Same Drop in MI, HF Admissions Seen in COVID-19’s Second Wave

It might have been predictable, researchers say, but that doesn’t make it less worrisome: the second national lockdown in the United Kingdom due to surging cases of COVID-19 was matched by a fall in MI and heart failure admissions of the same magnitude seen the first time around.

That’s despite widespread media coverage of the phenomenon, attributed to fears of catching the infection or not wanting to tax overburdened hospitals, and despite signs that admission rates crept closer to normal between the two lockdowns, write Jianhua Wu, PhD (University of Leeds, England), and colleagues in a research letter this week in the Journal of the American College of Cardiology.

As such, there are crucial lessons for public health officials and hospital administrators as numbers of infections crest yet again, senior author Chris Gale, MBBS, PhD (University of Leeds), told TCTMD.

“If I could predict what's going to happen now that we're in sort of a third lockdown, I would hope one thing and expect another,” Gale said. “That is, I would hope that there isn't a decline [in cardiac admissions], but I think I would expect that the public behavior will continue, and that is because people are fearful of coming to hospital because of worries around catching the contagion, that even when they have medical emergencies such as heart attack and heart failure, they elect to stay at home.”

As reported by TCTMD, cardiologists first started noticing a steep fall in MI admissions in late March, and formal papers documenting the phenomenon were published throughout the past year. Drops in the range of 25% to 40% were seen around the world, and not just for acute coronary syndromes, but also for stroke, cardiac arrest, acute heart failure, and other life-threatening conditions. In time, the mainstream media took up the story, reminding the public that acute conditions require urgent care, pandemic or not.

Riding the Waves

With all of that in mind, Gale and colleagues reviewed cardiovascular admissions using the National Heart Failure Audit, the Myocardial Ischemia National Audit Project, and the National Institute for Cardiovascular Outcomes Research NICOR data bank between November 1, 2018, and November 17, 2020, comparing admission patterns prior to and during the COVID-19 pandemic at the “fast-reporting” hospitals. For late March/early April, the investigators identified a more than 50% reduction in HF admissions and a 32% drop in MI admissions occurring during the 11 to 12 days following the start of the March 23 lockdown. Numbers climbed slowly higher over the next few months, reaching a peak in mid-to-late June that was 95% and 93% that of pre-COVID levels for HF and MI admissions, respectively.

Despite that recovery, numbers started to fall again in late October, slightly ahead of the second UK lockdown, Wu et al report.

The “shape” of this second drop, Gale noted, “is different from the first one—it’s more gradual, but it drops to the same level.” Importantly, no nadir was identified before the November data cutoff, meaning that rates could decline further.

“I think we will see going forward that this does not recover abruptly and that it lingers to a certain extent,” Gale said. “That's why it's so important that we push out that public health message that medical emergencies do not stop during a pandemic and heart attacks are an exemplar of a medical emergency that we know if not treated results in loss of life, and if not, in chronic long-term conditions such as recurrent heart attack, stroke, and heart failure.”

Cardiologists and cardiac surgeons played a crucial role in raising alarm bells about the “missing STEMIs” the first time around. Gale calls them “key stakeholders,” noting that they’ve proven they can continue to do emergency PCIs and surgeries successfully despite all of the other demands this ongoing pandemic has placed on strained health systems. But unless patients trust hospitals and the cardiologists ready and waiting to care for acute conditions, Gale expects to continue to see the same impact that followed the drop in acute admissions during the first wave, namely excess deaths, including those from untreated heart attacks, pulmonary embolism, cardiogenic shock, acute HF, and more.

“There really are important ramifications of not attending hospitals for a medical emergency,” said Gale.

Note: Co-author Mamas Mamas, BMBCh, DPhil, is the senior clinical editor of TCTMD.