Fewer Hospital Visits for Acute Stroke and Acute Coronary Syndrome During the COVID-19 Pandemic: A Reality or a Myth?

The first documented case of coronavirus disease 2019 (COVID-19) in the USA was reported in a 35-year-old man from Snohomish County, Washington on January 20, 2020. Since then, there have been almost 5,000,000 confirmed cases all around the world and more than 1,500,000 cases in the USA [1]. In spite of the unprecedented burden on healthcare infrastructure by this global pandemic, clinicians across the USA have made anecdotal observations in established health care trends. Specifically, the authors as well as other clinicians around the world have noted decreased hospital and emergency room visits and hospitalizations for acute stroke (AS) and acute myocardial infarction (AMI) at their institutions and the other hospitals around the world [2-9]. If this observation does indeed hold and is universal, reasons for it are manifold. Here, the authors present various theories for this observation, which is mostly based on the recently published opinions [2-9] and personal observation and communications with multiple clinicians who are involved in the care of AS and AMI patients. One theory is that the presentation of AS and AMI to hospitals is falsely low, and the patients do not go to the hospitals because of fear from the COVID-19 pandemic [2]. Recently the European Stroke Organization (ESO) published a statement and mentioned that among 426 stroke care providers from 55 countries, only one in five reported that stroke patients are currently receiving the usual acute and post-acute care at their hospital [2]. Similarly, a preliminary analysis during the early phase of the COVID-19 pandemic showed an estimated 38% reduction in the US cardiac catheterization for acute coronary syndrome (ACS), similar to the 40% reduction noticed in Spain [5, 6]. Fear and trepidation regarding exposure to the COVID-19 in clinical settings may compel many to avoid calling for help, and “ride the storm” at home instead. It is possible that patients, often those who are elderly and with multiple comorbidities, are deferring emergency services and are dying at home during this pandemic. A study in the UK reported a 25% decrease in emergency room admissions 1 week after initiation of the nationwide lockdown in March 2020 [10]. With the exceptions of admissions for pneumonia, which have increased, other morbidities such as myocardial ischemia and gastrointestinal abnormalities decreased [10]. Widespread stay-at-home mandates and city lockdowns have been adopted across the USA, and it could be another contributor to reduced emergency room visit rates for symptoms that are not typical of COVID-19. Some patients may even presume that hospitals and clinics are closed altogether, or doctors are too busy treating patients with COVID-19 to treat patients with stroke [2-4]. A study in 2019 found that individuals with intimate social networks consisting mainly of family members versus more robust social connections such as friends or co-workers were more likely to delay presentation for emergency services [11]. The study found that family members were more likely to opt for a watch-and-wait approach to symptom development, while non-family members were more likely to suggest seeking immediate medical attention. In a statement by the University of Texas Southwestern for the COVID-19 pandemic of patients isolated from loved ones, it is possible and perhaps likely that some stroke symptoms are going unnoticed [3]. In the USA, as social-isolation and self-quarantine become the norms, social networks are restricted, and, in many cases, people are limiting their exposure to their nuclear family. It is likely that patients are influenced by family to stay home, possibly out of fear of exposure to COVID-19 and passing it on to other family members. This temporal pattern could be similar to the “Christmas effect”, where intake census of non-life-threatening events is low during significant societal events [12]. Therefore, patients experiencing symptoms of atypical angina or mild neurological deficits characteristic of a transient ischemic attack may opt to stay at home and monitor the symptom progression rather than seek care immediately. Authors of this article, however, argue that a more immediate social circle has benefited their patients, particularly those who struggle with medication adherence. The increased oversight from family members and less variable routines likely improved adherence to medications, Manuscript submitted May 20, 2020, accepted May 27, 2020 Published online June 1, 2020