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Table of Contents
Year : 2021  |  Volume : 18  |  Issue : 2  |  Page : 138-141

Reduced Number of acute myocardial infarction cases at the time of lockdown during the COVID-19 pandemic in northern Iraq-Erbil: In search for exploring the possible explanation behind it

1 Department of Catheterization, Surgical Specialty Hospital-Cardiac Center, Erbil, Iraq
2 Department of Medicine, Erbil Teaching Hospital, Erbil, Iraq

Date of Submission19-Oct-2020
Date of Acceptance14-Mar-2021
Date of Web Publication26-Jun-2021

Correspondence Address:
Banan Qasim Rasool
Erbil Teaching Hospital, Erbil
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/MJBL.MJBL_75_20

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Background: Coronavirus disease-2019 (COVID-19) pandemic has led to a radical transformation of economic, social, and health-care networks. COVID-19 pandemic has reported a substantial drop in the number of patients presenting to cardiology Emergency Departments with acute coronary syndromes/acute myocardial infarction (ACS/AMI) and a drop in number of cardiac procedures. Objective: The objective was to describe how lockdown and COVID-19 pandemic has affected the evolution of AMI and hospital admissions due to ACS. We aimed to assess the impacts of COVID-19 on cardiology services and procedures performed on a daily basis before and during the pandemic. Materials and Methods: This single-centered retrospective study included all the consecutive patients with ACS/AMI including ST-segment elevation myocardial infarction (STEMI) and non-STEMI admitted to ER of Surgical Specialty Hospital-Cardiac Center/Erbil-Iraq, from the start of the lockdown (March 15, to April 15, 2020). The same analysis was conducted among patients presenting with ACS/AMI at the same identical time period before Lockdown (March 15, to April 15, 2019). Results: A total number of 40 patients admitted at SSH/Cardiac Center-Erbil with ACS/AMI during the study period, and showed a 37.5% drop in the number of patients with Myocardial Infarction comparing with the corresponding time window before the COVID-19 pandemic. Conclusion: These preliminary results strongly demonstrate a decrease in the number of admissions for ACS/AMI during the lockdown period (March 15, to April 15, 2020) due to multiple reasons.

Keywords: Acute myocardial infarction, COVID-19 pandemic, lockdown effects on cardiovascular health

How to cite this article:
Amen SO, Rasool BQ. Reduced Number of acute myocardial infarction cases at the time of lockdown during the COVID-19 pandemic in northern Iraq-Erbil: In search for exploring the possible explanation behind it. Med J Babylon 2021;18:138-41

How to cite this URL:
Amen SO, Rasool BQ. Reduced Number of acute myocardial infarction cases at the time of lockdown during the COVID-19 pandemic in northern Iraq-Erbil: In search for exploring the possible explanation behind it. Med J Babylon [serial online] 2021 [cited 2023 May 29];18:138-41. Available from: https://www.medjbabylon.org/text.asp?2021/18/2/138/319507

  Introduction Top

The emergence of coronavirus disease-2019 (COVID-19) pandemic has changed the delivery of medical care worldwide, and as a response to this pandemic routine hospital services including cardiac catheterization has been reconstructed in order to increase hospital capacity for infected patients with COVID-19 and to limit the risk of crossinfection.

This had led to the cancellation of most of the elective procedures, focusing only on the emergency procedures, and reduced access to care for patients other than COVID-19 related conditions.

Many countries have announced social containment mandates, known as lockdown, in order to reduce the spread of the virus. And this point has contributed to patients' delay in seeking for medical emergency care because of fear of contracting COVID-19 at hospitals, which has resulted in a reduction in cardiovascular admissions.[1],[2]

On the other hand, not reaching to hospitals during emergency conditions can still be regarded as a usual life of some population, which may not have access to the hospital due to any other social, economic, and environmental reasons other than the COVID-19 pandemic.

There is a significant reduction observed in both, the presentations of acute coronary syndromes/acute myocardial infarction (ACS/AMI) and the percutaneous coronary intervention (PCI) procedures worldwide.[3],[4]

The first case of COVID-19 was reported on March 6, 2020 in Erbil/Iraq and the governorate of Erbil has announced the urge of the introduction of Physical Distancing Measure-Lockdown on March 14, 2020 all over the city. Restricted measurement was taken among all the citizens, although people were allowed to leave their home only for very essential needs, including the seek for health care.

