The SARS-CoV-2 infection (COVID-19) era impact on incidence of sudden deaths due to myocardial infarction (Heart Attack) in States and Union Territories of India- A cross-sectional comparative study (2018-2022)

Figure 3A: Percentage of male and female sudden death in 2020 due to MI.

Figure 3B: State wise percentage share of female MI cases related sudden death in 2020.

Figure 3C: The state wise percentage share of male MI cases related sudden death in 2020.

Sudden death due to myocardial infarction in 2021 Data sources

In the year 2021 (COVID-19 era) total numbers of MI cases related sudden death were 28,449, out of which 24,510 (86.16%) were males and 3,936 (13.84%) were females, and 3 transgender (Figure 4A). The data on transgender is very less hence not taken for evaluation. Figures 4B and 4C shows the state wise percentage of female and male sudden death due to MI cases in 2021. In the year 2021 (COVID-19 era) of this study the female sudden deaths caused by MI were mostly in Maharashtra (42%), Kerala (16%), Gujarat (9%), Madhya Pradesh (5%), Karnataka (5%), Tamil Nadu (3%), Punjab (2%), Odisha (2%), Uttar Pradesh (2%), Chhattisgarh (2%), Haryana (2%), and Rajasthan (4%). Out of the above 12 states 5 are coastal states accounting for 75% of all MI cases related sudden death in 2021. The coastal states mentioned above have shown a similar trend like previous years 2020. During the year 2021 (COVID-19 era) the male sudden deaths caused by MI were found mostly in Maharashtra (36%), Gujarat (11%), Kerala (13%), Madhya Pradesh (6%), Karnataka (6%), Tamil Nadu (5%), Haryana (4%), Punjab (4%), Uttar Pradesh (2%), and Rajasthan (4%). Out of the above 10 states the 5 coastal states accounts for 71% of all MI cases related sudden death in 2021.

Figure 4A: Percentage of male and female sudden death in 2021 due to MI.

Figure 4B: State wise percentage share of female MI cases related sudden death in 2021.

Figure 4C: The state wise percentage share of male MI cases related sudden death in 2021.

Sudden death due to myocardial infarction in 2022

In the year 2022 (COVID-19 era) total numbers of MI cases related sudden death were 32,410, out of which 28,005 (86.42%) were males and 4,402 (13.58%) were females, and 3 transgender (Figure 5A). The data on transgender is very less hence not taken for evaluation.

Figure 5A: Percentage of male and female sudden death in 2022 due to MI.

Figures 5B and 5C shows the state wise percentage of female and male sudden death due to MI cases in 2022. In the year 2022 (COVID-19 era) of this study the female sudden deaths caused by MI were mostly in Maharashtra (43%), Kerala (14%), Gujarat (7%), Madhya Pradesh (4%), Karnataka (6%), Tamil Nadu (4%), Punjab (2%), Uttar Pradesh (3%), Uttarakhand (2%), Chhattisgarh (2%), Haryana (2%), and Rajasthan (4%). Out of the above 12 states 5 are coastal states accounting for 70% of all MI cases related sudden death in 2022. The coastal states mentioned above have shown a similar trend like previous years 2021. During the year 2022 (COVID-19 era) the male sudden deaths caused by MI were found mostly in Maharashtra (38%), Gujarat (9%), Kerala (12%), Madhya Pradesh (5%), Karnataka (6%), Tamil Nadu (5%), Haryana (4%), Punjab (3%), Odisha (2%), Uttar Pradesh (2%), and Rajasthan (4%). Out of the above 10 states the 5 coastal states accounts for 70% of all MI cases related sudden death in 2022.

Figure 5B: State wise percentage share of female MI cases related sudden death in 2022.

Figure 5C: The state wise percentage share of male MI cases related sudden death in 2022.

The total number of MI cases related sudden death during the study period i.e. from 1^st January 2018 to 31^st December 2022 is 1, 43,308, obtained by adding individual new MI cases related mortality detected by the states and UTs of India. The transgender data is not evaluated due to fewer amounts of data.

Table 2 elaborates the percent change in sudden death due to MI in males and females in comparison to previous year among various States and UTs of India. The percent change in total sudden death due to MI in males is never negative (indicates that it is continuously increasing) during the study period but in case of females it was negative (indicates that it reduced in 2021) in 2021 compared to 2020. The individual state and UTs percent change in sudden death due to MI in males and females is clearly elaborated, and we are not discussing it in details to reduce the length of this article. The largest and noteworthy percent change in sudden death due to MI in males is found in 2022 when it increased by 14.26% (is it due to delayed cardiomyopathy due to COVID-19 or its due to Vaccine? This will be a matter of research in coming era). The largest and noteworthy percent change in sudden death due to MI in females is also seen in 2022 when it increased by 11.84%.

Table 2: Percent change in sudden death due to MI in males and females in comparison to previous year.

