COMMENTARY

COVID-19: NICOR Report's Insights Into COVID and Cardiovascular Outcomes

Prof Mamas Mamas

Disclosures

October 12, 2020

This transcript has been edited for clarity.

Hi, welcome to Medscape UK. My name is Mamas Mamas. I'm professor of cardiology based at Keele University. And today we're going to focus on a publication by the National Institute of Cardiovascular Outcomes Research, the National COVID report.

The National Institute of Cardiovascular Outcomes Research, or NICOR, is important in that it collects data from national societies, including the British Heart Failure Association, the British Cardiovascular Intervention Society, the SCTS (Society for Cardiothoracic Surgery), BCS (British Cardiovascular Society), data around cardiac procedures in patients with congenital heart disease, and also data around procedures in patients undergoing electrophysiological procedures.

It collects these data for a number of reasons, but importantly for public reporting, particularly around outcomes.

As we know from the national transparency agenda, a number of cardiovascular services have to report either individual unit- or individual operator- outcomes, including percutaneous cardiac intervention (PCI) and cardiac surgery.

NICOR plays an important role in improving and maintaining the quality of cardiac services that we deliver to patients.

Under the national COVID emergency, the Government setup COPI [Control of Patient Information], and the importance of COPI was it enabled NICOR to work with NHS Digital, NHS England, HQIP [Healthcare Quality Improvement Partnership], and so forth, as well as the academic community, in making sense of what is happening to cardiovascular care during the COVID pandemic.

Challenging Times

And the report that NICOR has produced provides insight into what has happened to population health during these challenging times.

So this has been led by a number of academic groups, including Professor Colin Baigent, Oxford University, Professor Chris Gale, Leeds University, and myself, resulting in a number of analyses that have been published.

So what does the report tell us about cardiovascular care in the UK?

Fewer Admissions

Well, first and foremost, as is the case for many other health care systems, what we have seen during the COVID pandemic, particularly during the peak, is that admissions with emergent cardiac conditions have dropped significantly.

So for example, in patients with acute coronary syndrome (ACS), we've seen a 40% reduction in hospital admissions, more so in NSTEMI [non-ST segment elevation myocardial infarction] cases, compared with STEMI [ST segment elevation MI] cases.

We've also seen similar findings in heart failure, as well as stroke.

Interestingly, however, in the services that we deliver to patients, the quality is still maintained.

And so when you look at services for ACS, as well as other services such as stroke and heart failure, quality metrics are maintained.

So similar proportions of patients are getting to the cath lab, the timeliness of procedures is around the same as it was pre-COVID. And, importantly, we haven't seen major changes in mortality associated with hospitalisation, either for acute coronary syndrome, or heart failure, or stroke.

One of the interesting factors that we see is that the nature of the patients has changed.

What I mean by that is that the elderly, the comorbid, patients of BAME [Black and Minority Ethnic] origin are less likely to seek medical attention.

And this is important because parallel analyses that we've published have shown an increase in out-of-hospital cardiac arrest in exactly these patients.

So we see an increase from around 3.5% to over 5.8% of all acute coronary syndrome cases presenting with an out-of-hospital cardiac arrest.

And I think this may relate to the fact that patients at the peak of the pandemic were protecting the NHS, staying at home, and therefore were not seeking medical advice.

The downside of this is that we also report in another analysis that there has been an excess of 2000 cardiovascular deaths compared with this time last year. And the increase in cardiovascular deaths is mainly in patients with acute coronary syndrome, in patients with heart failure, in patients with stroke, but we also see an increase in conditions such as pulmonary embolus.

And this is exactly the cohort of patients where we've seen marked reductions in admission.

Why is this important? Well, it's important in that it's showing that this reduction in hospital admissions is having a knock-on effect, in that it's causing an increase in cardiovascular mortality and out-of-hospital cardiac arrests.

Places of Death

We're also seeing interesting epidemiological changes in the place of death.

A lot of the deaths that are happening are no longer happening in hospital, but there's been a translocation of cardiovascular mortality to the nursing home, and to people's homes. And this is an important observation. It's telling us that the greatest burden of excess mortality around cardiovascular disease is in our very elderly, mainly in the nursing homes. And indeed, other analyses that have been undertaken and are due to be published have shown that the marked excess mortality seems to be restricted to those over 70, particularly in the patients that are over 80 years old, in men and in women as well.