To understand the rate, nature, and reasons behind this change/reduction in the number of admitted patients in cardiology emergency departments with different types of ACS including ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI), we started analyzing the presenting cases to ERs of cardiovascular departments and we intend to revise these data revise them to provide an updated summary of changes in cardiology services in response to COVID-19 pandemic.

It is essential to assess the impact of lockdown and health-care restructuring on the performance of cardiology service provision and the changes needed to prepare for the recovery phase and potential rebound surge of clinical activity.

The main objective of the current analysis is to identify and describe the rate of hospital admissions due to ACS/AMI during the first month of the COVID-19 lockdown period from a national perspective and to discuss the possible logical reasons of this reduction in the number of presenting ACS/AMI cases.

  Materials and Methods Top

In this study we performed a retrospective analysis of rate, clinical presentation, and angiographic characteristic of consecutive patients with different age groups, including both genders, presenting to ER with ACS/AMI at a single center of Surgical Specialty Hospital-Cardiac Center/Erbil-Iraq.

This center is a local hub for cardiological procedures including Primary PCI. The study period was from March 15 to April 15, 2020 (lockdown period due to COVID-19 pandemic). A comparison was done between the rate of hospitalization during the study period and a control period (corresponding period of March 15, to April 15, 2019).

Statistical analysis

Data were analyzed using Microsoft Excel for Mac 2016, version 15.26 Microsoft Corporation by Impressa Systems, Santa Rosa, California. Differences in variables were tested using Student's t-test. P < 0.05 was considered statistically significant.

  Results Top

A total of 40 patients (72.5% male and 27.5% female) have been included in the analysis, in which all of them have been admitted to Cardiac Center/Erbil due to ACS/AMI during the period of Lockdown (March 15, to April 15, 2020) and primary PCI have been performed for all of them (single stent, staged PCI and for emergency coronary artery bypass graft [CABG] surgery). The mean age ± standard deviation of the study population (during the lockdown period) was 56.3 ± 12.5 years with an age range of (31–78).

There is a clear decline in the number of cases presented to our center for ACS/AMI, comparing to the same time window in 2019 (nonlockdown period) by a ratio of 37.5%. This study population included STEMI (31 patients, 77.5%) and NSTEMI (9 patients, 22.5%) while in 2019 (41 patients, 64.1%) presented with STEMI and (23 patients, 35.9%) presented with NSTEMI. The percentage difference in STEMI and NSTEMI patients before and during lockdown is 24.39% and 60.87% respectively. But a relative and absolute reduction was for NSTEMI.

Notably, the number of patients presenting with a chief complaint of chest pain has been reduced during the lockdown period comparing to the nonlockdown period by a ratio of 36.17%. [Figure 1] shows the percentage difference between March 15 to April 15 of 2019 and 2020.
Figure 1: The percentage difference between before and during lockdown period due to the COVID-19 pandemic

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There is a decline and a clear percentage difference between both groups of the study, in which patients presenting at the time of lockdown (March 15 to April 15, 2020) shows 62.5% with hypertension, 60% with diabetes mellitus, 30% were smoker, 27.5% with previous ischemic heart (IH) and 17.5% with positive family history for CAD and hyperlipidemia. On the other hand, patients of the control group (15 March to April 15, 2019) shows 60.9% with hypertension, 54.7% with DM, 32.8% were smoker, 26.6% with previous IH disease, 20.3% with positive family history for CAD and 14.1% with hyperlipidemia.

The clinical characteristics of patients with ACS/AMI during different time windows are shown in [Table 1].
Table 1: The clinical characteristic of patients with acute coronary syndromes/acute myocardial infarction during different time windows (before and during lockdown)

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About the angiographic profile of the patients included in the study period of March 15, to April 15, 2020, All of the 40 patients underwent primary PCI and findings suggested single-vessel disease in 85%, double vessel disease in 2.5%, three-vessel disease in need for emergency CABG surgery in 7.5% and only a portion of 5% were with no critical lesion. The most commonly occluded artery was the left anterior descending artery, counting for 55% of all the cases.

  Discussion Top

Since the outbreak of the novel COVID-19 in December 2019-Wuhan/China, there have been millions of confirmed and hundreds of reported deaths worldwide.[5]

A worse prognosis and a more severe progression of COVID-19 have been associated with cardiovascular risk factors, previous cardiac disease, and ACS/AMI.[6]

Previous reports of reduced admission for ACS/AMI and decreased performing coronary procedures in various countries affected by the COVID-19 pandemic.[7]

Worldwide cardiologists have noticed a significant slowdown of ACS/AMI attacks to ER. We aimed to analyze the ratio of this reduction (if present) in this study, and results were going concordance with most of the results of other countries across Europe, US, and Australia. There was a 37.5% reduction in the number of admitted patients presenting to our local Cardiac Center in Erbil/Iraq.

