Circulation Journal Report

AHA COVID-19 Newsroom

DALLAS, May 2, 2020 — American Heart Association volunteer experts issued Temporary Emergency Guidance to STEMI Systems of Care During the COVID-19 Pandemic, on behalf of the AHA’s Mission: Lifeline initiative, Get With The Guidelines (GWTG)–Coronary Artery Disease Systems of Care Advisory Work Group and the Council on Clinical Cardiology’s Committees on Acute Cardiac Care and General Cardiology and Interventional Cardiovascular Care, to ensure patients continue to receive life-saving treatments for acute cardiovascular disease such as timely coronary intervention, published today in the organization’s flagship journal Circulation.

The guidance also called for increased public awareness about the urgency of calling 911 as soon as possible for anyone with suspected heart attack symptoms. This recommendation is also affirmed by the joint statement, The new pandemic threat: People may die because they’re not calling 911, issued last week by the American Heart Association and seven cardiovascular care organizations.

Leaders from the Association’s GWTG–Coronary Artery Disease Systems of Care Advisory Work Group/Mission: Lifeline initiative and the Council on Clinical Cardiology science subcommittees note that the COVID-19 pandemic appears to have fundamentally changed how cardiovascular patients interact with the health care system, with an overall decrease in those seeking care, telemedicine replacing in person visits for stable patients and notable reductions in hospitalizations for acutely ill patients.

In the guidance, the leaders note:

  • Early analyses from Hong Kong imply there is a significant delay in patients seeking care during the COVID-19 crisis, with an increase in median time from signs and symptom onset to first medical contact from 82 minutes to 318 minutes, compared with the same time frame in 2019 to 2020, respectively.
  • Other countries, and more recently U.S. hospitals are reporting substantial declines in patients presenting by EMS [emergency medical services] or by direct presentation with STEMI (chest pain).
  • Patients and family members may be less likely to call 911 for cardiac symptoms. In some areas in the U.S., 911 call volumes have decreased, including calls with a chief complaint of cardiac symptoms suggestive of a heart attack, which may relate to reluctance of patients to engage with a system of care that could expose them to the coronavirus.
  • Patients experiencing suspected heart attack symptoms should continue to seek medical attention as soon as possible by calling 911. Earlier entry into the system of care will help offset the potential delays related to downstream coronavirus screening and the complexities related to prevention of exposure to health care workers.

“Chest pain should still elicit quick calls to 911,” said Alice K. Jacobs, M.D., Chair of the Association’s GWTG–Coronary Artery Disease Systems of Care Advisory Work Group/Mission: Lifeline initiative. “The time between chest pain or other heart attack symptoms to first medical contact represents the greatest opportunity for time to treatment improvement. Preliminary data confirm that patient calls to 911 have decreased by approximately 1/3 from January 1 through April 12 of this year, and more than a 20% decrease in 911 calls for chest pain during the same time period.[1] Calling 911 immediately is the best option to receive urgent, life-saving care as soon as possible, rather than no care during time in transit while a friend or loved one drives you to the hospital. It is also important for everyone to know – we have adapted our ED [emergency department] facilities to evaluate and provide physical separation within our centers to protect patients from COVID-19.”

Jacobs is a professor of medicine and vice chair for clinical affairs in the department of medicine at Boston University Medical Center.

The writers conclude: "… Cardiac emergencies will continue to occur, and all health care workers in the system of care should strive to maintain efficiency and quality to the extent possible given these constraints. Basic cardiac care and the tenets of our collective success should not be abandoned. Delays are bound to arise as health care systems adjust to increased patient volume, increased need for PPE [personal protective equipment] and as COVID-19 is front and center on our minds. All points in the STEMI System of Care continuum have a role in combating this pandemic. Adjustments must be made to this new (and temporary) reality with a clear focus on the foundation of systems of care. Importantly, when we see signs that the rate of viral spread is dissipating, we must maintain adherence to the practices of social distancing and personal protection, improve COVID testing capabilities and utilization, and be innovative in developing new care models to help prevent unnecessary resurgence of disease.”

The guidance is endorsed by the Association’s Council on Clinical Cardiology, including the Acute Cardiac Care and General Cardiology Committee and the Interventional Cardiovascular Care Committee.

The complete list of authors and disclosures are in the manuscript.

Additional COVID-19 Resources:

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[1] April 16, 2020: Evaluation of EMS Call Volume for 9-1-1 Responses for STEMI/Chest Pain, and Stroke Calls. Dataset from ESO real-world, de-identified data, compiled and aggregated from more than 1,300 agencies across the United States that use ESO’s products and services and agreed to have their data used for research purposes. Source: ESO.