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164]

Original Article

COVID‑19 and its Impact on the Management of Patients

with Acute Coronary Syndrome during the First COVID
Wave – A Questionnaire‑Based Survey among Interventional
Cardiologists from Southern India
Thoddi Ramamurthy Muralidharan1,2, Balakrishnan Vinod Kumar1,2, Preetam Krishnamurthy1, Nagendra Boopathy Senguttuvan1,2,3,
Jayanthy Venkata Balasubramaniyan1, Shanmugasundaram Sadhanandham1, Jebaraj Rathinasamy1, Ramesh Sankaran1, Manokar Panchanatham1,
Jayanthy Sathyanarayana Murthy1, Thanikachalam Sadagopan1
1
Department of Cardiology, Sri Ramachandra Institute of Higher Education and Research (Deemed to be University), 2C3 Research Foundation, Chennai, 3Adjunct
Faculty, Indian Institute of Technology Madras, Chennai, Tamil Nadu, India

Abstract
Background: The COVID‑19 pandemic has transformed the medical society in many ways. With significant drain on the resources and
altered healthcare priorities, there is a greater need for redeployment of the resources from noncommunicable diseases to COVID‑19‑related
healthcare services. To understand the impact of the COVID‑19 pandemic on the management of acute coronary syndrome (ACS) in Tamil
Nadu, a survey was administered across cardiologists in Tamil Nadu. Methods: A survey was done using an electronic questionnaire
administered regarding the change of patterns of acute coronary syndromes during the COVID through Google Forms with responses
collected in excel format. Results: Among 256 cardiologists contacted, 101 responded to the survey. Among cardiologists who responded, all
were interventional cardiologists– with most of them performing primary percutaneous coronary intervention (PCI) (95%) regularly during
pre‑COVID times. Most of them have noticed a significant reduction in the number of patients with ACS seeking health care (94%) and
another 61% of respondents felt that there was a reduction in the number of patients with acute coronary syndrome. There was a significant
delay in ST‑segment elevation myocardial infarction presentation to the hospital (88%) and significant reduction in the number of primary
PCI (47%). Only 19% of respondents did primary PCI for COVID‑positive patients. Conclusions: COVID pandemic has emerged as a big
challenge to the global health care system. Optimal acute coronary care could not be delivered in a timely manner due to multiple social,
patient, and physician‑related factors. The emerging techniques in rapid diagnosis of COVID‑19 and protective measures of COVID infection
are expected to improve the situation. Trial Registration: Clinical Trials Registry – India (CTRI), CTRI/2020/09/027517, Registered
September 1, 2020 http://CTRI. nic. In/Clinicaltrials/pmaindet2. php? trialid = 47025 and EncHid = and user Name =.

Keywords: Acute coronary syndrome, COVID‑19, primary percutaneous coronary intervention, revascularization

Address for correspondence: Dr. Nagendra Boopathy Senguttuvan,

Introduction Department of Cardiology, Sri Ramachandra Institute of Higher Education
and Research (Deemed to be University), Porur, Chennai ‑ 600 116,
The COVID‑19 disease has a severe impact on the global health Tamil Nadu, India.
care system.[1] Management of patients with acute coronary E‑mail: drsnboopathy@gmail.com
syndrome (ACS) is challenging during the COVID‑19
pandemic. There was significant disruption in normal life Submitted: 14‑Jun‑2021 Revised: 13-Jul-2021
with many countries imposing strict lockdown to prevent Accepted: 13‑Jul‑2021 Published: 14-Dec-2021
transmission of the disease. The lockdown resulted in major
impediments for patients (both having COVID and other This is an open access journal, and articles are distributed under the terms of the Creative
non‑COVID patients) to access healthcare. Both emergency Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
is given and the new creations are licensed under the identical terms.

Access this article online

For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
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Website:
www.j‑pcs.org How to cite this article: Muralidharan TR, Kumar BV, Krishnamurthy P,
Senguttuvan NB, Balasubramaniyan JV, Sadhanandham S, et al. COVID‑19
and its impact on the management of patients with acute coronary syndrome
DOI: during the first COVID wave – A questionnaire‑based survey among
10.4103/jpcs.jpcs_43_21 interventional cardiologists from Southern India. J Pract Cardiovasc Sci
2021;7:219-24.

