In some ways, the message to stay home during the COVID-19 pandemic may have worked a little too well.
Hospitals across the country, including Yale New Haven Health, are reporting fewer visits for heart attacks, acute strokes, and other medical emergencies. Although the phenomenon is not clearly understood and studies are underway, some medical experts believe patients are either choosing not to seek—or delaying—emergency department (ED) care because of the fear of contracting COVID-19.
“There is no biological reason to believe that this coronavirus decreases strokes from occurring—or heart attacks or appendicitis or other conditions we are seeing fewer cases of in the hospital,” says Charles Matouk, MD, chief of neurovascular surgery at Yale Medicine. “The messaging to 'shelter-in-place' has left people thinking that if they have a serious condition, it’s not safe to come to the hospital. For good reason, people fear they are violating those policies if they come in.”
While it is true that non-urgent medical procedures, such as a hip replacement, are on hold right now, that’s not so for acute chest or abdominal pain, strokes, and other serious events that always require immediate evaluation in an emergency department, Dr. Matouk adds.
“Yale has added additional measures to keep providers and patients safe from coronavirus exposure. What I tell people is that all the systems of care for stroke continue to be in place, and we are fully operational. We are ready and able to help those with emergencies,” Dr. Matouk says. “The sooner you are evaluated and treated, the greater your odds that what could be a major stroke will be a less serious one from which you’ll be able to have a better recovery.”
Stroke symptoms that should not be ignored, Dr. Matouk adds, include weakness on one side of the body, such as in a leg or an arm, a droopy face, blindness in one eye, or having trouble speaking or understanding what people are saying to you.
Decrease in heart attacks raises alarm
Meanwhile, Yale Medicine cardiovascular specialists say they are concerned about the noticeable drop in people with cardiac emergencies coming into the Yale New Haven Health System (YNHHS). Numbers per condition were not available, but overall visits to YNHHS emergency departments are down about 40%, says Vivek Parwani, MD, MPH, medical director of the Yale New Haven Hospital Emergency Department.
One recent paper showed that hospital admissions for one type of serious heart attack fell by 38% in nine major U.S. hospitals in March. Heart disease is the leading cause of death in the United States.
“There is clear evidence that if we take patients with heart symptoms quickly to a catheterization lab—where we open the artery—we can reduce fatalities and future heart dysfunction if we can treat them in a 90-minute window,” says Eric Velazquez, MD, chief of cardiovascular medicine for Yale Medicine. “In the flurry of worrying about COVID-19, people may have forgotten or not realize that there are reversible conditions that require urgent attention. No one needs to suffer in silence at home and miss out on life-benefiting treatment.”
As to why fewer people are showing up with symptoms, no one knows. Doctors are looking into whether it is because heart attack rates truly have declined—or whether people are just trying to tough out their symptoms.
“We have all been postulating. Maybe there is some miraculous cure from all of us staying at home. Air pollution is down, and we know that impacts the risk of coronary artery disease,” Dr. Velazquez says. “Physical stress may be decreased, but emotional stress and anxiety are likely higher, so that may be a wash. Personally, I don’t think it’s that we are eating better or drinking less.”
Like Dr. Matouk, Dr. Velazquez believes it is likely that patients are fearful of coming to the hospital and are suffering or stabilizing at home. “They may be having chest pain and deciding to live with it, and that is a problem if people are potentially dying at home or living through it but diminishing their quality of life, when all of this could have been avoided by seeking care,” he says.
Michael Remetz, MD, a Yale Medicine cardiologist, agrees.
“There is a great deal of anxiety and fear about making any contact with the medical system right now and most patients I talk to are afraid to go anywhere. And because this virus is particularly dangerous in elderly patients, that prevents them from leaving the house,” he says. “I encounter this fear every day, and I tell them we can have a phone visit to start.”
Dr. Velazquez notes that Yale Medicine has 10 cardiology offices open, with safety measures in place to protect both staff and patients. “We have made adjustments to mitigate the risks to our patients of COVID-19 infection. We are using universal precautions, and we assume everyone is positive until they have tested negative and keep them safe when they come into the clinic,” he says. “If we see something that needs more urgent attention, we can transfer patients to a non-COVID floor in the hospital that is reserved for cardiovascular care.”
But for heart attack symptoms—pressure, pain, fullness in the center of the chest that lasts more than a few minutes, goes away, and comes back—call 911 or get to the hospital right away, doctors advise. Other heart attack symptoms include shortness of breath, lightheadedness, and discomfort in one or both arms, neck, or stomach. Women are more likely than men to experience shortness of breath, nausea and vomiting, and back or jaw pain.
“Getting immediate help could be the difference between a heart attack that can be treated without any loss of function and death or severe heart failure,” Dr. Velazquez says.
The ED has beds, but keep visits for emergencies
Still, many people may worry about whether the hospital really is safe, after hearing weeks of reports of resources in short supply and overburdened health care workers.
Sharon Chekijian, MD, MPH, a Yale Medicine emergency medicine specialist, says she and her colleagues are prepared to take care of patients in the safest way possible. “All staff are masked and all patients are given masks upon arrival. Patients are placed in separate rooms, which are cleaned extensively between patients to minimize risk of infection,” she says. “We have also reorganized our staffing patterns to make sure we have extra resources to take care of the sickest patients, and we have minimized visitors.”
Furthermore, the ED is taking advantage of its teleconsult services in which specialists who may normally have seen a patient in the hospital can now do so over a video conference call.
Still, Dr. Chekijian cautions that ED visits should be reserved for true emergencies.
“We don’t want people to come rushing in for minor concerns that they could have seen their primary doctors for. But we do want people to come in for certain problems that can’t be solved by their primary care doctors,” she says.
In many cases, Dr. Chekijian says she has noticed patients are delaying care. “People with problems like appendicitis and gastrointestinal bleeds are waiting until they feel incapacitated, as opposed to coming in with early warning signs,” she says. “Delays in care can mean significant long-term consequences for patients. If in doubt, please call your primary care physician or specialist.”
Dr. Chekijian adds that she is particularly concerned about stroke and heart attack patients. “They should not shy away from coming to the ED,” she says. “As emergency physicians, we have done so much work in the past 10 to 20 years to educate the public about the symptoms of stroke, heart attack, and sepsis, and we don’t want to lose that ground.”
Dr. Velazquez agrees.
“While we are all aware of the impact of this pandemic, cardiovascular disease remains the number one cause of death in the world. If the hundreds and thousands of people who die each year from heart disease are avoiding health care, this is going to be a double whammy,” he says. “Because not only are we losing people from a disease we don’t have a cure for yet, but we have people who are avoiding therapeutic care.”