The NEJM has published an article[1] about conditions in Northern Italy, which was one of the regions hit the hardest by the outbreak of COVID-19. The research showed that in the period of February 20 to March 31 of 2020, when compared to the same time window of 2019-the total incidence of ACS/AMI is down by 30% with major heart attacks STEMI by 25% and minor heart attacks by 44%. Our results also showed a relative a more absolute down of NSTEMI BY 60.87%while STEMI by 24.39%.

The results from different regions showed the same reduction with variation among the populations, in which the USA showed a 38% drop,[8] Spain showed 40% drop,[4] Austria showed 39.4% drop.[3]

The main finding of the present study is the dramatic reduction in the number of hospitalizations for ACS/AMI in Erbil-Iraq during the COVID-19 pandemic. In fact, admissions for ACS/AMI were almost halved during the pandemic compared with the equivalent period of the previous year. The identification of the mechanisms leading to the reduction in admissions for ACS/AMI is beyond the scope of the present work. [Figure 2] shows the clinical profile of patients presenting with acute myocardial infarction before (2019) and during (2020) lockdown to ED. [Table 2] summarizes the angiographic profile and the occluded arteries of patients presenting with MI at different time windows before and during lockdown.
Figure 2: The clinical profile of patients presenting with acute myocardial infarction before (2019) and during (2020) lockdown to ER

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Table 2: The prevalence of occluded arteries in patients before and during the lockdown period

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Nevertheless, it is tempting to speculate that probably a multiplicity of factors, rather than a unique mechanism, contributed to the phenomenon. First, it is possible that the fear of contagion at the hospital has discouraged access to ER, particularly after the media diffused the news that the infection was largely spread across hospitalized patients and health-care personnel due to their frequent contacts with hospitalized patients.

Second, air and noise pollution in urban areas which have been linked to a higher incidence of ACS/AMI[9],[10],[11] have majorly decreased due to social distancing and the implementations of extensive lockdown rules.

After the start of regional lockdown which led to the economic slowdown and traffic restrictions, the concentration of fine PM (particular matter) fell by 54% in South Korea-Seoul, by 44% in Wuhan, China, and by 60% in New Delhi, India.[12] Los Angeles experienced its longest stretch of clean air on record meeting WHO guidelines,[13] in general cities with historical levels of PM2.5 pollution witnessed the most substantial drops.

This pollution decrease paradoxically could be expected to have a health benefit.[14]

The aftermath of the COVID-19 pandemic might bring surprising dividends to our understanding of the environmental roots of cardiovascular disease and may impact on pollution preventing policy. Epidemiologists, economists, and doctors should track the time trends of cardiovascular disease before, during, and after the lockdown days. This might well be the final, definitive proof that 'what is good for the environment is good for our health,[14] and our heart,[15] allowing the publication of formal evidence-based recommendations to lower air pollution-induced health risks.[13]

Third, due to the effects of lockdown people tend to have less stress from driving, long traffics, work pressures, fatigability from excessive work hours and feuds, and angst from dealing with relatives, colleagues, and bosses, which might have outweighed the stress from lockdown and social distancing.

Fourth, social distancing and lockdown in addition to a potentially increased awareness of optimizing immunity has resulted in less infection from bad bouts of cold, the flu, and community-acquired pneumonia which are known to raise the risk of ACS/AMI.[16]

The fifth point is that during the lockdown period people were eating lesser fast foods, home-cooked meals are generally healthier than restaurant foods, and cooked with less fat and salt. High-fat loading postmeal is known to cause instability of cholesterol plaques, increasing the risk of ASC/AMI[17] whilst the transient rise in blood pressure following a high salty meal will do the same.[18]

Finally, there is a possibility, in which minority of patients with ACS/AMI have suffered at home and could not seek medical attention.

Our study has several limitations. First, not all hospitals in Northern Iraq were included; the data are collected from a single center in Erbil only.

Second, there is no postdischarge follow-up data and there were missing data particularly regarding left ventricular ejection fraction that may confound multivariate adjustment.

