In this comparative study, we deliver evidence for a significant decline in admission rates due to acute cardiac events in a regional, but representative sample of the German population as compared to the previous years within the time period of the national lockdown during the SARS-CoV-2 pandemic in 2020. Right from the onset of social restrictions, admission numbers strongly decreased. While admissions of patients with STEMI and out-of-hospital cardiac arrest remain similar, significantly fewer patients with NSTEMI have been admitted. Moreover, in patients suffering from STEMI, we observed significantly higher hsTnT concentrations at admission during the study period compared to the previous years, suggesting that affected patients suffer a delay, or avoid hospital admission, and subsequently may increasing their risk of adverse outcomes. Iatrophobia, the fear of getting infected while in the hospital and framing issues due to public calls to stay at home might be among major reasons for this observation.
After severe acute respiratory syndrome coronavirus (SARS-CoV) in 2003 and the Middle East respiratory syndrome coronavirus (MERS-CoV) in 2012, the severe acute respiratory syndrome coronavirus in 2019 (SARS-CoV-2) is the third coronavirus pandemic of the twenty-first century . However, in contrast to the other two diseases, SARS-CoV-2 rapidly spread across the globe, infecting millions of people, and threatening their health and lives, and puts us globally in an unparalleled crisis situation. As a consequence, many countries initiated a global lockdown, including rigorous restrictions of public life to contain further spread of the virus, accompanied by daily crisis news in the media.
In Germany, many government decrees were implemented from March 21st, 2020 in order to minimize physical contact between people. Several public facilities, such as schools, universities, sports grounds, stadiums, amusement parks, cultural institutions, and shopping centers were closed. In addition, people were encouraged to work from home. The contact of more than two persons outside families was prohibited and a distance of 1.5 m between two persons had to be ensured. The pandemic and concomitant restrictions led to reduced working hours, rising unemployment rates, a stock market decline, and the fear of a global economic depression. Whether these measures also affect the incidence of acute cardiac events during a pandemic has rarely been evaluated yet and warrants further investigation.
Very recently, it has been shown for Northern Italy that the rate of admissions for acute coronary syndromes was significantly reduced during the COVID-19 outbreak and public shutdown to the same extent in patients with STEMI and NSTEMI . Similar observations have also been reported from the United States of America, Spain, and Austria [4, 10, 11]. These findings are in line with our study on a subset of the German population for overall admission and NSTEMI, respectively, even in situations where intensive care capacities for COVID-19 patients were sufficient.
The decline in admission of patients with acute cardiac events might be attributable to several factors. The first possible factor is the numerous calls by the government and throughout various media (i.e., press news, television, and social media) for people to seek medical contact only in case of an emergency to avoid exceedance of the country’s health system performance capability. However, neither government officials nor the media clearly defined what would be considered an emergency. As a consequence, patients may have delayed first medical contact and misgauged the severity of their symptoms.
The second possible factor contributing to our findings is framing issues. As a result, chest pain and dyspnea might be primarily attributed to a respiratory infection, rather than ACS, by the patient or even by the attending medical emergency service .
Next, it is well known that physical and emotional stress are associated with the incidence of acute cardiac events [1,2,3, 13]. Both of which alone or in combination potentially affect every single patient in this specific situation. On one side measures of social distancing resulting in work at home and thus possibly a decrease in work stress, reduced participation in sports events, and a decrease in adverse work-related physical exercise, and might reduce the stress burden of daily life, and consequently cardiac events in parts of the general population [2, 14, 15]. On the other side, however, the imminent threat of unemployment and the fear of getting infected with the coronavirus might also increase the stress levels leading to a higher rate of cardiac events among other parts of the population . We observed a significant decrease in patients admitted with NSTEMI, but similar or even slightly higher numbers of STEMI, suggesting that reduced stress burden did not contribute to the overall decline in acute cardiac events.
Finally, we believe iatrophobia might represent a major reason for the decrease in admissions due to acute cardiac events. Iatrophobia, which is defined as the fear of physicians, medical care, or the medical care system, is an important factor in delaying seeking care for medical conditions and their treatment . Among others, iatrophobia comprises the patient’s fear of illness and medical examination, fear of physician reactions, and fear related to barriers of care . Currently, the fear of getting in contact with SARS-CoV-2 infected patients and the risk of getting infected presumably keeps symptomatic patients from seeking acute medical care. Based on the personal experience, far more patients than before seek first medical contact by telephoning the physician on duty at our emergency department to report their symptoms and ask for advice on how to proceed. Moreover, some of them spontaneously admit a fear of getting infected while in the hospital. This hypothesis is supported by our observation that cardiac events usually accompanied by bearable symptoms and stable hemodynamic situations, such as NSTEMI declined while admissions due to STEMI, presumably felt more threatening by the patients, did not change. We assume that, due to iatrophobia, patients endure symptoms longer before seeking emergency medical advice. This puts them at risk for an adverse outcome, especially if those with ACS stay untreated . A very recent study from Italy reported on a substantially increased STEMI case fatality rate, which might be attributable to a delay in presentation for urgent medical attention because of reasons aforementioned . Additionally, in the Lombardy, a region in Italy struck hard by the SARS-CoV-2 pandemic, an increase in out-of-hospital cardiac arrest of 58% has been observed, while in our study, the IRR for out-of-hospital cardiac arrest remained the same . Regional differences in COVID-19 burden including direct effects of the pandemic might partly explain this difference.
Compared with the previous years, in our study, we presumed delayed admissions even of STEMI patients with a substantially longer time to first medical contact (as well as prolonged pain to balloon time), potentially resulting in more complications afterwards . This hypothesis is supported by our findings of significantly higher concentrations of hsTnT at admission in patients with STEMI compared with the previous years.
Our study has some limitations. This single center retrospective cohort study carries all the inherent limitations of retrospective research. However, as SARS-CoV-2 rapidly spread worldwide, the possibility to conduct a prospective study on the incidence of acute cardiovascular events has been, and is still very limited. Despite the retrospective character of our study, we closely assessed the patients admitted to our hospital with cardiovascular and other cardiac events daily from March 21st, 2020 until April 20th, 2020, and similar routine procedures as in the control period were applied. Thus, we believe that not a single event in the lockdown period has been missed. As a consequence, however, the decrease in admissions in 2020 as compared to 2017–2019 is probably underestimated. Furthermore, we can only hypothesize about the cause of the declined incidence, using clinical biomarkers, final diagnosis, and place of admission as surrogates. Questionnaires evaluating patients’ behaviors and attitudes were not available in time and should be part of future research. Moreover, to further substantiate our hypothesis of delayed admission of ACS patients, additional factors, including long-term mortality should be taken into consideration . However, our study compared the current data with the previous years’ using similar diagnostic methods and thus allows us to profoundly quantify the effects in this population during similar and good comparable time periods.