MI Hospitalizations Down 20% at COVID-19 Peak in Italy, With a Heavy Cost

New details emerging from Northern Italy highlight the extent to which patients with myocardial infarction stayed home and avoided hospitals, as well as the consequences of those decisions, when the COVID-19 pandemic first struck the country.

During the first wave of infection, which was defined as February 22 to May 13, 2020, there was a 20% reduction in hospitalizations for MI when compared with expected hospitalizations based on historical data. Investigators also observed a corresponding increase in the number of out-of-hospital cardiac deaths in 2020, which they believe might result from patients ignoring MI symptoms and avoiding hospitals during the pandemic. 

“We had a peak of out-of-hospital cardiac deaths, and we think it was more than a coincidence,” senior investigator Gianni Casella, MD (Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy), told TCTMD. Out-of-hospital cardiac deaths were higher in 2020 compared with past years (ratio of observed/expected 1.17; 95% CI 1.08-1.27), and this excess of deaths peaked in April 2020.

Delaying going to the hospital for MI and other time-sensitive conditions, or avoiding the trip altogether, is a documented phenomenon of the COVID-19 pandemic, with many researchers highlighting the so-called “missing MIs” as an unintended consequence of people either misinterpreting government stay-at-home orders or simply being afraid of contagion at a hospital. There has long been a worry that patients with MI avoiding care would be at risk for more dire complications, such as cardiac arrest, for example.

Fear of Coming to the Hospital

These new data, published in the Lancet Regional Health – Europe, part of a new suite of open-access journals focusing on different parts of the world, are derived from patients who were admitted to the hospital for MI in Emilia-Romagna, a region in Northern Italy with 4.5 million people. With more than 50 hospitals, this area has a well-structured public emergency service, including 10 cardiac catherization laboratories and around-the-clock interventional services. During the pandemic, there was a rearrangement of services to deal with COVID-19 cases, including a reduction in the number of elective procedures and surgeries, but the open labs continued to provide primary PCI for STEMI cases. One of the strengths of the new analysis, said Casella, is that it includes a homogeneous cohort of patients admitted to this well-organized regional health service.

We did our job the same way during the lockdown, but the people didn’t understand that, and they were worried. Gianni Casella

From January 2017 to June 2020, there were 31,381 admissions for MI, including 12,164 for STEMI and 19,217 for NSTEMI. Compared with the expected trend, there as a 19.5% reduction in daily admissions on February 22, 2020, and a 21.6% reduction in daily admissions on March 5, 2020. Declines in MI hospitalization were consistent for STEMI and NSTEMI and seen in both men and women. Notably, patients admitted to the hospital for MI during the first wave of the pandemic tended to be younger and have fewer risk factors and comorbidities compared with patients hospitalized in years past.

“When the lockdown started, we had a decline in the number of people arriving with myocardial infarction,” said Casella. As the director of his hospital’s cardiology department at his hospital, the largest in Bologna, Casella said he even made a television appearance in April to stress the importance of coming to the hospital if people experienced symptoms of MI and to reassure the public the hospital was safe. “Especially older patients, they might ignore symptoms of a heart attack out of fear of coming to the hospital,” he said. “That’s exactly what we observed in our study.”

Despite the rearrangement of some services, researchers observed no significant difference in the risk of death at 30 days among patients hospitalized with MI. From 2017 to 2020, the 30-day mortality rate of hospitalized MI patients was roughly 8.5%, and this rate did not vary in 2020 compared from historical patterns. “The treatment inside the hospital was exactly the same,” said Casella, referring to their protocols for managing patients with MI. “We did our job the same way during the lockdown, but the people didn’t understand that, and they were worried.”

Of the MI patients hospitalized between February and June 2020, just 56 were positive for SARS-CoV-2. These patients were older and were more likely to have heart failure than those who hadn’t contracted the virus. During follow-up, one-third of patients with SARS-CoV-2 infection died, with infection an independent predictor of 30-day mortality (OR 5.1; 95% CI 2.9-8.8).

Refined Public Health Messaging

To TCTMD, Casella said that while they can’t definitively link the increase in out-of-hospital cardiac mortality to the decline in MI hospitalizations, the association between two trends is pretty strong. In Bologna, he noted, emergency services have previously reported an increase in calls for cardiac arrest during the first wave of COVID-19.

During the second and third waves of the pandemic, Casella said the public health messaging has been refined to encourage people with symptoms of MI to not avoid the hospital, and he suspects they might not see the same reduction in hospitalizations during these later waves as they did during the first. “Last spring, everything was closed—outpatient clinics, primary care offices—so the message was quite heavy for people,” said Casella. “They were scared. They thought the hospital wasn’t a safe place to go.”

Casella said one of the messages from their paper is that the “healthcare system takes time to recover” from a shock like COVID-19. Hospitalizations for MI didn’t start to pick up until mid-April, when daily admissions increased by 10%. The number of admissions didn’t get back to normal until May 2020, which was after the first wave of the pandemic had come under control, he said.