Chest pain patients presenting to the ED at a regional University Hospital in Norway were analyzed in this study, examining how this patient population responded to the Covid-19 pandemic and subsequent national lockdown. The main findings were that 1) ED visits due to chest pain decreased substantially following the outbreak of Covid-19 and subsequent national lockdown. The abrupt decline persisted almost four months before normalizing. 2) Accompanying this decline was a relative decrease in elderly patients initially, but no apparent differences among sexes were found. 3) The marked drop from ORANGE to YELLOW triage levels imply that the patients on average presented with less severe symptoms.
Following the national lockdown in week 11, substantially fewer patients with chest pain presented to the ED at St. Olav’s University Hospital. The 35% decline in weekly visits following the national lockdown is compatible with the findings of a study by Myhre et al [14]. An initial report on the ED patient population at St. Olav’s University Hospital depicted an overall decline in all ED patient groups in the same period. By week 12, there were 39% fewer ED visits compared to weeks 2–10 [6]. Thus, the decline in ED visits at St. Olav’s University Hospital seems to be slightly more pronounced in the general ED population than in chest pain patients, a trend also noted in Italian data [4]. It is however unknown whether the general ED visits continued to decline after week 12 or not, which would result in a greater difference between these groups if this was the case. Such findings were reported in Finland, where a marked drop in ED visits following the national lockdown was accompanied by stable rates of admissions due to acute myocardial infarction [15]. The other possible scenario, where the number of ED visits recover or stabilize, entail a delay in the decline of ED visits due to chest pain compared to the general ED population. A large US multicenter study reported a faster recovery of visits due to serious cardiac conditions compared to overall ED visits [16]. Similarly, acute myocardial infarction cases recovered relatively faster also in Germany [5]. This could imply that the impact of Covid-19 has been greater in other patient populations compared to the chest pain population.
The number of ED visits due to chest pain at St. Olav’s University Hospital gradually recovered from the initial decline, normalizing in week 28 compared to 2019 data. There were 16% fewer patients presenting to the ED due to chest pain throughout weeks 11–27 compared to 2019, corresponding well to the overall reduction in ACS admissions seen in England in the same period [17]. The decline was however greater at its peak in England than in the current study [7], as was also seen in other European studies (39 to 45%) [4, 8]. Focusing on the initial four-week period (week 12 to 15) following the national lockdown in Norway, a 19% reduction was found. A German multicenter study reports a 39% reduction in admissions due to acute myocardial infarction during the same weeks [18], in line with Mafham et al.’s findings in England [7]. Although the study populations are not directly comparable, this suggests a greater and longer lasting initial decline in ACS admissions in Germany and England. Despite the decline being evident in England from week 10 [7], one week earlier than in the ED at St. Olav’s University Hospital [6], the national lockdown in Norway was implemented 11 days earlier than in England. One might speculate that the early initiation of a national lockdown in Norway contributed to a less severe course of Covid-19 throughout the study period. This could have resulted in fewer deaths from cardiovascular disease and lower total mortality in Norway during the lockdown period as reported by the NIPH, contrary to the development in many European countries [19]. According to Mafham et al., weekly ACS admissions had approximately recovered by August [17], a month later than in our data. In both Italy and Germany, the admissions and prevalence of acute myocardial infarction normalized in May [5, 20]. Considering that the delayed normalization in England also is seen for all acute myocardial infarction admissions (not only in the total ACS population) [17], it is likely that there is a genuine difference in the timing of normalization.
Relatively fewer elderly patients (over 60 years) presented to the ED at St. Olav’s University Hospital due to chest pain following the national lockdown in Norway (weeks 11–15). While similar findings were reported in a general ED population in the US [21], the opposite was found in New Zealand [22]. Considering the association between increasing age and increasing mortality from Covid-19 [23], one could expect the elderly to be more afraid of the consequences of acquiring Covid-19. Furthermore, the fear of Covid-19 infection is regarded as one of the most important factors causing the decline in ED visits [6, 8, 11]. This could potentially explain the disproportionate decline in elderly patients in our data. Additionally, emergency care of elderly patients is often initiated by their relatives [5]. The social distancing measures implemented to contain the spread of SARS-CoV-2 presumably resulted in elderly patients being isolated from their relatives, thus unintentionally preventing ED referrals of many elderly patients [5, 11]. Counteracting measures should therefore be considered to ensure adequate acute health care services for the elderly in similar situations in the future.
It is possible that the same mechanisms were at play during the general staff holiday (weeks 28–30), where relatively fewer elderly patients visited the ED due to chest pain compared to 2019. While the median age remained stable at 60 throughout weeks 28–30 in 2020, it peaked at 72 in week 29 in the corresponding 2019 period. Further examinations of this unexpected finding by differentiating the study population into 10-year age groups, revealed a substantial rise in the number of patients over 70 years old. A similar rise did not take place in 2020, where only 48 patients over 70 years presented to the ED in this period compared to 64 in 2019. There were profound declines in the total ED visits due to chest pain throughout this period both in 2019 and 2020, thus it seems as though the surge of elderly patients in 2019 were compensated by an increase in younger patients in 2020. This increase could be caused by more younger people staying at home due to travelling restrictions, contributing to an impression of normalizing numbers of ED visits during the general staff holiday.
Generally, chest pain patients sought out medical advice equally throughout the study period regardless of severity. The same trend was demonstrated in the general ED population at St. Olav’s University Hospital early on (6). Compatible findings are reported in the US (11, 23), although Italian data suggest that the patients on average were more severely ill (4). This could be attributed to the immense pressure on the Italian healthcare system in an early phase of the pandemic (24). In the current study, the proportion of patients triaged as ORANGE dropped (64–51%) during the Covid-19 period (weeks 11–27, 2020) compared to 2019, while patients triaged as YELLOW increased (28–43%). This implies that chest pain patients presenting to the ED at St. Olav’s University Hospital during the Covid-19 period were less severely ill than the previous year. The opposite was noted in New Zealand regarding triage levels, where the proportion of low acuity presentations decreased significantly (21). Considering that other parameters indicating severity were more in line with the current study, this is difficult to interpret. One might speculate how well the triage levels reflect the severity of these cases. The Norwegian Directorate of Health reported an 18% increase in patient contacts with GPs, and a 34% increase in the use of urgent care centers nationally during March 2020 compared to March 2019 [24]. In line with the gatekeeping role of the GP, one might speculate whether the threshold for referring patients to the ED increased in this period of high demand. Presumably, this would have resulted in relatively fewer low acuity presentations, which is not found in our data. This suggests that other mechanisms were more prominent in causing the decline in patients presenting to the ED. Moreover, no in-hospital mortality was recorded in the study population for several months during the Covid-19 period. This result could be coincidental considering the small data size, but it is in line with reports of normal or lower excess mortality rates in Norway in this period [25]. Other surrogate markers of severity used in this study, such as discharge diagnosis and level of care, did not indicate changes in the degree of severity, thus making the interpretation of these findings difficult.