The enormity of the Covid-19 pandemic sweeping the world has overwhelmed even the richest nations with the best health facilities. Governments are struggling to prevent the spread of the disease and treat the rapidly rising number of patients, even as they ensure that they do not neglect other health and societal priorities.
Although Covid-19 is the most impending health emergency in most countries, cardiovascular disease remains the world’s leading cause of death. This coronavirus crisis has dramatically altered the delivery of cardiology care as it has other emergency care.
With this as a background, a curious observation post the advent of Covid-19 is that the number of cases presenting themselves to Emergency Rooms have dropped by a third to half the usual level in many countries. The conditions for which patients seek Emergency Room care include myocardial infarction, strokes, asthmatic attacks, injuries, road traffic accidents and the like. Reports from medical facilities around the world seem to suggest that all these conditions seem to have gone into hiding since the Covid-19 onslaught.
Why could this be? Are people dying of strokes and heart attacks dying at home, without having sought medical attention?
After the onset of Covid-19, data compiled for 71 cardiac centres from Spain relating to patients with acute heart conditions suggests a 40% reduction in Primary Percutaneous Coronary Interventions – using angioplasty and stents – to treat the narrowing of arteries, 48% reduction in pre-planned, 57% reduction in diagnostic procedures for cardiac ailments and 81% in cardiac interventions.
In the US, the data compiled from nine high-volume cardiac centres post Covid-19 suggest a 38% decrease in non-surgical procedures for serious heart attacks. Further, a study from Hong Kong suggests significant delay in diagnosis and treatment for patients with serious attacks post Covid 19.
On May 6, the Indian Express reported that “the number of treatments for 825 types of unique critical non-Covid procedures by both private and government facilities across the country dropped over 20 per cent between February and April”. The newspaper quoted data provided by the National Health Authority to say that cardiology related procedures had fallen 76% in that period. Anecdotal evidence from hospitals, WhatsApp groups of cardiologists and personal communications suggest a significant drop in acute cardiac events in India too.
There could be several reasons for the drop in cardiac-related chest pains and cerebro-vascular accidents (strokes) cases, including:
- Fear of Covid-19 infections in hospitals leading to patients with minor symptoms failing to seek health care.
- Cardiologists generally preferring a more conservative strategy of thrombolysis to dissolve blood clots instead of Primary Percutaneous Coronary Intervention given the risks of possible transmission of the virus.
- Unavailability of alcohol beverages and tobacco products, which could heighten the risk of cardiac disease if consumed excessively.
- A significant drop in environmental pollution, which heightens the risk of cardiac conditions.
- Job-related and travel-related stress being significantly lower, with many from the corporate sector working from home.
- Better or controlled sleeping hours.
- Overall a better awareness of health and the need to care for it being reinforced in individuals.
- Data from all the countries with significant mortality due to Covid-19 suggests that it is highest in the extremes of age and, in them, with predisposing conditions, such as pre-existing diabetes, hypertension, chronic respiratory conditions and heart disease. A plausible explanation being that given the significant spread of Covid-19, the sickest patients were the ones most affected with the pandemic. So they are being taken to hospital with Covid-19, rather than for their comorbidities.
- Financial constraints given the global lockdown and secondary loss of income leading one to ignore one’s symptoms.
Falling pollution levels
So where have these emergency patients disappeared? Is it that they are dying at home, having failed to reach hospitals? Seemingly not, when we looked at mortality figures in Kerala at Gram Panchayats near where we are working. In keeping with this trend, the Indian Express reported that the number of deaths in Mumbai fell by about 21% in March compared with the same month of 2019. In Ahmedabad, overall deaths plummeted 67%.
Air pollution, we know, is the most important environmental risk factor contributing to global cardiovascular mortality and disability. Short-term elevations in levels of Particulate Matter 2.5 (PM 2.5) increase the relative risk of acute cardio-vascular events by 1% to 3% within a few days. Longer-term exposure over several years increases this risk by a larger magnitude.
Particulate Matter is microscopic particles of solid or liquid matter suspended in the air. Overall, ambient particulate matter ranks as the sixth leading risk factor for premature death globally. Air quality has vastly improved worldwide post Covid-19 and the lockdown in many nations. For example, Delhi and Mumbai have seen a 60% and a 34% reduction in a three-week period in 2020 compared to same period in 2019.
Evidence is accumulating that exposure to chronic and daily stressors and/or severe psychological trauma can also increase the risk of developing and dying from cardiovascular disease. In terms of common and daily stressors that may be experienced over prolonged periods, studies have found that social isolation and loneliness were associated with a 50% increased risk of incident cavdiovascular events. The increased risk associated with work-related stress was similar at 40%.
Chronic stressors have also been linked to worse prognosis in patients with existing cardiovascular disease. Several qualitative studies demonstrate that patients believe daily stressors are key underlying causes of cardiovascular disease and cardiovascular disease risk factors, such as poor diet and sedentary lifestyles.
With the lockdown in effect, the number of traffic accidents has come down significantly. Kerala reported a drop in number of accidents by 92.6%, fatalities by 91.1% and injuries by 93% corresponding to the same period in 2019, post lockdown.
It is plausible that all these factors taken together are what has lead to a fall in both mortality and rates of acute emergencies in hospitals countywide.
Jaideep Menon heads the Preventive Cardiology and Population Health Sciences at the Amrita Institute of Medical Science, Kochi.
Denny John is an economic epidemiologist and is Adjunct Faculty with Amrita Institute of Medical Sciences, Kochi. His Twitter handle is @djohn1976