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Muralidharan, et al.: COVID‑19#Acute coronary syndrome #coronary care in Tamil Nadu; India #impact on health care #perception of cardiologist

and elective procedures were disrupted globally. Although

major international societies and cardiological society of
India have proposed guidelines regarding the management of
such patients, a significant social, personal, and institutional
variations in adherence exist in real‑world practice.[1‑5] The
overwhelming of the system created new challenges in the
management of resources. We sought to know the impact of
the COVID‑19 pandemic on the management of ACS among
interventional cardiologists from Tamil Nadu, southern India.

Methods
Our study was a cross‑sectional study using electronic
questionnaire‑based survey (Supplementary appendix)
that was conducted in September 2020. Members of the
Tamil Nadu Interventional Council who are active in the Figure 1: A brief summary of the results of the study among the
society’s Whatsapp group were contacted individually for interventional cardiologists regarding their practices in acute coronary
participation in the study. The survey focused on the change syndrome during COVID era.
of patterns of acute coronary syndromes during the COVID
pandemic, COVID‑19 screening protocols, and changes in the reaction (RT‑PCR) (86.1%) over screening chest computer
management of non‑COVID patients with heart ailments. The tomography (CT) (58.4%); 44% wanted screening by both
survey was administered in English. The study was approved RT‑PCR and chest CT. Only 17% of respondents performed
by Medstar Multispeciality Hospital’s Ethics committee. All primary PCI for COVID‑positive patients. During primary
participants gave their consent for participation in this study, PCI in the COVID era, 54.5% encountered higher thrombus
and the study was registered in the clinical trials registry of burden in the culprit vessels compared with pre‑COVID
India (Clinical Trials Registry – India/2020/09/027517). The times. Though there was increase in thrombus burden, fewer
study was conceptualized by the first author and successfully respondents (36.6%) felt the need for glycoprotein 2b3a
executed by the second, third, and fourth authors. This study inhibitors. Tenecteplase was the commonly used thrombolytic
was funded by C3RF, a not‑for‑profit organization. agent (68.3%). More than one‑third of the participants (36.6%)
performed rescue PCI during the COVID pandemic. Elective
Results coronary evaluation in patients with ACS was done preferably
Of 256 participants, 101 (39%) responded to the survey. Almost within 2 days of presentation by most operators (91.1%).
all respondents but one was male (N = 100). We classified the Incidence of MINOCA was more frequently observed (51.5%)
locality of respondents based on tiers of cities as designated by compared with the pre‑COVID times. However, none of the
the Government of India.[6] Among the responders, 56% were operators observed any increase in the incidence of stent
from Tier 1 cities, 32% from Tier 2 cities, and 12% from Tier thrombosis. Most respondents (80%) managed patients with
3 cities. All were interventional cardiologists with majority cardiogenic shock; However, left ventricular assist devices
of them performing around 10–20 percutaneous coronary were used in <25% of patients with intra‑aortic balloon
intervention (PCI) per month (33.7%) with 95% of them being counterpulsation being the preferred modality (87%). Only
primary PCI operators before the COVID pandemic [Table 1]. 27% of respondents felt that there was increase in mechanical
complications with increased use of thrombolysis during
During the COVID pandemic, 94% of respondents noted the COVID pandemic. Among centers which were earlier
a significant reduction in the number of patients seeking performing coronary artery bypass graft (CABG), 59.4% did
medical attention to the hospital, and 61% felt that there not perform CABG during the COVID Pandemic. Despite
was also a reduction in the admission of patients with the initial conflicting reports on angiotensinogen‑converting
acute coronary syndrome. Importantly, participants (88%) enzyme (ACEi) and angiotensin receptor blockers (ARBs),
felt that patients with ST‑segment elevation myocardial most respondents (98%) continued usage of these medications.
infarction (STEMI) presented late to the hospital Most respondents felt that it was safe to initiate ACEi and
reducing the benefits of revascularization. Primary PCI ARB (98%) in appropriate patients with indications.
as a modality of revascularization was performed by less
than half of the participants compared with pre‑COVID
(95% vs. 47%) [Figure 1]. Despite the perception that Discussion
testing for COVID before intervention resulted in the delay Acute coronary syndrome is a major cause of mortality and
in primary PCI (81%), majority (62%) wanted to test for morbidity across the world. The burden of cardiovascular
COVID‑19 disease before Primary PCI. The interventional disease, despite great advances, has not seen significant
cardiologists preferred reverse transcription‑polymerase chain changes as reported in a multicentric prospective cohort study

