to April 19th, 2020), and attenuated lockdown (April 20th to May 21th) period. Only patients treated in the University hospital of Augsburg and 3 other hospitals located in the city of Augsburg and the county Augsburg were considered (about 550,000 inhabitants). Of those, 2 hospitals (in particular the University hospital of Augsburg) perform cardiac catheterization; the 2 hospitals without cardiac catheterization laboratories transfer the patients to the University hospital of Augsburg for invasive treatment of AMI. A total of 210 at least 24 h surviving AMI cases were treated in one of the 4 hospitals in this region within the study period. For the survey study, a questionnaire was sent out to 90 patients, of which 61 replied instantly or after a postal reminder (67.8%). Another 58 patients completed the questionnaire as a part of the routine interview (total response: 119). The study complies with the Declaration of Helsinki. All study participants gave written informed consent and the study was approved by the Ethics Committee of the Bavarian Medical Association (Bayerische Landesärztekammer). Data collection The study participants were interviewed shortly after intensive care by study nurses and further data were collected by review of the medical chart and discharge report. Information on the acute event (time of symptom onset), treatment procedures (PCI, coronary artery bypass grafting) complications during hospital stay (cardiogenic shock, ventricular 13 fibrillation, in-hospital mortality), cardiopulmonary resuscitation in- or outside the hospital, type of AMI (STEMI/ NSTEMI), time from symptom onset to hospital admission, time from admission to revascularization, and information on physician diagnosis of diabetes were gathered. 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