COVID-19 Resource Center

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Disclosures: Einstein reports he received consultant fees from W.L. Gore and Associates; institutional grant support from Canon Medical Systems, GE Healthcare, Roche Medical Systems, W.L. Gore and Associates and XyloCor Therapeutics; and travel/accommodations/meeting expenses from HeartFlow. Wadhera reports he received research support from the NHLBI/NIH and previously served as a consultant for Regeneron. Please see the studies for all other authors’ relevant financial disclosures.
January 11, 2021
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CV diagnostic testing down, ischemic heart disease deaths up during COVID-19 pandemic

Disclosures: Einstein reports he received consultant fees from W.L. Gore and Associates; institutional grant support from Canon Medical Systems, GE Healthcare, Roche Medical Systems, W.L. Gore and Associates and XyloCor Therapeutics; and travel/accommodations/meeting expenses from HeartFlow. Wadhera reports he received research support from the NHLBI/NIH and previously served as a consultant for Regeneron. Please see the studies for all other authors’ relevant financial disclosures.
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Deaths associated with CVD rose during the onset of the COVID-19 pandemic in the U.S., and the elevated mortality may be associated with a global trend in reduced CV diagnostic testing during that time, researchers wrote.

The prevalence of cardiac diagnostic testing dropped up to 64% worldwide during the pandemic period. During that time, researchers observed notable increases in rate of death associated with ischemic heart disease and hypertensive disorders, according to two studies.

Worldwide, cardiac diagnostic testing declined during the pandemic and was variable by country and region.

Both papers, published in the Journal of the American College of Cardiology, proposed that health care system factors may have contributed to the decline in cardiac diagnostic testing and the increase in deaths associated with certain CVDs.

COVID-19 and CVD diagnostic tests

The International Atomic Energy Agency conducted a worldwide survey that assessed changes in CV procedure volumes attributed to COVID-19 in March and April 2020. Utilizing these data, researchers evaluated changes in noninvasive and invasive cardiac diagnostic testing from 909 participating inpatient and outpatient centers from 108 countries and compared the data with figures from March 2019. Researchers also assessed the availability of personal protective equipment and pandemic-related testing practice changes.

“The COVID-19 pandemic represents an unprecedented challenge to global health and modern health care delivery,” Andrew J. Einstein, MD, PhD, cardiologist, cardiac imager and researcher in the Seymour, Paul and Gloria Milstein Division of Cardiology at Columbia University Irving Medical Center/New York-Presbyterian Hospital, and colleagues wrote. “Owing to the resources required to treat patients with COVID-19 and efforts to prevent its spread, the ability of world health care systems to concomitantly diagnose and treat noncommunicable diseases has been strained.”

According to the researchers, diagnostic procedure volumes for CVD decreased worldwide by 42% from March 2019 to March 2020 and 64% from March 2019 to April 2020.

The largest drops were observed in the Middle East (84% from March 2019 to April 2020) and Latin America (82% from March 2019 to April 2020).

Only the Far East experienced any recovery of CVD diagnostic testing, with a 47% drop from March 2019 to March 2020 improving to a 35% drop from March 2019 to April 2020.

Worldwide, all stress testing declined 78% from March 2019 to April 2020.

Individually, from March 2019 to April 2020:

  • nuclear stress studies declined 73%;
  • single-photon emission CT declined 74%;
  • stress ECG declined 84%;
  • stress echocardiogram declined 83%;
  • stress PET declined 56%; and
  • stress cardiac MRI declined 72% (P for all < .001).

In addition, from March 2019 to April 2020, transthoracic echocardiography declined 59%, transesophageal echocardiography declined 76% and diagnostic angiography, whether invasive or by CT, declined 55% (P < .001 for all), according to the researchers.

Based on March 2019 data, an estimated 718,000 cardiac diagnostic procedures that would have been performed during March and April 2020 were not, according to the study.

Reduction in diagnostic procedures was less severe in wealthier countries. The researchers found an 81% reduction in low-income countries; a 77% reduction in lower middle-income countries; a 62% reduction in upper middle-income countries; and a 63% reduction among high-income countries. This trend was consistent across all procedure types.

Most centers performing cardiac diagnostic testing reported canceling at least some outpatient activities (83%) and all outpatient activities were canceled at some point in approximately 45% of participating centers.

Extended hours for CVD diagnostic testing only occurred in 14% of centers, and weekend hours were introduced in even less (10%).

Shortages of the following were reported: surgical masks in 22% of centers, high-filtration masks in 52%, gloves in 7%, gowns in 27% and eye shielding in 39%, according to the researchers.

Greater reduction in cardiac procedure volume was noted in centers in countries with lower gross domestic product, centers that avoided exercise for stress testing and centers in which the survey respondent was redeployed to COVID-19-related activities.

