An assessment of emergency department visits for cardiovascular diseases in the early phase of the COVID-19 pandemic in Istanbul

Objectives: The coronavirus disease (COVID-19) pandemic has had a severe impact with an excess of one hundred million cases and over two million deaths worldwide. Countries have adopted different paths toward ‘flattening the curve’; however, many countries observed a common trend of people avoiding emergency departments (ED) for varying reasons. This study aims to investigate the ED utilization patterns of patients with cardiovascular diseases (CVD) in the early phases of COVID-19 in Istanbul, Turkey.

Methods: The data were retrospectively collected in eight hospitals, which were authorized and declared as pandemic hospitals by the Turkish Ministry of Health. The data for these two particular periods of 1st March–30th June were compared between 2019 and 2020.

Results: A substantial and statistically significant decrease of 22.7% was observed in the total number of visits to EDs for cases of CVD from 534 cases in 2019 to 413 cases in 2020. ED visits showed statistically insignificant decreases of 11.6% for acute coronary syndrome/ACS) and 30.6% for cerebrovascular events (CVE) between 2019 and 2020. Of the total 422 ACS cases, 67.8% were male and 32.2% were female; and of the 525 CVE cases, 50.3% were male and 49.7% were female. The median ages were 61 [6–97] for men and 69 [19–103] for women; the median ages were 59 [19–97] for patients with ACS and 68 [6–103] for patients with CVE. In 2020, the number of ACS cases showed a steady trend between March 1st and June 30th, followed by a prominent increase in June 2020. The monthly trends appeared to be very similar for CVE cases for 2019 and 2020. Of the 379 hospitalizations, 56.2% were diagnosed with ACS and 43.8% with CVE.

Conclusions: The findings suggest that patients tended to avoid timely medical care during the pandemic compared to pre-COVID-19. Stay-at-home orders and attempts to avoid contact with the virus may explain the dramatic decrease in the number of ED visits.

COVID-19; Cardio-vascular diseases; Emergency department; Pandemic effects; Turkey

[1] World Health Organization. Coronavirus disease (COVID-19). 2020. Available at: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/coronavirus-disease-covid-19 (Accessed: 12 October 2020).

[2] Centers for Disease Control and Prevention. COVID-19 overview and infection prevention and control priorities in non-US healthcare settings. 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/non-us-settings/overview/index.html (Accessed: 12 August 2020).

[3] Nicholls M. COVID-19 and cardiovascular disease. European Heart Journal. 2020; 41: 2727–2729.

[4] Rosenbaum L. The untold toll—the pandemic’s effects on patients without Covid-19. New England Journal of Medicine. 2020; 382: 2368–2371.

[5] Kansagra AP, Goyal MS, Hamilton S, Albers GW. Collateral effect of Covid-19 on stroke evaluation in the United States. New England Journal of Medicine. 2020; 383: 400–401.

[6] Garcia S, Albaghdadi MS, Meraj PM, Schmidt C, Garberich R, Jaffer FA, et al. Reduction in ST-segment elevation cardiac catheterization laboratory activations in the United States during COVID-19 pandemic. Journal of the American College of Cardiology. 2020; 75: 2871–2872.

[7] Blecker S, Jones SA, Petrilli CM, Admon AJ, Weerahandi H, Francois F, et al. Hospitalizations for chronic disease and acute conditions in the time of COVID-19. JAMA Internal Medicine. 2021; 181: 269–271.

[8] Baum A, Schwartz MD. Admissions to veterans affairs hospitals for emergency conditions during the COVID-19 pandemic. Journal of the American Medical Association. 2020; 324: 96–99.

[9] Nourazari S, Davis SR, Granovsky R, Austin R, Straff DJ, Joseph JW, et al. Decreased hospital admissions through emergency departments during the COVID-19 pandemic. The American Journal of Emergency Medicine. 2021; 42: 203–210.

