Heart Attacks at Home

The unintended consequences of COVID-19

In recent weeks, headlines from around the world have been dominated by stories of hospitals overwhelmed with patients suffering from symptoms attributable to COVID-19 and subsequent pleas to the public from frontline healthcare workers and public health officials to stay at home and stop the spread of the virus in the community.

These messages have achieved their aims in many geographies, and public health officials are now seeing rates of infection slowing through real-time tracking, with fewer patients needing to be hospitalized as the curve is ‘flattened’. Unfortunately, some of these messages are working too well, causing patients to actively stay away from healthcare contact due to fear or a misguided sense of public duty. As a result, the law of unintended consequences has come into operation: many people, either afraid to present to hospitals at this time, or simply unsure of the nature of their symptoms, are coming to hospital either late in their illness or not at all. The knock-on effects are simple: people are dying from preventable illnesses at home.

This phenomenon is manifest in the recent revelation that paramedic calls to out-of-hospital cardiac arrests had increased severalfold in New York, at a time when heart attacks presenting to hospital had halved. Further, my recent discussions with Cardiologists from around the world uniformly report the return of mechanical complications of heart attack previously only regularly seen before the widespread uptake of primary angioplasty programs; such life-threatening complications, including ventricular rupture, are usually only seen when patients attend hospital days after the onset of their symptoms. In similar fashion, colleagues from other disciplines describe a similar pattern: a gastrointestinal surgeon told me that he had seen cases of peritonitis due to delayed presentation after appendicitis and cholecystitis; a vascular surgeon reported that he had performed more amputations than ever before in such a short time for critical limb ischemia, owing to cases attending in states too advanced for any endovascular salvage.

Underlying health conditions (or comorbidities), such as cardiovascular disease, place patients at an increased risk of severe manifestations of COVID-19, but the real cost of this pandemic is not only in those disease sufferers that become infected, but also in those that do not come to hospital when the symptoms attributable to their underlying condition deteriorate. Patients with such comorbid conditions are well aware of the threat that COVID-19 poses to them, but perhaps less aware that they place themselves at risk also by staying away from hospitals; there is no mincing words: these patients are scared.

Here in the UK, recent data from the British Heart Foundation shows that the number of people seen in hospital for possible heart attacks dropped by 50% in March, which has led to a national campaign to educate and raise awareness that heart attack symptoms should not be ignored at any cost. And the UK is not alone - other countries in Europe are reporting similar drops in visits to hospital for heart attacks as well as other cardiovascular events.

Why? People are afraid to add to the burden of an already overburdened healthcare system and they are afraid of contracting COVID-19. While both of these reasons are valid, they should in no way prevent cardiac patients from seeking medical attention: delaying medical intervention for heart attack symptoms could lead to further heart damage or even death.

So, an equally important message to people who are living with cardiovascular disease should be: seek medical attention immediately if you think you are having a heart attack. The similarities in symptoms of a cardiac event and COVID-19—chest pain and shortness of breath—are also creating complications for paramedics. But that is not reason enough to ignore them.

Now is a good time to refresh our memories about what symptoms to look for if you think you are having a heart attack. Please bear in mind that individuals may not experience all of these symptoms, and that they may not necessarily be severe and/or of a sudden onset:

Chest discomfort: most heart attacks involve discomfort in the center or on the left side of the chest – this often lasts more than a few minutes or goes away and comes back repeatedly. Sometimes it can be mistaken for indigestion.

Pain that extends beyond your chest: symptoms can include pain or discomfort in one or both arms, back, neck, stomach or jaw.

Other signs: any of the symptoms above that are accompanied by a cold sweat, nausea, lightheadedness or dizziness, and anxiety .

Time is a critical factor when it comes to treating heart attacks, so as a Cardiologist, I implore patients not to delay in calling an ambulance if you think you are having a heart attack. As real as the threat of COVID-19 is to our lives, so too is the threat of a heart attack if left untreated; with this in mind, let us try to break the law of unintended consequences.