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Decrease in acute coronary syndrome presentations during the COVID-19 pandemic in upstate New York

Introduction The COVID-19 virus is a devastating pandemic that has impacted the US healthcare system significantly. More than one study reported a significant decrease in acute coronary syndrome admissions during that pandemic which is still due to unknown reasons. Methods This is a retrospective non-controlled multi-centered study of 180 patients (117 males and 63 females) with acute coronary syndrome (STEMI and NSTEMI) admitted during March/April of 2019 and March/April 2020 in Upstate New York. Results A total of 113 patients (61.9% males, 38.1% females) with a mean age of 72.3 ± 14.2 presented during March/April 2019 with ACS (STEMI + NSTEMI) while only 67 (70.1% males, 29.9% females) COVID-19 negative patients with a mean age of 65.1 ± 14.5 presented during the same period (March/April) in 2020. This is a drop by 40.7% (P < .05) of total ACS cases during the COVID-19 pandemic. In NSTEMI patients, 36.4% presented late (>24 hours of symptoms) during the COVID-19 pandemic in comparison with 2019 (27.1%, P = .033). Conclusion The COVID-19 pandemic led to a substantial drop by 40.7% (P < .05) of total ACS admissions in our area. This decrease in hospital admissions and late presentations can be a worrisome sign for an increase in future complications of myocardial infarctions.


Introduction
The severe acute respiratory syndrome Coronavirus 2 more commonly referred to as COVID-19 has been a devastating viral pandemic across the globe. The high transmission rate has led to widespread stay-at-home orders across the United States.
Although COVID-19 has led to surges in hospitalizations, the amount of acute coronary syndrome admissions has substantially decreased [1][2][3][4][5][6][7]. This phenomenon has been seen in multiple countries and thought to be due to multiple factors including hesitance of patients to visit the hospitals despite initial symptoms, better medication adherence, lower pollution levels, less smoking, and less physical strain. [6,7] The spread of the virus has led to stay-at-home orders from almost all states across the country. In New York State these orders were given on March 22nd, 2020. The first positive case of COVID-19 in Broome County, located in the southern tier of New York State, was on March 17th, 2020. [8] Our retrospective study investigates the impact that COVID-19 has had on the amount of ST elevation myocardial infarctions and non-ST elevation myocardial infarctions within our area during March and April of 2020. The diagnostic criteria for STEMI in this study were new ST elevation at the J point in at least 2 contiguous leads with ≥2 mm (0.2 mV) in men or ≥1.5 mm (0.15 mV) in women in leads V2-V3 and/or of ≥1 mm (0.1 mV) in other contiguous chest leads. The presence of a new LBBB with anginal symptoms was also considered diagnostic of STEMI. NSTEMI was defined as elevated troponin levels with anginal symptoms. Ischemic ECG changes may be present but are not required for the diagnosis.

Data collection
Data were retrieved by reviewing the electronic databases for all patients with positive troponins. Patients with troponin elevation due to non-cardiac causes, or type 2-5 MI were excluded. We retrospectively reviewed all STEMI and NSTEMI patients from March 2019 to April 2019 and March 2020 to April 2020. Relevant patient data including age, gender, home address, traveled miles to the hospital, onset of clinical symptoms, and management strategy were collected. This information was collected regardless of whether the patient underwent PCI or medical management Data for the overall hospital census (including surgical, internal medicine, OBGYN, pediatrics, intensive care unit, and cardiac care unit) during March/April 2019 and March/April 202 at the 4 hospitals was obtained.

Statistical Analysis
Abstracted medical records were entered into a computer and analyzed using SPSS V24. Categorical data were summarized using percentage and frequency, while numerical data were summarized using means and standard deviations. Differences in means were tested using the independent t-test with 95% confidence intervals. Differences in proportions were tested using Pearson's chi-square (independent groups). Statistical significance was assessed at the 0.05 level.

Funding
No extramural funding was used to support this work.

NSTEMI data
A total of 85 patients (61% males, 38.8% females) with a mean age of 73.9 ± 13 presented during March/April 2019 with NSTEMI while only 44 (75% males, 25% females) patients with a mean age of 68.5 ± 14 presented during the same period (March/April) in 2020. This is a drop by 48.2% (p< 0.05) of total NSTEMI cases during the COVID 19 pandemic. (Figure 1    cases as of May 1 st 2020) and other highly affected cities [9], the reported decrease in number of ACS admissions was similar [1][2][3][4][5][6][7]. Our data reports a drop by 40.7% (from 113 to 67 patients) (p < 0.05) of total ACS cases during the COVID 19 pandemic. (Figure 1) This is significantly higher than the number of total hospital admissions at all four hospitals which revealed a drop by 25.2% ( . This is a very interesting finding that suggests many patients with mild or anginal equivalent symptoms are likely staying at home and waiting longer before presenting to the hospital possibly due to the hesitance to be exposed to COVID 19 patients in hospitals. Moreover, a total of 28 patients presented during March/April 2019 with STEMI while only 23 patients presented during the same period (March/April) in 2020 which is a nonsignificant drop by 17.8% (p= 0.152) of total STEMI cases during the COVID 19 pandemic. However, 85 patients presented during March/April 2019 with NSTEMI and only 44 patients presented during the same period (March/April) in 2020. This is a significant drop by 48.2% (p< 0.05) of total NSTEMI cases during the COVID 19 pandemic. That is probably explained by the severity of the condition in STEMI patients, where they present with a more dramatic clinical picture that cannot be ignored or delayed as was seen by NSTEMI patients In 2019 35.4% of ACS admissions (STEMI and NSTEMI) were treated medically, while in 2020, only 14.9% were treated as such. This can be explained by the high proportion of elderly population with multiple comorbidities within our area. The mean age of patients that were treated medically was 89 ± 10.2. After discussion with the patients and their families, the decision was to treat them medically.
Our results go in conjunction with multiple similar studies performed throughout the world as presented in Table 3 Multiple hypothesis can be made as to why there is a significant drop in ACS admissions during the COVID 19 pandemic. Most likely due to the hesitance of patients to visit hospitals despite initial symptoms, but can also be due to misdiagnosis of ACS (since patients can present with cough and shortness of breath due to pulmonary edema) in the setting of multiple COVID 19 admissions, difficult transportation due to lockdowns in multiple countries and cities, better medication adherence, lower pollution levels, less smoking, and less physical strain. [6,7] Overall, this decrease in ACS admissions is worrisome, and it may reflect a later increase in acute and subacute myocardial infarction complications that result in increased morbidity and mortality.
J o u r n a l P r e -p r o o f

Study Limitations
Although this study was multi-centered, it was performed at a single county in Upstate New York with a total of 180 patients. Interestingly, our data showed similar results in comparison with other larger studies [1][2][3][4][5] We only studied STEMI and NSTEMI patients, while excluding patients presented with only unstable angina.

Conclusion
The COVID 19 pandemic led to a substantial decrease in ACS admissions across the world. In our study we report a drop by 40.7% (p < 0.05) of total ACS admissions which is similar to other studies. This decrease in hospital admissions and late presentations might be a sign for an increase in future complications of myocardial infarctions