[10] Wongtanasarasin W, Srisawang T, Yothiya W, Phinyo P. Impact of national lockdown towards emergency department visits and admission rates during the COVID‐19 pandemic in Thailand: a hospital‐based study. Emergency Medicine Australasia. 2021; 33: 316–323.

[11] Atlas Journal. The chronology of COVID-19 pandemic. 2020. Available at: https://www.atlasdergisi.com/gundem/covid-19- salgini-kronolojisi.html (Accessed: 4 December 2020).

[12] Metzler B, Siostrzonek P, Binder RK, Bauer A, Reinstadler SJ. Decline of acute coronary syndrome admissions in Austria since the outbreak of COVID-19: the pandemic response causes cardiac collateral damage. European Heart Journal. 2020; 41: 1852–1853.

[13] Rodríguez-Leor O, Cid-Álvarez B, Ojeda S, Martín-Moreiras J, Ramón Rumoroso J, López-Palop R, et al. Impacto de la pandemia de COVID-19 sobre la actividad asistencial en cardiología intervencionista en España. REC: Interventional Cardiology. 2020; 2: 82–89. (In Spanish)

[14] Hammad TA, Parikh M, Tashtish N, Lowry CM, Gorbey D, Forouzandeh F, et al. Impact of COVID‐19 pandemic on ST‐elevation myocardial infarction in a non‐COVID‐19 epicenter. Catheterization and Cardiovas-cular Interventions. 2021; 97: 208–214.

[15] Krumholz HM. Where have all the heart attacks gone? The New York Times. 2020. Available at: https://www.nytimes.com/2020/04/ 06/well/live/coronavirus-doctors-hospitals-emergency-care-heart-attack-stroke.html (Accessed: 3 December 2020).

[16] Solomon MD, McNulty EJ, Rana JS, Leong TK, Lee C, Sung S, et al. The Covid-19 pandemic and the incidence of acute myocardial infarction. New England Journal of Medicine. 2020; 383: 691–693.

[17] Wong LE, Hawkins JE, Langness S, Murrell KL, Iris P, Sammann A. Where are all the patients? Addressing Covid-19 fear to encourage sick patients to seek emergency care. NEJM Catalyst. 2020.

[18] Ageron FX, Sarasin F, Pasquier M, Carron PN. Urgences hospitalières: crise COVID-19 et aspects organisationnels. Revue Medicale Suisse. 2020; 16: 924–929. (In French)

[19] Mafham MM, Spata E, Goldacre R, Gair D, Curnow P, Bray M, et al. COVID-19 pandemic and admission rates for and management of acute coronary syndromes in England. The Lancet. 2020; 396: 381–389.

[20] De Rosa S, Spaccarotella C, Basso C, Calabrò MP, Curcio A, Filardi PP, et al. Società Italiana di Cardiologia, & CCU Academy investigators group. Reduction of hospitalizations for myocardial infarction in Italy in the COVID-19 era. European Heart Journal. 2020; 41: 2083–2088.

[21] Bhambhvani HP, Rodrigues AJ, Yu JS, Carr JB, Hayden Gephart M. Hospital volumes of 5 medical emergencies in the COVID-19 pandemic in 2 US medical centers. JAMA Internal Medicine. 2021; 181: 272–274.

[22] Daoulah A, Hersi AS, Al-Faifi SM, Alasmari A, Aljohar A, Balghith M, et al. STEMI and COVID-19 pandemic in Saudi Arabia. Current Problems in Cardiology. 2020; 46: 100656.

[23] Kuitunen I, Ponkilainen VT, Launonen AP, Reito A, Hevonkorpi TP, Paloneva J, et al. The effect of national lockdown due to COVID-19 on emergency department visits. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2020; 28: 114.

[24] Griffin S. Covid-19: “Huge rise” in deaths at home is not fully explained by virus, say experts. British Medical Journal. 2020; 369: m2115.

[25] Wu J, Mamas MA, Mohamed MO, Kwok CS, Roebuck C, Humberstone B, et al. Place and causes of acute cardiovascular mortality during the COVID-19 pandemic. Heart. 2020; 107: 113–119.