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Where Have All the Heart Attacks Gone? Where Have All the Heart Attacks Gone?
(31 minutes later)
The hospitals are eerily quiet, except for Covid-19.The hospitals are eerily quiet, except for Covid-19.
I have heard this sentiment from fellow doctors across the United States and in many other countries. We are all asking: Where are all the patients with heart attacks and stroke? They are missing from our hospitals.I have heard this sentiment from fellow doctors across the United States and in many other countries. We are all asking: Where are all the patients with heart attacks and stroke? They are missing from our hospitals.
Yale New Haven Hospital, where I work, has almost 300 people stricken with Covid-19, and the numbers keep rising — and yet we are not yet at capacity because of a marked decline in our usual types of patients. In more normal times, we never have so many empty beds.Yale New Haven Hospital, where I work, has almost 300 people stricken with Covid-19, and the numbers keep rising — and yet we are not yet at capacity because of a marked decline in our usual types of patients. In more normal times, we never have so many empty beds.
Our hospital is usually so full that patients wait in gurneys along the walls of the emergency department for a bed to become available on the general wards or even in the intensive care unit. We send people home from the hospital as soon as possible so we can free up beds for those who are waiting. But the pandemic has caused a previously unimaginable shift in the demand for hospital services.Our hospital is usually so full that patients wait in gurneys along the walls of the emergency department for a bed to become available on the general wards or even in the intensive care unit. We send people home from the hospital as soon as possible so we can free up beds for those who are waiting. But the pandemic has caused a previously unimaginable shift in the demand for hospital services.
Some of the excess capacity is indeed by design. We canceled elective procedures, though many of those patients never needed hospitalization. We are now providing care at home through telemedicine, but those services are for stable outpatients, not for those who are acutely ill.Some of the excess capacity is indeed by design. We canceled elective procedures, though many of those patients never needed hospitalization. We are now providing care at home through telemedicine, but those services are for stable outpatients, not for those who are acutely ill.
What is striking is that many of the emergencies have disappeared. Heart attack and stroke teams, always poised to rush in and save lives, are mostly idle. This is not just at my hospital. My fellow cardiologists have shared with me that their cardiology consultations have shrunk, except those related to Covid-19. In an informal Twitter poll by @angioplastyorg, an online community of cardiologists, almost half of the respondents reported that they are seeing a 40 percent to 60 percent reduction in admissions for heart attacks; about 20 percent reported more than a 60 percent reduction.What is striking is that many of the emergencies have disappeared. Heart attack and stroke teams, always poised to rush in and save lives, are mostly idle. This is not just at my hospital. My fellow cardiologists have shared with me that their cardiology consultations have shrunk, except those related to Covid-19. In an informal Twitter poll by @angioplastyorg, an online community of cardiologists, almost half of the respondents reported that they are seeing a 40 percent to 60 percent reduction in admissions for heart attacks; about 20 percent reported more than a 60 percent reduction.
And this is not a phenomenon specific to the United States. Investigators from Spain reported a 40 percent reduction in emergency procedures for heart attacks during the last week of March compared with the period just before the pandemic hit.And this is not a phenomenon specific to the United States. Investigators from Spain reported a 40 percent reduction in emergency procedures for heart attacks during the last week of March compared with the period just before the pandemic hit.
And it may not just be heart attacks and strokes. Colleagues on Twitter report a decline in many other emergencies, including acute appendicitis and acute gall bladder disease.And it may not just be heart attacks and strokes. Colleagues on Twitter report a decline in many other emergencies, including acute appendicitis and acute gall bladder disease.
The most concerning possible explanation is that people stay home and suffer rather than risk coming to the hospital and getting infected with coronavirus. This theory suggests that Covid-19 has instilled fear of face-to-face medical care. As a result, many people with urgent health problems may be opting to remain at home rather than call for help. And when they do finally seek medical attention, it is often only after their condition has worsened. Doctors from Hong Kong reported an increase in patients coming to the hospital late in the course of their heart attack, when treatment is less likely to be lifesaving.The most concerning possible explanation is that people stay home and suffer rather than risk coming to the hospital and getting infected with coronavirus. This theory suggests that Covid-19 has instilled fear of face-to-face medical care. As a result, many people with urgent health problems may be opting to remain at home rather than call for help. And when they do finally seek medical attention, it is often only after their condition has worsened. Doctors from Hong Kong reported an increase in patients coming to the hospital late in the course of their heart attack, when treatment is less likely to be lifesaving.
