Concerns About Delayed, Deferred Acute CV Care Substantiated

Patrice Wendling

May 28, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Admissions for primary acute cardiovascular conditions tumbled in the first weeks of the US COVID-19 pandemic and were paralleled by higher in-hospital mortality among those admitted, a multicenter study shows.

After examining acute cardiovascular (CV) hospitalizations from January 2019 through March 2020 across 15 centers in the Mass General Brigham health system, results show similar volume of hospitalizations in the first 2 months of 2020 compared with the same period in 2019.

When compared with March 2019, however, there was a significant 43.4% decline in total CV hospitalizations in March 2020 — a time in which COVID-19 cases rose steadily in the state from only a single case prior to March 1, 2020.

Similarly, daily CV hospitalizations rates held steady in the first 2 months of 2020 but declined by a significant 5.9% in March 2020 across the system.

This daily decline did not taper off during the month and was seen irrespective of whether the primary reason for admission was heart failure (–5.8%), chest pain/acute coronary syndrome (–5.5%), stroke (–4.9%), or other CV conditions (–10.5%; P ≤ .004 for all), the authors reported May 22 in the Journal of the American College of Cardiology.

"It's a cautionary tale for places that may not have seen the robust impacts of the pandemic as we saw in Massachusetts or other folks saw in New York or other areas," lead author Ankeet S. Bhatt, MD, Brigham and Women's Hospital and Harvard Medical School, Boston, told theheart.org | Medscape Cardiology.

"It's also a cautionary tale as to what's going to happen as we begin to try to systematically reopen both health systems and the community at large," he said. "We may see a rise in acute non-COVID conditions at the same time we see a rise or rebound in COVID conditions."

The study validates previous observations from other parts of the world and extends it beyond just ST-segment elevation myocardial infarction (STEMI) care, said Ehtisham Mahmud, MD, immediate past-president of the Society for Cardiovascular Angiography and Interventions (SCAI) and chief of cardiovascular medicine, University of California, San Diego.

"The part that does surprise me is the fact that stroke numbers are down because that's kind of a much less subtle diagnosis," Mahmud told theheart.org | Medscape Cardiology.

"Nevertheless, the way I would interpret this is that staying at home or sequestering at home hasn't dramatically altered our baseline risk factors; it might have decreased it a little bit but not to a 40% range," he said. "What's more likely to have happened is that people are staying at home with softer symptoms or waiting till their symptoms progress a lot more than they would have otherwise."

Surveys have documented Americans' reluctance to seek care during the pandemic, including a new SCAI survey, in which 57% of respondents said the fear of contracting COVID-19 could keep them from going to a hospital, even for urgent issues like a heart attack.

Another 36% rated going to the hospital as one of the riskiest behaviors to take part in as states begin to reopen — above going to the hair salon (27%) or the beach (16%). Notably, about 6% of survey respondents had a history of previous MI or stroke.

Anecdotal reports suggest late complications of MI in patients who deferred care may include cardiogenic shock, mechanical complications, ventricular septal defects, and rupture, Bhatt said.

At the same time, there has been growing recognition that patients with known CV disease face excess risks of severe illness with COVID-19.

In the present analysis, there were 281 in-hospital deaths during the study period. In-hospital all-cause mortality rates were higher in patients admitted in March 2020 vs those admitted in the preceding months (6.2% vs 3.8%; P = .06) and were similar between patients admitted in March 2020 vs March 2019 (6.2% vs 4.4%; P = .30).

Length of stay was significantly shorter in March 2020 vs March 2019 (4.8 days vs 6.0 days; P = .003).

These results should be viewed with caution, however, because of limited events and the potential for concurrent COVID-19 to contribute to the increased mortality, Bhatt noted.

In response to growing reports of "missing" MIs, several cardiovascular groups issued a plea last month for patients with MI and stroke symptoms to seek care during the pandemic. Still, it's been difficult to overcome patient fears of contracting COVID-19 and "stay-at-home" messaging in the lay media, he said.

The economic ripple effect of the pandemic may also be a factor, as estimates suggest that as many as 25 million Americans could lose insurance coverage because of the pandemic, Joseph E. Ebinger, MD, MS, and Prediman K. Shah, MD, both at Cedars-Sinai Medical Center in Los Angeles, suggest in an accompanying editorial.

"Despite billions of dollars in economic stimulus and relief from the federal government, millions of Americans are suffering the simultaneous loss of 'health and wealth,' the effects of which will likely continue far beyond the current COVID-19 crisis," they write.

"Such effects are felt most acutely by minority populations who have seen the largest increases in unemployment, as well as higher rates of COVID-19 infection and death."

The relative lack of minorities in the cohort precluded subanalyses by race, Bhatt noted. Other limitations include the reliance on administrative coding, which may have led to misclassification of the primary reason for admission.

To reverse the concerning trend of deferred or delayed admissions, strong public and health system messaging is needed that encourages patients with acute CV symptoms to present to hospital, and emphasizes mitigation strategies that prevent the spread of COVID-19 infection, Bhatt suggested.

Providers also need to identify their patients at high risk for adverse outcomes if care is deferred or delayed, and see them urgently, either in the clinic or by video visits, he said. "For patients that require that, there is a safe system in place in which we can deliver these services."

In an effort to shift Americans' behavioral patterns, SCAI just launched the multimedia SecondsCount initiative to educate people about the symptoms of CV disorders and signals of acute or subacute decompensation and, when present, to seek immediate medical care, Mahmud said.

The American Heart Association is working on a similar large-scale campaign to launch in early June, in addition to already communicating its concern to consumers through direct e-mail, social media, PSAs, and its website, president Robert Harrington, MD, Stanford University, California, said via email. 

Bhatt has received honorarium from Sanofi Pasteur and participates in clinical endpoint committees of a trial sponsored by the NIH. Mahmud reported no relevant financial relationships.

J Am Coll Cardiol Published online May 22, 2020. Abstract, Editorial

Follow Patrice Wendling on Twitter: @pwendl. For more from theheart.org | Medscape Cardiology, join us on Twitter and Facebook.

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