By: Benjamin S. Wessler, MD, MS; David M. Kent, MD, MS; Marvin A. Konstam, MD
JAMA-(ENEWSPF)- In the midst of the coronavirus disease 2019 (COVID-19) pandemic and, as many clinicians across the globe, we are seeing firsthand the pain and death caused by COVID-19. While there are more than 300 clinical trials currently underway for this illness, there are no specific therapies that are known to decrease mortality. In response to dire predictions and a lack of effective treatments, authorities across the world continue to recommend a series of aggressive mitigation strategies to slow the spread of COVID-19. While early fear of widespread coronavirus death and overwhelmed hospitals have played an important role in sounding the alarm about this pandemic and motivated important social distancing measures, these fears are also causing substantial harm. In this Viewpoint, using cardiac disease as an example, we explore the hazards associated both with the pandemic and initial response. We argue that clinicians’ ability to modulate fear—a sensitive but nonspecific response to threats—will be a major determinant of the magnitude of the pandemic’s effects.
Individual and Population Risks
As the global death toll from COVID-19 infections continues to rise, nearly all patients with infections will recover. The discrepancy between population and individual risks results from 3 complementary observations. First, it appears that the mean infection fatality rates are low (likely <1%).1 Second, mortality risk from COVID-19 is heterogenous across age groups and comorbid conditions,2 and third, as is common with population risk distributions, most patients have risks that are less than the mean.3 Our concern is that the mitigation strategies that seek to reduce the very real risk of spreading the virus across the population may lead people to delay or forgo essential care because of a tendency to substantially overestimate their individual risk with any given exposure.
Cardiac Risks Associated With Social Distancing and Staying Home
Social distancing strategies have come to dominate the worldwide approach to this illness. But a potentially deadly consequence that emerges from stay-at-home orders is that patients with symptoms hesitate or avoid seeking care. While cardiologists in some settings have been redeployed to support critical care colleagues in the care of patients with COVID-19 in intensive care units, many other acute care settings remain eerily quiet. Recent data from 9 high-volume centers across the US suggest a nearly 40% drop in catheterization laboratory activation for ST-elevation myocardial infarction care during this crisis.4 Apparent fear of COVID-19 is having the direct outcome of decreasing the use of life-saving evidence-based treatments. For patients with myocardial infarction who are not treated with timely reperfusion therapy, sudden death, stroke associated with left ventricular thrombus, and mechanical complications are likely to return to rates seen before the modern treatment era. There is early evidence that this might be occurring in New York, New York, where emergency calls for cardiac arrests have risen substantially in the weeks since COVID-19 has overtaken the city. If this trend moves across the country (or globe), then morbidity and mortality associated with myocardial infarction are likely to substantially increase.
Risks Associated With Disasters
Disasters increase the population risk of cardiac events. Widespread fear and emotional stress are known to directly precipitate acute coronary syndromes through abnormalities of autonomic tone that can increase platelet aggregation and rates of plaque rupture. Psychological distress seen during disasters also increases event rates through indirect outcomes, such as increased rates of smoking and sedentary lifestyles. Hurricane Katrina, previously considered the costliest natural disaster in US history, offers important lessons about what we can expect from the COVID-19 pandemic. Prior to Hurricane Katrina, the rate of hospitalization for myocardial infarction at Tulane Health Sciences Center in New Orleans, Louisiana, was 0.35% of all admissions per year. This rate increased the following year to 1.09% of admissions per year—a 3-fold increase over the pre-Katrina baseline.5 Evidence of increased rates of myocardial infarction in New Orleans persisted for years after the catastrophe—a pattern that has been seen in many other natural disasters. If the COVID-19 pandemic presents a similar hazard to the entire nation, it is likely that we will see 1 million to 2 million additional coronary events that are directly attributable to the current crisis (representing a 2-fold to 3-fold increase over 2019 event rates). This increase, coupled with worse clinical outcomes when patients avoid seeking effective care, creates a double hit from this pandemic in which morbidity and mortality associated with cardiac disease might well overtake the risks directly linked to the virus itself.
The risk of acquiring COVID-19 infection in the hospital is estimated at less than 1%,6 and the mean risk of death from the virus also appears less than 1%.1 For an individual, the conditional probability of these 2 events is exceedingly small. In contrast, the probability of dying of a myocardial infarction in the absence of evidence-based treatments is greater than 30%,7 with the risk decreasing to approximately 5% with revascularization and modern, evidence-based pharmacotherapy and critical care.8 Despite widespread fear of the virus, the mean risks associated with cardiac events are substantially greater than and the benefits of evidence-based therapies outweigh by orders of magnitude any small potential risk of nosocomial infection from COVID-19 (or the smaller conditional risk of death from the virus) in patients with acute cardiac symptoms. The true risk to patients is associated with both the virus and (somewhat paradoxically) the current mitigation strategies that, although they are appropriate, appear to discourage patients from seeking the very care that saves lives.
As an initial response to a new and uncertain threat, the precautionary principle (resolving uncertainty in favor of prevention and threat avoidance) is a sensible default strategy, and fear plays an adaptive role. But minimizing risks requires us then to prioritize information gathering to balance risks appropriately and rationally. In light of the emerging evidence that nosocomial transmission can be effectively controlled with standard infection-control measures (assuming adequate personal protective equipment are available), public health messaging must encourage the use of appropriate medical care (eg, rapid revascularization for myocardial infarctions), even while encouraging the public to otherwise stay at home. Overblown media depictions of the hospital as a war zone undoubtedly have a cost in terms of lives lost from treatable disease.
While we continue to care for the patients with COVID-19 and this disease dominates institutional planning, it is essential that hospitals shed the perception of being war zones and redefine themselves as safe zones. We will thereby restore our perceived and actual ability to provide proven, life-saving treatments to patients with other deadly but reversible conditions. The urgency of this restoration is magnified by the substantial increase in the number of coronary events to be anticipated in the months to come. To minimize the negative outcomes of this pandemic, we must keep patients from dying of fear—both of the pandemic and their fate in the hands of medical institutions.