Comment

COVID-19 and Acute Coronary Syndrome: Lessons for

Cardiology Division, Department of Medicine, Queen Mary Hospital, the University of Hong Kong, Hong Kong SAR, China

The Coronavirus Disease 2019 (COVID-19) pandemic activities, social interaction, pollution and respiratory The Lancet Regional
Health - Western Pacific
has brought unprecedented changes to our world and viral infections etc. Healthcare avoidance may also con-
2022;19: 100346
healthcare system. In addition to millions of infected tribute to the trend and it is worrying to observe the
Published online 22
patients, non-COVID-19 care is also severely under- increase in out-of-hospital cardiac arrest in some December 2021
mined due to change in human behaviour and resource countries.5,6 Indeed in current study, patients admitted https://doi.org/10.1016/j.
availability. Treatment of medically emergent condi- during pandemic tended to have higher clinical risk pro- lanwpc.2021.100346
tions like acute coronary syndrome (ACS) are particu- files which reflected patients were reluctant to seek care
larly vulnerable and worldwide there were reports of unless their symptoms were very severe. However, the
reduction in ACS admissions with worsened in-hospital authors lack data on out-of-hospital death and therefore it
outcome.1-3 In fact, healthcare avoidance and treatment is difficult to conclude whether there was any detrimental
delay were apparent2,3 and may further translate into effect of ‘medical distancing’ in authors’ study popula-
poorer medium or long term cardiovascular outcome tion.
such as higher incidence of heart failure (HF). The intriguing observation of higher proportion of
In the Lancet Regional Health Western Pacific, Liu ACS and STEMI patients received prompt revascularisa-
He and colleagues4 tried to address this issue by utiliz- tion revealed the change in interventional practice amid
ing data from a large database of 31 tertiary hospitals in COVID-19 pandemic. In many countries, hospital
Beijing, China. Information on ACS admission, in- administrations mandate cardiac catheterization labora-
patient treatment and outcome from December 2019 to tories (CCL) to stop or cut elective service for non-emer-
June 2020 were compared with those in the previous gent cases. This aims to reserve resources for COVID-
year. Moreover, HF admission incidence 7 months after 19 care and it also facilitates invasive management of
the study period was also evaluated to assess the impact ACS which is largely non-deferrable. Despite the study
of COVID-19 on short term outcome of ACS survivors. did not specify the rates of fibrinolytic use, more STEMI
The authors demonstrated that admissions for ST-eleva- patients received PCI promptly and more ACS patients
tion myocardial infarction (STEMI), Non-ST-elevation could be managed invasively which are recommended
myocardial infarction (Non-STEMI), and unstable by clinical guideline.7 In contrast, increasing evidence
angina (UAP) amid pandemic reduced by 38¢0%, demonstrated that optimal medical therapy is the key to
41¢0%, and 63¢3% respectively. Interestingly, proportion treatment of stable coronary artery disease. PCI is an
of ACS patients received revascularisation and STEMI adjunct to selected patients for improving symptoms or
patients receiving percutaneous coronary intervention prognosis.7 Although it is currently premature to con-
(PCI) within 24 hours were higher during COVID-19 clude such a change of CCL practice is entirely beneficial,
pandemic. In-hospital mortality was similar between interventional cardiologists can start to consider what
the study and control period. Importantly, there was no they should be offering to their patients. Further studies
increase in HF admissions within the 7 month interval are required to investigate whether this may lead to better
after study period. outcome for coronary artery disease patients overall.
The lower incidence of ACS admissions during Data showed current pandemic is causing excessive
COVID-19 was in line with other reports.1-3 Possible COVID-19 and non-COVID-19 deaths.8 The authors
underlying reasons include reduction in human showed no observed increase in in-hospital mortality of
ACS patients and HF incidence in 7 months during the
pandemic in Beijing, China. Although 7 months is a rel-
DOI of original article: http://dx.doi.org/10.1016/j.
lanwpc.2021.100335. atively short period and the full effect of COVID-19 on
ACS may yet to be fully unveiled, the data are reassuring
*Correspondence: Chor-Cheung Frankie TAM, Cardiology
Division, Department of Medicine, The University of Hong for health administrators. It must be emphasized that
Kong, K19, Queen Mary Hospital,102# Pok Fu Lam Road, such favourable outcome including those reported by
Hong Kong, China. Tel: (852) 2255-4694, Fax: (852) 2818-6304 Chinese Center for Disease Control and Prevention9
E-mail address: frankie.tamcc@gmail.com (C.-C.F. TAM). were achieved by massive collaborative effort of various
© 2021 The Author(s). Published by Elsevier Ltd. This is an parties to control the pandemic. The high transmissibility
open access article under the CC BY-NC-ND license (http:// of SARS-CoV-2 can quickly evolve into explosive outbreak
creativecommons.org/licenses/by-nc-nd/4.0/)

