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The sudden outbreak of the new coronavirus infection that caused a global pandemic caught people and healthcare systems off guard. As the virus was rapidly analyzed and tested, it was found that the main ways of transmission of SARS-Cov-2 is through respiratory droplets, aerosol transmission, infection vectors, and faecal-oral transmission. SARS-CoV-2 attaches to the target host cell angiotensin-converting enzyme-2 (ACE2) receptor, after which the virus is internalized and replicated. ACE2 receptors are highly expressed in upper and lower respiratory tract cells and mainly attack the respiratory tract and lungs (BMJ, n.d.).
However, as research progressed, it was discovered that many patients did not die from respiratory distress syndrome and respiratory failure, but directly or indirectly from acute coronary syndrome (ACS). Although various types of lockdown measures and people's reduced activity due to fear of infection have led to a decrease in emergency department admissions. However, in cardiology, this has led to delays or non-admissions of cardiac patients. Most acute heart diseases require treatment as soon as possible, so this also indirectly led to an increase in the number of patients diagnosed with heart disease as the final cause of death during the COVID-19 pandemic (Cesaro et al. 2022).
On December 26, 2022, the author conducted research in multiple countries and regions such as Hong Kong, Japan, and the United States, and published an article entitled "How has COVID-19 impacted the care of patients with acute coronary syndromes?" in the journal Expert Review of Cardiovascular Therapy. Through quasi-quantitative research, the relationship between SARS-CoV-2 and ACS was revealed, and treatment duration and strategies for ACS were studied after restrictive measures were taken to control infection in cities. Additionally, the rates of various surgeries and bed turnover rates for ACS before and after the COVID-19 pandemic were compared.
Direct relationship between COVID-19 and cardiovascular disease
When we did meta-analysis for 1527 patients with COVID-19, at least 8% of patients had an acute myocardial injury, and the risk of severe clinical presentations was 13 times higher. The SARS-CoV-2 has an inflammatory and thrombotic effect, and it has been confirmed that it causes endothelial dysfunction and coagulation disorders. At the same time, the virus is also associated with coronary artery spasm, plaque rupture or thrombosis caused by systemic inflammation and cytokine storms, which will increase the likelihood of ACS in COVID-19 patients.
In addition, for patients diagnosed with ST-segment elevation myocardial infarction (STEMI), viral load, thrombus size, and thrombus burden are higher, and the prognosis is poor. 5%-25% of hospitalized patients with COVID-19 have increased cardiac troponin, and the increase in cardiac troponin is associated with a worse prognosis (Cesaro et al. 2022). In critically ill patients, infection-induced microvascular disease or hypercoagulable state can lead to thrombosis of capillaries, veins, and/or arteries, which may result in end-organ damage due to distant thrombosis or embolic disease (BMJ, n.d.).
Indirect relationship between COVID-19 and cardiovascular disease
Due to the control of the epidemic, during the period of lockdown/circuit-breaker, due to hospital and social epidemic prevention policies, patients were hindered from entering the emergency department, which increased the time from the onset of ACS symptoms to the first medical contact, resulting in delayed treatment. Comparing STEMI patients who underwent percutaneous coronary intervention (PCI) in 2018 and 2020 (during the COVID-19 pandemic), the time from symptom onset to first medical contact increased from 82.5 minutes to 318 minutes; the time from hospital admission to catheterization laboratory surgery increased from 84.5 minutes to 110 minutes; and the time from catheter insertion to stent expansion increased from 20.5 minutes to 33 minutes. This indicates that healthcare workers need more preparation time due to the epidemic control and the need to wear additional personal protective equipment.
According to the European Society of Cardiology, PCI remains the first-line treatment for STEMI and high-risk non-ST elevation myocardial infarction (NSTEMI) patients, rather than thrombolysis. In the United States, compared to the same period in 2019, the occupancy rate (4.8%) and bed turnover rate (50%) of the cardiovascular intensive care unit (CCU) decreased, but the average length of stay increased from 3.26 days to 6.75 days. In Italy, the time from entering the surgical centre to stent expansion exceeded 60 minutes, an increase of 31.5% compared to before the COVID-19 pandemic, and the increase in time from entering the surgical centre to balloon expansion was related to inpatient mortality (OR 1.005, p=0.029) (Cesaro et al. 2022).
Conclusion
Due to the reduction in PCI surgery for ACS and STEMI patients, and the delay of PCI surgery and NSTEMI patient care caused by the epidemic control, there has also been an increase in the number of deaths due to ischemic heart disease, 1.04 to 1.18 in the United States. The most important impact of COVID-19 infection on ACS patients is on the cardiovascular system rather than the respiratory system, and we need to take timely interventions to prevent deterioration such as heart failure. Therefore, the role of secondary prevention and treatment centres such as clinics is particularly important. They can provide early screening and basic treatment. At the same time, reasonable treatment paths should be developed to minimize the time for blood flow reconstruction.
Reference:
Cesaro, Arturo, et al. “How Has Covid-19 Impacted the Care of Patients with Acute Coronary Syndromes?” Expert Review of Cardiovascular Therapy, vol. 21, no. 1, 2022, pp. 1–4., https://doi.org/10.1080/14779072.2023.2159809.
“2019 冠状病毒病（COVID-19）.” 2019 冠状病毒病（COVID-19） - 病因学 | BMJ Best Practice, BMJ, https://bestpractice.bmj.com/topics/zh-cn/3000201/aetiology.
ACS: Acute Coronary Syndrome. CAD: Coronary Artery Disease. COVID-19: Coronavirus disease 2019. PCI: Percutaneous Coronary Intervention.
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