New information regarding COVID-19 continues to emerge daily. This content was based on the sources available at the time of writing.
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Soon after the emergence of COVID-19, it became clear that patients with cardiovascular disease were among the groups facing a particularly high risk of poor outcomes. As the pandemic has progressed, concerning signs of collateral damage involving the heart have emerged. Of note, the number of out-of-hospital cardiac arrest cases spiked in the hard-hit Lombardy region of Italy after SARS-CoV-2 began spreading, according to research in the New England Journal of Medicine (NEJM).
There was a 58% increase in the number of out-of-hospital cardiac arrests across four provinces during the first 40 days of the pandemic. The two provinces that took the heaviest toll from COVID-19, Lodi and Cremona, saw jumps of 187% and 143%, respectively, with smaller increases in Pavia and Mantova, where the outbreak started later and infected fewer people.
What's causing this surge and what it means for population-level outcomes are not fully known, but there appears to be a need for the medical community to reassure the public about the safety and necessity of seeking emergency medical care—even during the global pandemic.
More Cardiac Arrest, but Less STEMI
An uptick in cardiac arrests may be related to a certain factor that hospitals around the world have been reporting as SARS-CoV-2 has been spreading: a dramatic reduction in the number of patients presenting with STEMIs. Research in the Journal of the American College of Cardiology estimates that high-volume cardiac catheterization labs in the United States saw a 38% drop in STEMI activations in the early days of the virus. Another study in NEJM showed that the Kaiser Permanente Northern California system experienced a decline of up to 48% in weekly hospitalization rates for acute MI—both STEMI and NSTEMI—during the pandemic.
Among the theories about what's causing the drop in STEMI presentations is the notion that patients with chest pain and other symptoms that normally would have prompted them to call for help are avoiding reaching out for fear of contracting COVID-19 in the ER. A poll performed by the American College of Emergency Physicians and Morning Consult found that 80% of people were concerned about getting COVID-19 if they had to go to the ER, and that 29% had delayed or avoided medical care due to infection concerns, giving credence to those concerns.
It could be that some patients experiencing the symptoms of a heart attack aren't getting to the hospital and are ultimately going into cardiac arrest and dying at home. The scope of the problem is not fully known, and it may never be, as medical systems are focusing their efforts on the continuing COVID-19 crisis.
STEMI Patients in Worse Shape
While the consequences of patient fears during the pandemic will require further retrospective study, there are some indications that patients with STEMI who do ultimately go to the hospital are showing up later and in worse condition than they normally would have. A small study in Circulation: Cardiovascular Quality and Outcomes demonstrated a dramatic increase in the time from symptom onset to first medical contact among STEMI patients in Hong Kong.
Another study, published in the European Heart Journal, showed that the case-fatality rate among patients presenting with STEMI more than tripled from 4.1% in 2019 to 13.7% in a comparator week during the COVID-19 pandemic. Major complications, such as cardiogenic shock, life-threatening arrhythmias, cardiac rupture/ventricular septal defect, and severe functional mitral regurgitation, nearly doubled. These findings "must sound an alarm bell to healthcare professionals and public regulatory agencies," the researchers say.
Pandemic Prompts Emergency Response Changes
While data continues to be collected from other parts of the world, the surge in out-of-hospital cardiac arrests reported in Italy might be viewed as a warning. Prior to COVID-19, survival had been improving, but those gains might stall or even reverse as the pandemic forces medical system operations to change.
The Regional Emergency Medical Services Council of New York City, for instance, instructed EMTs in April not to bring patients with out-of-hospital cardiac arrest to the hospital if resuscitation is not successful at the scene. That protocol change was made in response to the overwhelming number of patients already going to emergency departments in the city and concerns about exposure risk to healthcare workers.
People who arrest in public also might have a more difficult time receiving bystander CPR, which could have a detrimental effect on population-level outcomes. An anecdotal report in Resuscitation detailed a case in which a Chinese man in Sydney, Australia, did not receive CPR—and died—because of a fear that he was infected with SARS-CoV-2. The NEJM report out of Italy provided some evidence to indicate that this was not an isolated event: the proportion of patients who received bystander CPR dropped from 47% in 2019 to 31.4% during the pandemic, and the percentage who died despite attempted resuscitation by EMTs increased from 67.3% to 82.2%.
It is important for the public to realize that hospital systems are set up to handle emergent conditions like STEMI, even in the context of an infectious disease outbreak. Major professional societies, like the European Society of Cardiology and a US group including the American Heart Association and the American College of Cardiology, have urged people with symptoms of a heart attack to call for emergency help, highlighting the dangers of delaying.
If the public heeds the call, perhaps we can avoid a reversal of the hard-won progress in out-of-hospital cardiac arrest survival that has been made in recent years.
Members of the healthcare community have a key role to play in this, too. Cardiologists must educate their high-risk patients about worrisome cardiac symptoms and the need to call for help immediately when those symptoms arise. Emergency medical personnel who are first on the scene can make sure to get a prehospital ECG to shorten time to treatment. And hospitals should establish treatment pathways for patients with cardiac emergencies that are separate from those used for COVID-19 patients to lessen the chances of spreading SARS-CoV-2.