Discharge against medical advice in patients with acute coronary syndrome during the COVID-19 outbreak

Background: Patients' hesitation to seek medical care has seriously compromised the management of acute coronary syndrome during coronavirus disease 2019 (COVID-19) outbreak. In the present study, we have reported the rate of discharged against medical advice (DAMA) among patients referred to chest pain unit (CPU) of a tertiary cardiovascular center and compared their clinical outcomes with whom admitted or managed conservatively. Methods: Patients with modified HEART risk score ≥4 referred to the CPU were included in the present study. Population requiring CPU admission due to positive serial troponin were divided into admitted and DAMA groups. Patients with negative serial troponin were managed as outpatient (conservative treatment group). 30-day major adverse cardiac events (MACE) and all-cause mortality were compared between the study groups. Results: A modified HEART risk score (≥4) was calculated for 440 of 5490 patients visited our CPU. One hundred and one (22.9%), 80 (18.1%), and 249 (56.5%) patients were categorized as DAMA, admitted, and conservative treatment groups, respectively. Myocardial infarction was significantly higher in the DAMA versus admitted group (2 vs. 0; P ≤ 0.001). MACE and all-cause mortality were significantly higher in the DAMA group than that in the conservative treatment group (5 vs. 2; P = 0.02 and 4 vs. 2; P = 0.055, respectively). Conclusion: In the present study, we have demonstrated a considerable rate of DAMA in patients with high modified HEART risk score referring to CPU during the COVID-19 outbreak. Importantly, the DAMA group experienced a higher incidence rate of 30-day MACE and all-cause mortality compared to patients who were admitted or managed conservatively.