“These data have several important implications for cardiovascular health care delivery going forward,” the researchers wrote. “First, this report may serve to better inform studies evaluating the short- and long-term effects of COVID-19 on global cardiovascular disease outcomes. The cumulative impact of the current pandemic will likely result in consequences in delayed cardiovascular diagnosis that, if persistent, may not only erase prior population declines for this condition, but also hasten premature morbidity and mortality for millions of patients from low- to high-income countries alike.”

CV death amid COVID-19

Rishi K. Wadhera, MD, MPP, MPhil, assistant professor of medicine at Beth Israel Deaconess Medical Center and Harvard Medical School, and colleagues used data from the National Center for Health Statistics to evaluate the rate of CV deaths after the onset of the pandemic in the U.S., from March 18 to June 2, 2020 (pandemic period), compared with Jan. 1 to March 17, 2020 (pre-pandemic). In addition, changes in deaths were compared with the same periods in the previous year.

“In the United States, there have been marked increases in deaths caused by ischemic heart disease and hypertensive heart disease since the onset of the COVID-19 pandemic,” Wadhera and colleagues wrote. “In contrast, deaths caused by heart failure and cerebrovascular disease have not increased.”

From Jan. 1 to June 2, 2020, 397,042 deaths were caused by ischemic heart disease, HF, hypertensive disorders, cerebrovascular disease and other diseases of the circulatory system. According to the study, 199,311 occurred during the pre-pandemic period and 197,731 occurred during the pandemic period.

Nationwide, researchers observed an increase in deaths caused by ischemic heart disease during the pandemic period compared with the same period in 2019 (RR = 1.11; 95% CI, 1.04-1.18).

A similar increase was noted for deaths associated with hypertensive disorders (RR = 1.17; 95% CI, 1.09-1.26); however, the researchers found no increases in deaths related to HF (RR = 0.97; 95% CI, 0.92-1.01), cerebrovascular disease (RR = 1.03; 95% CI, 0.99-1.07) or other diseases of the circulatory system (RR = 0.99; 95% CI, 0.95-1.04).

“The large increase in population-level deaths caused by ischemic heart disease suggests that the pandemic may have had important indirect effects on cardiovascular outcomes,” the researchers wrote. “Although hospitalizations for acute myocardial infarction, and cardiac catheterization laboratory activations for ST-segment elevation myocardial infarction have declined substantially during the pandemic, it is unlikely that these changes reflect a true reduction in the incidence of cardiovascular events.

“Instead, our findings suggest that patients with acute coronary syndromes who require emergent treatment may be avoiding medical care and dying at home, possibly because of concerns about contracting the virus in a hospital setting, and consistent with reports that deaths at home have risen dramatically in areas of the United States hardest hit by COVID-19,” the researchers wrote.

According to the study, of the regions analyzed, New York City experienced the largest increase in deaths associated with ischemic heart disease (RR = 2.39; 95% CI, 1.39-4.09) during the pandemic period compared with the same period in 2019.

Researchers observed a modest increase in deaths associated with ischemic heart disease in the remainder of the state of New York (RR = 1.44; 95% CI, 1.16-1.79), New Jersey (RR = 1.45; 95% CI, 1.22-1.73), Michigan (RR = 1.23; 95% CI, 1.07-1.41) and Illinois (RR = 1.11; 95% CI, 1.04-1.19) but not in Massachusetts or Louisiana.

Moreover, deaths caused by hypertensive diseases during the pandemic period rose in New York City (RR = 2.64; 95% CI, 1.52-4.56), the remainder of the state of New York (RR = 1.28; 95% CI, 1.06-1.55), New Jersey (RR = 1.88; 95% CI, 1.38-2.57), Michigan (RR = 1.16; 95% CI, 1-1.35) and Illinois (RR = 1.3; 95% CI, 1.12-1.51).

New Jersey was the only state to experience an increase in deaths associated with cerebrovascular disease (RR = 1.28; 95% CI, 1.09-1.51).

New York City was the only jurisdiction to experience an increase in deaths associated with other diseases of the circulatory system (RR = 1.65; 95% CI, 1.2-2.27).

Researchers noted that death associated with HF did not increase in any state.

“Health care-system factors may also explain the rise in cardiovascular deaths during the pandemic,” the researchers wrote. “The cancellation of outpatient cardiovascular visits has likely delayed access to medication prescriptions/refills and important diagnostic testing.

“The delay of semi-elective cardiovascular procedures [may] have adversely affected higher-risk patients with cardiovascular disease,” the researchers wrote. “Health care systems in some regions were also pushed to adapt and reallocate resources rapidly to care for the surge of patients with COVID-19. The burden imposed on some hospitals may have led to delays in access to care or the delivery of suboptimal inpatient and procedural care for non-COVID-19 patients.”

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