Heart patients avoiding hospitals in pandemic are suffering permanent damage, cardiologists say

In the early days of public health restrictions prompted by the COVID-19 pandemic, health-care workers described an eerie quiet in emergency departments.

Half-empty waiting rooms and cancelled clinic appointments were particularly disquieting to cardiac physicians, who know heart attacks don't stop because there's a global pandemic.

Now, cardiologists and cardiac surgeons are bracing for a wave of patients showing up with permanent, life-altering heart damage, and — even worse — stories of people who died at home, untreated.

"We usually say time is muscle — heart muscle," Edmonton cardiologist Dr. Marcelo Shibata said in an interview. "The longer you take to go to the hospital, the more damage you have in your heart — if you survive."

Shibata is one of several specialists who say the pandemic is interfering with every stage of care for patients with potentially life-threatening heart problems.

They say patients are afraid to call 911 or go to emergency rooms for fear of contracting COVID-19 or burdening an already-overwhelmed health-care system.

Hospital outbreaks have cancelled follow-up appointments or moved them online.

Although all urgent heart surgeries are proceeding as planned in Alberta, hundreds of non-emergency procedures have been postponed to free up staff and beds for patients with COVID-19. 

One Toronto modelling exercise estimated 35 people would die in Ontario during the early months of the pandemic while waiting for cardiac surgeries considered elective.

A surge of Albertans gravely ill with COVID-19 and needing intensive care also pushed Alberta Health Services to open about 100 more beds and expand ICUs into unusual places. At times, cardiac care unit beds have become intensive care beds.

COVID-19 is also hampering patients' recoveries from heart attacks. Many fitness and rehabilitation programs have been shuttered or limited by public health restrictions.

Although patients with COVID-19 deserve excellent care, health-care leaders cannot ease responses to other serious health threats, doctors say.

Cardiac diseases have been the No. 2 killer of Canadians for a decade, responsible for more than 52,000 deaths in 2019, according to Statistics Canada. They are trumped only by cancer — another killer where timely diagnosis and treatment can make all the difference.

"We should not displace resources from cardiac care just for the sake of this pandemic," said Dr. John Dimitry, an Edmonton cardiologist and medical director of the cardiac care unit at the Misericordia Hospital. "We have to treat this just as seriously as COVID-19."

The fear factor of COVID-19

The Heart and Stroke Foundation's Patrice Lindsay says she hears fear and confusion from heart patients.

The Toronto-based director of health systems change with the organization says people email her, asking what to do after experiencing chest pain for days.

She tells them to call 911 immediately.

There is evidence that patients with cardiac conditions have more complications and worse outcomes if they develop COVID-19, so when a person experiences shortness of breath, chest pain, dizziness, or other possible signs of a heart problem, the decision to call 911 can be agonizing, Lindsay said.

A May survey by the foundation found 61 per cent of heart attack or stroke patients said they were afraid of going to the hospital if they required medical attention.

The foundation has been trying to spread the message that hospitals are safe, and staff have gone to great lengths to screen patients and isolate those with COVID-19.

The risks of delaying treatment for a heart attack or stroke are far more life-threatening than the risk of contracting COVID-19, Lindsay said.

Avoiding hospitals during COVID-19 is a global problem, not just a Canadian one. Studies of hospital admissions from the pandemic's early weeks found less than half the usual volumes of patients reporting heart attacks.

Alberta health system leaders say emergency visits for heart problems rebounded by the fall. But as active cases of COVID-19 climbed to more than 21,000 people in mid-December, doctors worried fear would again keep people at home.

"We'll never be able get rid of the fear factor, especially with the numbers as high as they are right now," Lindsay said.

The early disappearance of heart patients was alarming enough to the Canadian Cardiovascular Society that it created a website to track cardiac hospitalizations and procedures.

The data it has collected so far bolsters doctors' anecdotal observations that there was a dramatic decline in patients arriving in hospitals or undergoing heart-saving operations.

What troubles Dr. Harindra Wijeysundera, the cardiologist who chairs the effort, is that waiting lists for procedures to fix heart problems are not growing, suggesting patients are not seeing doctors and accessing diagnostic tests.

"There's this hidden population," said the Toronto-based Sunnybrook Health Sciences Centre specialist. "(It's) like the analogy of an iceberg. There's a lot of people under the surface who still haven't even got on the wait list."

The data show patients who did get onto wait lists were sicker and more of them died, Wijeysundera said.

As Canada rides out the second wave of COVID-19, it's important to take lessons from the first wave, and avoid shutting down care for other diseases, he said.

"They are lessons that came at a very human price," Wijeysundera said.

Permanent damage, shorter lives

The effects of delayed care are now limping into the exam rooms of Edmonton cardiologists like Dimitry and Shibata.

Both are seeing patients who unknowingly had heart attacks at home, and showed up weeks or months later feeling weak and unwell.

Some of the patients are younger, Dimitry said. People in their 40s and 50s who could have been treated with clot-busting drugs or angioplasty to re-open arteries within hours of a heart attack have permanently lost heart muscle.

It will significantly shorten their lives, he said.

In Calgary, Dr. Paul Fedak says patients with more profound damage are being wheeled into his operating room.

The cardiovascular surgeon says patients untreated early sometimes have holes in their heart, or valves that are ruptured.

"We have incredible treatments for people with cardiovascular disease, particularly those who have heart attacks and heart failure," he said.

Delay turns those treatable situations into emergencies or sometimes deaths, he said.

Alberta Health Services is trying to spread the word that hospitals are safe, said Dr. Dylan Taylor, who heads the cardiac sciences program in the Edmonton zone.

Early counts this winter suggest the number of hospitalizations for heart problems in Edmonton are higher compared to last year, he said.

Taylor acknowledges it will take months or years to see the true impact of COVID-19 on cardiac patients.

However he is adamant that heart patients displaced from critical care units to other wards are receiving the same level of care and monitoring as before the pandemic.

"To date, the evidence does not support any concern about cardiac care in the Edmonton zone being compromised by COVID," he said.