Explained: What led to a six-fold rise in heart attacks in Mumbai in the first half of 2021?

In the period between January-June 2021, nearly 3,000 people lost their lives to heart attacks every month which was around 500 in 2020.

Nearly 23.8 per cent (17,880) of the total 75,165 deaths recorded till June last year in Mumbai were attributed to heart attacks. This information was revealed through an RTI filed by an activist Chetan Kothari.

The raised figures have several questions about the sudden, surge in deaths related to heart attacks. Medical officials have attributed several factors behind the staggering spike – post-Covid development of thrombosis, delay in diagnosis in heart-related ailment amid the second wave, better recording of heart-attack cases, major lifestyle changes and additional distress noticed in the second wave .

What could have been the clinical reasons behind such a surge?

Data provided by the Brihanmumbai Municipal Corporation (BMC) showed that in 2019, a total of 5,849 patients lost their lives to heart attack in Mumbai. This dropped slightly by 3.6 per cent when in 2020, 5,633 patients succumbed to the disease. But, to everyone’s surprise, in the period between Jan-June 2021, a total of 17,880 succumbed to heart attacks in Mumbai with a surge of 217 per cent, compared to the previous year, as per the RTI.

Dr Avinash Supe, in-charge of the Covid-19 death committee, sees three major reasons for the surge in deaths related to heart attack – possibility of development of thrombosis among the Covid-19 recovered patients, delay in diagnosis of patients amid the pandemic and better recording of data.

“Globally, it has been witness that heart attack related deaths increased in the pandemic, so it is not a new phenomenon that has only been observed in Mumbai. Secondly, since the start of the pandemic, the medical practitioners are more conscious in segregation and bifurcation of types of deaths, so it has possibly helped to maintain better data related to heart attacks,” said Dr Supe.

Also, during the second wave, many patients avoided hospitals due to fear of contracting Covid-19, which further delayed life-saving treatment.

Dr Prafulla Kerkar, interventional cardiologist and chairperson of Guidelines Committee of Cardiological Society of India (CSI), said, “The pandemic has been blamed for people with heart attack symptoms reaching hospital late, which pushed up the mortality rate. Reperfusion therapies like Thrombolytic therapy (that dissolve clots) and timely interventions like angioplasty were delayed.”

He also said there is a possibility that patients who died of pre-existing heart conditions like decompensated heart disease or heart failure (the heart doesn’t pump blood as well as it should) were categorized as heart attacks without necessary investigation at a time the The health system was overwhelmed with Covid-19.

“A patient with heart failure is not identified as having a heart attack until it is shown in the ECG and cardiac enzyme levels are elevated. So, there is a possibility that the data also includes cases of heart failure,” he said.

Covid restrictions led to a more sedentary lifestyle. Can this lifestyle change have a correlation with heart attacks?

Other than the critical risk factors, the prolonged lifestyle changes in the pandemic added to the risk of developing heart attacks.

“Life has become more sedentary with less options of socialisation and physical activities. The sugar and cholesterol levels are going haywire along with weight gain. Along with that, during the second wave, a lot of people were under stress – all these can also be contributing to the rise in heart attacks,” said Dr Supe.

Doctors have to witness an increase in the prevalence of diabetes, hypertension, smoking, alcohol use and an unhealthy lifestyle in the last two years.

“Besides the rise in these risk factors, Indians have a genetic predisposition, smaller coronary arteries, a diet pattern with excessive consumption of trans fats and a sedentary lifestyle that puts them in a high-risk category for heart attacks,” said Dr Sanjith Saseedharan. , consultant and head of Critical Care, SL Raheja Hospital, Mahim.

Is there a clinical explanation behind linking Covid-19 with a higher risk of heart attacks?

Since the start of the pandemic, it has been observed that SARS-Cov-2 damages the heart and blood vessels in infected patients which leads to the development of clots, heart inflammation, arrhythmias, and heart failure. The Lancet – a science journal in August 2021 published that in the week after a diagnosis with Covid-19, the risk of a first heart attack increased by three to eight times.

Dr Kedar Todaskar, Director of Critical Care at Wockhardt Hospital and member of Maharashtra Covid-19 task force, said that though no clear-cut cause and effect relationship has been proven, data does suggest that Covid-19 infection was a risk factor for thrombosis – not only arterial but venous thrombosis which included deep vein thrombosis and pulmonary thromboembolism too apart from acute coronary syndromes.

“This is related to the virus interacting with the ACE2 receptors in the host body. So, all the organs with a predominance of ACE2 receptors are involved which includes the endothelium. The endothelium is the inner lining of all the vascular structures in the body which includes the arterial & the venous system. Covid-19 typically causes inflammation of the endothelium which is termed as Covid Endotheliitis. This endotheliitis is the cause of increased thrombotic events, thereby leading to the increase in the cardiac mortality and morbidity seen in the second wave,” he said.

Dr Saseedharan further explained that Covid-19 is an inflammatory disease which has the potential to destabilize plaques in the coronaries, which can lead to myocardial infarction. The severe affection of the lungs can also cause oxygen supply and mismatch, which also causes increased heart attacks. “This means that Covid-19 can also cause microvascular damages, which may have also contributed to heart ailments,” he added.

Some medical experts also raised voices about unscientifically certifying deaths without proper post-mortem or other apparent methods like an angiography proven coronary occlusion in the second wave.

“There is a distinct possibility that many of these patients died at home and thus ‘certified’ like heart attacks by the local general practitioner. Many of them might have not even visited the hospital due to the fear of relatives contracting Covid,” said Dr Saseedharan.

Do we need better multi-centred studies in India for more scientific analysis of this trend?

Dr Abdul Samad Ansari, Director, Critical Care Services, Nanavati Max Hospital, said that many patients have suffered from Acute Cardiac Events during the pandemic due to the thrombotic state created by the infection.

But he also raised the need for better investigation by involving population dynamic or demographic statistics, past history of Covid-19 infection, vaccination status and existing medication routine.

“If these patients had no history of past or present Covid infection and died purely due to cardiac complications, then the causes could be major lifestyle changes, additional distress or any new clinical anomaly, yet to be analysed. It’s advisable to read the data in conjunction with associated risk factors for cardiac complications,” he said.

Dr Shashank Joshi, member of the state Covid-19 task force, also laid emphasis on proper audit and scientific analysis.

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