ED visits for suspected MI, stroke down during COVID-19 pandemic
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Many U.S. institutions have reported significant declines in the volume of patients presenting to the ED with potential MI or stroke due to fears associated with COVID-19.
Some health care professionals have noticed a dropoff in acute MI and stroke cases since the United States began taking stringent measures to combat the pandemic in mid-March, likely caused by patients delaying their presentation to the ED with MI or stroke or not seeking medical attention at all.
“What we’re seeing in our community is that there is a great reluctance to seek emergency care, and that’s understandable,” Michael C. Kurz, MD, MS-HES, FACEP, FAHA, vice chair for research in the department of emergency medicine at the University of Alabama at Birmingham School of Medicine and director of the UAB Post-Cardiac Arrest Service, told Healio. “We have a pandemic going on, and the emergency department is the front line to care for that pandemic. Patients who may develop symptoms of a heart attack or a stroke may be concerned about seeking emergency care and exposing themselves to even greater risk.”
Decreases since mid-March
In a recent study of nine high-volume cardiac catheterization laboratories in the U.S., cath lab activations for STEMI dropped 38% in March compared with the monthly rate from January 2019 to February 2020.
In a study published in Stroke, researchers found that the COVID-19 outbreak impacted stroke care in China, with led to a significant decrease in admissions by approximately 40% from February 2019 to February 2020. The rate of thrombectomy and thrombolysis also decreased by approximately 25%. In another study published in Stroke, there was a 25% reduction in stroke admissions and thrombectomies in Barcelona, Spain.
This trend is in contrast to the rate of CV events, including MI and stroke, which generally increases with stress, as has been shown in several studies. For example, a study published in The Lancet found an association between amygdalar activity, the region of the brain that is involved in stress, and CVD. Activity in the amygdala was linked to arterial inflammation (r = 0.49; P < .0001) and the risk for CVD events (HR = 1.59; 95% CI, 1.27-1.98).
Shlee S. Song, MD, director of the comprehensive stroke center and of the telestroke program and associate professor of neurology at Cedars-Sinai, told Healio that her institution would see approximately 100 stroke codes a month before the COVID-19 pandemic, but that number has since dropped by half.
“We are concerned,” Song said in an interview. “We are wondering if there are mild patients out there who normally would be coming to the hospital for an urgent evaluation who are not coming in because they are afraid of catching something in the emergency room or think that the COVID-19 impact is so tremendous like it is in New York City that their milder symptoms should not warrant an emergency room evaluation. I’ve heard both things from some of the patients who have come in.”
Reassurance needed
Data such as these have prompted physicians and cardiology societies to urge patients with MI or stroke to seek medical treatment immediately.
On April 22, 2020, the American Heart Association and seven other professional societies released a letter emphasizing the importance of seeking urgent medical care for suspected MI or stroke despite the fear of COVID-19.
“The bottom line is the same as it’s always been: when a medical emergency strikes, call 911. Get to a hospital,” Robert A. Harrington, MD, president of the AHA, and presidents of other societies wrote.
“The COVID-19 pandemic has not affected the care of patients who potentially have an acute MI or stroke from the perspective of the medical professional because acute MI or stroke are life-threatening time-sensitive emergencies where the benefit of immediate intervention outweighs any potential risk of infection from COVID-19,” Michelle M. Kittleson, MD, PhD, professor of medicine and a cardiologist at Smidt Heart Institute at Cedars-Sinai, told Healio.
Patients who wait or forgo care in the ED for potential MI or stroke face risks including fatal arrhythmias, rupture of vital cardiac structures, HF and death. Cardiologists should encourage their patients to call or utilize telehealth services if they have symptoms related to these events, even if, in the case of transient ischemic attack, their symptoms have resolved, Song said in an interview.
“There are many of our colleagues who can set up video visits, so we are able to get the acute care and start ordering the diagnostic tests and place patients on their correct prevention therapies from home,” Song said.
Some patients may be anxious that their suspected MI or stroke is something less serious and does not justify a hospital visit or clinician resources. However, cardiologists should tell their patients to seek care regardless of potential anxiety and inform them of MI and stroke symptoms to be mindful of, Kittleson said.
“[Patients] may feel embarrassed to utilize urgent medical resources only to discover that their symptoms were a false alarm,” she told Healio. “I like to tell patients that it isn’t their job to decide if their symptom warrants urgent medical attention; it’s mine. When in doubt, patients should not make the decision to avoid the ED on their own; they should reach out to their internist or cardiologist who has the experience to appropriately triage their symptoms. “
Precautions within ED
Institutions have taken necessary precautions to protect both patients and the health care providers caring for them. Examples of this include EDs with separate areas for patients with suspected respiratory illness or COVID-19, and health care professionals in the ED checking patients’ temperatures across all triage areas and asking them about fever, cough and a loss of taste or smell.
Song said her center is utilizing telehealth in the form of a robot in the ED to triage patients with suspected stroke. Through this, health care professionals can quickly evaluate patients without coming into close contact with them, which can also help with rationing personal protective equipment (PPE).
“If there are 10 team members are going in and out of the room and donning-doffing constantly, that could delay care,” Song said. “This way, we are working with the ED staff to not delay care for donning and doffing PPE. We can quickly see on camera with the ED staff and start triaging the patient for stroke.”
Safety of the environment remains a priority.
“Patients who have symptoms of an emergency should feel comfortable that their health care providers have gone through great lengths to make sure that they can seek that care in a safe environment,” Kurz said in an interview. “We understand no one wants to be infected with the virus that causes COVID-19, but emergency health care providers involved are completely engaged to ensure everyone can feel comfortable accessing the same emergency systems of care that were available prior to the pandemic. As an emergency physician and prehospital provider, that commitment to our patients has not changed.”
For the latest news on COVID-19 including case counts, information about the global public health response and emerging research, please visit the COVID-19 Resource Center on Healio.
References:
American Heart Association. The new pandemic threat: People may die because they’re not calling 911. Available at: www.newsroom.heart.org/news/the-new-pandemic-threat-people-may-die-because-theyre-not-calling-911. Accessed May 28, 2020.
Garcia S, et al. J Am Coll Cardiol. 2020;doi:10.1016/j.jacc.2020.04.011.
Rudilosso S, et al. Stroke. 2020;doi:10.1161/STROKEAHA.120.030329.
Tawakol A, et al. Lancet. 2017;doi:10.1016/S0140-6736(16)31714-7.
Zhao J, et al. Stroke. 2020;doi:10.1161/STROKEAHA.120.030225
For more information:
Michelle M. Kittleson, MD, PhD, can be reached at michelle.kittleson@cshs.org; Twitter: @mkittlesonmd.
Michael C. Kurz, MD, MS-HES, FACEP, can be reached at mkurz@uab.edu.
Shlee S. Song, MD, can be reached at shlee.song@cshs.org.
Disclosures: Kittleson reports no relevant financial disclosures. Kurz reports he received support from the NIH and other foundations. Song reports she is a site investigator for several stroke trials supported by the NIH and for the TIMELESS trial sponsored by Genentech.
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Garcia S, et al. J Am Coll Cardiol. 2020;doi:10.1016/j.jacc.2020.04.011.
Rudilosso S, et al. Stroke. 2020;doi:10.1161/STROKEAHA.120.030329.
Tawakol A, et al. Lancet. 2017;doi:10.1016/S0140-6736(16)31714-7.
Zhao J, et al. Stroke. 2020;doi:10.1161/STROKEAHA.120.030225.
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