When a patient is having a heart attack, it is crucial that he or she receive a balloon angioplasty quickly to open a blocked artery. If the patient does not receive one, the tissue in the artery can deteriorate and break, causing an even more serious emergency.
Dr. Jason Wasfy, an assistant professor at Harvard Medical School and a cardiologist at Massachusetts General Hospital, says that the breaking of an artery that way is rare.
“I have seen that probably only three times in my 10 years as a cardiologist,” Wasfy said.
One of those incidents occurred during the pandemic. For Wasfy, it was one sign that many people experiencing heart attacks and strokes were shunning the emergency room in order to avoid contracting the coronavirus.
During one week in March, Wasfy saw no heart attack patients in the cardiac intensive care unit at Massachusetts General.
“It was really unusual and alarming,” he said. “I had never seen that happen before.”
That motivated Wasfy to investigate other hospitals in the Massachusetts General Brigham system. He found admissions for heart attacks had dropped by 40% in March and April compared to 2019. Admissions for strokes had declined 50%.
Patients avoiding the emergency room even with life-threatening conditions became common after the pandemic began in late February. An analysis of Kaiser Permanente hospitals in Northern California found that weekly admissions for heart attacks had dropped by almost half by mid-April. An article in the Journal of the American Medical Association found that admissions for heart failure and strokes to Veterans Affairs Hospitals fell 49% and 52%, respectively, during March and April when compared to 2019.
Many of the people who did not go to the hospital despite having a stroke likely had a minor one. But failing to get a minor one treated often leads to bigger problems later on.
“Stroke is treatable, and the symptoms can be completely reversible,” said Adrienne Dula, a professor of neurology at the University of Texas-Austin’s Dell Medical School. “The critical variable is time. The longer you wait, the more tissue in your brain is going to die.”
Stroke is a leading cause of disability in the United States. Stroke victims often suffer paralysis, loss of mobility, and impaired speech.
“Even if you have a mild stroke, you should be evaluated acutely,” said Dr. Saqib Chaudhry, a vascular neurologist at Inova Hospital in Virginia. “The reason for that is to avoid a major stroke … many studies show that your risk for a major stroke is greatest in the first few weeks after a minor stroke.”
Dula and her colleagues found that in Texas, an average of 63 stroke patients per day arrived at hospitals per day in February of this year. That had dropped to 43 in March and April. In an article published in the Journal of Stroke and Cerebrovascular Diseases, Chaudhry and his colleagues found that in one Virginia hospital that patients presenting with stroke dropped 22% in April and 40% in May when compared to the months prior to the pandemic.
Dula said, “We can’t definitively say” why patients avoided the emergency room, “but we can hypothesize that stay-at-home orders motivated this as well as patients’ hesitancy and anxiety about going to a hospital” due to COVID-19.
Chaudhry suggests the pandemic may have kept stroke patients away for another reason.
“Keeping elderly people isolated may be a double-edged sword,” he said. While acknowledging that it was needed to keep elderly people safe from the virus, Chaudry noted it could mean that other family members are not seeing the signs of a stroke.
“The elderly may not have the chances to see a family member who will notice impaired speech or a drooping face,” he said.
Patient volumes at emergency rooms have been returning to normal in recent months, but in much of Texas, volumes are still down compared to 2019, said Dula.
“We’re still very concerned about people not coming in,” Wasfy said. “When I do telemedicine, I still see people who are afraid to come in to get an echocardiogram or their labs. It’s concerning because those tests can be life-saving.”
Dr. Tim Anderson, a primary-care physician and an instructor at Beth Israel Deaconess Medical Center at Harvard Medical School, says that many of the consequences will not be readily apparent.
“Time will tell, and it may be multiple years to understand whether or not chronic disease like heart failure see a spike because people didn’t seek care earlier,” Anderson said.
Anderson’s own research found that hospitals in Boston experienced a 53% drop in heart failure patients in March and April.
Anderson warns, “In some cases, people may have been avoiding the hospital to the point that they died at home.”
Some evidence suggests that may have happened. A June article in Academic Emergency Medicine found that the number of incidents in which emergency medical services reported a patient as having died nearly doubled in March and April.
