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HEART ATTACK IN THE TIMES OF COVID

By Dr. Roopa Salwan in Cardiac Sciences

May 15 , 2020 | 4 min read

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World over,  fewer patients with heart attack are being seen in the emergency. Decrease in disease due to reduction of pollution, reduced stress by staying at home, decrease in eating out, etc is wishful thinking. There may be some reduction but more likely patients are not reporting to hospitals for treatment and the number of sudden deaths is increasing. 

Heart Attack occurs when the blood flow to the heart muscle is cut off by the formation of a clot, usually on an underlying cholesterol deposit (plaque). With every passing minute, the heart muscle gets progressively injured and may get permanently damaged if the flow is not restored. 

Symptoms are usually pain is in the center of the chest, more like pressure, radiates to arms, jaw, neck, back, and may be associated with profuse sweating and a sense of doom. It may be milder, feeling like gas, or a cervical pain, may come and go and then become constant, progressively increasing, at times becoming unbearable. The patient just knows that there is something really wrong.

In the presence of chest discomfort, ECG is the first test done, there are changes called ST Elevation – that are diagnostic of blockage of a heart artery. These changes in a clinical context are adequate to diagnose a heart attack 

Chest discomfort that comes and goes, with ECG changes suggestive of heart attack, usually is investigated further with 2 tests: troponin I and ECHO. Checkout the difference between ECHO test and ECG.

Troponin I is a blood test that indicates injury to heart muscle – it is a very sensitive test – is abnormal 4 – 6 hours after the onset of discomfort. 

ECHO is a ultrasound of the heart – if a part of the heart is not contracting strong enough or the heart is weak – it is visible. These defects develop after an injury to the heart. The presence of a normal ECHO does not rule out underlying heart problem.

If a patient has STEMI or acute heart attack – the standard of care is to shift the patient to the cath lab as fast as possible, the  Cardiologist does a procedure to open the artery, usually by placing a stent, after giving blood thinner. Restoration of blood flow stops the heart attack and the heart starts healing. Recovery of the heart is slow if there have been delays in reaching hospital and delivery of care. Care is a team or Institution-based process – where the emergency, Cardiologist, and Post-procedure  CCU care are all done in an integrated seamless manner. Coordination between all team members is essential for each patient to get the best care. With the optimal process of care the mortality after suffering heart attack has reduced from 20% in the 1980’s to 4-5% these days.

In the COVID -19 pandemic, fear has overtaken all – patients and healthcare workers. This fear is more from lack of understanding. As we care for patients with COVID infection, and we learn from others doing the same world over, we realize that this epidemic will take its time to settle. We all have to learn to take precautions: they are universal.

These precautions work if done together – Hand Hygiene, Screening, Distancing, and use of Masks. Each sounds small but put together, by each one of us, the effect is huge: A chain is as strong as its weakest link! 

At Max, if a patient comes in with Chest pain suggestive of a heart attack, and the ECG shows changes that require an immediate procedure, CODE STEMI is activated – the cath lab is prepared, the Interventional Cardiologist, technical staff, and nurses are ready – while the emergency team prepares the patient and shifts to the Cath lab – usually within 15 minutes and the procedure is performed. In the COVID Times – universal precautions are taken, so you will find all of us working with PPE kits. After the procedure, the patient will be shifted to the CCU and observed for 48 – 72 hours till recovery and mobilization before discharge. If there is any index of suspicion, COVID testing will be done. To prevent spread of infection in the hospital, knowing that some patients are asymptomatic carriers, we are inclined to  COVID testing more liberally although ICMR does not mandate the test. 

In the last month, we have seen 40% decrease in the number of patients with acute heart attacks as compared to April last year. A majority of patients, particularly elderly women, have come in 24 – 48 hours after the onset of heart attack – they fear putting their loved ones at risk of acquiring infection and suffering till it is unbearable. Unfortunately, these delays translate to poor outcomes. 

It is my humble request, that if you are not well and need hospital care – please do not delay – it is painful to see patients with treatable diseases die from delays in care. Please do not fear the emergency or worry about unnecessary isolation – we will take precautions to keep healthcare workers and patients safe as we continue to do what we can –  serve and take care of patients