www.thelancet.com Vol 19 Month February, 2022 1

which places huge demand on medical resources and 2 Kite TA, Ludman PF, Gale CP, Wu J, Caixeta A, Mansourati J,
precipitates eventual healthcare system collapse. China et al. International Prospective Registry of Acute Coronary Syn-
dromes in Patients With COVID-19. J Am Coll Cardiol. 2021;77
adopted a strict, swift and decisive ‘elimination’ strategy (20):2466–2476.
to combat COVID-19 which preserves the healthcare sys- 3 De Luca G, Verdoia M, Cercek M, Jensen LO, Vavlukis M, Calmac L,
et al. Impact of COVID-19 Pandemic on Mechanical Reperfusion for
tem for the people and healthcare workers. Hopefully Patients With STEMI. J Am Coll Cardiol. 2020;76(20):2321–2330.
with the advent of vaccines and anti-virals, we can finally 4 Liu H, Feng L, Xin D, et al. Impact of COVID-19 Pandemic on Hospi-
see the way to end the war against COVID-19. tal Admissions of Acute Coronary Syndrome: A Beijing Inpatient
Database Study. The Lancet Regional Health - Western Pacific.
COVID-19 pandemic is changing the world and 2022;19:100335.
healthcare system. ACS admissions reduced but care 5 Baldi E, Sechi GM, Mare C, Canevari F, Brancaglione A, Primi R,
quality maintained which resulted in similar in-hospital et al. Out-of-Hospital Cardiac Arrest during the Covid-19 Outbreak in
Italy. N Engl J Med. 2020;383(5):496–498.
outcome and short term incidence of HF compared 6 Lai PH, Lancet EA, Weiden MD, Webber MP, Zeig-Owens R, Hall
with pre-COVID-19 era. This can only be accomplished CB, et al. Characteristics Associated With Out-of-Hospital Cardiac
Arrests and Resuscitations During the Novel Coronavirus Disease
by a stable healthcare system which requires enormous 2019 Pandemic in New York City. JAMA Cardiol.
effort to sustain when confronted by such an infectious 7 Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP,
disease. Notably, this necessitates concerted effort from Benedetto U, et al. 2018 ESC/EACTS Guidelines on myocardial
revascularization. Eur Heart J. 2019;40:87–165. 10.1093/
everyone and collaboration is the key to success for all. eurheartj/ehy394.
8 Woolf SH, Chapman DA, Sabo RT, Weinberger DM, Hill L, Taylor
DDH. Excess Deaths From COVID-19 and Other Causes, March-July
Declaration of interests 2020. JAMA. 2020;324(15):1562–1564.
Nil. 9 Liu J, Zhang LY, Y Zhou Y, et al. Excess mortality in Wuhan city
and other parts of China during the three months of the covid-19
outbreak: findings from nationwide mortality registries. BMJ.
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2 www.thelancet.com Vol 19 Month February, 2022