Covid-19 has impacted all aspects of our life. Healthcare services had to be dramatically redesigned with much of the focus placed on treating those who were infected. The nation also changed the way they viewed Hospitals and there was large reduction in patients attending Hospitals for a wide variety of health-problems.
The latest research, published this week in the Lancet, has shown a significant reduction in patients attending Hospitals with Heart Attacks. This has also been seen in Spain, Italy, the USA and the Far East. Many cities have published their data showing a 30-60% reduction in attendance.
This is worrying for Doctors because patients who don’t get prompt treatment for heart attacks are much more likely to suffer later complications. I was interviewed by the Mail on Sunday about my thoughts on this, and I wanted to expand with this blog post.
Covid-19 and Heart Attacks: What has the Research Shown?
We looked at our patient data in our sector of London and we saw an almost 50% reduction compared to the same period last year. The research paper published in the Lancet has shown, has used Hospital data from England to show there has been a 40% reduction in all heart attack attendances.
They use the phrase “Acute Coronary Syndromes” – this term combines all types of heart attacks, from the most minor to the most severe. Very minor heart attacks can be treated with medicines – often “blood thinning” medicines such as Aspirin, Clopidogrel, Ticagrelor or Prasugrel. This could be understandable – minor heart attacks could be ignored by a patient. They may think it was indigestion or acid reflux. This has always been true even outside of the pandemic. However, they have also shown a 25% reduction in the most dangerous type of heart attacks, called ST Elevation Myocardial Infarction (STEMI). These are need urgent treatment to reduce the risk of irreversible heart damage.
It appears that people were so worried about the risks of attending Hospitals during the pandemic that they ignored the symptoms and stayed at home. We are still learning the consequences and it may be that then number of sudden deaths at home will be much higher during the pandemic.
Covid-19 and Heart Attacks: What was my personal experience?
As a Consultant Cardiologist, I was struck by the significant reduction in people attending with Heart Attacks. I noticed this immediately when the formal lockdown started. There was striking reduction in ambulance call-outs for heart attacks. An overnight on-call for Primary Angioplasty, suddenly became a lot quieter. In the past, I would expect to be called out of bed, 2 or even 3 times to go into the Hospital and perform acute invasive angioplasty. After lockdown, this dropped to zero during some shifts. This is alarming because it not expected that heart attacks would suddenly stop during a pandemic.
Coming to the Hospital Too Late
Those patients that did attend often presented late after the heart attack. Many had very severe heart attacks with significant heart damage. In one case I treated, the patient had severe blockages of two out of the three major coronary arteries; this had made his heart very weak and it needed urgent support. This was very challenging to treat by angioplasty and required a long procedure. He was very sick but Importantly, his condition had been made worse because he had avoided coming into Hospital despite severe chest pains for several days. He told me, he had avoided the Hospital because he was afraid of the virus and thought he would contract it from the Hospital.
Ordinarily, anyone suffering such severe symptoms of central crushing chest pain would attend an Emergency Department straightaway. In normal times, even small twinges of chest pains can cause patients to rush into the Hospital. The fear of the pandemic meant that people were prepared to suffer at home rather than attend the Hospital. This story was frequently repeated over the weeks and months. I am sorry to say, I have seen poor outcomes for a few patients who attended too late.
Heart attacks in those with Covid-19
Those that had active Covid-19 infection had a great deal of clot. This issue remains hotly debated in the medical community but amongst those actively treating patients with the condition, it has become increasingly clear that Covid-19 is a “pro-thrombotic” condition (‘pro-clotting’). This means, in some people with the Covid-19 virus, it creates clots within arteries and veins. I have seen patients with extensive heart artery clots, lung clots and clots in the brain. Our protocols for treatment of Covid-19 now include blood thinning medication to reduce this risk and we are contributing to research studies to try to understand this better.
If a patient with Covid-19 develops a heart attack, we have developed clear pathways to ensure patients get the right treatment as fast as possible. At the beginning of the crisis, UK Cardiologists were worried we would be inundated with heart attack cases caused by the virus. This concern was raised by what was being seen in Italy. Fortunately, this has not been the case and our systems have withstood the viral assault. We have dedicated cardiac Catheter Labs for those with Covid-19 to reduce the risk of cross-infection. We have dedicated sterile equipment and cleaning areas.
