Spotlighting PCI Trends During the COVID-19 Pandemic, with Gregory Weiss, MD

A great deal has changed since the beginning of the COVID-19 pandemic in early 2020. The first year, we played catch-up trying to figure out how to get a handle on the rapidly deteriorating situation. While focusing on the respiratory consequences of COVID-19 infection clinicians were slow to recognize trends in other key healthcare metrics.

Pre-pandemic trends in the most severe form of heart attack, ST Elevation Myocardial Infraction (STEMI) had remained steady and predictable with heart disease rates rising and remaining the number one cause of death for Americans. During the pandemic clinicians noticed some unusual changes in the frequency of patients seeking care leading to percutaneous coronary interventions (PCI) for acute STEMI.

While it is known now that COVID-19 has clear effects on the cardiovascular system the pandemic itself had an unexpected effect on PCI. Clinicians began to notice that fewer patients were presenting with STEMI which led to fewer coronary interventions. Manoj Thangam, MD, and colleagues at Ascension Health System sought to determine both the PCI trends during the pandemic and the reasons behind them. They presented their findings at the Society for Cardiovascular Angiography & Interventions (SCAI) 2022 scientific sessions in Atlanta, GA.

The authors pulled data from several centers that monitor percutaneous interventions (PCI) for STEMI in an effort to compare predicted PCI volume before widespread COVID-19 prevalence and during documented surges. The prevailing trend prior to April of 2020, the first COVID surge, was a steady increase in STEMI and PCI in keeping with an overall increase in the prevalence of coronary heart disease in the United States.1 April 2020 then saw a dramatic decrease in STEMI and PCI with a subsequent rise until December 2020, the second surge.¹ The expected number of cases per month has yet to recover from pandemic levels.

While the study itself does not point clearly to the cause for this decrease and failure to reach expected PCI and STEMI rates now that widespread immunity to COVID 19 has been achieved there are several possibilities to consider.

“Despite STEMI rates rising, we’ve never gotten back to our pre-COVID baseline which probably tells us there is still hesitation to come to the hospital despite having a major heart attack,” Thangam said.

Even though a hesitancy to come into the hospital for chest pain undoubtedly plays a part in the reductions in coronary interventions, the authors concede that continued analysis is necessary as well as consideration for the ramifications of this trend. If the number of acute coronary syndromes (ACS) are, in fact, continuing to rise and people are simply not going to the hospital the authors suspect a subsequent rise in mortality, heart failure, and other morbidities related to coronary disease in the aftermath of the pandemic.

Other causes should also be entertained. Further study should look into all-cause mortality during the COVID-19 pandemic. It has been assumed that a large number of deaths due to COVID-19 over the last 2 years were related to the respiratory complications so often cited in reports. The truth is that cardiovascular complications related to COVID-19 are well described and that mortality related to viral infection is likely multifactorial.

Although respiratory failure is common in serious COVID-19 infection, long-term cardiac damage may lead to more ACS, STEMI, and PCI down the road. We must ask the tough questions. Are more people dying at home of coronary heart disease? Are more people suffering heart attacks that are non-fatal and simply brushing them off?

It is essential that clinicians continue to encourage patients to come into the hospital for chest pain and exertional dyspnea, especially if they have risk factors for coronary heart disease. The risk of dying or long-term morbidity is high. This is not just about numbers—it is about quality of life and fear. The authors of this abstract are right to highlight the impact of global media campaigns telling people to stay home as a potential reason for reduced PCI and STEMI volumes. I suspect however, as with most emerging evidence, that this reasoning is only the tip of the iceberg.

References:

1. https://www.jscai.org/article/S2772-9303(22)00063-1/fulltext