 What's up everybody? This is Dr. Ali Hader. Today is April 20, 2020. And what I want to talk about today regarding COVID is sort of the non-COVID related medical problems and sequelae that has occurred as a result of this pandemic. So we all sort of either have seen firsthand if we're in the healthcare field. We've heard from colleagues and friends or on social media or on the news about how COVID-19 in many places is sort of overwhelming these hospitals and the COVID patients are taken over the majority of the inpatient care in a lot of facilities. Now one thing that we're not seeing a lot of is sort of everything else, especially heart disease. So cardiovascular problems often take up a large chunk of the admissions and inpatient volume of a lot of hospitals and healthcare systems. You know cardiovascular disease remains the number one killer in men and women throughout the world. And you would think during the pandemic heart disease is not sort of going to stop. But what we've been seeing is a significant drop in the number of heart attack admissions and other cardiology related admissions sort of all around the United States and even the world. Now even in my institution we've noticed a significant drop in the number of acute heart attacks that have been coming in or STEMIs we call them which is an ST elevation my carlin fraction. This is the most serious type of heart attack when your artery is completely blocked and it warrants you to be rushed to the cardiac catheterization laboratory to try and get that artery open. And generally at our center we're on a given week around this time of year we're expecting to see anywhere between five and even up to 10 cases in a week. But we've sort of seen a little bit of a dip in that volume. Now talking to colleagues across the United States from New York to Michigan everyone's sort of noticing a similar trend. Now there was a recent paper that just came out in Jack that looked at data from nine centers and they looked at the volume of these acute heart attacks coming in before the pandemic and after the pandemic. Now granted there's only about a a month and a half of data but they found about a 38 percent reduction in the number of these sort of acute heart attacks coming in to these centers. Similarly Spain did a similar study where they looked at their activations of these acute heart attacks and they found a 40 percent drop in that. There's some data out of England showing a 50 percent reduction in the number of people presenting to the emergency room with heart attack-like symptoms. So there's no question there's a trend of reduction in the number of these cases. Now the question is why exactly is this happening? Now this topic has been hotly discussed recently particularly among cardiologists and this is occurring on social media the people publishing opinion pieces. There's other video content out there about it and really we're all kind of noticing this trend and the question is exactly why is this going on? Why are we seeing less heart attacks during this pandemic? Now there's several possible reasons this could be happening. I think the general consensus is there's three main reasons why we're seeing this reduction in the number of heart attacks as well as other cardiovascular emergencies, congestive heart failure, even the number of strokes has come down. So what's going on here? Well let's take a look. Now the first main reason that we all think is sort of going on is simply that people are very concerned and too scared to come to the emergency room right? Because of this COVID-19 pandemic everybody is socially distancing. We're all wearing masks everywhere. We're stressed out to even go to the grocery store so the last place a lot of people want to go is the emergency room because they're picturing this area filled with virus and they don't want to expose themselves. And it's a valid, valid fear right? So what's going to happen in those situations is someone may be having a heart attack symptom at home whether it's chest pain or severe shortness of breath, maybe they passed out and they are going to try to ride this out at home okay? Now the problem with that is if you're actually having a severe heart attack and you try to ride it out at home, you A, may not survive or B, you may be riding this heart attack out at home until the point where you get so sick and there's been a lot of heart muscle damage that by the time you decide to come to the hospital you may not survive, you may have serious long-term complications because a lot of your heart muscle has already sort of died. So staying home if you think you're having a heart attack is not really a great idea. Now to kind of support some of these theories let's look at some of the numbers. Now in New York they've reported a 400% increase in the number of cardiac arrests that are occurring and sure a huge chunk of this is likely related to COVID-19 but I guarantee you a large portion of this is people who opted not to seek medical attention when they had a serious problem going on. Now I've heard from several colleagues scenarios that sort of support this. We've had some cases of patients who came to the hospital about a day or two after they started having chest pain and they ended up having a severe complication something called the mechanical rupture where a whole rupture is in the walls of the heart and patients have a very high mortality from that and there have been cases of people like that who didn't survive. I've also heard of cases of people who had patients who stayed at home because they were having chest pain but they ignored it, they didn't want to come in and they ended up dying at home. So this is actually happening out there and we have stories and we have data to support it. A second reason that could be going on is because of this social distancing we are just seeing less heart attacks occur because there's a reduction in the stressors that generally precipitated. Number one people are not seeing family as much they're not going to their jobs and these are two major sources of stress especially in the United States and we know that stress is a risk factor okay people are exerting themselves less not only they're not going to the gym or exercising they're not going to their jobs it may require physical activity so potentially less heavy exertion is playing a role here. Additionally people are not going out to eat they're not going to their restaurants they're not getting fast food they're not going to get those unhealthy foods high salt pro inflammatory things that taste oh so good but are potentially very bad for you so that's probably also reducing some of the admissions for again heart attacks and congestive heart failure and strokes due to blood pressure spikes etc and third there probably are people who are coming in with primary cardiac problems except they're coming in with COVID-19 now people with COVID who are really sick they can definitely get an organ involvement they can get cardiac manifestations we can see markers of cardiac injury that we normally would attribute to a primary heart problem but we're sort of blaming it all on the COVID and focusing on that so there may in fact be people coming in with these sort of true primary cardiac issues that are being lumped together in their COVID diagnosis now this is super important to recognize because these people who are potentially not coming in when they're having a real problem are people who could actually be treated and saved right COVID-19 when you get really sick you're right our treatments are not that great right now and a lot of these people who get ventilated will pass away but if you're having a heart attack or a stroke and you get into the hospital early we can save you okay so if you're not going to come seek medical attention when that's happening you're just going to become a collateral damage statistic of COVID-19 even though you never have the disease okay so that's what we want to avoid recently the ACC has also released a statement and trying to get the message directly to the patients that if you are having chest pain symptoms severe shortness of breath or stroke-like symptoms call 911 you will get taken care of okay the emergency rooms are being super cautious and we will protect you while we try to treat your underlying problem there's also a lot of campaigns on social media from physicians of all specialties including cardiologists to send the message out there that despite the social distancing that we are doing and need to do to try to spread the decrease the spread of COVID-19 we still need to be able to take care of your other problems so anyway that's it for now and hopefully we can get the message out there to people that you know don't let the fear of COVID-19 stand in the way of serious medical issues that are going on thanks