COVID-19 period comparison with pre-COVID-19 era

The annual number of total new MI cases related mortality detected by the states and UTs of India, during a year i.e. 1^st January to end i.e. 31^st December is 25,764; 28,005; 28,680; 28,449 and 32,410; for years 2018, 2019, 2020, 2021, and 2022 respectively. The annual number of total new MI cases related mortality detected during the pre-COVID-19 as well as in COVID-19 period have similar increasing trends separately except a slight fall in 2021. The base year 2018 is having least whereas the last year 2022 is having the largest number of total new MI cases related mortality detected in one individual year.

Table 3, Comparison of mean mortality in males due to MI during COVID-19 period and pre- COVID-19 period with percentage change in COVID-19 period compared to pre COVID-19 period.

Table 3: Comparison of mean mortality in males due to MI during COVID-19 period and pre- COVID-19 period with percentage change in COVID-19 period compared to pre COVID-19 period.

Table 4: Comparison of mean mortality in females due to MI during COVID-19 period and pre- COVID-19 period with percentage change in COVID-19 period compared to pre COVID-19 period.

This study revealed that there is 25.80 percent increase in total number of new MI cases related mortality in 2022 in comparison to pre-COVID-19 year of 2018. The mean of total number of MI cases related sudden death during pre-COVID-19 period (2018-2019) is 26,884.5 whereas during the COVID-19 period (2020-2022) it increased to 29846.33. There is an overall increase of 11.02 percent in new MI cases related mortality during the COVID-19 period.

Table 3, shows the comparison of mean sudden death in males due to MI during COVID-19 period and pre- COVID-19 period with percentage change in COVID-19 period compared to pre COVID-19 period, in different states and UTs of India (Figures 6A and 6B). The total number of new MI cases related mortality in males during the study period is 1, 22,919, obtained by adding individual new MI cases related mortality detected by the states and UTs of India. The mean number of total new MI cases related mortality in males during pre-COVID-19 period (2018-2019) is 23,030.5 whereas during the COVID-19 period (2020-2022) it increased to 25619.33 (Figures 6A and 6B).

Figure 6A: Comparison of mean fatalities due to MI during COVID-19 period with pre-pandemic period. Period-Mean

Figure 6B: Percent increase in Mean fatalities due to MI in COVID-19 period compared to pre COVID-19 period. due to MI in COVID-19 period compared to pre COVID-19 period.

There is an overall increase of 11.24 percent in sudden death due to MI cases in males during the COVID-19 period, (Figures 6A-6B). The finding of this study is that the total number of Male-Sudden death due to Myocardial Infarction cases detected increased continuously during pre-COVID-19 years and during COVID-19 years.

The male-sudden death due to myocardial infarction increased during COVID-19 year 2022 by 26.71 percent in comparison to 2018 pre-COVID-19 year. Percent wise topmost state reporting sudden death due to MI in males is Maharashtra, while Kerala, Gujarat, Madhya Pradesh, Karnataka, Tamil Nadu, Haryana, Punjab, Odisha, Uttar Pradesh, and Rajasthan are also important contributors.

The annual number of total new MI cases related mortality in males detected by the states and UTs of India, during a year i.e. 1^st January to end i.e. 31st December is 22,101; 23,960; 24,343; 24,510 and 28,005; for years 2018, 2019, 2020, 2021, and 2022 respectively. The annual number of total new MI cases related mortality in males detected during the pre-COVID-19 as well as in COVID-19 period have similar increasing trends separately. The base year 2018 is having least whereas the last year 2022 is having the largest number of total new MI cases related mortality detected in one individual year. Maharashtra remained on the top in reporting Male-Sudden death due to Myocardial Infarction during the study period. The comparison of mean mortality in males due to MI during COVID-19 period and pre- COVID-19 period is elaborated with percentage change in COVID-19 period compared to pre COVID-19 period. Mizoram with 182.64% is at top in percentage change in COVID-19 period compared to pre COVID-19 period in Male-Sudden death due to Myocardial Infarction whereas Odisha is at bottom with-100%.

Female-sudden death due to myocardial infarction

The total number of female-Sudden death due to Myocardial Infarction cases increased continuously during pre-COVID-19 years and during COVID-19 years, except 2021, in which a slight drop. The female-Sudden death due to Myocardial Infarction increased during COVID-19 year 2022 by 20.17 percent in comparison to 2018 pre- COVID-19 year. Percent wise top 3 states reporting sudden death due to MI in females include Maharashtra, Kerala and Gujarat.

The total number of new MI cases related mortality in female during the study period is 20,378, obtained by adding individual new MI cases related mortality detected by the states and UTs of India. The mean number of total new MI cases related mortality in female during pre-COVID-19 period (2018-2019) is 3,852.5 whereas during the COVID-19 period (2020-2022) it increased to 4,224.33. There is an overall increase of 9.65 percent in new MI cases related mortality in female during the COVID-19 period.

This study also revealed that sudden death due to MI is very less (about 14%) in females compared to males (86%), or we can say that compared to females, males are 6 times more likely to have sudden death due to MI.

