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The COVID-19 pandemic continues to present a public health challenge and has had a significant impact on the presentation, time-dependent management, and clinical outcomes of ST elevation myocardial infarction (STEMI). Patients with COVID-19 and pre-disposing cardiovascular risk factors like hypertension, hyperlipidemia, and diabetes mellitus are at a higher risk of developing STEMI, and global trends have highlighted delayed management of STEMI, which may contribute to worse clinical outcomes. Prolonged time to intervention has also resulted in an increased rate of no reflow, which is an independent risk factor for worse outcomes in these patients. Timely primary percutaneous coronary intervention (PCI) remains standard of care for STEMI and can be attained within the recommended 90 minutes timeline from hospital presentation. A coordinated, safe, standardized, algorithmic approach among emergency medical services, emergency departments, and cardiac catheterization laboratory is needed to ensure optimal patient outcome during and after the COVID-19 pandemic. The focus of this case report is to highlight the challenges of PCI for ST elevation myocardial infarction in the COVID-19 era.

Introduction Obstructive Sleep Apnea (OSA) is one of the strongest modifiable risk factors for Atrial Fibrillation (AF). Although, STOP-BANG questionnaire is a well-validated screening tool for OSA, its adoption and utility to screen newly diagnosed AF has not been reported in a large rural healthcare system. Our aim was to identify the characteristics in patients with AF, which led to screening and referral for a sleep study by providers. In addition, we identified the provider specialty types that had the highest rate of screening for OSA and sleep study referral. Methods We conducted a retrospective multicenter study that identified newly diagnosed patients with AF from January 2018- January 2020. STOP-BANG questionnaire, patient demographics, electrocardiogram, and sleep study data were collected. A logistic regression model was used to identify patient characteristics that were associated with increased screening. Using a chi-squared test, we compared differences in provider specialty that screened for OSA and referred patients for a sleep study. Results Among the study cohort (N=845), 136 (16.1 %) were female and 709 (83.9 %) were male. Only 82 patients (9.7%) had confirmed OSA screening by STOP-BANG questionnaire. Among higher risk patients for OSA (at least 3 of the following: age>50, male, hypertension, BMI>35), the screened patients were 5.8 years younger (95% CI: 3.7-7.9, p<0.001) compared to patients that were not screened. Patients who were screened for OSA had significantly higher BMI (p<0.001), hypertension (p<0.001), and diabetes mellitus (p<0.001). Our findings revealed that OSA screening providers, were most commonly Primary Care Providers (PCP) (47.5%) followed by cardiologists (31.7). Furthermore, PCPs (48.5 %) and cardiologists (14.1%) were most likely to provide referrals for a sleep study. All of the patients, who were screened using STOP-BANG questionnaire and referred for a sleep study, were diagnosed with OSA. Conclusion Our findings revealed underutilization of STOP-BANG to screen for OSA in newly diagnosed AF patients. Screening pattern may be tilted towards patients with obvious and severe forms of OSA therefore missing on milder cases. This study could prompt systemic adoption of STOP-BANG questionnaire, education, and periodic evaluation of healthcare providers in a large rural healthcare system to improve outcomes in AF patients. Support (If Any)

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