Reply: Are We Missing Something in the Management of Acute Coronary Syndromes in COVID-19-Negative Patients?

Experiences worldwide have observed fewer cardiovascular hospitalizations as the coronavirus disease 2019 (COVID-19) pandemic has swept across the globe (1). Although Dr. D’Amario and colleagues highlighted the case of ST-segment elevation myocardial infarction, it appears this system-wide disruption in health care use has extended to other common cardiovascular and noncardiovascular conditions. Patients who have been hospitalized during this pandemic period represent a particularly high-risk cohort compared with historical control subjects. What may explain this seemingly outsized impact on hospitalizations for non−COVID-19 related conditions in the United States and worldwide?

Several ecological factors might have contributed. For instance, reduction in air pollution might have triggered less acute cardiopulmonary illnesses. Enhanced mitigation measures such as masks and physical distancing might have prevented transmission and spread of other viral or bacterial vectors (2). Changes in health behaviors, including reduction in fast food intake, might have contributed. However, because of the population-wide impact across diverse communities with different approaches to physical distancing, in addition to the magnitude of the reductions seen even early in the pandemic, it is unlikely that fewer hospitalizations could be attributable to these factors alone.

The indirect effects of the COVID-19 pandemic are likely to be far reaching. Patients and caregivers may be averse toward even necessary health care exposure during the pandemic. Established systems of care designed to facilitate expeditious care for high-risk cardiovascular presentations have been disrupted (3). This may lead to diagnostic or treatment delays, such as longer time windows to reperfusion in the setting of ST-segment elevation myocardial infarction due to procedures surrounding assessment of COVID-19 status. In addition, the pandemic may have led to appropriate triage of lower-risk cardiovascular patients to be cared for via increasingly used outpatient telehealth platforms, whereas higher-risk patients were selectively hospitalized.

Clear, targeted public messaging campaigns such as the American Heart Association’s Don't Die of Doubt initiative (4) and others will remain critically important. Continued surveillance will be needed to understand the true health impact of the pandemic and mediators of delayed and/or deferred care, particularly as non−COVID-19 cases rebound back to pre-pandemic levels. In tandem, these disruptions necessitate investments in innovative strategies to communicate with and care for high-risk patients. These advances may not only inform responses to current and future pandemics but may be lead to enduring improvements in effective and efficient health care delivery.