Cardiac Arrest Tracked Stages of Lockdown

The recent uptick in out-of-hospital cardiac arrests (OHCAs) could be a consequence of heart attack patients avoiding hospitals during COVID-19, one Denver group suggested.

There were significantly more OHCAs in the first 2 weeks of the local shelter-in-place order compared with the period before COVID or the early COVID period between the declaration of emergency and the statewide shelter-in-place order (46 vs 26 and 27 per week, respectively, P=0.001 and P=0.004).

Despite the increase in OHCAs, there were progressively fewer average ambulance activations per week across time (P=0.007):

• 2,218 in the pre-mandate period from Jan. 1 to March 7
• 2,129 in the peri-mandate period from March 8 to 28
• 1,921 in the post-mandate period from March 29 to April 11

The report by Brian Stauffer, MD, of Denver Health Medical Center, and colleagues was published in the Aug. 24 issue of JACC: Cardiovascular Interventions.

“A review at the patient level is essential to obtain a more granular understanding of these data. However, in the interim, providers should consider the unintended consequence of the pandemic response in the context of chronic and emergent cardiovascular disease,” Stauffer’s group urged.

“One possibility suggested by our data is that patients with acute coronary syndromes are not presenting for care, resulting in an increase in OHCA,” they said.

“I have little doubt that some patients avoided needed medical care because of fears of catching COVID. Unfortunately, some died and are counted among the excess number of cardiac arrest cases noted in Denver,” commented Michael Sayre, MD, of the University of Washington in Seattle.

“It was our observation here in New York, too, that patients were too scared to come to the hospitals. There needs to be a lot more education and awareness of this. Without this, I predict this trend will continue in all the hotspots,” said Sripal Bangalore, MD, MHA, of NYU Langone Health.

Notably, a 38% drop in catheterization lab activations for hospital ST-segment elevation MI (STEMI) was reported from nine high-volume centers in the U.S. due to COVID-19.

“This is one of the ‘unintended consequences’ of restructuring of medical services, which included cancellation of elective procedures, to create ICU capacity to accommodate COVID patients,” Santiago Garcia, MD, of Minneapolis Heart Institute and an author on that STEMI paper, told MedPage Today.

To avoid unnecessary avoidance of care during a second wave of COVID — coming perhaps as early as the fall or winter — communities will need to take several steps, Garcia suggested:

• Hospitals need to make a clear distinction between elective and urgent procedures and communicate this clearly to the community.
• Patients should be told that many of the symptoms attributed to COVID-19 (e.g., dyspnea, fatigue, chest pain) can be signs of a heart attack or other cardiac problems that should prompt evaluation in the ED or clinic.
• Patients need to be reassured that hospitals are safe and the issue of lack of PPE has been resolved in most of the U.S.

The American College of Cardiology, American Heart Association, and European Society of Cardiology have each issued similar guidance, urging immediate medical attention for symptoms or signs of a heart attack. Bystanders have also been encouraged to perform CPR on those suffering cardiac arrest during the COVID-19 era.

“While the exact reasons for the higher observed rates of out of hospital cardiac arrest are not known, the marked reduction in hospitalizations for acute MI increases the likelihood that complications from delayed reperfusion, including heart failure, cardiogenic shock, mechanical complications and cardiac arrest, will occur,” commented Ty Gluckman, MD, of Providence St. Joseph Health in Portland, Oregon.

Gluckman also recently reported a dip in heart attack hospitalizations across hospitals at his health system — although his group found some rebound by May.

Stauffer and colleagues noted that most OHCAs are related to myocardial ischemia, but noted the possibility of COVID-19 complications being responsible during the pandemic.

“Unfortunately, during this time frame, COVID-19 testing was not widely available, but it is interesting to note that the excess in OHCA was greater than the number of patients who died with COVID-19 diagnoses during the same time frame,” they said.

Their study relied on the Denver Health Paramedic Division database.

Compared with historical data from 2011-2019, there were more than twice as many total OHCAs as normal during the post-mandate period (P=0.002).

Ambulance activations had been on the rise (from 3,072 in 2011 to 4,716 in 2019) until this year (3,841 so far in 2020).