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Table 1: Responses of the respondents

Questions Responses (N, %)
How many PCIs were done before COVID?
<10/month 38 (37.6)
10‑20/month 34 (33.7)
>40/month 0
20‑30/month 29 (28.7)
Do you perform PPCI?
Yes 96 (95.0)
No 5 (5.0)
How many PPCIs were done by you pre‑COVID era?
<3/month 22 (21.7)
5‑10/month 34 (33.7)
3‑5/month 16 (15.8)
>10/month 29 (28.7)
Do you feel that COVID has impacted your practice?
Yes 95 (94.1)
No 6 (5.9)
Do you think the number of patients with ACS has decreased?
Yes 62 (61.4)
No 39 (38.6)
Do you think the number of patients with STEMI has decreased?
Yes 62 (61.4)
No 39 (38.6)
Do you think patients with STEMI have late presentation during COVID?
Yes 89 (88.1)
No 12 (11.9)
Do you perform PPCI during COVID?
Yes 48 (47.5)
No 53 (52.5)
If yes, do you test them for COVID before taking them on table?
Yes 63 (62.4)
No 38 (37.6)
Did COVID testing cause delay in door to balloon time?
Yes 82 (81.2)
No 19 (18.8)
Do you think the thrombus load is higher during COVID era?
Yes 55 (54.5)
No 46 (45.5)
Do you think the use of GP 2b3a inhibitors increased compared to pre‑COVID era?
Yes 38 (37.6)
No 63 (62.4)
In the case of pharmacoinvasive therapy, which agent would you like to use?
Reteplase 16 (15.8)
Tenecteplase 68 (67.3)
Alteplase 3 (3.0)
Streptokinase 14 (13.9)
When would you like to plan your intervention after pharmacoinvasive therapy?
Within 24 h 46 (45.5)
Within 1‑2 days 47 (46.5)
>2 days 8 (7.9)
What proportion of patients does require rescue PCI postlysis during COVID era?
<25% 0
25%‑50% 18 (17.8)
50%‑75% 7 (6.9)
Do you think MINOCA has increased during COVID?
Yes 52 (51.5)
Contd...

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Table 1: Contd...
Questions Responses (N, %)
No 49 (48.5)
Did you manage cardiogenic shock during this period?
Yes 81 (80.2)
No 20 (19.8)
If yes did you use mechanical support (IABP)?
<10% 0
>50% 0
10%‑50% 8 (7.9)
Do you think the mortality of cardiogenic shock is higher now?
Yes 73 (72.3)
No 28 (27.7)
Do you think the usage of imaging has changed during COVID era?
Increased 30 (29.7)
Decreased 38 (37.6)
Same
If COVID positive patient has STEMI, what did you prefer as your treatment strategy?
Thrombolysis 82 (81.2)
PPCI 19 (18.8)
Do you find acute stent thrombosis increased during this period?
Yes 19 (18.8)
No 82 (81.2)
Are you seeing more mechanical complication with lysis?
Yes 27 (26.7)
No 74 (73.3)
Whether heart failure admissions associated with ACS are more during this period?
Yes 62 (61.4)
No 39 (38.6)
In your practice what is the incidence of COVID positivity observed in patients admitted with heart failure?
<10% 0
10%‑25% 47 (46.5)
25%‑50% 16 (15.8)
>50% 0
Does your center perform emergency/elective CABG during COVID era?
Yes 60 (59.4)
No 41 (40.6)
Did you use ACEi/ARB in your patients if required?
Yes 99 (98.0)
No 2 (2.0)
Do you think it is safe using ACEi/ARB in patients with COVID?
Yes 97 (96.0)
No 4 (4.0)
In your patients who were on ACEi/ARB, what do you prefer with the drugs?
Continue 99 (98.0)
Discontinue 2 (2.0)
PCIs: Percutaneous interventions, PPCIs: Primary PCIs, ACS: Acute coronary syndrome, STEMI: ST‑Segment‑Elevation Myocardial Infarction,
IABP: Intra‑aortic balloon counter pulsation, CABG: Coronary artery bypass graft, ACEi: Angiotensin converting enzyme inhibitors, ARB: Angiotensin
receptor blockers

