The impact of the COVID-19 national lockdown on acute coronary syndromes related hospitalization in Johannesburg, South Africa

Evidence from low- and middle-income countries (LMICs) on how COVID-19 lockdown measures affected acute coronary syndrome (ACS) care is limited. We assessed the impact of South Africa’s national lockdown on ACS hospitalisations and clinical severity at presentation at a large tertiary hospital in Johannesburg. We conducted a retrospective cohort study of adults admitted with ACS under the Division of Cardiology at Charlotte Maxeke Johannesburg Academic Hospital during the national COVID-19 lockdown (26 March-30 June 2020) and the corresponding pre-pandemic period (26 March-30 June 2019). ACS was classified as ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), or unstable angina (UA). ACS subtype distribution, left ventricular ejection fraction (LVEF), and management strategies were compared between the two study periods. Monthly ACS admission rates were analysed using Poisson regression to estimate incidence rate ratios (IRRs), with quasi-Poisson regression used where overdispersion was present. Logistic regression was used to evaluate factors associated with LVEF and PCI use, with results reported as odds ratios (ORs) and adjusted ORs (aORs) with 95% confidence intervals (CIs). Of the 784 patients screened, 199 ACS admissions were included, mean age 58.4 ± 12.1 years (95% CI 56.5–59.9) and 70% men: 119 during the pre-pandemic period and 80 during the pandemic period, representing a 32.8% reduction in overall ACS admissions. The estimated ACS admission rate was lower during the pandemic (IRR 0.67, 95% CI 0.42–1.06). The largest declines were observed for UA (44.7%), STEMI (34.2%), and NSTEMI (22.6%). Patients admitted during the pandemic period had a significantly lower LVEF than those admitted during the pre-pandemic period (44.7 ± 14.8% vs. 53.4 ± 11.6%; mean difference, -8.7% points; 95% CI, -12.6 to -4.8; p < 0.001). Admission during the pandemic period was associated with lower odds of LVEF ≥ 40% (aOR 0.36, 95% CI 0.21–0.63; p < 0.001) and higher odds of undergoing PCI (aOR 2.70, 95% CI 1.59–4.57; p < 0.001). There were fewer ACS hospitalisations during South Africa’s national COVID-19 lockdown, with greater myocardial dysfunction and a higher likelihood of undergoing PCI. These findings suggest that pandemic-related restrictions, changes in healthcare-seeking behaviour, and altered referral patterns may have influenced access to emergency cardiovascular care in this LMIC setting. Not applicable.