Christine M. Albert, MD, MPH, FACC, and Joanna Chikwe, MD, FACC

The experience of COVID-19 in the U.S. is a tale of two countries. National headlines have focused on health care systems overwhelmed by patients, exponential spread and high mortality in cities such as New York and New Orleans and in states like Michigan. But this has not been the experience of much of the U.S. Take California, which at 40 million has a population double that of New York state's 19 million.

Although it now appears that SARS-CoV-2 was circulating in the San Francisco Bay area for several weeks before the first cases were recognized in New York State, the impact of the disease has been vastly different. This is largely because early and effective social distancing slowed growth to a tiny fraction of the cases and deaths observed in New York.

Fortunately, despite extensive surge preparations, far fewer COVID-19 patients have needed hospital admission in California compared with New York. This may also partly explain why outcomes of hospitalized patients in California, where frontline staff and resources were never as overwhelmed as their New York counterparts, have been remarkably good.

However, this flattening of the COVID-19 curve has come at a terrible cost. Patients are now scared to go to their primary care doctors, their cardiologists' offices and the emergency room, where admissions are down by over 70% in many institutions.

Outpatient offices are also empty. Instead of the regular flow of patients for cardiovascular screening, elective assessment and intervention, we are seeing ventricular free wall rupture and ischemic ventricular septal defects often too late to salvage.

There is no way of knowing how many patients are dying at home of cardiac causes unrelated to COVID-19 because they have delayed seeking medical attention. One hint is that the mortality in most states last month was many times higher than normal, and only half of that was attributed to coronavirus.

While reducing nonessential medical care was a key part of the strategy for hospitals facing overwhelming demands on their critical care capacity, in the rest of the country where hospitals are sitting empty there is increasing concern that a quiet epidemic of cardiovascular mortality may exceed anything due to SARS-CoV-2.

The catheterization laboratory and operating rooms are quiet too. This is partly because that same normal flow of patients from primary care check-up to cardiology offices, testing and referral has completely ground to a halt.

It is partly because many states banned elective cardiac procedures for weeks to ensure there was sufficient critical care capacity for what was projected to be thousands of patients needing ventilators.

In states like California this never materialized, and the ban on elective care was lifted in early May. However, when we call patients to offer them a date for the cardiac surgery they still need, almost all of them – with the news headlines from New York, New Orleans and Michigan in mind – say, thank you but they prefer to wait a month or two longer.

Health care institutions and government are understandably extremely cautious about promoting a message that it is safe to see your health care provider and safe to go to the hospital for elective procedures.

The balance of risks for the truly elective cardiac patient is entirely different from the patient needing emergency surgery.

The risk associated with a hospital stay may not be the main issue, because the hospital has the ability to control exposure to SARS-CoV-2 through screening staff and patients, creating isolation areas, and changing how we interact with patients and each other.

Probably the greater challenge now is the risk of community spread of SARS-CoV-2 to patients after they have been discharged home. Again, lack of granular data on true disease prevalence and outcomes limits our ability to make informed decisions with our patients.

Much of this uncertainty will not be resolved soon. If we agree there is a significant and unacceptable increase in cardiac mortality, several things need to happen now to mitigate this particular curve, irrespective of the uncertainty.

First, regions like California where Sars-CoV-2 occupies a small fraction of critical care capacity, must start using the channels employed so effectively to keep patients at home to tell then it is safe to seek medical care, with a united message to the community from all care providers.

Second, we must support our community physicians: we need to recognize they are our best way of ensuring that patients who need hospital care receive it; perhaps even more importantly, they are key in reducing the need for hospital care through effective prevention and medical management.

We must ensure community physicians weather the financial and personal storms of this pandemic, with the resources they need to deliver patient care in this "new normal."

The emergency and critical care services have been the front line for COVID-19. Now primary care and cardiology offices are our best hope to prevent a surge in cardiac mortality.

Clinical Topics: Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, COVID-19 Hub, Cardiac Surgery and CHD and Pediatrics, Congenital Heart Disease

Keywords: ACC Publications, Cardiology Magazine, COVID-19, Pandemics, Coronavirus, Internship and Residency, Patient Discharge, Length of Stay, Fellowships and Scholarships, Hospitals, General, Heart Septal Defects, Ventricular

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