‘Terrible’ Spike in Cardiac Arrest Deaths During Lombardy’s COVID-19 Surge

Chilling numbers out of northern Italy point to a 58% increase in the number of out-of-hospital cardiac arrests (OHCAs) in the first 40 days of the COVID-19 pandemic there, as compared with the same period last year.

This spike in arrests appeared to follow the geographic time course of the outbreak, such that the percent increase in OHCA was steepest in the two provinces that experienced the earliest cases of COVID-19 and had the highest number of cumulative cases per 100,000 people, Simone Savastano, MD (Fondazione IRCCS Policlinico San Matteo, Pavia, Italy), senior author on the study, told TCTMD. For the province of Lodi, the increase in OHCA was 187%, and for Cremona, it was 143%. In Pavia and Mantova, where the epidemic hit later and fewer people were infected per capita, the increases in cardiac arrest were 24% and 18%, respectively.

“When the COVID epidemic started, we noticed an important reduction in STEMI and so some of us thought that maybe cardiac arrest can also be reduced, so we questioned our database and very quickly we had a terrible answer,” Savastano said. “It was exactly the contrary: out-of-hospital cardiac arrests were increasing day by day, and they went hand in hand with the COVID-19 trend.”

The dramatic drop in acute MIs during the COVID-19 epidemic has emerged as a devastating side story, with cardiologists and researchers increasingly convinced that hospital avoidance by patients terrified of the contagion has helped to drive the numbers down. And while some of these “missing STEMIs” are arriving to the hospital late, with dire complications from that delay, there are growing fears that many patients are arresting and dying at home, the cause of death impossible to disentangle from COVID-19.

Savastano believes their Lombardy data, published as a research letter in the New England Journal of Medicine, is the first to provide a snapshot of cardiac arrest numbers in a region hit hard, and hit early, by the COVID-19 pandemic.

“We are providing data from a quite large territory and so I think that our data could be [representative] of other countries as well,” Savastano told TCTMD. “That’s why we decided to publish this as an early letter, in order to get this information out quickly, to share this information with other countries that are facing, now, the COVID epidemic.”

Cardiac Arrest Also a Killer in COVID-19

The research letter draws on data from the Lombardia Cardiac Arrest Registry, first launched in 2015, as well as daily reports of new COVID-19 cases from the National Department of Civil Protection and the emergency medical system’s electronic database that tracks symptoms and cardiac deaths. COVID-19 positivity was inferred from symptoms suggestive of infection prior to the arrest (fever lasting ≥ 3 days before OHCA, plus cough, dyspnea, or both) or on the basis SARS-CoV-2-positive pharyngeal swabs obtained either prior to the arrest or after death. All emergency response personnel were instructed to ask about patient symptoms prior to arrival and don protective equipment before administering care. 

In all, there were 362 OHCAs between February 20 and March 31, 2020, as compared with 229 in over the same period in 2019. Among the 2020 patients, 103 had confirmed or suspected COVID-19. While it’s impossible to differentiate between arrests directly caused by complications of COVID-19 versus those resulting indirectly, as a result of hospital avoidance, the authors estimate that COVID-19 accounts for 77.4% of the increase in cases of out-of-hospital cardiac arrest observed in these four Italian provinces.

In COVID-19 patients, Savastano speculated to TCTMD that “hypoxia, pulmonary embolism, or mechanical complication of MI may have played a role.”

Overall, the proportion of cardiac arrests due to medical causes (as opposed to causes like trauma, drowning, or electrocution) was 6.5% higher than in 2019, out-of-hospital arrests were 7.3% higher, unwitnessed arrests were 11.3% higher, and median time to emergency medical services (EMS) arrival was 3 minutes longer. In patients for whom EMS attempted resuscitation, deaths were almost 15% higher than during the same 40-day period in 2019. Tragically, the proportion of patients receiving bystander CPR was 15.6% lower than in 2019. Overall mortality was nearly 89%, up from 77% in 2019.

More Lessons From Lombardy

To TCTMD, Savastano stressed that cardiac symptoms and the risk of cardiac arrest in COVID-19 patients need to be on the radar of physicians and hospital systems now facing down this pandemic in other parts of the world, emphasizing also that advice to stay home does not extend to patients with fast-evolving symptoms.

“If I can make a suggestion to our colleagues, I would say that COVID patients are very hard to take care of at home,” he advised. “Our hospital system was very burdened by the epidemic, so we tried to leave patients at home and to prescribe drugs at home; probably, sometimes, we didn’t pay the right attention to symptoms. Regretfully, we now know the progression of respiratory distress is very, very quick, so it's quite difficult to decide which patients can be left at home and which need to be taken to the hospital.

“We have to be very careful to pay attention to symptoms and also to instruct the patient to be very careful with their symptoms and to activate the emergency response system quickly” if they need it, particularly in the case of chest pain or other symptoms related to the heart, Savastano said.