Discussion:
This case highlights the issues that have been raised before by others
regarding the corona virus, stay-at-home regulations and demand for
emergency care for non-COVID conditions. A recent article published in
the Washington Post (1), has reported that physicians in the United
States, Spain and UK have all noticed a serious decline in the number of
patients coming to the ER not only for typical problems like
appendicitis, bowel obstructions, gall bladder problems but also for the
more critical heart attacks and strokes. Metzler reports a 40% decline
in the number of admissions for STEMI and non-STEMI in Austria during
the COVID-19 pandemic (2). In a soon to be published report by Garcia
(3), number of cardiac catheterization laboratory activations for STEMI
have been reduced by almost 40% in 9 high volume centers in the United
States.
The reasons for this decline are many and include a fear for catching a
deadly virus in the hospital, the instruction to strictly stay in-house,
consideration of many heart related symptoms of shortness of breath and
chest discomfort by patients to be related to respiratory infections and
best dealt with at home etc.
This patient’s pain started two days earlier, but he did not seek
attention until later. From conversation with him and his wife, they
were concerned about the risk of catching the deadly COVID-19 in the
hospital. The patient was not a smoker or a known diabetic, and did not
have any family history of coronary artery disease. A heart attack was
not on their mind but respiratory infection and fear of COVID-19 was the
first and foremost concern of theirs. It was not until his chest pain
had persisted for two days that he finally came to ER. Had he come when
the pain had started, this patient would likely have had an uneventful
recovery after treatment of the RCA occlusion per the ACC guidelines.
His avoidance of an ER visit in a timely fashion because of the fear of
COVID-19, led to the catastrophic complication of STEMI that surgeons
rarely see today because of successful results of timely percutaneous
revascularization.
Whatever the reason for this patient’s or that of others to delay
seeking medical attention during this pandemic, the concern remains that
this delay will lead to increased morbidity and mortality in the coming
weeks and months. There most certainly are many others like this
patient, who have suffered or will suffer a catastrophic complication
due to delay in treatment. Metzler posits that if 40% of people are not
seeking care for acute coronary syndromes, and assuming 40% of those
untreated people suffer a significant complication or death (2), the
effect of COVID-19 pandemic on non-COVID related health of our
population may be even more devastating than COVID-19 itself. And this
case just highlights the fact that this assumption may not be too far
from the truth.
REFERENCES.
- Bernstein, L. and Sellers FS. (2020) Patients with heart attacks,
strokes and even appendicitis vanish from hsoptals. Washington
Post. April 19, 2020.
https://www.washingtonpost.com/health/patients-with-heart-attacks-strokes-and-even-appendicitis-vanish-from-hospitals/2020/04/19/9ca3ef24-7eb4-11ea-9040-68981f488eed_story.html
- Metzler B, Siostrzonek P, Binder RK, Bauer A and Reinstadler SJ.
(2020) Decline of acute coronary syndrome admissions in Austria since
the outbreak of COVID-19: the pandemic response causes cardiac
collateral damage. Eur Heart J 0, 1-2.
Doi:10.1093/eurheartj/ehaa314
- Garcia S, Albaghdadi MS, Meraj PM, et al. (2020) Reduction in
ST-segment elevation cardiac catheterization laboratory activations in
the United States during COVID-19 pandemic. J Amer Coll
Cardiol, https://doi.org/10.1016/j.jacc.2020.04.011