Series: What Are We Missing?

13. A Heart Has To Be Seen

Dr. Jane Caldwell:
What we've missed: health and safety in a pandemic. A heart-to-heart talk with Dr. James Januzzi. Welcome to On Medical Grounds, an authentic blend of timely scientific and medical knowledge. I'm your host Jane Caldwell. Today, we're speaking with Dr. James Januzzi, Hutter Family Professor of Medicine at Harvard Medical School and staff cardiologist at Massachusetts General Hospital.

We'll discuss what we've missed in cardiac care due to pressures from the COVID pandemic and what we can do to turn this trend around. Hello Dr. Januzzi, welcome to On Medical Grounds.

Dr. James Januzzi:
Thank you so much, Jane. It's a real pleasure to be here.

Dr. Jane Caldwell:
MedPage Today published a report last year and the data indicate that fewer people with existing health problems sought medical care during the winter 2020 COVID-19 peak. This includes patients with cardiac conditions. Could you elaborate?

Dr. James Januzzi:
Sure. It was really kind of a bewildering time for many reasons, not the least of which of course was the fact that it was a first in lifetime experience for us all to deal with a pandemic of the severity that we were contending with.

But from a cardiologist's perspective, it was even more bewildering, that although our patients did not come into the office for their routine preventative care, which is something we can discuss later in terms of the impact that that will have, we also noticed a dramatic reduction in the number of people presenting to the emergency department with acute cardiovascular disorders.

For example, at the Massachusetts General Brigham and Women's Hospital Consortium, we noted a substantial decline in the number of people coming in with heart attacks, a substantial reduction in the number of people presenting with acute heart failure requiring hospitalization, and in total, the reduction of acute presentations, largely parallel.

The severity of the pandemic, such that as the pandemic began to improve during the end of the first and even second surges, we saw a return of patients coming to the hospital with their acute diagnoses. So taken together, it suggests that a large number of patients who are suffering from heart attacks or heart failure events were experiencing them at home and not presenting to the hospital, which raises obvious concerns about the impact that this may have on the quality of care they receive and their outcomes.

[VOICE OVER] Dr. Jane Caldwell:
According to a national database, there was a sharp reduction in adult cardiac surgery volumes during the COVID pandemic. Tom Nguyen, MD, from the University of California San Francisco summarized the data at a recent virtual meeting of the Society of Thoracic Surgeons. There was a 53% reduction during April 2020 when compared to the 2019 monthly averages. This drop coincided roughly with the first wave of the pandemic. The regions hardest hit by the pandemic were the Mid-Atlantic and New England regions. The Mid-Atlantic region in particular had a tremendous 75% reduction in elective cardiac surgery and a 59% decline in non-elective surgeries that month. This coincided, quite naturally, with a significant increase in mortality. Operative mortality as measured by observed-to-expected ratio rose by 75%.

By July 2020, cardiac surgery volumes rose to pre-pandemic levels. However, they did not exceed prior volumes. Where did elective surgery cases go? This suggests a backlog of surgeries waiting to be performed. How many mortalities does this represent?

Dr. Jane Caldwell:
Can you address the long-term effects of delaying treatment for heart attack and stroke?

Dr. James Januzzi:
There are so many potential downsides. I can't even begin to list them, but it's easy to say right up front that the risk for dying from a heart attack, stroke, heart failure, or other acute cardiovascular complications is dramatic in the early days.

So although our mortality statistics for heart attacks have improved dramatically in recent years, for those that do not come to the hospital, the mortality is no better than it was in the 1960s. So for someone to suffer a heart attack, or as we say in medicine, a myocardial infarction at home, they're exposed to substantial short-term risk for dying from the heart attack.

But then there are longer term consequences to the extent that the treatments that we give for heart attacks for strokes and other cardiovascular diagnoses, not only help to reduce the consequences of those events, but also to prevent subsequent events. Those that remained at home are not only exposed to risk for an initial event, but if they survived it, they were exposed to risk for future events as well that we had not been able to prevent.

Dr. Jane Caldwell:
Deaths and morbidities due to delayed treatment have been described as COVID collateral damage.How can we turn this around to increase awareness and promote early diagnosis and treatment?

Dr. James Januzzi:
Well, thanks for that question, Jane. I would start off first by saying that people should take a step back and recognize the false dichotomy of complications because of COVID as opposed to complications with COVID.