over the period from 1990 to 2015.[7] In our study to understand COVID infection and ACS share a lot of similarities in terms
the impact of COVID on contemporary cardiology practice, we of presentation. Libby et al.[8] has proposed that COVID‑19 is
found that the participants observed a reduction in the number an endothelial disease, and hence pathophysiologically may be
of patients seeking medical attention to the hospital, decrease similar to ACS. Reports about the presence of inflammatory
in the admission of patients with ACS, significant delay in pathophysiological mechanisms, triggering plaque disruption
the diagnosis and management of the patients with ACS who and generating a prothrombotic milieu supported an anticipated
received medical treatment. increase in the number of patients presenting with ACS during

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the COVID‑19 pandemic.[9‑11] Activation of pro‑inflammatory face this “medical discrimination.” Protection of our health
interleukins pathway is the proposed mechanism of cytokine care workers is an important priority in the management of
storm observed in patients with ACS and COVID‑19.[12] Similar COVID‑19 pandemic. However, rigorous testing for COVID
to previous viral pandemics, hypotension, cardiomegaly, and has resulted in an additional delay for revascularization. As
arrhythmia are recognized as harbingers of acute heart failure in suggested by major societal guidelines, adequate personal
COVID‑19 too.[13] Heart failure is a recognized vulnerable state protective equipment (PPE) for appropriate care should be
during respiratory viral infections for increased adverse events. used by health care workers in high‑risk situations while doing
The subtle compensated state of heart failure can easily be procedures in patients with ACS undergoing PCI with pending
tilted toward decompensation state due to COVID‑19 leading COVID results.[1‑5] The reduction in patients with ACS and
to arrhythmic and ischemic risk[14] in patients with heart failure. heart failure may actually be due to reduced incidence of ACS
Reduction in the activation of cardiac catheterization for which could potentially be attributed to reduced air pollution,
STEMI seems to be a worldwide phenomenon. There has lower stress in daily life, increased utility of physical activities
been about 38% reduction in the volume of catheterization for among the public, reduced intake of fast‑food consumption,
STEMI in the United States and 48% reduction in Spain.[15,16] and positive effects of work from home by the majority of
Furthermore, similar survey among health care professionals working community.[5]
by the European Society Cardiology showed a perception of The renin‑angiotensin‑aldosterone system (RAAS) is an
decrease in STEMI as high as 40%.[17] In addition, an increase in important mechanism for maintaining vascular homeostasis
the first medical contact time i.e., symptom onset to ambulance and plays an important role in cardiac pathophysiology of
arrival (82.5 min to 318 min) timing during the pandemic heart failure and ACS. The ACE2, an enzyme that counters the
was noted from Hong Kong.[18] Significant delays were also RAAS activation, has been discovered to function as a receptor
reported from India.[19] There was extensive restructuring to the severe acute respiratory syndrome (SARS) viruses. The
across countries in cardiology services with at least two‑thirds interaction between the SARS virus and ACE2 was thought to
requiring substantial change in their service setup. A study by be a potential factor for infectivity. There were concerns about
Meenakshisundaram et al.[5] in South India also showed similar the use of RAAS inhibition, whether it may alter ACE2 and
trends toward lower incidence of ACS and STEMI. A recent possibly be responsible for virulence in the ongoing COVID
registry data (Luca et al.) also showed similar trends with 19% pandemic. The initial reports suggested that ACE inhibitors and
reduction in primary PCI.[20] Furthermore, it was observed in ARB increased susceptibility toward COVID infection.[23] This
the registry data that there was increase in mortality in patients led to a widespread withdrawal of the use of ACE inhibitors
in the COVID pandemic (2019%–4.9%, 2020%–6.8%; odds and ARB in the treatment of hypertension and heart failure
ratio – 1.41, confidence interval – 1.15–1.71 P < 0.001), the patients.[24] However, many studies have conclusively proven
mortality rate among COVID‑19 patients were much higher that there was no definite evidence of RAAS inhibition to alter
compared with non‑COVID‑19 patients (29% vs. 5.5%). The ACE2 levels and activity in humans. ACE2 may in fact be
higher mortality was attributed to the longer ischemia time beneficial rather than harmful in patients with lung injury.[25]
associated with treatment during the challenging times. In our study, most of the respondents continued the use of
Patients with STEMI are often breathless due to heart failure these agents (98%). The international society guidelines also
which further increases the suspicion among paramedics suggested that RAAS inhibition should not be withheld in
and emergency physicians regarding their COVID status. patients with appropriate indications for the same.[26]
A case series published by Bangalore et al.[21] showed COVID
patients presented with electrocardiography suggestive of Conclusions
STEMI but still had normal coronaries. Cardiac enzymes COVID‑19 has multiple collateral damages among
are frequently elevated in COVID patients and the diagnosis cardiovascular care that included delay in clinical presentation,
of ACS is difficult.[22] The similarity of the presentation and delay in receiving optimal treatment due to various reasons, and
low sensitivity of initial diagnostic modalities to diagnose increased incidence of MI‑related complications. Multipronged
COVID‑19 had led to a high degree of suspicion of COVID approach involving public education to avoid apprehension in
infection in patients presenting with ACS and heart failure. reaching hospitals when required, novel diagnostic kits that can
Hence, apprehensions of contracting COVID infection rapidly diagnose COVID infection, and early revascularization
on visiting hospital by the public, strict enforcement of of patients with STEMI/high‑risk ACS pending their COVID
lockdown leading to nonavailability of transports and medical status with the usage of the utility of PPE of level‑3 as
staffs, and stringent screening protocols followed at the recommended by major societies should be implemented.
emergency department of various institutions waiting for
COVID results could be the possible reasons for such delay Limitations
in getting appropriate treatment, especially in patients with Only 39% of the population responded to the questionnaire.
STEMI. We perceive this as collateral damage of COVID‑19 As it based on the memory of the participants, it has its own
in addition to its direct impact on the health‑care system. limitations, especially limited to memory. There were more
Paradoxically, patients with severe disease are more likely to responses from Tier 1 and Tier 2 cities and rural areas were

