Frain Kristina, Rathod Krishnaraj S, Tumi Ebrahiem, Chen Yang, Hamshere Stephen, Choudry Fizzah, Akhtar Mohammed M, Curtis Miles, Amersey Rajiv, Guttmann Oliver, O'Mahony Constantinos, Jain Ajay, Wragg Andrew, Baumbach Andreas, Mathur Anthony, Jones Daniel A, Rees Paul
Faculty of Medicine, Barts and The London School of Medicine and Dentistry, Queen Mary University of London London E1 4NS, UK.
St Bartholomew's Hospital, Barts Health NHS Trust London EC1A 7BE, UK.
Am J Cardiovasc Dis. 2021 Oct 25;11(5):647-658. eCollection 2021.
The clinical environment has been forced to adapt to meet the unprecedented challenges posed by the COVID-19 pandemic. Intensive care facilities were expanded in anticipation of the pandemic where the consequences include severe delays in elective procedures. Emergent procedures such as Percutaneous Coronary Intervention (PCI) in acute myocardial infarction (AMI) in which delays in timely delivery have well established adverse prognostic effects must also be explored in the context of changes in procedure and public behaviour associated with the COVID-19 pandemic. The aim for this single centre retrospective cohort study is to determine if door-to-balloon (D2B) times in PCI for ST Elevation Myocardial Infarction (STEMI) during the United Kingdom's first wave of the COVID-19 pandemic differed from pre-COVID-19 populations.
Data was extracted from our single centre PCI database for all patients that underwent pPCI for STEMI. The reference (Pre-COVID-19) cohort was collected over the period 01-03-2019 to 31-05-2019 and the exposure group (COVID-19) over the period 01-03-2020 to 31-05-2020. Baseline patient characteristics for both populations were extracted. The primary outcome measurement was D2B times. Secondary outcome measurements included: time of symptom onset to call for help, transfer time to first hospital, transfer time from non-PCI to PCI centre, time from call-to-help to PCI centre, time to table and onset of symptoms to balloon time. Categorical and continuous variables were assessed with Chi squared and Mann-Whitney U analysis respectively. Procedural times were calculated and compared in the context of heterogeneity findings.
4 baseline patient characteristics were unbalanced between populations with statistical significance (P<0.05). The pre-covid-19 cohort was more likely to have suffered out of hospital cardiac arrest (OHCA) and had left circumflex disease, whereas the 1 wave cohort were more likely to have been investigated with left ventriculography and be of Afro-Caribbean origin. No statistically significant difference in in-hospital procedural times was found with D2B, C2B, O2B times comparable between groups. Pre-hospital delays were the greatest contributors in missed target times: the 1 wave group had significantly longer delayed time of symptom onset to call for help (Control: 31 mins; IQR [82.5] vs 1 wave: 60 mins; IQR [90.0], P=0.001) and time taken from call for help to arrival at the PCI hospital (control: 72 mins; IQR [23] vs 1 wave: 80 mins; IQR [66.5], P=0.042).
Enhanced infection prevention and control procedures considering the COVID-19 pandemic did not impede the delivery of pPCI in our single centre cohort. The public health impact of the pandemic has been demonstrated with times being significantly impacted by patient related delays. The recovery of public engagement in emergency medical services must become the focus for public health initiatives as we emerge from the height of COVID-19 disease burden in the UK.
临床环境被迫做出调整，以应对新冠疫情带来的前所未有的挑战。为应对疫情，重症监护设施得到了扩充，其后果包括择期手术严重延迟。对于诸如急性心肌梗死（AMI）的经皮冠状动脉介入治疗（PCI）这类紧急手术，在与新冠疫情相关的手术流程和公众行为发生变化的背景下，也必须对及时实施手术的延迟所产生的不良预后影响进行探究。这项单中心回顾性队列研究的目的是确定在英国第一波新冠疫情期间，ST段抬高型心肌梗死（STEMI）患者接受PCI治疗时的门球时间（D2B）是否与新冠疫情之前的人群有所不同。
从我们单中心的PCI数据库中提取所有接受直接PCI治疗STEMI患者的数据。参照组（新冠疫情之前）的数据收集时间为2019年3月1日至2019年5月31日，暴露组（新冠疫情期间）的数据收集时间为2020年3月1日至2020年5月31日。提取两组人群的基线患者特征。主要结局指标是D2B时间。次要结局指标包括：症状发作至呼救时间、转运至第一家医院的时间、从非PCI医院转运至PCI中心的时间、从呼救至到达PCI中心的时间、上台时间以及症状发作至球囊扩张时间。分别采用卡方检验和曼-惠特尼U检验对分类变量和连续变量进行评估。在存在异质性结果的情况下计算并比较手术时间。
4项基线患者特征在两组人群之间存在统计学意义上的不平衡（P<0.05）。新冠疫情之前的队列更有可能发生院外心脏骤停（OHCA）且患有左旋支病变，而第一波疫情队列更有可能接受左心室造影检查且为非洲加勒比裔。在住院手术时间方面未发现统计学上的显著差异，两组之间的D2B、C2B、O2B时间相当。院前延迟是未达目标时间的最大因素：第一波疫情组症状发作至呼救的延迟时间显著更长（对照组：31分钟；四分位间距[82.5]，而第一波疫情组：60分钟；四分位间距[90.０]，P=0.001）以及从呼救至到达PCI医院的时间（对照组：72分钟；四分位间距[23]，而第一波疫情组：80分钟；四分位间距[66.5]，P=0.042）。
考虑到新冠疫情而加强的感染预防和控制措施并未妨碍我们单中心队列中直接PCI的实施。疫情对公众健康的影响已得到证实，患者相关延迟对时间产生了显著影响。随着我们从英国新冠疾病负担的高峰期走出，恢复公众对紧急医疗服务的参与度必须成为公共卫生举措的重点。
