The ongoing pandemic of the novel coronavirus SARS-CoV-2 disease (COVID-19) unsettles people worldwide and has led to 287,399 deaths globally by May 13, 2020 [1]. To protect the local health system from overload and to maintain intensive care capacities for COVID-19 patients, elective admissions have been reduced and postponed. In addition to hygiene advices, the World Health Organization (WHO) strongly recommends limiting face-to-face contact with others via social distancing [2]. Subsequently, changes in the pattern of hospital admissions have been observed [3‐6]. Valuable time passes with the ubiquitous differential diagnosis of respiratory insufficiency caused by COVID-19, which is frequently aimed to exclude before detailed examinations (e.g., physical examination, ultrasound, computed tomography, coronary angiography) take place [7]. Therefore, concerns have been raised regarding underdiagnosing of harmful but treatable cardiovascular diseases.

At the Saarland University hospital, a tertiary referral center, a significant decrease in medical contacts at the emergency department and the number of patients presenting with ACS was documented during the first wave of the COVID-19 pandemic. This was mainly driven due to an 85% decrease in admission for unstable angina during shutdown conditions whereas the reduction in admissions caused by myocardial infarction was not significant. Regarding acute cerebrovascular events there was a numerically reduction in our analyses.

During the past weeks, reports on increasing numbers of COVID-19 positive patients in China, US and Europe dominated the reporting in the lay press and resulted in pressure on health care systems like in Northern Italy. This coverage led to great fear and uncertainty in several countries, including Germany [10]. In England attendances at the emergency department have fallen by 25% the week after the prime minister Boris Johnson announced a lockdown on 23 March [11]. Similar decline of emergency department visits could also be observed for paediatric emergency department visits [6]. To exclude a seasonal effect in the analyses, we compared the visit volume with the same period of the previous year. Proportionally more patients who had been admitted to the emergency department subsequently required inpatient treatment, indicating that consultations for less severe reasons decreased. In calendar weeks 15–16, the emergency department visit volume graphs of 2019 and 2020 get closer, which may have several reasons like behavior and travelling attitudes. Exemplarily, Christmas and Midsummer holidays have been associated with higher risk of myocardial infarction; a weekend-effect with delay in coronary angiography for NSTEMI resulting in a higher mortality has been described [12, 13]. Behavior during the Easter holidays may have been different in 2020 due to the government restrictions in Germany. In 2019 (Easter at calendar week 16), the festivity with the family and/or a short vacation was obvious, so that more trivial health problems potentially were solved in the family itself and a relevant number of people were located abroad. In 2020 (Easter at calendar week 15) neither a family visit nor a journey was allowed due to the lockdown in our region. Patients who had previously postponed their doctor’s appointment may have gone to see a doctor due to the increasing level of suffering.

We found an “atypical” low number of cardiovascular events compared with the weeks before the regional outbreak of the pandemic and compared with the same period of the previous year. A similar trend was observed in cardiovascular centers in Austria [14], the severely affected Northern Italy [3] and Iran [15]. It can be assumed by a stable incidence of patients having an ACS that patients abstain from seeing a doctor despite symptoms of acute myocardial ischemia. This is in line with the increasing number of out-of-hospital cardiac arrest in Italy compared with the same period in 2019 [4]. In COVID-19 patients, cardiac injury is a common feature whereby the mechanisms have not yet been finally clarified [16]. In our analyses, there was only one patient with myocardial infarction who was tested positive for the virus, but regarding a total number of 62 patients presenting with ACS the ratio was 1,6%—and is therefore in the area of the overall prevalence in our hospital. A significant reduction in catheterization laboratory activations during COVID-19 pandemic due to a decline in patients with STEMI was observed in the US [17].

Although the difference was not statistically significant, we documented a numerically lower number of transient ischemic attacks and ischemic strokes. According to the World Stroke Organization there is a significant fall in stroke presentations globally [5]. One may speculate that patients with mild or moderate symptoms refrain from consulting health care providers. The increase in intracerebral haemorrhage could be (1) directly attributed to underdiagnosed and therefore undertreated cerebral ischemia, (2) less strictly controlled blood pressure values due to reduced contacts with doctors or (3) an increase of accidents in the household (e.g., due to self-made construction work or family violence during the shutdown and government restrictions) [18‐21].

Coagulopathy, inflammatory responses, and endothelial dysfunction are associated with COVID-19 [22‐24]. As a result of this, with (symptomatic as well as asymptomatic) spread of SARS-CoV-2 infection an increased rate of acute cardiovascular and acute cerebrovascular events can be assumed [25]. The reduction in ED numbers was not substantiated by an objective increase of COVID-19 infections. Despite testing the day of admission, by now, we identified only one patient with acute myocardial infarction and one patient with acute cerebrovascular event with coincidental SARS-CoV-2 infection. In addition, only one patient with previously known COVID-19 was admitted with an acute cerebrovascular event. Given the overall low number of positive test at our hospital, patients’ concern about an increased risk of infection in the hospital appears unsubstantiated.

As a result of the legal provisions that no non-urgent or preventive medical examinations should take place during the shutdown, it can be assumed that a high rate of underdiagnosed diseases can be expected. The general recommendation to reduce social contacts in everyday life wherever and whenever possible led more people to stay at their presumed safe homes. This recommendation could have impaired respectively delayed scheduled and unscheduled doctor visits. Whether the rate of successfully treated COVID-19-positive patients outweighs the high number of undiagnosed diseases caused by the shutdown remains to be answered. It would be fatal if there would be an increase in deaths—especially in those without COVID-19 having harmful, but treatable diseases.

Patients presented directly at the department of neurology and pediatrics or transferred directly to specialized departments were not included in the analysis of the total number of patients presented at the central emergency department at the Saarland University Medical Center.

The COVID-19 pandemic is associated with a significant decrease in all-cause admission and admissions due to acute cardiovascular and potentially cerebrovascular events in the emergency department. Regarding acute cerebrovascular events there was a numerical difference which needs to be scrutinized in large sample series. Increase of test capacity adapted to the pandemic process up to the general testing for inpatients has been succeeded in order to be able to maintain standard medical care and offers chances to restart indicated preventive medicine. Essential part of successful medical treatment maintains the step that the patient comes to see a doctor at all. As a result of these observations, regional media campaigns as already started are important to encourage patients to continue to see a doctor if they have health-related problems.