Sex- and Age-Related Impact of the COVID-19 Pandemic on Emergency Department Visits for Chest Pain in Curitiba, Brazil.

BACKGROUND: Women have higher mortality from acute coronary syndrome (ACS) compared with men. Women may hesitate to search for emergency care when experiencing chest pain, which delays treatment.
OBJECTIVE: Our aim was to evaluate the changes in emergency visits for chest pain according to sex and age during the COVID-19 pandemic period compared with previous years.
METHODS: We collected data on chest pain visits (International Classification of Diseases, Tenth Revision, Clinical Modification codes I20 [unstable angina], I21 [myocardial infarction], and R07.1-4 [chest pain]) from all public emergency departments (EDs) in Curitiba, Brazil. We compared the weekly rates of visits per 100,000 habitants on the epidemiologic weeks 11-52 of 2020 (COVID-19 pandemic period) with the average rates of the same weeks of 2018 and 2019 using Poisson regression.
RESULTS: From 2018 to 2020, 37,448 individuals presented to the ED for chest pain, of whom 8493 presented during the COVID-19 pandemic period. Compared with previous years, we observed a 23% reduction in chest pain visits (10.1 vs. 13.0 visits per 100,000 habitants/week; p < 0.001), but this reduction was greater in women than in men (30% vs. 15%; p < 0.001). This reduction was associated with age among women (27%, 31%, and 36% for < 50 years, between 50 and 69 years and > 70 years, respectively, p for age-related trend = 0.041), but not among men.
CONCLUSIONS: In this population-level study of Curitiba, Brazil, the reduction in ED visits during the COVID-19 pandemic was greater in women than in men, particularly among those > 70 years of age, suggesting that the sex- and age-related disparities in health care delivery for ACS may have worsened during the COVID-19 pandemic.

INTRODUCTION

The COVID-19 pandemic caused a number of impacts on health care, including cardiovascular (CV) emergency care. An increase in CV deaths (1) and a decline in acute coronary syndrome (ACS) and chest pain admission rates in the early months of the pandemic (2) were reported, raising concern on the possibility of patients being reluctant to seek emergency care. Previous studies have suggested that women delay seeking emergency care when they experience chest pain (3), less likely report “classic” anginal symptoms and more often neglect ACS-related symptoms compared to men, which may contribute to their higher short-term mortality from STEMI.(4) Other factors, such as older age and socioeconomic status, have also been associated with longer time from symptom onset to first medical contact.(5) These behavioral characteristics imply that reluctance to seek the emergency department (ED) during the pandemic may differ among different demographic subgroups. However, sex- and age-related disparities in seeking emergency care when experiencing chest pain during the pandemic period have been poorly evaluated. We hypothesized that the reduction in ED visits during the COVID pandemic differed according to age and sex.

METHODS

We collected data regarding adults (>18 years) chest pain visits from nine emergency departments, comprising all emergency units (UPA – Unidades de Pronto Atendimento in Portuguese) from the municipal public health system of the city of Curitiba, Brazil. These units are the first contact for patients who seek medical care due to chest pain. Curitiba city has 1.9 million inhabitants, with 45% of its population having access only to this public health system. Every ED visit in this system receives an ICD-10 code, which is registered in an electronic database by the attendant physician. For this study, only the first visit was used for those individuals who had repeated visits for chest pain. Chest pain visits were defined as those with ICD-10 codes I20 (unstable angina), I21 (myocardial infarction) and R07.1-4 (chest pain). We compared the weekly rates of visits per 100,000 population in epidemiological weeks 11 to 52 of 2020 (pandemic period) with the mean rates for the same weeks in 2018 and 2019 using Poisson regression. Age-adjusted sex differences were calculated using information from the 2010 Brazilian census.(6) Trends over time were calculated adding period-sex and period-age category interaction terms on Poisson regression. We further added a period-age category-sex interaction (age-sex interaction) to test if the association between trends over time in ED visits and age category differed according to sex. The proportion of ER visits for chest pain that were diagnosed as acute myocardial infarction was compared between these periods using logistic regression. All analyses were conducted using Stata, version 15 (StataCorp LLC, College Station, TX). The Ethics Committee approved the study protocol.

RESULTS

We included 37,448 individuals who presented in the ED for chest pain from 2018 to 2020, of whom 8,493 presented during the pandemic period. Overall, there was a 23% reduction in the rates of individuals presenting with chest pain at the ED during the pandemic period (average of 10.1 visits per 100,000 habitants/week), in comparison with the same epidemiological weeks of 2018 and 2019 (average of 13.0 ER visits per 100.000 habitants/week, p<0.001). The reduction in emergency room visits for chest pain was most pronounced in the first twenty weeks of the pandemic (epidemiological weeks 11 and 31) than in the last twenty weeks of the year (epidemiological weeks 32 to 52, figure 1 ). This reduction was much greater in women than in men (30% vs 15%, p<0.001) in all age categories.

