Background:

Since the global spread of SARS-CoV-2 and concomitant implementation of vast measures to stop the virus from spreading, decreased admission numbers of patients with ST-segment myocardial infarction (STEMI) who, additionally, were reported to be in worse clinical condition compared to before the outbreak, have been observed. These findings led to the hypothesis that patients suffering from STEMI avoid contacting health care professionals, despite the presence of severe symptoms. Among other theories, the influence of stress and fear of COVID-19, as well as the effect of social distancing measures, have been suggested as important factors potentially dissuading patients from seeking timely medical care. However, up to know there are no analyses of the effects of lockdown, fear and stress on STEMI patients’ outcomes.

Methods and Findings:

A prospective, observational study on STEMI patients admitted to our tertiary care center during the COVID-19 pandemic was conducted. The primary outcome was survival. Secondary outcomes were patients’ symptoms as measured by NYHA class, left ventricular systolic function, and levels of cardiac biomarkers. Additionally, patients’ levels of stress and fear of COVID-19 at admission were assessed using well-established questionnaires (Fear of COVID-19 Scale and the COVID Stress Scales, and correlated to clinical data.

In our study, 67 consecutive patients were included, 16 patients in the lockdown group (March 21 and April 19,2020), and 51 in the post-lockdown group (April 20 and July 31,2020).

Lockdown patients had a significantly increased time to first medical contact. 46.2% (6 out of 16) patients of the lockdown group compared to 20.0% (7 out of 51 patients) patients of the post-lockdown group indicated a period longer than 12 hours before seeking medical care (p=0.05).

Lockdown group’s serum troponin T levels at admission were significantly higher than in the post-lockdown group (2803±3780 ng/l vs. 1196±2075 ng/l; p=0.03). Additionally, LVEF was significantly decreased in the lockdown group (lockdown: 10 out of 15 patients with highly impaired LVEF; post-lockdown: 12 out of 46; p=0.02) with a corresponding increase in left ventricular end-diastolic pressure (lockdown: 30.2±9.2 mmHg; post-lockdown: 22.3±8.7 mmHg; p=0.01). Moreover, significantly more patients in the lockdown group were in need of circulatory support (lockdown: 9 out of 16, post-lockdown: 10 out of 45; p=0.03). 

For the primary outcome, STEMI patients admitting during lockdown had significantly lower survival rates (confirmed deaths, lockdown: 9 out of 16 patients (56.3%); post-lockdown: 10 out of 51 patients (20%); log-rank: p=0.05). No significant changes could be detected for serum troponin T levels and LVEF at the end of follow-up. Correlation of the effect of stress and fear of COVID-19 with patient characteristics and clinical outcomes did not bring forth significant results.

Conclusions:

This is the first study prospectively evaluating the effect of lockdown, and stress and fear of COVID-19 on STEMI patients’ outcomes. Our results suggest that lockdown deteriorates survival of STEMI patients, possibly by prolonging the time from symptom onset to first medical contact, while stress and fear of COVID-19 do not affect their outcomes. Consequently, in the future management of the pandemic, the awareness of heart attack signs has to be increased in the general population to minimize potential cardiovascular collateral damage.