COVID-19 US : Heart patients avoid ERs – people are afraid to interact with medical care

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Emergency room visits in the U.S. for chest pain and heart attacks fell early this spring, according to a study that supports fears that the coronavirus outbreak scared away people from going to the hospital.

ER visits were up for respiratory illnesses and pneumonia, but were down for nearly every other kind of injury or ailment, the Centers for Disease Control and Prevention reported Wednesday.

Overall, fewer ER patients showed up: Visits were down 42% in a four-week period that stretched from late March through most of April, compared to the same time last year.

At the time, hospitals is some U.S. cities – most notably New York – were overwhelmed treating COVID-19 patients. But the CDC study covers 43 states, and saw big declines, particularly in visits involving preteens.

Some of that may be good news – there may have been fewer injuries from some types of accidents, for example, because people were staying at home and not doing as many risky things at work or play.

But some experts worry about the CDC finding 1,100 fewer visits per week for heart attacks, and 24,000 fewer for chest pain.

The finding seems to parallel death certificate reports. In each of the first three weeks of April, the nation saw 2,000 more deaths than normal in a category that is primarily heart attacks.

That may be the result of some patients worrying more about catching the coronavirus at a crowded ER than their heart problems, some experts think.

“There’s a lot of evidence that suggests people are afraid to interact with medical care, and are deciding not to act on their symptoms,” said Wayne Rosamond, a University of North Carolina researcher who studies heart disease and stroke trends.

The CDC report echoes research in the U.S. and Italy, which showed reductions in heart-related hospital admissions and use of labs to clear clogged arteries but no drop in heart attack deaths during coronavirus.

The latest study found a small increase in people arriving at the ER in cardiac arrest – their heart had stopped.

One possible explanation: “They could have been people with heart attacks who waited too long,” Dr. Harlan Krumholz, a Yale University cardiologist and health care researcher, said in an email.

“If someone is having acute chest pain and think they’re having a heart attack, they should call 911,” Rosamond said. “You shouldn’t ignore these things. You should seek help.”


As health care systems around the world struggle with the Covid-19 pandemic, Adventist Health Lodi Memorial (LMH), a 150-bed community hospital in California’s Central Valley, is experiencing record low emergency department (ED) volume. California was one of the first states to report a confirmed case of Covid-19 and was the first to issue a statewide shelter-in-place order on March 19, 2020.

The volume of patients presenting to the LMH ED dropped significantly after the shelter-in-place mandate (Figure 1). By the first week in April, volume was down approximately 50% since the first week of March, when the LMH ED treated 1,098 patients, to the second week of April, when 611 patients were treated.

Figure 1

This decrease was initially welcomed as the hospital prepared for a potential surge in respiratory patients. With time, however, the decrease in ED volume persisted and was accompanied by alarming statistics.

First, data suggested that a proportion of high-acuity patients expected to need medical care were not presenting to the hospital. Despite significantly lower daily volume, the percentage of patients admitted to LMH from the ED remained unchanged at 13%.

If the expected high-acuity patients were presenting to the hospital and low-acuity patients were staying home, the percentage of patients admitted should be expected to increase.

Second, emergency medical services (EMS) reported the highest-ever number of cardiac arrests in the field — 45% more than the previous month — suggesting that patients were waiting too long to seek cardiac care (Figure 2). Of note, all of these EMS heart patients tested negative for Covid-19.

Figure 2

Third, in the month of March, all stroke patients arrived too late to receive tissue plasminogen activator (tPA), which is surprising given that LMH administers tPA for three to eight stroke patients every month.

This information again suggested a new culture of waiting to seek emergency care and was supported by subsequent histories of patients who reported they chose to wait several days after the onset of stroke symptoms to present for care.

The initial relief of having lower volumes turned to concern as it became clear that members of the community were avoiding the ED even when they had life-threatening emergencies.

This decrease in ED volume is not unique to Lodi. The Covid-19 pandemic has altered the lives of approximately 316 million Americans who are under shelter-in-place orders as of April 15, 2020. Nationally, visits to EDs are down nearly 50% since mid-March (2020 week 11) when weekly ED visits exceeded 2.23 million, to mid-April (2020 week 15) when weekly ED visits had declined to 1.18 million.1

News media around the U.S. are reporting lower ED volumes and publishing stories of patients afraid to go to the hospital — in some cases with dire consequences.2-7 Internationally, Italy and Hong Kong are reporting fewer strokes and delayed presentation of myocardial infarctions, respectively.8,9

This suggests a global problem.10

reference

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