Waiting Lists

There are other knock-on effects that the NICOR report has shown. So first and foremost, it showed marked reductions in cardiovascular procedure activity. For example, from March until June, there has been a reduction in 45,000 procedures undertaken in England.

Why is this important? It's important because many of these procedures are important. For example, things like pacemaker box changes, or pacemaker implantations: close to a 20,000 reduction in pacemaker numbers; diagnostic cardiac catheterisation, a reduction of over 10,000. Now, you may say that diagnostic cardiac catheterisation does not impact on prognosis, but we know that many of the procedures that we do from a cardiovascular perspective certainly do.

So for example, we have analysed what is happening to patients with critical aortic stenosis. And we have observed that in the period between March and June, there are 2200 fewer TAVI [trans-catheter aortic valve implantation] and surgical AVR [aortic valve replacement] procedures undertaken in England.

The reduction in surgical AVR activity is around 80%. In TAVI, it's around 40%. Well this is going to have a huge impact on patients and may also be contributing to the excess cardiovascular mortality that we're seeing.

For example, data from the United States has shown that patients on the waiting list for TAVI that have symptomatic aortic stenosis at 80 days have something like a 2% to 3% risk of mortality and a 10% increased risk of heart failure hospitalisation.

And therefore our data would suggest that a reduction in 2200 patients waiting for treatments of aortic stenosis, up to now, may cause something like 300 excess deaths. That's important. And now that we're in the middle or the start of a second wave of COVID, these effects are going to be compounded.

Second Wave

There are also important lessons to be learned around cardiovascular reporting. Clearly, it's important to report individual operator outcomes and unit outcomes. And this forms part of the national transparency agenda. But when we've looked at causes of mortality during the COVID pandemic, what we find is that 1 in 10 of all deaths following PCI are COVID-related.

Now, this is going to make it challenging for national reporting, particularly given that there will be operators or centres that may appear as outliers. Now, this may not relate to the fact that this has been a change in the quality of the procedures that have been undertaken, but rather, an excess of COVID deaths, which may have happened in the community. And so therefore, it will be very difficult and challenging in national reporting, because a lot of the risk models that we have developed to help us in adjustment of risk weren't developed to take into account 10% of all deaths being COVID-related.

Protecting Patients

I think the other interesting aspect is that we know that patients with cardiovascular disease are at particularly increased risk of mortality when they have COVID infection, and some of the analyses that have been documented in the report are around patients with acute coronary syndrome that happen to be COVID positive.

Of course, it's unclear whether the patients developed COVID in the community, which triggered an ACS event, or whether they captured COVID in the hospital. What we do know, however, is that patients with COVID have very bad outcomes. We know that the mortality at 30 days of patients with COVID presenting with an acute coronary syndrome is something like 40%.

And we also know that even in those that received revascularisation, the mortality was similarly elevated. And this really moves towards trying to protect our patients at greatest risk, those with cardiovascular disease, particularly now that the wards are filling up with patients with COVID.

Important Report

I think that the NICOR report is important in several ways.

I think, first and foremost, it provides an overview of how COVID may have affected cardiovascular disease presentation, but also of our cardiovascular services during these challenging times.

I think secondly, it's important in that many of the findings are actionable. For example, the reduction in aortic valve interventions, whether it be by surgery or TAVI.

I think it raises the question of how we're going to manage these. And I think, really, the community needs to respond in a multi-disciplinary manner about how we can treat patients with cardiovascular disease, particularly those where the treatment is time dependent, and will have a prognostic impact.

I think this will be even more challenging and come to the fore during the second wave, where we have already a large waiting list of patients waiting for treatments of their cardiovascular disease.

And finally, I think what this shows is the importance of having up-to-date data.

I think the national societies have done an exemplary job in uploading their data in real time. And I think NHS Digital and NICOR have done again, an exemplary job, many people working overtime, to enable the rapid analysis of this data and the creation of this report.

I think what would be a shame would be if these lessons learned and opportunities around rapid access to data were to cease after the COVID pandemic.

So in conclusion, I think that the NICOR report has been very important. It has given us insight into what is happening with cardiovascular care.

And I think that any effects that we've seen at the first wave are going to be exacerbated by the growing second wave that we're currently dealing with.

So thank you, and perhaps you can give insight as to what is happening in your experience for your patients with cardiovascular disease. Thank you.

You can follow Mamas Mamas on  Twitter

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