August 4, 2020

expert reaction to study looking at patient response, treatments and mortality for heart attacks during the COVID-19 pandemic

A study, published in European Heart Journal Quality of Care & Clinical Outcomes, looked at patient response, treatments and mortality for heart attacks during the COVID-19 pandemic.

Prof Steve Goodacre, Professor of Emergency Medicine, University of Sheffield, said:

“The research appears to have been competently performed and uses a well-respected database.

“The conclusion that admissions with heart attack fell after lockdown was shown in a previous study published by the Lancet: https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(20)31356-8.pdf

“It is an observational study so we can only use the data to describe what is happening. It can’t tell us why something is happening. So it tells us that hospitals admitted fewer people with heart attacks after lockdown, but it can’t tell us why. It also tells us that death rates were higher in those admitted with a common type of heart attack but it can’t tell us what happened to the people who would normally have been admitted with this type of heart attack but were not admitted. In general, we have to be careful that we don’t overstate what this sort of study can tell us.

“Heart attacks are not unique in this respect, but they are relatively common and we have good evidence that treating them saves lives. So we are most likely to be able to identify and measure indirect deaths due to heart attack. Estimating indirect deaths for other conditions is likely to be more speculative.

“We should be careful not to overstate what we know about indirect deaths and how many there are likely to have been. The previous Lancet study on this topic estimated that there had been 5000 fewer heart attack admissions than expected across England between January and May. This could have led to a few hundred avoidable deaths. Each one is obviously a tragedy, but the total number needs to be considered in the light of the total estimated number of excess deaths across the pandemic, which runs into tens of thousands.”

Prof Robert Storey, Professor of Cardiology, University of Sheffield, said:

“These high-quality data show clearly the effect that COVID-19 and the lockdown had on heart attack patients: people were less likely to attend hospital and this led to more deaths due to heart attack. This fits with the perceptions of cardiologists in many affected countries and so was not just a UK phenomenon. Indeed this risk of people with heart attacks not seeking help from the NHS when necessary was recognised at the start of the lockdown*. When patients attended hospital, it seems the quality of care was not affected by the pandemic. There are clear lessons to learn from this, an important one being that advice on staying at home should be nuanced so as not to discourage people with symptoms of heart attack or stroke from seeking help from the emergency services and attending hospital as necessary.

“It is possible that COVID-19 contributed to some of the excess in heart attack deaths since the coronavirus infection is known to increase blood clot formation and this might lead to more severe heart attacks, which are mostly caused by blood clots forming in the blood vessels supplying the heart muscle. However, it is likely that most of the excess was due to reluctance to seek help and attend hospital since there are many effective treatments now for reducing heart attack risk.”

*see my published quote from March 2020 via Science Media Centre: https://www.sciencemediacentre.org/expert-reaction-to-three-papers-on-impact-of-covid-19-infection-on-cardiovascular-system/

Prof Barbara Casadei who is a British Heart Foundation Professor at the University of Oxford and Honorary Consultant Cardiologist at the John Radcliffe Hospital, said:

“The research is good quality and in keeping with data collected all over the world. We published a “living” (continuously updated) paper in the Lancet using the central NHS Healthcare data that included near real-time analyses based on all acute coronary syndrome (ACS) admissions in the 147 acute hospitals across England and showed a 40% reduction in ACS admission by the beginning of April (the reduction started at the beginning of March i.e. well before lockdown) which partially recovered thanks to a media/BHF/Gov campaign – see picture below (the dotted red line marks the start of lockdown).

“Again, across the world and in the UK, similar trends were observed for stroke and cancer admissions. Although it is difficult to quantify the impact of these trends with precision, it is likely they contributed to the excess mortality observed in England and elsewhere (Italy in particular) that cannot be directly attributed to the coronavirus infection – see below data from Public Health England (male and female over 85) and Italy – excess mortality in blue and Covid mortality in yellow.

‘Patient response, treatments and mortality for acute myocardial infarction during the COVID-19 pandemic’ by Jianhua Wu et al. is published in European Heart Journal Quality of Care & Clinical Outcomes

DOI: https://doi.org/10.1093/ehjqcco/qcaa062

Declared interests

None received.