Case Rates, Treatment Approaches, and Outcomes in Acute Myocardial Infarction During the Coronavirus Disease 2019 Pandemic
Case Rates, Treatment Approaches, and Outcomes in Acute Myocardial Infarction During the Coronavirus Disease 2019 Pandemic
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DOI：
10.1001/jamacardio.2020.3629
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发表时间：
2020-12-01
期刊：
影响因子：
24
通讯作者：
Spinelli, Kateri J.
中科院分区：
文献类型：
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作者：
Gluckman, Ty J.;Wilson, Michael A.;Spinelli, Kateri J.
这项横断面研究检查了患者数量的增加和减少，以及在冠状病毒疾病发作之前和之后立即出现急性心肌梗死的个人所经历的治疗的相关变化2019.关键点病例率，治疗方法，在2019冠状病毒病（COVID-19）大流行期间，急性心肌梗死（AMI）患者的住院结局发生了变化？在这项涉及14724名AMI患者的15244例住院病例的横断面研究中，病例率在2020年2月23日开始下降，5周后略有恢复。虽然治疗方法无统计学显著差异，但ST段抬高型心肌梗死患者的风险调整死亡率显著增加。本研究的结果表明，在分析的COVID-19大流行期间，AMI住院和住院结局发生了变化;需要进行额外的研究来解释ST段抬高心肌梗死患者的死亡率较高。重要性2019冠状病毒病（COVID-19）大流行改变了全球的医疗保健服务。虽然在大流行期间，急性心肌梗死（AMI）住院率有所下降，但对住院结局的影响尚不清楚。目的明确急性心肌梗死（AMI）发病率、患者人口统计学资料、心血管合并症、治疗方法和住院结局在大流行期间的变化。设计、设置和患者这项横断面研究回顾性分析了2018年12月30日至2020年5月16日期间，普罗维登斯圣约瑟夫卫生系统49家医院中的1家医院（位于6个州（阿拉斯加、华盛顿、蒙大拿、俄勒冈州、加州和德克萨斯州）发生的AMI住院患者。该队列包括18岁或以上出院时主要诊断为AMI（ST段抬高型心肌梗死[STEMI]或非ST段抬高型心肌梗死[NSTEMI]）的患者。进行分段回归分析以评估每周病例量的变化。病例分为3个时期之一：COVID-19之前（2018年12月30日至2020年2月22日），COVID-19早期（2020年2月23日至2020年3月28日），以及COVID-19后期（2020年3月29日至2020年5月16日）。使用观察与预期（O/E）比值和协变量调整多变量模型对住院死亡率进行风险调整。暴露住院日期。主要结果和测量主要结果是AMI（STEMI或NSTEMI）住院的每周发生率。次要结局是该患者人群的患者特征、治疗方法和住院结局。结果该队列包括15 244例AMI住院患者（其中4955例为STEMI [33%]，10 289例为NSTEMI [67%]），涉及14 724例患者（平均[SD]年龄68 [13]岁，10 019例男性[66%]）。从2020年2月23日开始，AMI相关住院病例以每周-19.0（95%CI，-29.0至-9.0）例的速度下降，持续5周（COVID-19早期）。此后，AMI相关住院率以每周+10.5（95%CI，+4.6至+16.5）例的速度增加（COVID-19后期）。在各阶段，未观察到患者人口统计学、心血管合并症和治疗方法的明显差异。急性心肌梗死早期O/E死亡率增加（1.27; 95%CI，1.07 -1.48），与STEMI患者不成比例相关（1.96; 95%CI，1.22 -2.70）。虽然AMI的O/E死亡率在后期没有统计学差异（1.23; 95%CI，0.98 -1.47），但STEMI患者的O/E死亡率增加（2.40; 95%CI，1.65-3.16），风险调整后增加（优势比，1.52; 95%CI，1.02-2.26）。结论和相关性这项横断面研究发现，在COVID-19早期和晚期，AMI住院率发生了重要变化，预后更差。未来的研究需要确定STEMI患者死亡率增加的原因。
This cross-sectional study examines the increases and decreases in patient volume and the associated changes in treatment experienced by individuals presenting with acute myocardial infarction before and immediately after the onset of the coronavirus disease 2019.Key PointsQuestionHow have case rates, treatment approaches, and in-hospital outcomes changed for patients with acute myocardial infarction (AMI) during the coronavirus disease 2019 (COVID-19) pandemic? FindingsIn this cross-sectional study of 15 244 hospitalizations involving 14 724 patients with AMI, case rates began to decrease on February 23, 2020, followed by a modest recovery after 5 weeks. Although no statistically significant difference in treatment approaches was found, the risk-adjusted mortality rate among patients with ST-segment elevation myocardial infarction increased substantially. MeaningThe findings of this study show that changes in AMI hospitalizations and in-hospital outcomes occurred during the COVID-19 pandemic periods analyzed; additional research is warranted to explain the higher mortality rate among patients with