There are other possible explanations for the missing patients. In this time of social distancing, our meals, social interactions and physical activity patterns tend to be very different. Maybe we have removed some of the triggers for heart attacks and strokes, like excessive eating and drinking or abrupt periods of physical exertion. This theory merits research but seems unlikely to explain the dramatic changes we’re observing.There are other possible explanations for the missing patients. In this time of social distancing, our meals, social interactions and physical activity patterns tend to be very different. Maybe we have removed some of the triggers for heart attacks and strokes, like excessive eating and drinking or abrupt periods of physical exertion. This theory merits research but seems unlikely to explain the dramatic changes we’re observing.
We actually expected to see more heart attacks during this time. Respiratory infections typically increase the risk of heart attacks. Studies suggest that recent respiratory infections can double the risk of a heart attack or stroke. The risk seems to begin soon after the respiratory infection develops, so any rise in heart attacks or strokes should be evident by now. We urge people to get flu vaccines every year, in part, to protect their hearts.We actually expected to see more heart attacks during this time. Respiratory infections typically increase the risk of heart attacks. Studies suggest that recent respiratory infections can double the risk of a heart attack or stroke. The risk seems to begin soon after the respiratory infection develops, so any rise in heart attacks or strokes should be evident by now. We urge people to get flu vaccines every year, in part, to protect their hearts.
Also, times of stress increase the risk of heart attacks and strokes. Depression, anxiety and frustration, feelings that the pandemic might exacerbate, are all associated with a doubling or more of heart attack risks. Work and life stress, which also may be higher with the acute disruptions we’ve all been going through, can markedly increase the risk of a heart attack. Moreover, events like earthquakes or terrorist attacks or war, in which an entire society is exposed to a stressor, are risk factors for heart attacks. Finally, Covid-19 can actually affect the heart, which should be increasing the number of patients with heart problems.Also, times of stress increase the risk of heart attacks and strokes. Depression, anxiety and frustration, feelings that the pandemic might exacerbate, are all associated with a doubling or more of heart attack risks. Work and life stress, which also may be higher with the acute disruptions we’ve all been going through, can markedly increase the risk of a heart attack. Moreover, events like earthquakes or terrorist attacks or war, in which an entire society is exposed to a stressor, are risk factors for heart attacks. Finally, Covid-19 can actually affect the heart, which should be increasing the number of patients with heart problems.
Experts are bringing together data to confirm these patterns. We hope to gain a greater understanding of their causes and consequences.
Meanwhile, the immediate message to patients is clear: Don’t delay needed treatment. If fear of the pandemic leads people to delay or avoid care, then the death rate will extend far beyond those directly infected by the virus. Time to treatment dictates the outcomes for people with heart attacks and strokes. These deaths may not be labeled Covid-19 deaths, but surely, they are collateral damage.
Updated June 22, 2020Updated June 22, 2020
A commentary published this month on the website of the British Journal of Sports Medicine points out that covering your face during exercise “comes with issues of potential breathing restriction and discomfort” and requires “balancing benefits versus possible adverse events.” Masks do alter exercise, says Cedric X. Bryant, the president and chief science officer of the American Council on Exercise, a nonprofit organization that funds exercise research and certifies fitness professionals. “In my personal experience,” he says, “heart rates are higher at the same relative intensity when you wear a mask.” Some people also could experience lightheadedness during familiar workouts while masked, says Len Kravitz, a professor of exercise science at the University of New Mexico.A commentary published this month on the website of the British Journal of Sports Medicine points out that covering your face during exercise “comes with issues of potential breathing restriction and discomfort” and requires “balancing benefits versus possible adverse events.” Masks do alter exercise, says Cedric X. Bryant, the president and chief science officer of the American Council on Exercise, a nonprofit organization that funds exercise research and certifies fitness professionals. “In my personal experience,” he says, “heart rates are higher at the same relative intensity when you wear a mask.” Some people also could experience lightheadedness during familiar workouts while masked, says Len Kravitz, a professor of exercise science at the University of New Mexico.
