Across Europe, Data Confirm ‘Missing STEMIs’ in COVID-19 Era

With an eye toward the second wave, experts urge public health campaigns to ease patients’ fear of going to the hospital.

Across Europe, Data Confirm ‘Missing STEMIs’ in COVID-19 Era

Data spanning 77 centers in 18 European countries support the idea that the COVID-19 pandemic hampered prompt STEMI care, researchers say, perhaps due to “fear of contagion” and health system overload. Fewer patients underwent primary PCI and, for those who did, the waits were longer.

More of TCTMD's coverage on our COVID-19 hub.
More of TCTMD's coverage on our COVID-19 hub.

Results from the ISACS-STEMI COVID-19 registry, published online today in the Journal of the American College of Cardiology, confirm earlier reports from outbreak hot spots, including New York City.

Lead investigator Giuseppe De Luca, MD (Eastern Piedmont University-Novara, Italy), told TCTMD that what struck him most is that the reduction in primary PCI in March and April of 2020 wasn’t across the board. Rather, there was heterogeneity among centers, which he attributed to regional variations in fear—the researchers found no evidence that it stemmed from actual COVID-19 prevalence and mortality rates.

De Luca offered an additional possibility. “One thing we encountered in Italy was a high rate of infection among healthcare providers. Probably some hospitals, due to better organization and protection devices, [had] less contamination and this could have created more trust towards the institution” at the local level, he suggested.

It may be also that in the COVID-19 era more STEMI patients died before hospitalization, driving down primary PCI, De Luca said. “We know that the ambulance system and the emergency system were in some ways overcrowded. There [were] a lot of calls. This may in some way have delayed the treatment and transportation of some patients.”

Unfortunately, De Luca predicted that these patterns are likely to continue in COVID-19’s “second wave.” This time around, the absolute number of infected individuals is much higher and, although the cases tend to be less severe, will strain transportation systems yet again. Hospitals this time around have more plans in place for STEMI care, though. “Now all patients are treated as COVID-positive, so in some ways we are better prepared,” he said, though safety precautions still take time.

COVID-19 is “continuing to present an unprecedented challenge for healthcare systems,” Duk-Woo Park, MD, PhD, and Yujin Yang, MD (Asan Medical Center, Seoul, South Korea), agree.

Tackling this will require healthcare societies to emphasize recognition and response to STEMI symptoms among both healthcare professionals and the public, they write in an accompanying editorial. “Many countries are now experiencing second waves of the COVID-19 outbreak, in which optimal and well-timed STEMI management seems like a candle flickering in the wind.”

Fewer Primary PCIs, Higher Mortality

The retrospective registry included data on 6,609 STEMI patients who underwent primary PCI in March/April 2020 and March/April 2019 at high-volume centers that typically perform more than 120 such cases per year. Baseline characteristics were similar before and during the pandemic.

The number of primary PCI-treated STEMIs dropped from 595 to 494 per million residents between these two periods in 2019 and 2020 (incidence rate ratio [IRR] 0.81; 95% CI 0.78-0.84). Differences in primary PCI were particularly acute in patients with hypertension (IRR 0.77; 95% CI 0.74-0.81) compared with those without high blood pressure (IRR 0.86; 95% CI 0.81-0.90; P for interaction = 0.005).

More patients arrived at the PCI via ambulance direct from the community in 2020 compared to 2019 (58.3% vs 54.3%), while fewer were transferred (24.0% vs 27.0%; P = 0.005). Yet the proportions of patients with delays grew between 2019 and 2020, with an increase in in-hospital mortality.

Primary PCI for STEMI: During vs Before COVID-19




P Value

Total Ischemia Time > 12 H



< 0.001

Door-to-Balloon Time > 30 Min



< 0.001

In-Hospital Mortality



< 0.001

Ischemia and door-to-balloon times remained significantly longer after accounting for potential confounders (adjusted OR 1.34 and 1.17, respectively). Death risk, too, stayed elevated (adjusted OR 1.46), even when excluding patients with COVID-19. There were no disparities in cardiogenic shock or out-of-hospital cardiac arrest prior to presentation, infarct location, or the need for rescue procedures after failed thrombolysis.

As to the hypertension finding, De Luca said that patients with this comorbidity may have been more reluctant to potentially expose themselves to the SARS-CoV-2 virus, particularly early on when there were worries that renin-angiotensin-aldosterone system antagonists might increase the odds of infection or severity of COVID-19. This concept has since been debunked.

Addressing patients’ fears will be key in ensuring prompt care, he urged. Without public health initiatives, not only STEMI but also other acute conditions will take their toll at a population level—as COVID-19 mortality rates wane, other causes of death will rise, stressed De Luca. “I am sure about that.”

The focus thus far has been on how many people are infected, he said, “but nobody talks about the side effects of the [COVID-19] situation concerning the fact that people do not show up to the hospital despite [having] dangerous diseases.”

Vast Majority Were COVID-19-Negative

Timothy Henry, MD (The Christ Hospital, Cincinnati, OH), who at TCT Connect 2020 presented results from the North American COVID-19 ST-Segment Elevation Myocardial Infarction (NACMI) registry, said the size of this new analysis is impressive and that its message is consistent with what has been seen worldwide: “Not only were there less people coming in, but the processes were slowed down a little bit.”

What’s interesting here, said Henry, is that a mere 62 patients out of 2,956 in the study’s 2020 cohort were positive for COVID-19—just 2.1%. For these individuals, mortality reached 29%; in NACMI, the rate was 32%.

Regarding delays, Henry pointed out to TCTMD that the door-to-balloon increase was quite small, rising from a median of 34 minutes (interquartile range [IQR] 21-36 minutes) in 2019 to 36 minutes (IQR 24-60 minutes) in 2020. What’s more informative—though tricky to ascertain—is the ischemia time, he added. Here the medians were 181 minutes (IQR 120-301) and 200 minutes (IQR 127-357), respectively.

He also observed that this report only provides insight into the people who made it to the hospital. It’s crucial to get the word out to the public, said Henry, “that if you’re having chest pain, you need to come to the hospital. This really confirms that.

Caitlin E. Cox is News Editor of TCTMD and Associate Director, Editorial Content at the Cardiovascular Research Foundation. She produces the…

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  • This study was promoted by Eastern Piedmont University - Novara, Italy, without any financial support.
  • De Luca, Park, Yang, and Henry report no relevant conflicts of interest.