Months after the coronavirus pandemic first shut down nonurgent medical services, and hospital admissions plummeted, Philadelphia-area health systems say patients are beginning to return for visits — but critical stroke and cardiac cases are still troublingly low.

A below-average number of stroke and heart attack cases is worrisome for hospitals because these are emergency events that can’t be curtailed by a pandemic the way stay-at-home orders and shuttered offices may explain fewer car accidents. What’s more, although lots of nonurgent care and preventive screenings were delayed because of the pandemic, strokes and severe heart conditions must be treated quickly — within hours — or patients risk irreversible long-term damage and fewer treatment options.

“We had people die because they waited too long,” said Merle Carter, vice chair of emergency medicine for Einstein Healthcare Network, whose emergency department saw significantly fewer patients between March and May. Many of those who did show up had waited too long.

“They’d come in with facial droops they had for two or three days,” Carter said. “If they’d come in when it started … we might have been able to help.”

Now, doctors are increasingly concerned that a potential surge in COVID-19 cases in the fall could make matters even worse.

Stroke and cardiac cases dropped during the pandemic

As more businesses reopen, and people begin to resume more of their pre-pandemic routines, they are also coming back to the doctor. But Philadelphia-area hospitals report that in many cases, their patients are now sicker.

“We really do see two health crises for 2020: the first being the pandemic, the second being the impact of the care that wasn’t delivered,” said Jonathan Gleason, chief quality officer for Jefferson Health. “We’re seeing patients with more advanced disease and having some unfortunate outcomes that could have been prevented had they sought care earlier.”

In April, when COVID-19 cases peaked at Philadelphia-area hospitals, Jefferson’s severe heart attack and stroke volume was down 40% compared with April of last year. Between February and May, those types of cases were 25% below the number of cases in the same four-month period last year, which indicates that stroke and heart patients began returning to the hospital in the spring — but not entirely, Gleason said.

Penn Medicine also saw a drop in heart attack and stroke cases, but over the last month, those patients have been returning at about the same rate as the health system’s overall patient volume, said Jay Giri, an assistant professor of cardiovascular medicine at Penn.

Between March and May, heart attacks were down 25% and stroke cases were down 14% at Penn Medicine, compared with the same time last year.

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The declines are worrisome because doctors don’t believe that patients necessarily had fewer stroke and cardiac episodes — they just didn’t come to the hospital for help.

“We’re worried about the downstream effects of a future stroke. Maybe they didn’t have a disabling deficit this time, but two months down the line, they can’t move their whole left side,” said Lori Lorant-Tobias, medical director of Pottstown Hospital’s emergency department, where stroke cases were 52% lower in April than the same month last year.

Across the entire Tower Health system, which includes Pottstown Hospital, stroke cases were down 15% and heart attacks were down 16% between February and June, compared with the same time last year. St. Christopher’s Hospital for Children, also part of Tower, isn’t included in the data because it does not treat stroke and heart attack.

Even more troubling, a new study published in JAMA suggests that delaying treatment for emergencies such as heart attacks may have been fatal for some patients.

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The study looked at “excess deaths” — the number of deaths above what is expected based on past data — in March and April, many of which were attributed to COVID-19. But other “excess deaths” were attributed to chronic diseases, including diabetes, heart disease, Alzheimer’s disease, and cerebrovascular diseases such as stroke, said Steven Woolf, director emeritus of Virginia Commonwealth University’s Center on Society and Health and the study’s lead author.

Woolf and his colleagues offered two potential explanations for these deaths: Some were likely people who died of complications from undiagnosed COVID-19.

“The other possibility,” Woolf said, “is they didn’t have COVID-19 but died of other things because they could not receive care for an acute emergency.”

Fall COVID-19 surge could delay care again

With more chilling data surfacing about how COVID-19 has already affected patient care, hospitals are relieved to see patients returning for routine visits. But doctors are still worried that the effects of delayed care — both urgent needs, such as heart problems, and more routine care, such as preventive cancer screenings — could continue for months to come. And a potential surge in COVID-19 cases in the fall could make matters worse.

“Time really is everything in the treatment of many of these conditions,” said Gleason, of Jefferson. “The impact on any one individual may not be significant, assuming people rapidly begin to resume care, but apply it to a whole population, and it becomes a really big issue.”

Much of the decline in medical services during the pandemic can be attributed to state-mandated shutdowns of all nonurgent procedures, a move that many states made to preserve valuable personal protective equipment, ventilators, and medical staff to treat a surge of COVID-19 patients.

But hospital emergency departments remained open for truly urgent cases. These types of cases dropped in part because people were reluctant to go to the hospital and risk exposure to the virus.

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Hospitals are now strategizing how they can learn from the last several months to prevent another major drop in non-COVID-19 cases, should the virus bring back fears about seeking care in the fall.

Sending a strong message that the hospital is safe is a major part of that preparation, said Giri, of Penn.

Not only is the hospital safe, “it’s a place where everyone actually follows the rules,” he said.

“There’s been a lot of controversy over masks and social distancing. There is no controversy over these issues in the hospital,” Giri said.