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Heart, Lung and Circulation

Letter to the Editor Regarding: Acute Coronary Syndrome in the COVID-19 Pandemic: Reduced Cases and Increased Ischaemic Time by Sutherland et al. Heart Lung Circ. 2022;31(1):69-76

Published:January 11, 2022DOI:https://doi.org/10.1016/j.hlc.2021.11.008
      To the Editor
      Sutherland and colleagues recently reported a reduction in patients admitted with acute coronary syndrome (ACS) and an increase in total ischaemic time during the first and second wave of the COVID-19 outbreak in Melbourne [
      • Sutherland N.
      • Dayawansa N.H.
      • Filipopoulos B.
      • Vasanthakumar S.
      • Narayan O.
      • Ponnuthurai F.A.
      • et al.
      Acute coronary syndrome in the COVID-19 pandemic: reduced cases and increased ischaemic time.
      ]. They also observed a 20% rebound increase in ACS presentations following the relaxation of public health restrictions in November–December 2020 compared to the same period of 2019 and suggested that this could represent long-term sequelae of untreated ACS including reinfarction and heart failure. However, several additional mechanisms could play a role.

      Daily Life Triggers

      A trend of reduced hospitalisations for all ACS types during the pandemic has been observed worldwide [
      • Sutherland N.
      • Dayawansa N.H.
      • Filipopoulos B.
      • Vasanthakumar S.
      • Narayan O.
      • Ponnuthurai F.A.
      • et al.
      Acute coronary syndrome in the COVID-19 pandemic: reduced cases and increased ischaemic time.
      ,
      • Fardman A.
      • Oren D.
      • Berkovitch A.
      • Segev A.
      • Levy Y.
      • Beigel R.
      • et al.
      Post Covid-19 acute myocardial infarction rebound.
      ,
      • Rattka M.
      • Dreyhaupt J.
      • Winsauer C.
      • Stuhler L.
      • Baumhardt M.
      • Thiessen K.
      • et al.
      Effect of the COVID-19 pandemic on mortality of patients with STEMI: a systematic review and meta-analysis.
      ]. Besides social distancing, stay-at-home orders, and fear of acquiring the infection, attenuated exposure to well-recognised ACS triggers, particularly reduced air pollution, and decreased physical and work activities, has been linked to this phenomenon [
      • Rattka M.
      • Dreyhaupt J.
      • Winsauer C.
      • Stuhler L.
      • Baumhardt M.
      • Thiessen K.
      • et al.
      Effect of the COVID-19 pandemic on mortality of patients with STEMI: a systematic review and meta-analysis.
      ,
      • Čulić V.
      • AlTurki A.
      • Proietti R.
      Covid-19 pandemic and possible rebound phenomenon in incidence of acute myocardial infarction.
      ]. The alleviation of restrictions after the pandemic waves restored the level of exposure to ACS triggers which could have contributed to a gradual increase in ACS hospitalisations [
      • Čulić V.
      • AlTurki A.
      • Proietti R.
      Covid-19 pandemic and possible rebound phenomenon in incidence of acute myocardial infarction.
      ]. Moreover, fear of lack of medical care, lockdown stress, anger, loneliness, job loss, financial stress, and binge smoking have been suggested as ACS triggers due to the ramification of the pandemic [
      • Hammoudeh A.
      • Abu-Hantash H.
      • Tabbalat R.
      • Al-Mousa E.
      • Madanat E.
      • Al-Muhaisen R.
      • et al.
      The Covid-19 pandemic and triggered acute myocardial infarction among non-infected individuals.
      ]. Along this line, a post-restriction increase in hospitalisations for ST-segment elevation myocardial infarction has been documented in Israel [
      • Fardman A.
      • Oren D.
      • Berkovitch A.
      • Segev A.
      • Levy Y.
      • Beigel R.
      • et al.
      Post Covid-19 acute myocardial infarction rebound.
      ].

      Population Vulnerability

      Anti-pandemic measures favour sedentary behaviour, physical inactivity, unhealthy nutritional habits, weight gain, and increased alcohol consumption, as confirmed by recent meta-analyses [
      • Bakaloudi D.R.
      • Barazzoni R.
      • Bischoff S.C.
      • Breda J.
      • Wickramasinghe K.
      • Chourdakis M.
      Impact of the first COVID-19 lockdown on body weight: a combined systematic review and a meta-analysis.
      ,
      • Bakaloudi D.R.
      • Jeyakumar D.T.
      • Jayawardena R.
      • Chourdakis M.
      The impact of COVID-19 lockdown on snacking habits, fast-food and alcohol consumption: a systematic review of the evidence.
      ]. Consequent negative effects on metabolism likely worsened the population’s cardiovascular health and, given their presence for over a year now, could have increased the number of vulnerable coronary patients [
      • Čulić V.
      • AlTurki A.
      • Proietti R.
      Covid-19 pandemic and possible rebound phenomenon in incidence of acute myocardial infarction.
      ]. Accordingly, increased population cardiovascular vulnerability coupled with enhanced exposure to ACS triggers could be important mechanisms of a rebound increase in ACS.

      References

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        • Dayawansa N.H.
        • Filipopoulos B.
        • Vasanthakumar S.
        • Narayan O.
        • Ponnuthurai F.A.
        • et al.
        Acute coronary syndrome in the COVID-19 pandemic: reduced cases and increased ischaemic time.
        Heart Lung Circ. 2022; 31: 69-76https://doi.org/10.1016/j.hlc.2021.07.023
        • Fardman A.
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        Post Covid-19 acute myocardial infarction rebound.
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        • Rattka M.
        • Dreyhaupt J.
        • Winsauer C.
        • Stuhler L.
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        • Thiessen K.
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        Effect of the COVID-19 pandemic on mortality of patients with STEMI: a systematic review and meta-analysis.
        Heart. 2021; https://doi.org/10.1136/heartjnl-2020-318360
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        Covid-19 pandemic and possible rebound phenomenon in incidence of acute myocardial infarction.
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        • Abu-Hantash H.
        • Tabbalat R.
        • Al-Mousa E.
        • Madanat E.
        • Al-Muhaisen R.
        • et al.
        The Covid-19 pandemic and triggered acute myocardial infarction among non-infected individuals.
        Int J Clin Cardiol. 2020; 7: 185
        • Bakaloudi D.R.
        • Barazzoni R.
        • Bischoff S.C.
        • Breda J.
        • Wickramasinghe K.
        • Chourdakis M.
        Impact of the first COVID-19 lockdown on body weight: a combined systematic review and a meta-analysis.
        Clin Nutr. 2021; https://doi.org/10.1016/j.clnu.2021.04.015
        • Bakaloudi D.R.
        • Jeyakumar D.T.
        • Jayawardena R.
        • Chourdakis M.
        The impact of COVID-19 lockdown on snacking habits, fast-food and alcohol consumption: a systematic review of the evidence.
        Clin Nutr. 2021; https://doi.org/10.1016/j.clnu.2021.04.020

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