  Conclusion Top

With the start of lockdown in Northern Iraq/Erbil City, we analyzed that the COVID-19 pandemic has led to a significant reduction in the number of ACS/AMI presenting to ERs with a significant reduction in performed cardiological procedures.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Bromage DI, Cannatà A, Rind IA, Gregorio C, Piper S, Shah AM, et al. The impact of COVID-19 on heart failure hospitalization and management: Report from a Heart Failure Unit in London during the peak of the pandemic. Eur J Heart Fail 2020;22:978-84.  Back to cited text no. 2
Metzler B, Siostrzonek P, Binder RK, Bauer A, Reinstadler SJ. Decline of acute coronary syndrome admissions in Austria since the outbreak of COVID-19: The pandemic response causes cardiac collateral damage. Eur Heart J 2020;41:1852-3.  Back to cited text no. 3
Rodríguez-Leor O, Cid-Álvarez B, Ojeda S, Martín-Moreiras J, Rumoroso J, López-Palop R, et al. Impact of the COVID-19 pandemic on interventional cardiology activity in Spain. REC: interventional cardiology (English Edition); 2020. doi: 10.24875/RECICE.M20000123.  Back to cited text no. 4
Mehta P, McAuley DF, Brown M, Sanchez E, Tattersall RS, Manson JJ, et al. COVID-19: Consider cytokine storm syndromes and immunosuppression. Lancet 2020;395:1033-4.  Back to cited text no. 5
Atri D, Siddiqi HK, Lang JP, Nauffal V, Morrow DA, Bohula EA. COVID-19 for the cardiologist: Basic virology, epidemiology, cardiac manifestations, and potential therapeutic strategies. JACC Basic Transl Sci 2020;5:518-36.  Back to cited text no. 6
Mafham MM, Spata E, Goldacre R, Gair D, Curnow P, Bray M, et al. COVID-19 pandemic and admission rates for and management of acute coronary syndromes in England. Lancet 2020;396:381-9.  Back to cited text no. 7
Garcia S, Albaghdadi MS, Meraj PM, Schmidt C, Garberich R, Jaffer FA, et al. Reduction in ST-segment elevation cardiac catheterization laboratory activations in the United States during COVID-19 pandemic. J Am Coll Cardiol 2020;75:2871-2.  Back to cited text no. 8
Peters A, Dockery DW, Muller JE, Mittleman MA. Increased particulate air pollution and the triggering of myocardial infarction. Circulation 2001;103:2810-5.  Back to cited text no. 9
Lelieveld J, Pozzer A, Pöschl U, Fnais M, Haines A, Münzel T. Loss of life expectancy from air pollution compared to other risk factors: A worldwide perspective. Cardiovasc Res 2020;116:1910-7.  Back to cited text no. 10
Lelieveld J, Klingmüller K, Pozzer A, Pöschl U, Fnais M, Daiber A, et al. Cardiovascular disease burden from ambient air pollution in Europe reassessed using novel hazard ratio functions. Eur Heart J 2019;40:1590-6.  Back to cited text no. 11
Amsalu E, Wang T, Li H, Liu Y, Wang A, Liu X, et al. Acute effects of fine particulate matter (PM2.5) on hospital admissions for cardiovascular disease in Beijing, China: A time-series study. Environ Health 2019;18:70.  Back to cited text no. 12
Rajagopalan S, Al-Kindi SG, Brook RD. Air pollution and cardiovascular disease: JACC state-of-the-art review. J Am Coll Cardiol 2018;72:2054-70.  Back to cited text no. 13
Watts N, Amann M, Arnell N, Ayeb-Karlsson S, Belesova K, Berry H, et al. The 2018 report of the Lancet Countdown on health and climate change: Shaping the health of nations for centuries to come. Lancet 2018;392:2479-514.  Back to cited text no. 14
Hadley MB, Vedanthan R, Fuster V. Air pollution and cardiovascular disease: A window of opportunity. Nat Rev Cardiol 2018;15:193-4.  Back to cited text no. 15
Cuervo G, Viasus D, Carratalà J. Acute myocardial infarction after laboratory-confirmed influenza infection. N Engl J Med 2018;378:2540.  Back to cited text no. 16
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Boegehold MA. The effect of high salt intake on endothelial function: Reduced vascular nitric oxide in the absence of hypertension. J Vasc Res 2013;50:458-67.  Back to cited text no. 18


  [Figure 1], [Figure 2]

  [Table 1], [Table 2]


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