New York City sees sharp rise in out-of-hospital cardiac arrests, deaths during coronavirus pandemic
There has been a dramatic increase in out-of-hospital cardiac arrest cases and deaths in New York City due to the Covid-19 pandemic, according to researchers from the Albert Einstein College of Medicine, Montefiore Health System and the Fire Department of the City of New York (FDNY). They found a three-fold increase in out-of-hospital non-traumatic cardiac-arrest cases in March and April 2020 compared to the same period in 2019. On the worst day — April 6 — cardiac arrests peaked at 305 cases, an increase of nearly 10-fold compared with the same day one year earlier. The death rate for cardiac arrest cases also went up, from 75% in 2019 to more than 90% during the same period in 2020.
According to the researchers, this could imply that more patients are calling 911 closer to death and delaying seeking treatment due to the coronavirus pandemic. “We can’t rule out the possibility that some people may have died from delays in seeking or receiving treatment for non-Covid-19-related conditions. However, the dramatic increase in cardiac arrests compared to the same period in 2019, strongly indicates that the pandemic was directly or indirectly responsible for that surge in cardiac arrests and deaths,” says senior author Dr David Prezant, professor of medicine at Einstein, a clinical pulmonologist at Montefiore, and the Chief Medical Officer at the FDNY, in the analysis published in JAMA Cardiology. Relatively few, if any, patients were tested to confirm the presence of Covid-19, says the research team. “So we couldn’t distinguish between cardiac arrests attributable to Covid-19 and those that may have resulted from other health conditions,” explains Dr Prezant.
The NYC 911 emergency medical services (EMS) system is the largest in the US serving a population of more than 8.4 million and responding to more than 1.5 million medical calls annually. In the NYC 911 system, cardiac arrests receive the highest response priority and three units — firefighter-certified first responders, basic life support units and paramedic advanced life support units — are immediately dispatched.
Using data from the NYC 911 EMS system, the study compared patients with out-of-hospital cardiac arrest who received resuscitation during the Covid-19 period and their outcomes with patients and outcomes during the same period in 2019. “Data was analyzed for patients 18 years or older with out-of-hospital cardiac arrest who received EMS resuscitation from March 1, 2020 (when the first case of Covid-19 was diagnosed in New York City) through April 25, 2020 (when EMS call volume had receded to pre-Covid-19 levels). For comparison, cardiac-arrest data was also analyzed for the same period during 2019,” says the team.
Between March 1 and April 25, 2020, 3,989 patients underwent EMS resuscitation attempts for out-of-hospital cardiac arrests, compared to 1,336 patients who were treated during that period in 2019. According to the researchers, the analysis shows there were 2,653 excess out-of-hospital cardiac arrests in 2020, a number that, by itself, represents double the number of patients with out-of-hospital cardiac arrests who underwent EMS resuscitation during the comparable 2019 period. More than 90% of these excess cases resulted in out-of-hospital deaths, some of which likely contributed to the 17,118 confirmed and suspected Covid-19–related deaths that occurred in NYC during the first 8 weeks of the pandemic, they explain.
“A total of 5,325 patients were included in the main analysis (2,935 men (56.2%) and 2,292 women (43.9%). Compared with 2019, 2020 had an excess of 2,653 patients with out-of-hospital cardiac arrest who underwent EMS resuscitation, an incidence rate triple that of 2019 (47.5/100 000 versus 15.9/100 000). The tragedy of the Covid-19 pandemic is not just the number of patients infected, but the large increase in out-of-hospital cardiac arrests and deaths,” says the study.
Risk factors for excess Covid-19-related out-of-hospital cardiac arrests included older age and minority race/ethnicity, after adjustment for underlying health conditions. The analysis shows that on average, the 2020 patients were older (average age of 72 versus 68 for the 2019 cardiac-arrest patients), less likely to be white (20.4% white versus 32.9%), and more likely to have cardiac rhythms that do not respond to defibrillator shocks (92% versus 81%). Further, cardiac arrest patients in 2020 were also more likely to have hypertension (53.5% versus 45.7%), more likely to have diabetes (35.7% versus 26%), and more likely to have physical limitations (56.6% versus 47.5%).
Why might a respiratory disease like Covid-19 trigger heart problems? The researchers say that in addition to overwhelming pneumonia and acute respiratory failure, the novel coronavirus damages the lining of blood vessels, leading to blood clots that can trigger heart attacks even in people with no previous cardiopulmonary diseases.
The findings show that it is critical to intervene early in the course of Covid-19 infection before often-fatal cardiac arrests occur, experts warn. They say that identifying patients with the greatest risk for out-of-hospital cardiac arrest and death during the Covid-19 pandemic should allow for early, targeted interventions in the outpatient setting that could lead to reductions in out-of-hospital deaths. “The findings underline the critical need, particularly during a pandemic, to provide better access to healthcare and outreach for vulnerable patients with chronic conditions. Early, targeted interventions for those at-risk individuals — regular telemedicine visits and home-based monitoring of vital signs including oxygen saturation levels, for example — might help to reduce out-of-hospital fatalities,” says Dr Prezant.