Forgetting “routine” deep venous thrombosis and stroke during COVID-19 is a parallel pandemic that will be costly if ignored

The current COVID-19 pandemic has resulted in a huge strategic and clinical change within the UK National Health Service (NHS) to ensure that it can cope with the surge in demand of respiratory patients. However, when attention is acutely shifted, routine care will suffer and that could be deadly for some and enormously expensive for the NHS in the long term. Fig , A, shows the increasing public interest over time relating to COVID-19 search terms in the Google Trends health category for the United Kingdom (UK) over the last 30 days. Clearly, COVID-19 is of significant interest for the population of the UK.

Fig.

Thirty-day variation for internet searches for information on COVID-19 (A), deep venous thrombosis (DVT) (B), and stroke (C) in the UK.

The National Institute of Clinical and Healthcare Excellence guidelines recommend compression duplex ultrasonography for deep venous thrombosis (DVT) within 4 hours of presentation if possible, or within 24 hours after medical mitigation.¹ Because the UK went into lockdown on March 23, 2019, six acute NHS trusts performed on average (mean ± standard deviation) 27 ± 12 duplex scans for DVT, where 21% were positive. This is compared with the exact same week in 2019 where 70 ± 35 scans were performed, 20% of which were positive for DVT. This represents a 61% drop in DVT assessment and up to 59% of potential DVTs that have not been identified.

Fig, B, shows the decline in interest over time of public searches using search terms of DVT in the Google Trends health category in the UK. Fig, B, highlights a similar decrease to that we have seen in DVT referrals for duplex. Venous duplex referrals are a surrogate for the number of patients accessing primary or secondary care for DVT. Therefore, the decline seen may not be due to administration or medical abandonment but perhaps due to cultural avoidance of health care as a result of COVID-19 fear.

Similarly, the National Institute of Clinical and Healthcare Excellence guidelines recommend carotid duplex within 7 days of stroke symptoms.² Since the UK lockdown, seven acute NHS trusts, which include four regional hyperacute stroke centers, have performed on average (mean ± standard deviation) 12 ± 6 carotid duplex scans where 19% had greater than 50% stenosis. This is compared with the same week in 2019 where 24 ± 16 carotid duplex scans were performed with 21% having greater than 50% stenosis. This represents a 50% drop in referral for carotid scans and up to 54% of significant stenosis not identified.

Fig, C, demonstrates the decline in interest over time of public search terms for stroke in the health category of Google Trends in the UK. Again, the decline in referrals for carotid duplex, which is a surrogate for the number of patients presenting at rapid access clinics with transient ischemic attacks, may not be due to pandemic administration change or medical abandonment but perhaps due to public cultural avoidance of health care as a result of COVID-19 fear.

Our data poses four important questions:

• 1.Has COVID-19 changed the public priorities around their health choices?
• 2.Are physicians prophylactically treating DVT to avoid referring their patients into secondary care for duplex scanning (to avoid potential COVID-19 infection)?
• 3.Has the incidence of stroke and DVT actually decreased in the community through stress reduction of home working and isolation/encouraging more healthy living?
• 4.Are non-COVID-19-related pathologies being missed during this time of critical strain on the health care system?

During this time of significant change, it is important that public health officials continue to promote appropriate and timely uptake of primary and secondary care and not just social distancing, even more so if we face a protracted period of isolation. If they fail, we will face a parallel pandemic of post-thrombotic limb syndrome, venous ulceration, and disabling stroke, the personal and societal cost of which will be ghastly and avoidable.