The COVID-19 Pandemic and Associated Inequities in Acute Myocardial Infarction Treatment and Outcomes

Abstract

ImportanceThe COVID-19 pandemic disrupted usual care for emergent conditions, such as acute myocardial infarction (AMI). Understanding whether Black and Hispanic individuals experiencing AMI had greater increases in poor outcomes compared with White individuals during the pandemic has important equity implications.ObjectiveTo investigate whether the COVID-19 pandemic was associated with increased disparities in treatment and outcomes among Medicare patients hospitalized with AMI.Design, Setting, and ParticipantsThis cross-sectional study used Medicare data for patients hospitalized with AMI between January 2016 and November 2020. Patients were categorized as Hispanic, non-Hispanic Black, and non-Hispanic White. The association between race and ethnicity and outcomes as a function of the proportion of hospitalized patients with COVID-19 was evaluated using interrupted time series. Data were analyzed from October 2022 to June 2023.ExposureThe main exposure was a hospital’s proportion of hospitalized patients with COVID-19 on a weekly basis as a proxy for care disruption during the pandemic.Main Outcomes and MeasuresRevascularization, 30-day mortality, 30-day readmission, and nonhome discharges.ResultsA total of 1 319 273 admissions for AMI (579 817 females [44.0%]; 122 972 Black [9.3%], 117 668 Hispanic [8.9%], and 1 078 633 White [81.8%]; mean [SD] age, 77 [8.4] years) were included. For patients with non–ST segment elevation MI (NSTEMI) overall, the adjusted odds of mortality and nonhome discharges increased by 51% (adjusted odds ratio [aOR], 1.51; 95% CI, 1.29-1.76; P < .001) and 32% (aOR, 1.32; 95% CI, 1.15-1.52; P < .001), respectively, and the odds of revascularization decreased by 27% (aOR, 0.73; 95% CI, 0.64-0.83; P < .001) among patients hospitalized during weeks with a high hospital COVID-19 burden (>30%) vs patients hospitalized prior to the pandemic. Black individuals with NSTEMI experienced a clinically insignificant 7% greater increase in the odds of mortality (aOR, 1.07; 95% CI, 1.00-1.15; P = .04) for each 10% increase in the COVID-19 hospital burden but no increases in readmissions or nonhome discharges or reductions in revascularization rates compared with White individuals. There were no differential increases in adverse outcomes among Hispanic compared with White patients with NSTEMI based on hospital COVID-19 burden. Increases in hospital COVID-19 burden were not associated with changes in outcomes or the use of revascularization in STEMI overall or by racial or ethnic group.Conclusions and RelevanceThis study found that while hospital COVID-19 burden was associated with worse treatment and outcomes for NSTEMI, race and ethnicity–associated inequities did not increase significantly during the pandemic. These findings suggest the need for additional efforts to mitigate outcomes associated with the COVID-19 pandemic for patients admitted with AMI when the hospital COVID-19 burden is substantially increased.

Mortality for Time-Sensitive Conditions at Urban vs Rural Hospitals During the COVID-19 Pandemic

“…The results of our study also lend support to concerns about the pandemic’s impact on AMI, another life-threatening condition, for which prior studies have shown mixed results . We found increased odds of inpatient mortality for non–COVID-19 AMI at urban hospitals throughout the entire pandemic period of 2020 through 2021 and at rural hospitals in those months corresponding to the initial wave of COVID-19 in 2020 and subsequent waves in 2021.…”

“…Likewise, reluctance to seek care among patients without STEMI was indicated by a greater reduction in hospitalizations during the COVID-19 lockdown compared with STEMI admissions . System stress is another factor for worse patient outcomes, as a recent study found lower revascularization rates but higher mortality rates for patients without STEMI who were admitted during periods of high hospital COVID-19 burdens …”

“… 34 System stress is another factor for worse patient outcomes, as a recent study found lower revascularization rates but higher mortality rates for patients without STEMI who were admitted during periods of high hospital COVID-19 burdens. 35 …”

Safety, Surge, and Strain: Where and When Does Risk Occur in Critical Care?*

“…Significant mortality increases occurred (OR 1.23 vs. baseline) in the United Kingdom as the occupancy of intensive care beds exceeded 85% (6) and in the United States during peak pandemic weeks (OR 1.37 vs. baseline) (7). Investigators have found effects on mortality during surge for specific conditions as well-for example, an increase in non-ST-elevation myocardial infarction mortality of over 50% (8).…”

Type 2 Myocardial Infarction: Another Hidden Cause of Mortality During the COVID-19 Pandemic

“…In a large-scale American patients presented with NSTEMI (n=1,022,439), the odds of mortality increased by 51% (adjusted odds ratio [aOR], 1.51; 95% confidence interval [CI], 1.29–1.76; p<0.001) and the rate of revascularization decreased by 27% (aOR, 0.73; 95% CI, 0.64–0.83; p<0.001) among patients hospitalized during weeks with a high hospital COVID-19 burden (>30%) versus patients hospitalized prior to the pandemic. 5) …”