According to a recent report in The Indian Express, Mumbai witnessed a six-fold rise in deaths related to heart attacks in the first six month of 2021 during the second wave of Covid-19 as compared to the previous year.
“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% (17,880) of the total 75,165 deaths recorded till June last year in Mumbai were attributed to heart attacks,” the report said.
The numbers came to light in a reply to an RTI request filed by activist Chetan Kothari. But before we take a look at why we saw a sharp rise in the number of deaths, and its link with Covid, it is important to know what causes heart attacks, and why Indians are more susceptible to them.
Heart of the matter
Inflammation in the body — akin to the swelling, redness and warmth of a boil on the skin — is the ‘sine qua non’, or a stage set up for many diseases, including cardiovascular diseases, of which heart attacks and sudden deaths are the two most dire complications.
Inflammation is not only the underlying cause, but also a trigger for cardiovascular events like heart attacks (acute myocardial infarction), and sudden cardiac arrest as detailed above.
Unfortunately, many of us Indians are already predisposed to an inflammatory state in the body because of our lifestyle — for instance, too much sitting; too little sleeping; a diet full of refined starch, sugar, saturated and trans-fats; psycho-social-financial stress; conditions like abdominal obesity, prediabetes, diabetes, cholesterol, hypertension and smoking. These are all detrimental to our health. Chronic inflammatory diseases like rheumatoid arthritis, psoriasis, kidney and lung diseases etc are also additional predisposing states.
If we are to go by the recent study of CT angiography in people without heart symptoms, published by the American Heart Association journal Circulation Heart Failure Circulation — at least 40% of Indians above age 50 could be carrying fatty deposits (atherosclerotic plaques) in their coronary arteries due to the above risk factors, causing varying degrees of narrowing in the coronary arteries.
Indians are predisposed to an inflammatory state in the body because of our lifestyle — sedentariness, less sleep, a diet full of refined starch, sugar, saturated and trans-fats, and conditions like abdominal obesity and diabetes
What’s the Covid link
In severe Covid-19 infections, the heart and lungs are the organs most affected by the intense inflammation triggered by the virus. Like any acute inflammation or infection, the virus can release chemicals in the blood, called cytokines, along with stress hormones cortisol and adrenaline, which can destabilise atherosclerotic plaques.
In other words, fatty plaques along the lining of coronary arteries, which were lying quiet, suddenly rupture, the way a skin boil ruptures, exposing a raw surface where the flowing blood clots. Such a clot embedded on a fatty plaque narrows the coronary artery further, or completely chokes it, causing a heart attack (acute myocardial infarction) in which the person experiences chest pain lasting more than 15 to 20 minutes.
In severe Covid-19 infections, the heart and lungs are the organs most affected by the intense inflammation triggered by the virus
Sometimes the sudden narrowing of the artery may stop the rhythmic beating of the heart and cause sudden cardiac arrest after the patient experiences chest pain or even before he or she experiences any symptoms.
Thus, one can see that the best treatment for a heart attack patient is to reach the hospital as soon as possible so that the blocked coronary artery can be opened with clot dissolving injection, or balloon angioplasty, or by both serially. (A cardiac arrest victim has to be resuscitated then and there to prevent brain death, as the heart has stopped beating and supplying blood to vital organs like the brain).
What makes Covid so dangerous?
Besides the destabilisation of fatty deposits in already diseased arteries, as discussed above, Covid infection can cause severe inflammation of the inner lining of all arteries and veins (endothelium) of the body predisposing it to clotting and spasm.
Thus, on the one hand, thrombi (clots) can form in arteries and veins causing heart attacks, strokes and venous thrombo-embolism (from the leg veins to the lungs), respectively, and on the other, people with heart attacks fare worse if already infected with Covid.
In addition, the coronavirus, directly or indirectly (through low oxygen levels, sepsis etc) injures the heart muscle (myocardium) weakening its pumping (causing myocarditis and heart failure) and generating rhythm abnormalities.
Why did the numbers rise?
One can imagine how Covid-19, especially the second wave (March-May 2021) made for a perfect setting for increased number of heart attacks and deaths. Let’s not summarily look past the months of sedentariness, social isolation, mental stress, increased prevalence of hypertension and diabetes, and low turnout for check-ups and consultation.
Late reporting to hospitals after the onset of symptoms like chest pain and breathlessness due to fear was an additional spoiler, negating or markedly reducing the benefits of revascularisation (opening the blocked coronary artery with “clot busting’ injections, or balloon angioplasty, which are more successful, the earlier they are administered) and other treatments.
I recall a case of a 75-year-old diabetic gentleman, who complained of chest pain at night while sweating, from last year. Their family physician advised them to get admitted immediately, but the fear of getting Covid during hospitalisation prevented him from going to the hospital.
Next day, he had a recurrence of severe chest pain and now, by the time he was admitted to the hospital, his heart muscle was severely and irreversibly damaged, and he was in a state of shock with very low blood pressure. Such patients of cardiogenic shock do not respond well to clot dissolving drugs, or balloon angioplasty, and have high mortality. Unfortunately, despite all efforts and huge cost, the gentleman passed away.
Late reporting to hospitals after the onset of symptoms like chest pain and breathlessness due to fear of contracting Covid infection contributed to the rise in heart attack-related deaths
Stories abound of people who have succumbed with cardiac arrest even before reaching the hospital. In some, the problems persist even after a Covid infection subsides. Last year’s August 14 issue of The Lancet reported a study, which showed that in the week after a Covid-19 diagnosis, the risk of a first heart attack (and brain stroke) increased by three to eight times.
This persistence of low grade inflammation could have made people in 2021 more susceptible to heart attacks due to the infection they had in 2020. Add to this the increased number of cases in the second wave (March-May 2021) due to the rapid transmission of the mutant virus, and better reporting, and we have reasons for the heightened number of heart attack deaths in 2021.
Of course, there could be a possibility of some mislabelling of deaths due to heart failure or sudden deaths as heart attack deaths, increasing the figure still further.
As we have seen, a heart attack or acute myocardial infarction is chest pain due to a blocked coronary artery, whereas sudden cardiac arrest and death due to heart failure (weak pumping capacity of heart) are strictly speaking different. Some of these cases could have been labelled as heart attack deaths.
The writer is an interventional cardiologist practicing in Mumbai and author of the book ‘Romancing the Heart: Understanding, Preventing, Reversing and Healing Coronary Heart Disease’