In other words, a heart attack. Some people look at it as being a heart-related issue, but if a person dies because they didn't come in because of fear from COVID, or even if they had COVID themselves and didn't feel well enough to come to the hospital, ultimately that complication is squarely on the pandemic itself.

And so the first thing to say is that a heightened awareness of symptoms and signs and recognition that being in the hospital is the safest environment that someone can look for. Even during a pandemic, one should not ignore signs and symptoms that suggest an acute cardiovascular illness. However, in addition, it's imperative that all of us pull together and continue doing what we are doing to help stem the tide of the coronavirus pandemic.

So vaccinations, being cautious with respect to exposure to folks who may or who may be infective, mask wearing at times of high case load. You know, we're not endorsing wearing masks for the rest of our lives, but certainly at times when there's a large number of cases out and about that, it would, it would certainly be advisable.

These are the things that we can do on multiple fronts to help not only improve the outcomes from acute cardiovascular disease, but also make it safer for those of our patients that want to come in and are fearful because of a high number of cases in the community.

[VOICE OVER] Dr. Jane Caldwell:
Common heart attack symptoms are: pressure, tightness, pain, or a squeezing or aching sensation in the chest or arms that may spread to the neck, jaw or back; nausea, indigestion, heartburn or abdominal pain; shortness of breath; cold sweat; fatigue; lightheadedness or sudden dizziness.

Not all people who have heart attacks have the same symptoms or the same severity of symptoms. Women are more likely than men to have heart attack symptoms unrelated to chest pain and often describe heart attack pain as pressure or tightness.
It is necessary to change the perception that people should stay away from the hospital. Heart attack and stroke are life-threatening, but treatable, if caught in time. Masks, protective gear, vaccinations, social distancing, cleaning and sanitation procedures allow hospitals to provide safe care for all.

Dr. Jane Caldwell:
Can you give me some advice? What should I say to a friend or a relative who is experiencing symptoms of a heart attack? And they're hesitant to go to the hospital?

Dr. James Januzzi:
To answer that question in short form, there is no safer place than being in the hospital if a person has a symptom suggestive of a heart attack. The mortality of a heart attack, if not cared for in the hospital is the same as it was in the 1960s, which is to say it's about a 50/50 survival. Whereas, if you get into the hospital, you have a 95% survival. So that, that statistic alone should tell us how critically important it is for our patients not to ignore or delay their presentation. A delayed presentation is often associated with a higher risk for subsequent complications, such as heart failure, irregular heart rhythms, and death.

So even waiting, time is muscle, as we say, and the heart is a muscle that gets damaged in a heartbeat. Even waiting may increase the risk for these unwanted complications. So the earliest signs of symptoms that suggest a heart attack call 911. It’s so important to get in in a timely fashion.

Dr. Jane Caldwell:
Are there any symptoms of long COVID that are similar to heart conditions?

Dr. James Januzzi:
It's a really good question. And the answer is absolutely. Yes, the long-term persistent symptoms associated with coronavirus are numerous and maybe associated with a number of different organs being involved. First of all, noteworthy is the fact that coronavirus infection may cause scarring. Or what we say in medicine is fibrosis. And so scarring or fibrosis of lung tissue may lead to shortness of breath, which may mimic symptoms of heart disease. In addition, in the short term, after an acute coronavirus infection after COVID-19, we, we see not infrequently patients coming back with something called pericarditis, which is irritation of the lining outside of the heart muscle.

This may present with chest pain and mimic a heart attack. Of course, other long COVID symptoms, including fatigue, inattentiveness, confusion, headaches, these may all be mistaken for either cardiovascular or cerebrovascular complications. And it really illustrates just how very, very important it is that we as a medical community, not only embrace the fact that long haulers, people with coronavirus persistent symptoms are really suffering; such that we can try to get our arms around this and find better approaches for how we can care for them.

Dr. Jane Caldwell:
Doctor, thank you so much for your time and continued efforts, not only to treat, but to educate patients on the importance of early cardiac care.

Dr. James Januzzi:
Well, I really appreciate the opportunity to speak on this topic because it's just so, so, difficult for us from a medical perspective, to see people suffering over these last couple of years. And we're really hopeful for better days ahead.

Dr. Jane Caldwell:
We are too. Thank you again. And thank you for listening to the On Medical Grounds Podcast. We know your time is valuable. The resources that were referred to in this podcast can be found at onmedicalgrounds.com. Please be sure to check the subscribe button to be alerted when we post new content.

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