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Canadian Journal of Cardiology

Reply to Čulić et al—COVID-19 Pandemic and Possible Rebound Phenomenon in Incidence of Acute Myocardial Infarction

Published:December 14, 2020DOI:https://doi.org/10.1016/j.cjca.2020.12.007
      To the Editor:
      We agree with Čulić et al
      • Čulic V.
      • AlTurki A.
      • Proietti R.
      Covid-19. COVID-19 pandemic and possible rebound phenomenon in incidence of acute myocardial infarction.
      regarding to the fact that the observed ST-segment elevation myocardial infarction (STEMI) hospitalisation rebound phenomenon is not entirely unexpected. Nonetheless, our report
      • Fardman A.
      • Oren D.
      • Berkovitch A.
      • et al.
      Post COVID-19 acute myocardial infarction rebound.
      is indeed the first description of this worrisome trend. Israel saw its first confirmed COVID-19 patient on February 21. The first documented in-state transmission of the virus subsequently occurred on February 22. New government regulations calling for social distancing; limiting gatherings; and restrictions on public transportation, schools, universities, and businesses were announced on March 10. Subsequently, on March 14, the Israeli government declared its plan for extending the quarantine to all nonessential workers, effectively bringing the country to a social and financial halt. Between March 14 and April 18, citizens were restricted to a 500-meter radius from their home. All outdoor physical activity was prohibited. Beginning on April 12, mask wearing became mandatory with the exception of children < 6 years of age. From April 19 to May 4, the Israeli government began to alleviate its restrictions, mainly in the area of limitation on free movement, reopening of street stores, and expanding the staff present in the workplace in private-sector firms. On May 3, schools reopened, and then on May 4 most imposed restrictions were lifted.

      Ministry of Health. Coronavirus News and Updates: Ministry of Health, Israel. Available at: https://www.gov.il/en/departments/topics/corona-main-sub. Accessed July 25, 2020.

      Although the explication of underlying mechanisms for the rebound increase in STEMI hospitalisations remains obscure, several considerations may be proposed. Čulić and colleagues
      • Čulic V.
      • AlTurki A.
      • Proietti R.
      Covid-19. COVID-19 pandemic and possible rebound phenomenon in incidence of acute myocardial infarction.
      hypothesised that the pandemic itself as well as anti-pandemic measures adversely affected healthy lifestyle and cardiovascular risk profile during the nationwide lockdown. They mentioned that social isolation, movement restriction, financial uncertainty, and fear of contracting the virus acted as fertile ground for unwholesome behaviours such as smoking binges, poor sleep hygiene, dietary indiscretion, sedentary lifestyle, and emotional frailty. However, a rebound increase in STEMI hospitalisations was detected as early as the second half of April, approximately 8 weeks from the first detected COVID-19 case in Israel and 6 weeks since the social restrictions were announced. It remains unclear whether this time frame is long enough to establish a substantial change in cardiovascular risk factors and subsequently affect an atherosclerotic plaque. In contrast to these long-term exposures, the role of vigourous physical activity and emotional upset as precipitating external triggers for acute myocardial infarction has been described previously.
      • Smyth A.
      • O'Donnell M.
      • Lamelas P.
      • et al.
      Physical activity and anger or emotional upset as triggers of acute myocardial infarction: the INTERHEART Study.
      Unsurprisingly, relief of movement restrictions has permitted renewal of physical activities after a period of sedentary lifestyle. In addition, anti-pandemic actions, personal and global economic instability, and changes in the social infrastructure resulted in increased levels of psychological stress, anger, and emotional upset. We hypothesise that these triggers could, at least partially, explain a surge of STEMI correlating with both resolution of the first wave of the COVID-19 pandemic and the lift of shelter-in-place restrictions.

      Funding Sources

      The authors have no funding sources to declare.

      Disclosures

      The authors have no conflicts of interest to disclose.

      References

        • Čulic V.
        • AlTurki A.
        • Proietti R.
        Covid-19. COVID-19 pandemic and possible rebound phenomenon in incidence of acute myocardial infarction.
        Can J Cardiol. 2021; 37: 1294
        • Fardman A.
        • Oren D.
        • Berkovitch A.
        • et al.
        Post COVID-19 acute myocardial infarction rebound.
        Can J Cardiol. 2020; 36 (1832.e15-1832.e16)
      1. Ministry of Health. Coronavirus News and Updates: Ministry of Health, Israel. Available at: https://www.gov.il/en/departments/topics/corona-main-sub. Accessed July 25, 2020.

        • Smyth A.
        • O'Donnell M.
        • Lamelas P.
        • et al.
        Physical activity and anger or emotional upset as triggers of acute myocardial infarction: the INTERHEART Study.
        Circulation. 2016; 134: 1059-1067

      Linked Article

      • COVID-19 Pandemic and Possible Rebound Phenomenon in Incidence of Acute Myocardial Infarction
        Canadian Journal of CardiologyVol. 37Issue 8
        • Preview
          Multiple studies have observed reduced hospital admissions for acute myocardial infarction (MI) during the COVID-19 pandemic.1,2 However, Fardman et al. describe a striking increase in hospitalizations for ST-segment elevation MI (STEMI), parallel with the persisting trend of reduced hospitalizations for non-STEMI after the first wave of the COVID-19 pandemic and social-distancing restrictions.2
        • Full-Text
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      • Post COVID-19 Acute Myocardial Infarction Rebound
        Canadian Journal of CardiologyVol. 36Issue 11
        • Preview
          As the first wave of COVID-19 came to a relative trough during May 2020 in parts of Europe and some states in the United States, for example Vermont, New York, and New Jersey, we are now beginning to observe a resurgence in acute myocardial infarction (AMI) admissions in Israel.1
        • Full-Text
        • PDF