The puts and takes of death in the era of Covid-19

An interesting piece that correlates with my concern for definitions, measurement, all-causes mortality, etc. From Where Have All the Heart Attacks Gone? by Harlan M. Krumholz, M.D.

The hospitals are eerily quiet, except for Covid-19.

I have heard this sentiment from fellow doctors across the United States and in many other countries. We are all asking: Where are all the patients with heart attacks and stroke? They are missing from our hospitals.

Yale New Haven Hospital, where I work, has almost 300 people stricken with Covid-19, and the numbers keep rising — and yet we are not yet at capacity because of a marked decline in our usual types of patients. In more normal times, we never have so many empty beds.

Our hospital is usually so full that patients wait in gurneys along the walls of the emergency department for a bed to become available on the general wards or even in the intensive care unit. We send people home from the hospital as soon as possible so we can free up beds for those who are waiting. But the pandemic has caused a previously unimaginable shift in the demand for hospital services.

Some of the excess capacity is indeed by design. We canceled elective procedures, though many of those patients never needed hospitalization. We are now providing care at home through telemedicine, but those services are for stable outpatients, not for those who are acutely ill.

What is striking is that many of the emergencies have disappeared. Heart attack and stroke teams, always poised to rush in and save lives, are mostly idle. This is not just at my hospital. My fellow cardiologists have shared with me that their cardiology consultations have shrunk, except those related to Covid-19. In an informal Twitter poll by @angioplastyorg, an online community of cardiologists, almost half of the respondents reported that they are seeing a 40 percent to 60 percent reduction in admissions for heart attacks; about 20 percent reported more than a 60 percent reduction.

And this is not a phenomenon specific to the United States. Investigators from Spain reported a 40 percent reduction in emergency procedures for heart attacks during the last week of March compared with the period just before the pandemic hit.

And it may not just be heart attacks and strokes. Colleagues on Twitter report a decline in many other emergencies, including acute appendicitis and acute gall bladder disease.

I have been hearing the same thing from many quarters. Three weeks ago we were desperately worried about overloading hospitals and shortage of ventilators.

Some select hospitals in some few counties/cities for brief periods of time do seem overloaded. But the great majority seem to have planned and anticipated a base load of Covid-19 cases which has not yet emerged. Part of this is good planning and emergency preparedness. Part of it seems that the demand forecasted for hospital access, ICUs and ventilators was greater than the reality. Maybe it is just a matter of timing. Maybe.

Krumholz offers some speculative hypotheses why baseload emergency work has dried up.

The most concerning possible explanation is that people stay home and suffer rather than risk coming to the hospital and getting infected with coronavirus. This theory suggests that Covid-19 has instilled fear of face-to-face medical care. As a result, many people with urgent health problems may be opting to remain at home rather than call for help. And when they do finally seek medical attention, it is often only after their condition has worsened. Doctors from Hong Kong reported an increase in patients coming to the hospital late in the course of their heart attack, when treatment is less likely to be lifesaving.

There are other possible explanations for the missing patients. In this time of social distancing, our meals, social interactions and physical activity patterns tend to be very different. Maybe we have removed some of the triggers for heart attacks and strokes, like excessive eating and drinking or abrupt periods of physical exertion. This theory merits research but seems unlikely to explain the dramatic changes we’re observing.

We actually expected to see more heart attacks during this time. Respiratory infections typically increase the risk of heart attacks. Studies suggest that recent respiratory infections can double the risk of a heart attack or stroke. The risk seems to begin soon after the respiratory infection develops, so any rise in heart attacks or strokes should be evident by now. We urge people to get flu vaccines every year, in part, to protect their hearts.

Also, times of stress increase the risk of heart attacks and strokes. Depression, anxiety and frustration, feelings that the pandemic might exacerbate, are all associated with a doubling or more of heart attack risks. Work and life stress, which also may be higher with the acute disruptions we’ve all been going through, can markedly increase the risk of a heart attack. Moreover, events like earthquakes or terrorist attacks or war, in which an entire society is exposed to a stressor, are risk factors for heart attacks. Finally, Covid-19 can actually affect the heart, which should be increasing the number of patients with heart problems.

All hypotheses seem plausible but not particularly likely.

But the whole conversation goes to a larger point - the importance of all-causes mortality rates.

The closest analogy is to that of cholesterol panic of the mid-and late-1980s. Everywhere you turned there were recommendations of getting cholesterol count down. Change your diet. Exercise. Take medications. Seemed to me at the time as a massive sales job with weak statistical underpinnings. And after a few years, the first large scale review came out.

The findings were that the medications were reducing the number of deaths linked to cholesterol but that overall deaths had remained the same. People on the (expensive) medications died at the same overall rate as everyone else. While fewer died from cholesterol related heart disease, more died from other causes such as suicide, pneumonia, etc.. All the cost of the anti-cholesterol monitoring and the expensive drugs bought us was a shifting around of causes death. It did not reduce the number of deaths which was the original purpose.

Another similar review was done another decade or so later with similar outcomes.

I wonder whether we will see something similar in the Covid-19 counts.

Covid-19 deaths go down but suicide rates, heart attack deaths etc., go up. Lives that could have been saved by going to the ER are now lost.

In many, but certainly not all, corners, the economic costs of lock-downs have been horrendous, hitting the poorest and most fragile the hardest. But it certainly could be worthwhile if the overall death rate is kept low.

But if the actions to forestall deaths by Covid-19 are outweighed by the rise in numbers of non-Corvid deaths which are due to those actions, then it will have been wasted effort.

I read somewhere this morning that suicide deaths in Tennessee were materially higher since the lockdown and exceeded the number of Covid-19 cases.

We don't know, but it is interesting to see this report of quiet hospitals and suppressed emergency deaths.