Figure 1

Number of chest pain visits per week in the emergency department (ED) units in 2019 and 2020 in Curitiba, Brazil.

Among women, the reduction in chest pain ED visits was greater in older ages (27%, 31% and 36% for <50 years, between 50-69 years and > 70 years, respectively, p for age-related trend = 0.041, Figure 2 ). By contrast, the reduction in chest pain ED visits tended to be more pronounced at younger ages among men (19%, 10% and 11% for < 50 years, between 50 and 69 years and >70 years, respectively, p for age-related trend = 0.067, p for age-sex interaction = 0.006). The proportion of ED visits for chest pain that were diagnosed as myocardial infarction did not change significantly during the COVID-19 pandemic period compared to previous years (1.5 vs 1.8%, OR=1.21, 95%CI 0.99, 1.47; p=0.054), even when stratified by age and sex (Supplemental Table 1). Although there was a significant reduction on the overall ED visits, it did not follow the same age and sex relationships as the chest pain ED visits (Supplemental table 2).

Figure 2

Percentual change in weekly ED visits for chest pain during the pandemic period (epidemiological weeks 11 to 52 in 2020), as compared with the same epidemiological weeks in 2018 and 2019, according to sex and age category.

DISCUSSION

The main finding of this population-level study was that a significant reduction in the rates of ED visits for chest pain occurred during the pandemic period, as compared with the previous two years, and this reduction was greater among women compared to men, particularly among women over 70 years old. The reduction on chest pain ED visits was not accompanied by a significantly higher proportion of a diagnosis of myocardial infarction, suggesting that the overall reduction of ED visits was not only due to a reduction of less severe visits. Compared to men, women have higher short-time mortality after an ACS, especially after STEMI, and this has been partially explained by delays in treatment among women. (4) Our data suggests that sex- and age-related disparities may have worsened during the pandemic. While older women were less likely to search medical attention than younger women, this association was inverse among men, suggesting that this behavior was age and sex specific.

The reduction in ED visits for acute CV diseases during the COVID-19 pandemic has been previously described. Reports from the United States have found a 40% decrease in the cardiac catheterization laboratory activation for primary PCI, with similar reductions in admissions for ACS in other countries.(2,7) Nevertheless, these studies did not report whether these findings differ according to age and sex. A more recent study evaluating ED visits for serious cardiovascular conditions in eighteen states in the United States found that visits for NSTEMI and acute heart failure significantly dropped, with steeper reductions among women and people over 65 years old in the early periods of the pandemic.(8) Our study adds that women, especially over 70 years old, were also less likely to search for medical attention when experiencing chest pain during the pandemic period, which may indicate the existence of a behavioral pattern that make these groups more vulnerable to CV emergencies during the outbreak.

Before the pandemic, women with STEMI had already experienced greater delays until reperfusion compared with men, mostly driven by time from symptom onset to first medical contact (3). The reasons for these differences are likely multifactorial, and include lack of awareness, misinterpretation of symptoms, barriers to accessing care, fear, and embarrassment.(4) During the pandemic, these factors may have led to the decision not to seek emergency care when experiencing chest pain. It has been shown that women, especially as they become older, are more likely to comply with public recommendations of staying at home during this period, which may have contributed to these disparities. (10)

Our data have important implications for the current and future outbreaks. Women were less likely to seek care for chest pain during the COVID-19 pandemic. This may result in delayed medical care support, and consequently, increase the risk of complications from myocardial infarction and other deadly causes of chest pain.

Limitations

Our study has limitations: we included only emergency departments from the municipal public health system, and our results may not be generalized to private hospitals which provide care to patients with different income and education levels. Also, our inclusion criteria included the ICD codes for R07.1-4, which is subjective and not specific. Women presenting with “atypical” symptoms, such as nausea, fatigue, or dyspnea, may have been left out from the analysis.

CONCLUSIONS

In conclusion, the COVID-19 pandemic resulted in a significant reduction in the rates of ED visits due to chest pain, affecting disproportionally the rate of women seeking care, especially those over 70 years old. More studies should be performed to determine the reasons for these age- and sex-related differences and their impacts on health.

Article Summary

1. Why is this topic important?

The pandemic had a major impact on healthcare systems, including emergency cardiovascular care. Delays in accessing emergency care when experiencing chest pain may result in inadequate medical support and higher risk of complications from myocardial infarction.

2. What does this study attempt to show?

Our study showed differences in emergency room visits according to sex and age category to identify groups most at risk of delaying or not seeking medical care when experiencing chest pain.

3. What are the key findings?

•Women were less likely to search for medical attention for chest pain during the pandemic period, particularly among those over 70 years of age.

•This suggests the sex- and age-related disparities in accessing healthcare for chest pain may have increased during the pandemic.

4. How is patient care impacted?

The pandemic increased the disparity in patients seeking care for chest pain.

Funding: None

Conflicts of interest: None.

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