Where are all the cardiac patients?

As health-care professionals, we are focused on preparing for and implementing effective management strategies for the onslaught of COVID-19 patients within our health regions. This pandemic represents an unprecedented operational challenge for our health-care systems and leadership. As front-line cardiovascular specialists, we are also concerned for an unexpected but significant potential effect of this pandemic — a future second wave of cardiovascular complications.

In the Calgary Zone of Alberta Health Services where we work and around the world, health-care providers are seeing fewer and fewer patients with acute cardiac conditions coming to hospitals. This concerning drop in health-care utilization corresponds to the onset of the COVID-19 pandemic and widespread social distancing. For example, every day at our hospitals, we typically encounter at least two or three new patients presenting with acute coronary syndromes (“heart attacks”). Also, we see several patients with new or worsening heart failure who require hospitalization and urgent care. Our primary care colleagues in rural or smaller hospitals routinely contact us to transfer such cardiac patients to our hospitals for management. These encounters are now infrequent as we anxiously await the peak of the COVID-19 pandemic. It is eerily quiet in our cardiac units while we wait for the invisible enemy to strike. Some may say that fewer heart attacks are a good thing. We can use the cardiac units for the increased number of COVID-19 patients. We can have cardiac health-care workers available for the management of critically ill pandemic patients, and less stress on the usual diagnostic testing and procedural services that would otherwise be busy with cardiac patients. So why are we worried?

Unfortunately, heart disease does not disappear or significantly decrease in prevalence during a pandemic, which leads us to ask — where are all the cardiac patients? What is happening to them? There are many theories about this. People with known heart disease or such risk factors as high blood pressure and diabetes could be social distancing and staying at home, avoiding stress, and being more compliant with their medications. One could speculate that people are using the threat of lung complications with COVID-19 as an impetus to quit smoking. These changes in behaviour, if true, would be welcomed, but would not realistically explain the immediate and dramatic reduction in patients presenting to our hospitals with heart attacks, heart failure, and other urgent cardiac issues.

Our concern is that many vulnerable cardiac patients are still out there, either not seeking the help they need or not referred for cardiac assessment because of our overwhelming focus on the COVID-19 pandemic. The predominant messaging from the media is to stay home if you are sick and call your community/ public health call number if you have flu-like symptoms like a fever or cough. We, as health-care professionals, have postponed or cancelled standard testing, including screening tests for identification of major cardiovascular issues. We are suspending all but the most urgent and emergent cardiac interventions, including surgery for coronary artery and valvular heart disease. We delay clinic visits, opting for phone or video calls for those we feel are most urgent.

These measures are reasonable and prudent in a crisis. We strongly support the overarching public health strategy of Alberta and the nation. In doing all of this, however, we must ask if we have inadvertently given our communities the impression that medical issues other than COVID-19 are less critical? Do patients believe that we don’t have the time or resources to manage them? Many patients may be fearful of being infected if they come to the hospital. We hear this from our ambulatory clinic patients. Could healthcare professionals be attributing cardiac symptoms such as chest pain as symptoms of COVID-19? Are we under-investigating for cardiovascular diseases and its complications? There are many questions. We won’t have the answers we seek until this pandemic is over.

Whatever the underlying reason that we are not seeing patients with urgent cardiac issues in our emergency rooms and hospitals, these patients are still out there. Their cardiac conditions will not go away. While we must continue to address the pandemic as a priority, as we are doing across Canada, we must remember that heart disease is still the leading killer of Canadians, even during a pandemic. We will lose far more people in our communities to cardiovascular disease this year and every year, than from COVID-19 complications.

Cardiovascular health-care professionals are committed to providing the highest level of medical and surgical care to our patients. Our cardiac patients need to know that they are important. We will do everything we can to provide them with the care they need when they need it. We can do this effectively during the pandemic. Our patients should not dismiss chest pain, worsening shortness of breath, or other cardiac symptoms out of fear or misunderstanding of our health-care priorities. We are here for you if you need us. Come and see us.

Debra Isaac, is a cardiologist and Clinical Professor, with Cumming School of Medicine, University of Calgary; and Medical Director, Southern Alberta Transplant Program, Alberta Health Services. Paul W.M. Fedak is Zone Clinical Department Head, Department

of Cardiac Sciences, Alberta Health Services; Director, Libin Cardiovascular Institute; Professor,

Cumming School of Medicine, University of Calgary; and Merck Chair in Cardiovascular Research.