Where Are All The STEMIs?

[J.Adderton, BSN, MSN]

As cases of COVID-19 continue to rise in the U.S., cardiologists have been stumped by the drop in ST elevated myocardial infarction (STEMI) cases. In fact, physicians and hospitals around the world are asking, where are all the STEMIs? In Spain, the Spanish Society of Cardiology recently published a paper showing a 40% drop in STEMIs. An online article, The Mystery of the Missing STEMIs During the COVID-19 Pandemic, provides additional insight and estimates into the falling number of STEMI cases:

• Jonathan Reiner, MD, at George Washington University Hospital, estimates the hospital recently treated just 2-3 STEMI cases in a 3-week period. Reiner reports they usually see 3 cases each week.
• Bernhard Reimers, MD from Humanities Research Hospital in Milan, Italy, estimates STEMI cases are down by 70%.
• Chandan Devireddy, MD, at Emory University School of Medicine in Atlanta, estimates a 20% to 50% drop in STEMIs in a 1-month period.
• New Data Supports Claims

Although there's been observances and estimates of lower STEMI rates, there hasn't been any data to support the claims...until now. The findings of a study, led by Dr. Santiago Garcia, MD, at the Minneapolis Heart Institute at Abbott Northwest Hospital, reports findings consistent with the 40% drop in Spain. The study, published in the Journal of the American College of Cardiology, was conducted from January 1,2019 to March 31, 2020, with March 1 as the U.S. starting point for COVID-19.

Study Details

The study pulled data from nine high volume hospitals across the U.S. They used a specific model to look at cardiac catheterization laboratory activations from the previous year leading up to the first month of the COVID-19 U.S. outbreak. For STEMIs, it's crucial to activate the cardiac catheterization lab for percutaneous coronary intervention (PCI) for the best patient outcomes. The researchers found an astounding 38% drop in STEMIs during the study time period. The total STEMI activations went from >180 monthly to only 138 activations each month.

Why Is This Happening?

Some cardiologists expected heart attacks to increase based on the stress people are experiencing during the COVID- 19 outbreak. Also, viruses (like flu) have been shown to induce STEMIs resulting in activation of the cardiac lab team. So why are the numbers falling? There are several theories circulating among cardiologists.

Social Distancing and Sheltering at Home

We may be living a more sedentary lifestyle as we practice social distancing and quarantine to prevent giving coronavirus to other people. With gyms closed and sporting activities on hold, it is theorized that we are not engaging in strenuous activity that precipitates MIs. Some cardiologists suggest people are sleeping more and possibly smoking less (since virus attacks the lungs).

Commutes and Pollution

In many larger cities, pollution levels are high and getting to work can be very stressful. One theory is that with fewer cars on the road, pollution levels are much lower. And, without stressful commutes and crowded transit systems, overall daily stress is reduced.

Does the Virus Protect?

Although some cardiologists have suggested COVID-19 protects the cardiac systems of those infected. Dr. Reiner quickly debunks the theory since it’s not possible for the virus to reverse plaques or make plaques more stable. He believes there are other, more plausible explanations, stating “There have to be other behavioral issues having to do with people taking their medications, having lower blood pressure, I don’t know”.

Altruism and a Strained System

Another notion is potential patients want medical resources to be available for people who are worse off. Some people may be seeking help, but unable to be seen by a cardiologist or have tests done due to the strain on healthcare.

Leary of Medical Care

Could it be that people are afraid of getting COVID-19 in doctor offices, hospitals and emergency departments? Part of mitigation is limiting nonessential healthcare services, but perhaps some have difficulty knowing what is essential and what can wait.

Study Implications

Garcia and colleagues are planning to continue to study the underlying cause of STEMIs as the pandemic continues. The researchers are particularly interested in determining the role patient anxiety is playing in the number of STEMIs decreasing in U.S. hospitals.

Want Your Input

What factor or factors do you think are driving down STEMIs numbers?

[Susie2310]

I think that all of the suggested possibilities in the article could be contributing factors to the decrease in STEMI's.

