Dr M. Adam Ali
Adam Ali is a Health Education England fellow in Medical Education at MedShr, the world’s leading discussion platform for doctors. He also holds honorary posts as an Honorary Research Assistant at UCL Institute of Ophthalmology: Ocular Biology and Therapeutics, and an Honorary Research Fellow at Moorfields Eye Hospital.
With COVID-19 exerting unprecedented strain on the NHS, and presenting severe risks for vulnerable people, how do healthcare providers protect and care for patients with cardiovascular disease?
How has the COVID-19 pandemic affected patients with cardiovascular disease?
The COVID-19 pandemic has exerted unprecedented strain on an already overstretched health service, with many healthcare providers needing to completely reconfigure services. But how has the NHS provided tests and treatment for pre-existing conditions while minimising high risk patients’ exposure to COVID-19?
Fewer cardiac patients presented to A&E
One recent study, published in Heart, reported drastic decreases in use of cardiology services by assessing changes in one UK centre in the first month of the UK lockdown. There was a 53% reduction in patients presenting to Emergency Departments with chest pain or shortness of breath, and a 40% reduction in the number of patients who received a diagnosis of myocardial infarction. This pattern was also reflected in the tests ordered by doctors and healthcare providers, with a 46% drop in the number of cardiac enzyme tests requested, and an 87% decrease in the use of ECGs. Some of these data suggest people suffering from heart attacks may have delayed or even avoided attending hospital for fear of contracting COVID-19 infection.
There was a 53% reduction in patients presenting to Emergency Departments with chest pain or shortness of breath, and a 40% reduction in the number of patients who received a diagnosis of myocardial infarction.
Impact on diagnostic tests and investigations
Staff shortages had a significant impact on the normal running of outpatient investigations clinics, with many clinical staff redeployed to acute settings such as the Coronary Care Unit. Services were stratified into urgent and routine, with the routine requiring rescheduling. The number of outpatient ECGs and echocardiograms dropped by more than half, and ambulatory cardiac monitoring also dropped by 73%. All routine transoesophageal echo was cancelled, and CTCA scans for myocardial ischaemia reduced by 63%.
These drops were also seen in cardiac surgery and coronary catheterisation. It is thought that significant drops in referral were likely related to patients delaying hospital visits; late presentation to hospital may have caused patients more severe ischaemic cardiac injury requiring more urgent angiography.
New triage guidance implemented
With ongoing pressure on the NHS, the British Heart Rhythm Society (BHRS) guidance on triage for cardiac device implantation was implemented, with only patients with urgent device-related issues – such as arrhythmias or battery depletion – being brought in for face-to-face assessment. Similarly, only patients with complete or symptomatic second-degree heart block had pacing procedures performed, reflective of the general prioritisation of emergency needs.
Technology-enabled consultations and case discussions
The NHS adapted quickly to reconfigure services and protect both patients and staff. Virtual triage and clinics slowly replaced face-to-face services where possible, incorporating phone consultations and employing more technology-enabled case services (TECS). Multi-disciplinary team (MDT) meetings likewise transitioned into video conferencing calls and private groups on MedShr, a case discussion platform for healthcare providers. This change has had an unexpected benefit: team members who previously could not attend due to geographic limitations could now partake remotely to discuss patients.
Many other specialties, such as haematology and oncology, have also had to adapt quickly to provide essential services while minimising risk of COVID-19 exposure for high-risk patients.
Sources/references: Fersia O, Bryant S, Nicholson R, McMeeken K, Brown C, Donaldson B, Jardine A, Grierson V, Whalen V, Mackay A. The impact of the COVID-19 pandemic on cardiology services. Open Heart. 2020 Aug;7(2):e001359. doi: 10.1136/openhrt-2020-001359. PMID: 32855212; PMCID: PMC7454176.