How Can Providers Address the Rise of "Silent MI" during COVID-19?

By Dr. Payal Kohli, MD, FACC

New information regarding COVID-19 continues to emerge daily. This content was based on the sources available at the time of writing.

The COVID-19 pandemic has instilled fear in all of us—fear of being close to other people, fear of leaving our homes, and fear of catching this deadly virus that has taken so many American lives.

During the pandemic, we have been told by health experts and the news to "shelter in place" and weather the storm outside, so is it such a surprise that many patients experiencing the most severe types of acute coronary syndromes (ACS), including STEMI, have been choosing to stay at home rather than risk exposure at a hospital?

"Coronaphobia" and Medical Outcomes

Despite the SARS-CoV-2 virus having myocardial and vascular receptors and increasing the risk of thrombosis (which one might expect to increase the risk of acute myocardial infarction), there has been a substantial decrease in admissions for acute myocardial infarctions during the COVID-19 pandemic, including both STEMI activation (38% decrease) and NSTEMI admissions, according to research published in the Journal of the American College of Cardiology and Cardiovascular Research.

Despite the lower number of STEMI presentations—and likely due to delays in diagnoses—there has been an increase in out-of-hospital cardiac arrests during the pandemic. This trend is also paired with worse mortality for patients who have presented with STEMI, according to a study in the European Heart Journal.

Extreme fear of catching the virus, which has been termed "coronaphobia" by researchers, extends beyond acute medical situations and can affect many aspects of patients' lives. For instance, patients with chronic medical conditions like diabetes and hypertension appear to be especially impacted by healthcare changes during the pandemic, as these conditions can become worse if patients do not seek routine care. Research in Diabetes & Metabolic Syndrome found that 67% of physicians surveyed believed that the pandemic has had a moderate to severe impact on their chronic disease patients.

The Emergence of "Silent MI" during the COVID-19 Pandemic

The term "silent MI" was historically reserved only for ACS cases that were asymptomatic and therefore undetected during the acute event. Now, its definition has expanded to include presentations of ACS that were diagnosed late or undiagnosed due to patients not seeking care or other delays in emergency care during the COVID-19 pandemic.

According to research published in Circulation: Cardiovascular Quality and Outcomes, worse STEMI outcomes during the pandemic are partly the result of patients presenting later and in worse condition. As a sequela, these presentations may result in more complications and higher case-fatality rates. The aforementioned European Heart Journal study notes that the case-fatality rate for STEMI patients during a given week in 2020 was more than triple the rate from the corresponding week in 2019 (4.1% vs. 13.7%).

The COVID-19 infection itself could also play a role. Research presented at a late-breaking session at TCT Connect concluded that patients with STEMI and COVID-19 were more likely to present with cardiogenic shock than the COVID-19 negative group (20% vs. 17%), were less likely to receive angiography (5% vs 21%), and had the highest in-hospital mortality rates (32% vs. 12%), the highest in-hospital stroke rates (3.4% vs. 2%), and longer hospital stays (six days vs. three).

The patients with the highest risk of STEMI and worse complications are those with chronic medical conditions, who also tend to have the worst outcomes from contracting COVID-19. These points indicate the urgent need for fast, effective diagnostic approaches to detect acute cardiac events.

To learn more about the power of the ECG in today's clinical landscape, browse our Diagnostic ECG Clinical Insights Center.

Where Diagnostic ECG Fits into the Care Pathway

Diagnostic ECG can help to improve detection of silent MI during the COVID-19 pandemic and can also support better STEMI diagnoses and outcomes. Diagnostic ECG can quickly and accurately determine whether an acute STEMI is ongoing, which can enable early diagnosis and triage and help to prevent further adverse outcomes tied to delays in patient care or concurrent COVID-19 infection.

Diagnostic ECG can also help to distinguish between STEMI and pericarditis or myocarditis due to COVID-19 infection. Whether in an office or in an acute care setting, providers should turn their attention to diagnostic ECG to reduce the morbidity and mortality from cardiac events and flatten the "silent MI" curve that has resulted from the pandemic.

Dr. Payal Kohli, MD, FACC is a top graduate of MIT and Harvard Medical School (magna cum laude) and, as a practicing noninvasive cardiologist, is the managing partner of Cherry Creek Heart in Denver, Colorado.

The opinions, beliefs, and viewpoints expressed in this article are solely those of the author and do not necessarily reflect the opinions, beliefs, and viewpoints of GE Healthcare. The author is a paid consultant for GE Healthcare and was compensated for creation of this article.