I also think it's possible that due to the Covid-19 situation some people are deciding not to seek care for chest pain for fear of not being allowed to have a family member/loved one stay with them when they are in the hospital. I suspect that some people may be deciding to "take their chances" at home where they can have their family member/loved one with them instead of being in the hospital and possibly dying in the hospital without them.

Preventing family members/loved ones from being with patients in the hospital or other health care facilities, while the best course of action from the perspective of infection control and disease transmission, is very distressing for many patients and their family members/loved ones. I think it is possible that some people are considering that this could happen to them and are simply choosing to forgo seeking care.

[Maureen1991]

I would guess a decrease in "everyday pre-Covid-19 stress", and/or an increase in sleep, or a change in the timing of sleep (maybe the same number of hours but more in tune to the person's own biorhythm rather than a forced "alarm clock" awake time) might be contributing factors.

Is there a database, or is anyone keeping track on current active STEMI patients regarding weather or not they are currently working, working from home or not working (when they normally would be) during the pandemic?

Further, how has their diet changed? Less eating out (processed, high fat, sodium meals)? Increase/decrease of daily calories? Drinking more fluids? Type of fluids?

I find this very interesting!

[Curious1alwys, BSN, RN]

WOW!, interesting. Until all the out of shape people get back on the exertion bandwagon after the crisis and POW!, here they come. I think in general Covid is not looking good for the heart.

[Wuzzie]

Or these people are just too afraid to call for help and are dying at home of "natural causes".

[MelEpiRN]

We are seeing similar trends with the stroke population across the US. We are all very nervous people are not seeking help (due to a myriad of reasons).

[emtb2rn, BSN, RN, EMT-B]

We were just talking about the decline in mi & stroke pts. Although we are starting to see an increase in the “why are you here, seriously, why are you here” folks. And the psych cases, which were non-existent for a few weeks, are coming back to normal levels.

Agree that there will be a rush when things get back to normal. Whenever & whatever that will look like....

[Maureen1991]

4 hours ago, Wuzzie said:

Or these people are just too afraid to call for help and are dying at home of "natural causes".

My gut tells me there will be a wave of folks whom have died home alone from various conditions to include cardiac and Covid-19 related deaths. I also agree many folks do not want to go to the hospital due to fear or not wanting to overwhelm the medical system further. We also know, denial can often be a symptom in acute cardiac conditions. Denial along with the rationalization that one does not want to go to the ED at this time, could absolutely play a role in the decreased number of STEMI patients.

Very interesting, but also a sad time indeed.

[Susie2310]

Another possibility I can think of that I think may be deterring some people from seeking care is that some people, especially some people with a history of significant chronic disease/s or other significant or complex medical problems, or some people who are elderly, may fear being subjected to subtle or overt pressure by health care professionals to stop seeking curative care and to switch to palliative care/hospice or to choose DNR status when they present for care or during the course of care, or even having these decisions made for them against their wishes.

In addition, people are more vulnerable when receiving health care when the circumstances do not permit them to have a trusted person with them who knows their medical history and their wishes in regard to health care decisions/preferences and who can support them in accomplishing this.

[toomuchbaloney]

How many physician specialty groups are following their patients intentionally, with phone calls during this time?

[Wuzzie]

We are and we're swamped with those calls as well as setting up video/tele visits, local labs, follow ups, patient freak-outs, pissed off patients, order faxing, trying to help patients download apps on their Iphone 4s not to mention we are still seeing treatment patients face-to-face. Yet the PTB think we haven't anything to do so we are being sent home for low-census. ?

[toomuchbaloney]

Just now, Wuzzie said:

We are and we're swamped with those calls as well as setting up video/tele visits, local labs, follow ups, patient freak-outs, pissed off patients, order faxing, trying to help patients download apps on their Iphone 4s not to mention we are still seeing treatment patients face-to-face. Yet the PTB think we haven't anything to do so we are being sent home for low-census. ?

Good to hear about the follow up.

Of course, PTB are focused upon billable hours, so...