ST-segment elevation myocardial infarction.ImportanceThe coronavirus disease 2019 (COVID-19) pandemic has changed health care delivery worldwide. Although decreases in hospitalization for acute myocardial infarction (AMI) have been reported during the pandemic, the implication for in-hospital outcomes is not well understood. ObjectiveTo define changes in AMI case rates, patient demographics, cardiovascular comorbidities, treatment approaches, and in-hospital outcomes during the pandemic. Design, Setting, and ParticipantsThis cross-sectional study retrospectively analyzed AMI hospitalizations that occurred between December 30, 2018, and May 16, 2020, in 1 of the 49 hospitals in the Providence St Joseph Health system located in 6 states (Alaska, Washington, Montana, Oregon, California, and Texas). The cohort included patients aged 18 years or older who had a principal discharge diagnosis of AMI (ST-segment elevation myocardial infarction [STEMI] or non-ST-segment elevation myocardial infarction [NSTEMI]). Segmented regression analysis was performed to assess changes in weekly case volumes. Cases were grouped into 1 of 3 periods: before COVID-19 (December 30, 2018, to February 22, 2020), early COVID-19 (February 23, 2020, to March 28, 2020), and later COVID-19 (March 29, 2020, to May 16, 2020). In-hospital mortality was risk-adjusted using an observed to expected (O/E) ratio and covariate-adjusted multivariable model. ExposureDate of hospitalization. Main Outcomes and MeasuresThe primary outcome was the weekly rate of AMI (STEMI or NSTEMI) hospitalizations. The secondary outcomes were patient characteristics, treatment approaches, and in-hospital outcomes of this patient population. ResultsThe cohort included 15 244 AMI hospitalizations (of which 4955 were for STEMI [33%] and 10 289 for NSTEMI [67%]) involving 14 724 patients (mean [SD] age of 68 [13] years and 10 019 men [66%]). Beginning February 23, 2020, AMI-associated hospitalizations decreased at a rate of -19.0 (95% CI, -29.0 to -9.0) cases per week for 5 weeks (early COVID-19 period). Thereafter, AMI-associated hospitalizations increased at a rate of +10.5 (95% CI, +4.6 to +16.5) cases per week (later COVID-19 period). No appreciable differences in patient demographics, cardiovascular comorbidities, and treatment approaches were observed across periods. The O/E mortality ratio for AMI increased during the early period (1.27; 95% CI,1.07-1.48), which was disproportionately associated with patients with STEMI (1.96; 95% CI,1.22-2.70). Although the O/E mortality ratio for AMI was not statistically different during the later period (1.23; 95% CI,0.98-1.47), increases in the O/E mortality ratio were noted for patients with STEMI (2.40; 95% CI, 1.65-3.16) and after risk adjustment (odds ratio, 1.52; 95% CI, 1.02-2.26). Conclusions and RelevanceThis cross-sectional study found important changes in AMI hospitalization rates and worse outcomes during the early and later COVID-19 periods. Future studies are needed to identify contributors to the increased mortality rate among patients with STEMI.