The annual number of total new MI cases related mortality in female detected by the states and UTs of India, during a year i.e. 1st January to end i.e. 31st December is 3663, 4042, 4335, 3936 and 4402; for years 2018, 2019, 2020, 2021, and 2022 respectively. The annual number of total new MI cases related mortality in female detected during the pre-COVID-19 as well as in COVID-19 period have similar increasing trends separately, except 2021. The base year 2018 is having least whereas the last year 2022 is having the largest number of total new MI cases related mortality detected in one individual year. This study revealed that there is 20.17 percent increase in total number of new MI cases related mortality in females in 2022 in comparison to pre-COVID-19 year of 2018.

Maharashtra remained on the top in reporting female-Sudden death due to Myocardial Infarction during the study period. The comparison of mean mortality in females due to MI during COVID-19 period and pre- COVID-19 period is elaborated in Table 4, with percentage change in COVID-19 period compared to pre COVID-19 period. Mizoram with 266.67% is at top in percentage change in COVID-19 period compared to pre COVID-19 period in Male-Sudden death due to Myocardial Infarction whereas Manipur is at bottom with-91%. Table 5, shows the statistical analysis of sudden death due to MI during study period. It is not elaborated to reduce the length of the article. There is wide gap in minimum and maximum sudden death due to MI during study period in different States and UTs of India as shown in Table 5. Hence the 95% C.I is also having big gap as well as a huge difference in mean is also seen between males and females due to the fact that lesser number of female sudden death is found due to MI.

Table 5: Statistical Analysis of mortality due to MI during study period.

Discussion

In this total-population based study incorporating all sudden death due to MI (2018-2022), the study revealed that COVID-19 era increased the sudden death due to MI. One research study found that there is fault in mortality registration due to COVID-19, which must be corrected to assess the direct and indirect impact of COVID-19 pandemic like MI [20,21]. There is a wide gap in public health management systems of various states and UTs of India, evident from NITI AAYOG reports analysis [22]. Some densely populated states like Bihar and Uttar Pradesh continue to secure bottom ranks in state health index annual report of NITI Aayog, indicating poor performance of public health management systems. Another face is that the data reported by such states is likely to have errors due to this poor performance. During the era of COVID-19 pandemic, one study found that that COVID-19 have negative impact on NCD (Non-Communicable Disease)- OPD health services such as myocardial infarction, hence there is possibility that the real count of sudden death due to MI may be more then what is reported to NCRB by states and UTs of India [23]. Another study found that some densely populated states like Bihar have very less Medical Certification Of Cause of Death (MCCD) due to a poor public health management system, and this reduced/improper data on MCCD may interfere with actual assessment of title mentioned research question [24].There is multisystem organ involvement in COVID-19 which may increase the incidence and prevalence of NCD like CVD, DM, etc. in coming years, hence the post-COVID-19 assessment of condition like MI, DM, etc. must be monitored closely to be able to apply interventions timely to check flood in cases of NCDs in coming years as after impact of COVID-19. Screening for NCD like CVD, DM after COVID-19 must be increased, especially for high-risk individuals, or older individuals. Prompt management of any complications due to NCDs should be initiated, at mass level. Such timely interventions will to improve prognosis and quality of life in patients suffering from NCDs following COVID-19 [25].

Strength and limitations

This is the first study as per our knowledge to assess the impact of COVID-19 era on the sudden death due to MI. Our study cannot prove the causality i.e. due to observational, cross-sectional, retrospective nature of our study. Of course the hypothesis is generated due to such studies only leading to foundations of future research. As discussed above, there is also risk for incomplete or inaccurate data due to faulty MCCD, misclassification bias, and residual confounding in register-based studies. However, if any type of misclassification, etc., which is likely to lead to underestimation of the associations. Nevertheless, the calculations and our findings remain robust. This is one of the largest studies incorporating all sudden death due to MI during COVID-19 in a country to find out the impact of COVID-19 era on MI.

Conclusion

This study revealed that COVID-19 era increased sudden death due to MI. COVID-19 is associated with many severe consequences due to multi-organ involvement as it is not limited to RTI like its predecessors (respiratory tract infection), it can cause even death, which makes assessing post-COVID-19 impact on various NCDs a necessary public health issue. Myocardial injury is a significant sequel of COVID-19-infection and further research investigations are needed to determine the underlying patho-physiology and manifestations to timely check a massive increase in global burden of disease due to after impact of COVID-19. Regular follow-up and clinical examination for arrhythmia monitoring and imaging studies is needed in patients with myocardial damage related to COVID-19. We recommend monitoring and follow up of the following conditions at mass level after COVID-19, particularly in vulnerable population already suffering from any previous cardiac ailments:-

• Test to assess blood clots, heart attack, stroke

• Tests to assess myocarditis, pericarditis, arrhythmias, heart failure, cardiomyopathy, cardiac arrest angina, etc.

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