The steroid, dexamethasone, is the first treatment shown to reduce mortality in severely ill patients, according to scientists in Britain. The drug appears to reduce inflammation caused by the immune system, protecting the tissues. In the study, dexamethasone reduced deaths of patients on ventilators by one-third, and deaths of patients on oxygen by one-fifth.The steroid, dexamethasone, is the first treatment shown to reduce mortality in severely ill patients, according to scientists in Britain. The drug appears to reduce inflammation caused by the immune system, protecting the tissues. In the study, dexamethasone reduced deaths of patients on ventilators by one-third, and deaths of patients on oxygen by one-fifth.
The coronavirus emergency relief package gives many American workers paid leave if they need to take time off because of the virus. It gives qualified workers two weeks of paid sick leave if they are ill, quarantined or seeking diagnosis or preventive care for coronavirus, or if they are caring for sick family members. It gives 12 weeks of paid leave to people caring for children whose schools are closed or whose child care provider is unavailable because of the coronavirus. It is the first time the United States has had widespread federally mandated paid leave, and includes people who don’t typically get such benefits, like part-time and gig economy workers. But the measure excludes at least half of private-sector workers, including those at the country’s largest employers, and gives small employers significant leeway to deny leave.The coronavirus emergency relief package gives many American workers paid leave if they need to take time off because of the virus. It gives qualified workers two weeks of paid sick leave if they are ill, quarantined or seeking diagnosis or preventive care for coronavirus, or if they are caring for sick family members. It gives 12 weeks of paid leave to people caring for children whose schools are closed or whose child care provider is unavailable because of the coronavirus. It is the first time the United States has had widespread federally mandated paid leave, and includes people who don’t typically get such benefits, like part-time and gig economy workers. But the measure excludes at least half of private-sector workers, including those at the country’s largest employers, and gives small employers significant leeway to deny leave.
So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.
Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.
A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.
The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.
States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.
Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.
If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)
If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.
If you’re sick and you think you’ve been exposed to the new coronavirus, the C.D.C. recommends that you call your healthcare provider and explain your symptoms and fears. They will decide if you need to be tested. Keep in mind that there’s a chance — because of a lack of testing kits or because you’re asymptomatic, for instance — you won’t be able to get tested.If you’re sick and you think you’ve been exposed to the new coronavirus, the C.D.C. recommends that you call your healthcare provider and explain your symptoms and fears. They will decide if you need to be tested. Keep in mind that there’s a chance — because of a lack of testing kits or because you’re asymptomatic, for instance — you won’t be able to get tested.
Experts are bringing together data to confirm these patterns. We hope to gain a greater understanding of their causes and consequences.
Meanwhile, the immediate message to patients is clear: Don’t delay needed treatment. If fear of the pandemic leads people to delay or avoid care, then the death rate will extend far beyond those directly infected by the virus. Time to treatment dictates the outcomes for people with heart attacks and strokes. These deaths may not be labeled Covid-19 deaths, but surely, they are collateral damage.
The public needs to know that hospitals are equipped not only to care for people with Covid-19 but also those who have other life-threatening health problems. Yes, we in health care are working to keep people out of the hospital if we can, but we can safely provide care for those people who are not sick from Covid-19. Masks and protective gear for health care workers and patients go a long way to ensure a safe environment. Also, people with chronic conditions need to know that avoidance of needed care could ultimately be as big a threat as the virus itself.The public needs to know that hospitals are equipped not only to care for people with Covid-19 but also those who have other life-threatening health problems. Yes, we in health care are working to keep people out of the hospital if we can, but we can safely provide care for those people who are not sick from Covid-19. Masks and protective gear for health care workers and patients go a long way to ensure a safe environment. Also, people with chronic conditions need to know that avoidance of needed care could ultimately be as big a threat as the virus itself.
As we fight coronavirus, we need to combat perceptions that everyone else must stay away from the hospital. The pandemic toll will be much worse if it leads people to avoid care for life-threatening, yet treatable, conditions like heart attacks and strokes.As we fight coronavirus, we need to combat perceptions that everyone else must stay away from the hospital. The pandemic toll will be much worse if it leads people to avoid care for life-threatening, yet treatable, conditions like heart attacks and strokes.
Harlan Krumholz, M.D., is professor of medicine at Yale and director of the Yale New Haven Hospital Center for Outcomes Research and Evaluation.Harlan Krumholz, M.D., is professor of medicine at Yale and director of the Yale New Haven Hospital Center for Outcomes Research and Evaluation.