Disruption of healthcare: Will the COVID pandemic worsen non-COVID outcomes and disease outbreaks?

The spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has surpassed many early predictions and has created an evolving global public health and economic crisis [1]. As we confront the most devastating infectious disease epidemic of the past 100 years, we must realize that many more serious illnesses and avoidable deaths are likely, not just from Coronavirus Disease 2019 (COVID-19) but as a consequence of the social disruption it has caused, including the fear, and lack of trust, and structural dysfunction in our current reimbursement model of accessing and paying for medical care [2]. Numerous reports have documented a marked drop in vaccinations and primary prevention services, and an increased number of patients with heart disease, strokes, and other acute diseases who have been harmed because they were afraid to seek medical care during the pandemic [3]. The recent sharp drop in hospital admissions for acute myocardial infarctions (AMI) reported in several countries has baffled cardiovascular experts [[4], [5], [6]]. For example, Italy has seen a corresponding rise in AMI fatality rates in non-infected people who do present to hospitals, according to a new study [7]. In 54 hospital coronary care units, investigators counted 319 AMI cases during the week at the height of the coronavirus outbreak in northern Italy. In the same week a year earlier, they counted 618. Although the outbreak was worst in northern Italy, the decline in AMI admissions occurred throughout the country. The researchers also found a 47% reduction in hospitalizations for heart failure and a 53% reduction for atrial fibrillation. Patients with AMI who managed to get to the hospital during the pandemic also had worse outcomes. The death rate among patients with ST-elevation AMI (STEMI) more than tripled, from 4% in 2019 to 14% during the outbreak. Considering the reported fall in admission rates combined with the increased fatality rates suggests that overall deaths from AMI increased by 75% [8]. Cardiac complication rates of STEMI intervention increased by 80%, from 10.6% to 19%. Of the patients with STEMI, 21% were positive for COVID-19 and 29% died, which was more than two-and-a-half times the 12% death rate in STEMI patients without COVID-19. A significant delay in time to revascularization during STEMI was also present. These findings are in line with studies reporting up to 50% declines in the number of STEMI interventions [9], AMI hospitalizations [10], and aortic dissections in the US [11], Hong Kong, and Spain during the pandemic [12]. Equally perplexing is conflicting data about crude mortality variations in different countries [13]. The reported all-cause mortality has increased in the US, Italy [14], and in Sweden, which recorded an almost 30% increase in crude mortality during the epidemic [15], but the crude death rate has gone down in Israel [16] and Norway [17] during the past 4 months, as compared with previous years. Although no two countries are exactly alike, making comparisons inexact, this variation in mortality raises challenging questions about how public health data are defined, collected and reported [18]. These drops in the number of patients with acute non-COVID-19 infections presenting to hospitals are even more puzzling as it is almost axiomatic that in times of social upheavals, the risk of AMIs and strokes increased markedly [19,20] given the well documented effects of stress and the brain-heart connection [21]. Depression, anxiety and frustration-emotions exacerbated by the pandemic—are all associated with at least a doubling of the risks for AMI. At least a quarter of cardiac patients have depression, and early treatment, before the onset of symptomatic cardiovascular disease, can decrease the risk of AMI and strokes by almost half [22]. Work and life stress, which also may be increased during times of great unrest, can markedly increase the risk of AMI. Moreover, events such as earthquakes, terrorist attacks, or war, in which an entire society is exposed to great stress, are risk factors for AMI. Finally, COVID-19 can directly affect the heart, which should be increasing the number of patients with heart problems [23]. The current decline in mortality in some affected countries may foretell higher-than-expected morbidity and mortality, once non-COVID-19-related care resumes, given delays in chronic care treatments, a large backlog of postponed surgeries [24] (estimated to be 28 million worldwide), and a surge of mental health issues for both healthcare providers and the public [25]. This response may be similar to what occurs after physician strikes are over and elective services are resumed, when overall mortality rates are higher than pre-strike rates [26].