Stroke Patient Care Amid COVID-19 Pandemic

Physicians across the globe are urging patients with acute coronary or stroke symptoms to seek emergency care, despite orders to shelter in place during the COVID-19 pandemic.

APRIL 16, 2020 -- Physicians across the globe are urging patients with acute coronary or stroke symptoms to seek emergency care, despite orders to shelter in place during the COVID-19 pandemic.

Statements issued today by the American College of Cardiology (ACC) and European Society of Cardiology (ESC) come as hospitals are seeing troubling declines in the number of patients presenting with myocardial infarction (MI) or stroke.

Recent reports suggest a drop of about 40% in ST-segment elevation MI (STEMI) admissions alone in the US and Spain during the outbreak.

"Due to fears of contracting COVID-19 or taking up space in hospitals, patients experiencing a heart attack or stroke are delaying their essential care, causing a new public health crisis," Martha Gulati, MD, editor-in-chief of ACC's patient engagement initiative, CardioSmart , said in a statement.

She pointed out that hospitals and catheterization labs are taking the "utmost precautions" to ensure that the novel coronavirus not be spread and that early care saves lives and reduces the risk of complications.

As part of its appeal, a newly created CardioSmart infographic, "Coronavirus and Your Heart: Don't Ignore Heart Symptoms," details common MI and stroke symptoms and encourages patients who think they're having an event not to delay calling 911 because of fears of contracting COVID-19 at the hospital. The infographic also encourages patients to continue routine heart care, possibly through telehealth or a phone call, to ensure they stay healthy.

"We encourage clinicians to widely distribute these tools to their patients. Make sure that patients know when telehealth is an appropriate option, and when they should call 911 instead," said Gulati, who is also chief of cardiology at the University of Arizona College of Medicine, Phoenix. "Clinicians should work with patients to ensure medication adherence, and always continue to advocate for heart-healthy measures that can be taken even in times of self-isolation and social distancing."

ESC president Barbara Casadei, MD, DPhil, also emphasized that people experiencing MI symptoms should call an ambulance immediately, even if they are self-isolating because they, or someone they live with, may have COVID-19.

"Instructions to 'stay at home' and 'don't come to the hospital' do not apply to patients with heart attack symptoms," she said in a statement.

Hospitals also must have designated areas for MI patients to prevent the spread of coronavirus infections, said Casadei, also an honorary consultant cardiologist at the John Radcliffe Hospital in Oxford, England.

"Every minute counts when you have a heart attack," she said. "If you have symptoms of COVID-19 such as a high temperature or new persistent cough, tell the emergency services in advance. But get to a hospital quickly.

"Your life matters. If you are having a heart attack, we know how to save you and can do so very rapidly and effectively."

Disappearing STEMIs

Even before the professional societies issued their appeals, cardiologists were expressing concern about patients they are no longer seeing — but are trying to remain connected with — during the pandemic.Samreen Raza, MD, Baylor Scott and White Heart Hospital, Plano, Texas, tweeted: "As your Cardiologists, we want you to know, that we are still here for you and to take care of your heart (emoji)."

Harlan Krumholz, MD, Yale New Haven Hospital, Connecticut, detailed the "previously unimaginable" shift in demand for hospital services in a recent piece for the New York Times, citing an informal Twitter poll by @angioplastyorg, in which half of respondents reported seeing a 40% to 60% reduction in MI admissions.

A Spanish Society of Cardiology survey of 71 centers in the STEMI network also reported a 40% decrease in patients treated with percutaneous coronary intervention for STEMI and a 5% COVID-19 infection rate among interventional cardiologists during the week of March 16–22 (after the outbreak), as compared with February 24–March 1.

Just days later, a rapid research letter, published April 10 in the Journal of the American College of Cardiology, identified a 38% reduction in STEMI activations at nine high-volume US catheterization labs on March 1, as compared with the 14 months leading up to the COVID-19 pandemic.

All nine sites had more than 180 STEMI cath lab activations every month (mean 23.6 activations/month) in the period before the outbreak, but reported only 138 activations (mean 15.3 activations/month) after the outbreak.

"A priori, given potential heightened environmental and psychosocial stressors, and a higher case of STEMI induced by viral illness (eg, similar to influenza) or mimickers such as COVID-19 myopericarditis, an increase in STEMI activations would have been expected," lead author Santiago Garcia, MD, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minnesota, said.

Potential etiologies for the decrease in STEMI activations include avoidance of medical care due to social distancing or concerns of contracting COVID-19 in the hospital, STEMI misdiagnosis, and increased use of pharmacologic reperfusion due to COVID-19.

"As the pandemic continues, we plan to continue to follow this early signal and investigate its causes," the authors said. "It is particularly crucial to understand if patient-based anxiety is decreasing presentation of STEMI patients to the US hospital system."

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References
Sources: J Am Coll Cardiol. LetterAmerican College of Cardiology statement. Full text European Society of Cardiology statement. Full text

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