In some patients with Covid-19 – they are too unwell to have urgent angioplasty (the opening up of the artery with a wire, balloon and stent -typically all done by a small cut in the hand artery). This has meant we have designed protocols to use clot-busting drugs called thrombolytics. These drugs used to be the standard treatment of heart attacks until the mid-2000s. They can be highly effective but have a major draw back of increasing the risk of major bleeding.
I have written a Review Article that discusses the best evidence to guide heart attack treatment during the Covid-19 pandemic and this has been published in the highly respected journal Heart, which is part of the British Medical Journal group. You can read that article here.
What is a Heart Attack?
This part of the blog-post can also be read on my website with additional images that can help understanding.
Heart Attacks are a life-threatening condition in which a heart artery (‘coronary artery’) blocks suddenly with a clot. Clots occur because there is plaque rupture. Even patients with very mild atherosclerosis or coronary plaque can have a heart attack and, we often see, these patients are more unwell than those with established heart disease. This appears to occur because younger patients or those with minimal plaque are not used to the lack of blood supply and so their hearts suffer more.
Those patients with established coronary artery disease may have episodes of ‘stable angina’ – this is a discomfort that comes on during exertion, and then goes away during rest. Those with angina are often well treated on multiple medications and this can dramatically reduce the risk of a heart attack.
Heart Attacks can occur at any time, particularly at times of stress because this causes sudden changes in blood pressure (‘hypertension’), and causes a feeling of a heaviness across the chest – like a band or belt across the chest. This discomfort, (many doctor’s frequently refer to this as a ‘pain’, but most patients says it isn’t really a pain, rather a sensation of heavy weight on their chest) can move into your arm or neck. Classically, we think of left arm discomfort being related to the heart, but the discomfort can move into the right arm, both or even into the back. Patients will feel uncomfortable, sometimes with sense of dread or fear. They may become sweaty, cold and clammy. Patients having a heart attack often vomit, or may retch.
These symptoms can be short lived, lasting only for a few minutes. In these situations, the heart artery may have re-opened temporarily but action should still be taken. It is known that severe heart attacks often have ‘warning’ episodes that came earlier in the day or week. Symptoms that are ongoing and progressive – getting worse with time, should trigger people to call for an ambulance.
How are Heart Attacks Diagnosed and Treated?
Urgent treatment is essential. All patients with a heart attack need to be assessed urgently in a Hospital. When patients are first picked up an ambulance, they will undertake an ECG and give the patient Aspirin 300mg (usually best chewed). Patients are also given a GTN spray or tablets under the tongue. This a nitrate medicine that causes the coronary arteries to dilate and expand in size. In some cases, the GTN spray can help stop or slow down the progress of some heart attacks.
Patients are then taken to Hospitals. In London, patients with certain ECG changes will be taken to ‘Heart Attack Centres’ which operate with a full team on standby 24/7/365.
In some cases, patients are taken to District General Hospitals – these may, or may not have dedicated Cardiac teams. In this situation, the team in the Emergency department will assess the patient and make a decision on whether they need treatment to a Heart Attack Centre. This decision is often made based on the clinical information about the patient, the electrocardiogram and the blood tests. The team at the Heart Attack Centre are often notified and they may be involved in the decision making.
Once at the Hospital, patients will be assessed promptly and have an ECG, a bedside echocardiogram and treatment with blood thinning medicines. This can include Aspirin with Clopidogrel, or Ticagrelor or Prasugrel. A high dose is required when it is first started. An injection of a type of heparin is also given – such as fondaparinux.
Blood tests can help make an assessment. In some cases, heart attacks are very obvious but in some cases, we rely upon measuring a blood enzyme called Troponin. This is a highly specific cardiac enzyme that is only detectable in the blood if there has been any heart damage. While many Doctors will call all elevations of Troponin a ‘heart attack’ – this is not the case. Cardiologists know that troponin elevation can occur for many reasons, including chest infections, developing a pneumonia or even a viral infection. If there is active chest pain, changes on the ECG and a troponin elevation, then a a true heart attack will be diagnosed.