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underrepresented in this survey which reduces its applicability acute coronary syndromes. Tex Heart Inst J 2007;34:11-8.
in the general population. 11. Tang N, Bai H, Chen X, Gong J, Li D, Sun Z. Anticoagulant treatment
is associated with decreased mortality in severe coronavirus disease
Ethics clearance 2019 patients with coagulopathy. J Thromb Haemost 2020;18:1094-9.
12. Kox M, Waalders NJ, Kooistra EJ, Gerretsen J, Pickkers P. Cytokine
Medstar Specialty Hospitals Ethics Committee (C3RF002) levels in critically ill patients with COVID-19 and other conditions.
Bengaluru. JAMA 2020;324:1565-7.
13. Badawi A, Ryoo SG. Prevalence of comorbidities in the middle East
Acknowledgment respiratory syndrome coronavirus (MERS-CoV): A systematic review
Tamil Nadu Intervention Council. and meta-analysis. Int J Infect Dis 2016;49:129-33.
14. Nguyen JL, Yang W, Ito K, Matte TD, Shaman J, Kinney PL. Seasonal
Financial support and sponsorship influenza infections and cardiovascular disease mortality. JAMA Cardiol
Nil. 2016;1:274-81.
15. Garcia S, Albaghdadi MS, Meraj PM, Schmidt C, Garberich R, Jaffer FA,
Conflicts of interest et al. Reduction in ST-segment elevation cardiac catheterization
laboratory activations in the United States during COVID-19 pandemic.
There are no conflicts of interest. J Am Coll Cardiol 2020;75:2871-2.
16. Kwong JC, Schwartz KL, Campitelli MA, Chung H, Crowcroft NS,
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