Abstract
The COVID-19 pandemic has had a profound impact on healthcare worldwide.
Emergency presentations to hospital unrelated to COVID-19 have
generally, significantly reduced. At our centre we have observed a
substantial surge in the number of patients presenting with type A
Aortic dissection (TAD). Despite having the warmest April on record, we
have performed 8 TAD repairs, more than in any single month over the
last decade. On histopathological examination there is no evidence of a
direct link between the COVID-19 virus. We hypothesise that this surge
relates to exacerbation of hypertension due to the substantial increase
in mental health problems observed, associated with the pandemic and the
‘lock-down’ required to control the spread of the virus.
During these unprecedented times we have seen a significant reduction in
emergency medical attendance for non-COVID-19 associated illness.
Despite this general trend, there has been a substantial increase in the
incidence of acute type A aortic dissection (TAD) at our centre.
We have performed 8 TAD repairs in April 2020. This is more than in any
single month during the last decade. The mean number of TAD repairs in
April over the previous 10 years was 2.1 (Table 1). Furthermore, several
additional patients referred were transferred elsewhere due to our
intensive care capacity.
The seasonal variation in TAD incidence is well documented, with a
significantly greater occurrence during winter, peaking in January as we
observe in our own data (Table 1)1. The
pathophysiological mechanism behind this is thought to be the influence
of lower climatic temperatures raising arterial blood pressure through
increased sympathetic activity exacerbating hypertension – one of the
key aetiological factors for TAD1. In the UK, April
2020 has been the warmest since records began and from this, we would
have expected a drop in the usual incidence of TAD for this time of
year.
A recent report has suggested an association between regional influenza
activity and higher admission rates for TAD, although the
pathophysiological explanation for this remains unclear and direct
evidence of influenza in aortic tissue has not been previously examined
in the context of aortic dissection2.
Histopathological assessment of the resected aortas of patients in our
series has not identified any evidence of an aortitis or suggestion of a
direct link with COVID-19. Furthermore, none of our TAD patients have
been symptomatic of COVID-19 at the time of presentation, nor had they
history of having had the disease. They may, however, have been
asymptomatic carriers.
This surge in TAD may in fact be associated with increased psychological
stress associated with the COVID-19 pandemic. The UK population has been
subjected to a “lock-down” with social isolation since March
23rd. With the lock-down came increasing unemployment,
potential financial difficulties and uncertainty together with an
existential threat to life, which has undoubtedly caused a prolonged
period of increased stress. As early as towards the end of March 2020
mental health experts warned of a “second pandemic” of acute stress
disorders, post-traumatic stress disorder, emotional disturbance, sleep
disorders, depressive syndromes and eventually
suicides3. Indeed, this has become a reality. A review
of the impact of COVID-19 on mental health in China, revealed an
incidence of anxiety and depression in as many as 35% of survey
respondents4.
A recent report from New York has observed a 76.5% reduction in
incidence of TAD during the pandemic5. However, they
report a significant increase in ‘at-home’ deaths over this period and
postulate that patients may be fearful of seeking medical attention
during the pandemic and that there has actually not been a true decline
in incidence of TAD. In sharp contrast to healthcare in the USA, the
National Health Service in the UK is publicly funded, and this may well
be responsible for our differing experiences of TAD presenting to
hospital.
It is widely recognised that stressful events can incite the development
of a TAD by acute exacerbations of hypertension, and the prolonged state
of heightened anxiety associated with the COVID-19 pandemic may have
tipped the balance for many patients.
At the same time, it has been reported that general practitioner
appointments in the UK have fallen by at least 30% over this period. It
is not difficult to see how a combination of increased mental stress and
reduced health care provisions might lead to an increase of episodes of
poorly controlled hypertension and subsequently in the incidence of TAD.
We aim to highlight the increased incidence of this life-threatening
disease during the current pandemic as a reminder to the medical
community of this important, but often delayed, diagnosis.