As ED Visits Declined Amid COVID-19 in England, CV Deaths Ticked Up

For every 12 cardiac admissions to hospital emergency rooms across England that never occurred during the first month of the COVID-19 pandemic, one cardiac death would have been prevented or delayed, according to a new modelling study.

As previously reported by TCTMD, countries across Europe and around the world saw stark drops in the number of patients presenting to emergency departments (EDs) with acute coronary syndromes and other urgent symptoms in the first wave of COVID-19.

“Many studies have documented a reduction in ED visits; however, to the best of our knowledge, none of them have studied the consequences of this reduction,” lead investigator Michail Katsoulis, PhD (University College London, England), told TCTMD. Katsoulis and colleagues published their analysis earlier this week in Circulation: Cardiovascular Quality and Outcomes.

There are mounting concerns that “non-attendance” at emergency departments, either out of fear of coronavirus infection or a reluctance to overwhelm already strained hospital systems, will create a domino effect for later morbidity and mortality, Katsoulis noted in an email. “For some diseases, such as cancer, it’s difficult to quantify the adverse health effect because it is likely that the consequences will only become manifest in the longer term. In contrast, for MI and other cardiac diseases, it is more plausible to assume that we might observe short-term consequences.

“Unfortunately,” he continued, “this negative prediction came true.”

Fewer Admissions, More Deaths

Katsoulis and colleagues extracted data from a sentinel network of 60 EDs across England, scaled by a factor of three to account for the 180 EDs country wide. CVD mortality data were obtained from the office of national statistics and defined as deaths due to coronary disease, heart failure, or sudden cardiac death based on ICD-10 codes. Deaths among patients also diagnosed with COVID-19 were excluded from the analysis. Effects of reduced ED visits over time were considered for a range of time periods out to 20 days.

The overall decline in ED visits for cardiac conditions was 35% as compared with the average weekly rates from prior to the pandemic, both earlier in the year and in prior years. In the model, every 100 ED admissions for cardiac disease that didn’t occur were associated with between 3.1 and 8.4 excess cardiac deaths, translating into a weekly rate of between 84 and 232.

“This corresponds to an increase in weekly non-COVID-19 cardiac mortality of up to 18%, compared to the previous 5 years, and implies that one cardiac death could have been prevented or delayed for every 12 ED visits with suspected cardiac disease,” Katsoulis and colleagues conclude.

Some Unknowns

The study looked only at short-term cardiac mortality, raising the potential that additional deaths are still possible, and even “likely,” down the road. To TCTMD,  Katsoulis cautioned that they “cannot be sure about this question.”

Unfortunately, this negative prediction came true. Michail Katsoulis

“There is a risk that longer-term impacts of undertreatment on cardiovascular morbidity and mortality will continue to emerge over time,” he acknowledged. However, on a positive note, the stark decline in ED attendance in England was seen primarily in the first month of the pandemic. “After mid-April, the attendance at EDs for all diseases, including cardiac conditions, was back to normal levels, in some cases even higher than in previous years. For this reason, we want to remain somewhat optimistic that we won’t observe any high spike in cardiac (or non-COVID) mortality over a longer time due to untreated cardiac conditions from mid-March to mid-April.”

But as others have repeatedly said over the past year, it’s critical that public health messaging clearly reminds patients not to ignore acute symptoms, even as countries like the United States face surges in hospital admissions and community infections.

“Policy makers should ensure that any measures introduced to control COVID-19 infection do not adversely affect the management of heart disease and other non-COVID illnesses,” Katsoulis said.

Finally, there remains the possibility that other factors, beyond hospital avoidance or access, have had a hand in the increased cardiac mortality numbers reported. “One assumption that we cannot be sure we met is that the COVID-19 pandemic only affects excess deaths from cardiac disease through the reduction in ED admissions,” said Katsoulis, “and not through other factors, such as increased anxiety leading to an increased incidence rate of myocardial infarction.”