*Strengths and Limitations*

The main strength of this study is that for the first time, the FCV-19S was administered in CV patients, suggesting that COVID-19 fear may contribute to the delay in regular checks and hospital admissions for stable and acute CV patients.

Due to the limited number of participants, it was difficult to conduct subgroup analyses. For example, the gender analysis included only a small number of female patients. However, this fact is representative of the clinical AMI reality, where there is a male:female event ratio of 5:1 [36]. However, despite the lower incidence of acute coronary artery disease in females, women have worse short- and long-term outcomes than men [37,38]. Moreover, the pre-hospital delay from symptom onset to admission is generally significantly longer for women also ordinarily [39].

These aspects, in addition to an overall greater fear of COVID-19 for women compared to males [40], may result in a further delay in hospital access in the case of AMI for women due to the COVID-19 fear, which could worsen their outcomes. Our preliminary results are in agreement with studies conducted in cohorts of general subjects in different parts of the world [21], suggesting that the female gender may represent a critical predictor for psychological distress. Therefore, although limited in sample size, this study can broaden the knowledge and improve understanding of the factors associated with shortterm outcomes after AMI hospitalization by being, to the best of our knowledge, the first to assess fear of COVID-19 in AMI patients.

Unfortunately, we did not enroll AMI patients during the first pandemic wave. Nonetheless, in light of the data collected in the period November 2020–May 2020, the differences observed in the items might be attributable more to the characteristics of the lockdown (e.g., more rigorous lockdown measures) than to the differences between stable and acute CV disease.

Of note, all patients belong to Italian nationality, whereas it was reported that migrants and other similar groups showed a particular fear of COVID and may represent an interesting cohort to study also in the CV setting [41].

### **5. Conclusions**

The COVID-19 pandemic has an impact not only on the rate but also on the timing of AMI hospital admissions. Since the symptom-onset-to-first-medical-contact time plays a crucial role in a longer delay, and patients presented with higher levels of emotional and symptomatic fear expressions than the general population, a major cause of this delayed presentation could be attributable to changes in patient behavior and risk perception, which arouses reluctance to come to the hospital for fear of contracting COVID-19, as confirmed by the patients themselves in previously published reports [42,43]. Interestingly, recent data have not confirmed the association between a decrease in hospital admissions for acute coronary syndrome and a decrease in air pollution due to lockdown containment measures, indirectly giving strength to other hypotheses for the drop observed in AMI procedures [44].

While it is true that patients may develop some sort of addiction to the fear of COVID-19, measures should be put in place to assist high CV risk and more vulnerable patients and (e.g., women, elderly, frail subjects), along with correct information to patients on the pandemic course and on the risks of delayed access to the hospital in case of acute events. In addition, a multidisciplinary team should be implemented when possible, including not only cardiologists and hemodynamics but also psychologists (to provide psychological support to CV patients and reduce distress and subsequent mental problems), in order to avoid patients who have presented too late and are hemodynamically unstable for COVID fear as well as AMI complications.

**Author Contributions:** Conceptualization, C.V. and M.M.; methodology, M.M.; data validation, M.M.; formal analysis, C.V.; writing—original draft preparation, C.V.; writing—review and editing, M.M., F.G., A.P., K.C., A.M. and S.B.; project administration, A.P. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board of PISA (protocol code number 19214, 11 February 2021).

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study.

**Data Availability Statement:** Data available on request from the authors.

**Conflicts of Interest:** The authors declare no conflict of interest.