There are two principle types of heart attack and this is diagnosed based on the ECG. If there is no ST elevation, called ‘NSTEMI’, then the treatment will be according to the patient’s risk scores and their progress. In my practice, we typically perform coronary angiography within a 24 hour period and sooner if possible.
In ‘STEMI’ angiography and angioplasty must be performed as fast as possible. Ideally this should be within 2 hours of the chest pain starting, and within 1 hour of attending the hospital if it has capabilities (all ‘Heart Attack Centres’ in London are able to do this). The need for urgency is simple: the coronary artery is fully blocked by clot, and the longer it remains blocked, the more heart damage occurs. The amount of damage can be estimated by blood tests called Troponin and by scans such as echocardiography.
In some cases, particularly in the Left Anterior Descending (LAD) Artery this can leave very severe scarring and weakened heart. If the Right Coronary Artery (RCA) is blocked, then the electrical conducting system of the heart can be disrupted and the patient can develop a condition called Complete Heart Block. In this situation, prompt treatment of the heart attack will resolve the Complete Heart Block, but if there is no treatment a Pacemaker may needed. Without treatment, the heart can stop.
What can happen if heart attacks are not treated promptly
If heart attacks are not treated within the right time frame, then considerable heart damage can occur. If more than 12-hours have elapsed since severe chest pain started, there can be limited value from Angioplasty as the heart damage is usually complete.
During this Covid-19 pandemic, I have seen many patients presenting very late after their heart attack started. They have a lot of clot within their heart arteries and this has been difficult to treat.
The potential complications are:
- Heart Failure
- Valve disruption
- Holes within the heart
- Clot within the heart
I have seen patients be left with severe Heart Failure – where the pumping function of the heart is severely reduced. Acute heart failure can mean the lungs fill rapidly with water causing severe acute breathlessness. Even when stabilised, these patients will be breathless and fatigued when they do their activities. Their ankles may swell and they may not be able to lie flat. A lot of medications are required and in many cases, this can stabilise a patient. However, it is well established that heart failure can have a worse prognosis than many cancers.
Those patients with a lot of scar can suffer from arrhythmias – this is a problem with the conducting issue of the heart. Atrial fibrillation is a common arrhythmia and can be triggered after a heart attack but it is rarely life threatening. In some patients, ventricular tachycardia or ventricular fibrillation can occur. In both situations, these are life-threatening arrhythmias and require near instantaneous treatment. Without an electrical shock to the heart, the patient will die.
Patients with untreated heart attacks can also have scarring of parts of the heart that hold together the heart valves. This means the valves can be acutely disrupted, causing severe leaking. Acute mitral regurgitation can cause the patient to become destabilised with sudden water on the lungs. Performing an operation to fix this valve can be difficult and risky in the context of an acute heart attack.
Holes in the Heart
In some cases, the heart damage can extend through the entire thickness of the heart muscle. In this case, a hole can develop. If this occurs in the heart muscle that separates the heart chambers then an abnormal connection is created. This will shunt blood between these chambers in an abnormal way and can make the patient critically unwell. The lungs can fill with fluid and urgent treatment is required. This can be very difficult as open heart surgery may be needed, but the heart can be too weak to tolerate such an operation. The heart muscle can be too weak to stitch. In some cases, we try to fix this a special device that is inserted via the leg artery. However, this remains a non-standard treatment and the decision is made on a case-by-case basis.
In some unfortunate cases, the whole can be on the outer muscle wall of the heart. This is called a ventricular perforation and this causes dramatic leakage of blood from the heart into the space around it. This causes a condition caused tamponade and this is rapidly fatal. Unfortunately, patients who develop this can rarely be saved, even if it occurs within the Hospital.
Strokes and LV thrombus
In patients with significant heart attacks, parts of the heart stop working such that the blood does not move properly. This allows clots to form within the heart. This is dangerous as these clots can fire off smaller clots which tend to travel to the brain. This can cause devastating stroke – a condition where part of the brain stops working. This can cause severe disability and life-long health related issues. Very careful blood thinning is required to prevent this from occurring.
I was interviewed by the Mail On Sunday about this.
Original Research Article at the Lancet.
I have writen an article advising UK Cardiologists on the best treatment for Heart Attacks during the Covid-19 Pandemic.
If you want to discuss this more, please contact me.