CVD Deaths Increased, Imaging Decreased During Pandemic

Debra L. Beck

January 11, 2021

While the direct toll of the COVID-19 pandemic is being tallied and shared on the nightly news, the indirect effects will undoubtedly take years to fully measure.  

In two papers published online January 11 in the Journal of the American College of Cardiology, researchers have started the process of quantifying the impact of the pandemic on the care of patients with cardiovascular disease (CVD).

In the first study, Rishi Wadhera, MD, MPP, MPhil, and colleagues from the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, examined population-level data to determine how deaths due to cardiovascular causes changed in the United States in the early months of the pandemic relative to the same periods in 2019.

In a second paper, Andrew J. Einstein, MD, PhD, from Columbia University Irving Medical Center/New York Presbyterian Hospital, New York City, and colleagues looked at the pandemic's international impact on the diagnosis of heart disease.

Using data from the National Center for Health Statistics, Wadhera and colleagues compared death rates from cardiovascular causes in the United States from March 18, 2020 to June 2, 2020 (the first wave of the pandemic) and from January 1, 2020 to March 17, 2020 (the period just before the pandemic started), and compared them to the same periods in 2019. ICD codes were used to identify underlying causes of death.

Relative to 2019, they found a significant increase in deaths from ischemic heart disease nationally (1.11; 95% CI, 1.04 - 1.18), as well as an increase in deaths caused by hypertensive disease (1.17; 95% CI, 1.09 - 1.26). There was no apparent increase in deaths from heart failure, cerebrovascular disease, or other diseases of the circulatory system.

When they looked just at New York City, the area hit hardest during the early part of the pandemic, the relative increases in deaths due to ischemic heart disease were more pronounced.

Deaths due to ischemic heart disease or hypertensive diseases jumped 139% and 164%, respectively, between March 18, 2020 and June 2, 2020.

More modest increases in deaths were seen in the remainder of New York state, New Jersey, Michigan and Illinois, while Massachusetts and Louisiana did not see a change in cardiovascular deaths.

Several studies from different parts of the world have indicated a 40% to 50% drop in hospitalization for myocardial infarction in the initial months of the pandemic, said Wadhera in an interview.

"We wanted to understand where did all the heart attacks go? And we worried that patients with urgent heart conditions were not seeking the medical care they needed. I think our data suggest that this may have been the case," reported Wadhera.  

"This very much reflects the reality of what we're seeing on the ground," he told theheart.org | Medscape Cardiology. "After the initial surge ended, when hospital volumes began to return to normal, we saw patients come into the hospital who clearly had a heart attack during the surge months — and were now experiencing complications of that event — because they had initially not come into the hospital due to concerns about exposure to the virus."

A limitation of their data, he stressed, is whether some deaths coded as CVD deaths were really deaths from undiagnosed COVID-19. "It's possible that some portion of the increased deaths we observed really reflect the cardiovascular complications of undiagnosed COVID-19, because we know that testing was quite limited during the early first surge of cases."

"I think that basically three factors — patients avoiding the health care system because of fear of getting COVID, health care systems being strained and overwhelmed leading to the deferral of cardiovascular care and semi-elective procedures, and the cardiovascular complications of COVID-19 itself — all probably collectively contributed to the rise in cardiovascular deaths that we observed," said Wadhera.

In an accompanying editorial, Michael N. Young, MD, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, and colleagues write that these data, taken together with an earlier study showing an increase in out-of-hospital cardiac arrests at the pandemic peak in New York City, "support the notion of excess fatalities due to unattended comorbid illnesses." That said, attribution of death in the COVID era "remains problematic."

In the second article, Andrew Einstein, MD, PhD, and the INCAPS COVID Investigators Group took a broader approach and looked at the impact of COVID-19 on cardiac diagnostic procedures in over 100 countries.

The INCAPS group (International Atomic Energy Agency Noninvasive Cardiology Protocols Study) has for the past decade conducted numerous studies addressing the use of best practices and worldwide practice variation in CVD diagnosis.

For this effort, they sent a survey link to INCAPS participants worldwide, ultimately including 909 survey responses from 108 countries in the final analysis.

Compared to March 2019, overall procedure volume decreased 42% in March 2020 and 64% in April 2020.

The greatest decreases were seen in stress testing (78%) and transesophageal echocardiography (76%), both procedures, noted Einstein, associated with a greater risk of aerosolization.

"Whether as we reset after COVID we return to the same place in terms of the use of cardiovascular diagnostic testing remains to be seen, but it certainly poses an opportunity to improve our utilization of various modes of testing," said Einstein.

Using regression analysis, Einstein and colleagues were able to see that sites located in low-income and lower-middle-income countries saw an additional 22% reduction in cardiac procedures and less availability of personal protective equipment (PPE) and telehealth.

Fifty-two percent of survey respondents reported significant shortages of N95 masks early in the pandemic, with fewer issues in supplies of gloves, gowns, and face shields. Lower-income countries were more likely to face significant PPE shortages and less likely to be able to implement telehealth strategies to make up for reduced in-person care. PPE shortage itself, however, was not related to lower procedural volume on multivariable regression.

"It all really begs the question of whether there is more that the world can do to help out the developing world in terms of managing the pandemic in all its facets," said Einstein in an interview, adding he was "shocked" to learn how difficult it was for some lower-income countries to get sufficient PPE.

Did Shut Downs Go Too Far?

Calling this a "remarkable study," an editorial written by Darryl P. Leong, MBBS, PhD, John W. Eikelboom, MBBS, and Salim Yusuf, MBBS, DPhil, all from McMaster University, Hamilton, Ontario, Canada, suggests that perhaps health systems in some places went too far in closing down during the first wave of the pandemic, naming specifically Canada, Eastern Europe, and Saudi Arabia as examples.

"Although these measures were taken to prepare for the worst, overwhelming numbers of patients with COVID-19 did not materialize during the first wave of the pandemic in these countries. It is possible that delaying so-called nonessential services may have been unnecessary and potentially harmful, because it likely led to delays in providing care for the treatment of serious non-COVID-19 illnesses."

Since then, more experience and more data have largely allowed hospital systems to "tackle the ebb and flow" of COVID-19 cases in ways that limit shut downs of important health services, they said.

Given the more pronounced effect in low- and middle-income countries, they stressed the need to focus resources on ways to promote prevention and treatment that do not rely on diagnostic procedures.

"This calls for more emphasis on developing efficient systems of telehealth, especially in poorer countries or in remote settings in all countries," Leong and colleagues conclude.

Wadhera has reported research support from the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health, along with fellow senior author Robert Yeh, who has also received personal fees and grants from several companies not related to the submitted work. Einstein, Leong, Eikelboom, and Yusuf have reported no relevant financial relationships.

J Am Coll Cardiol. 2021;77:159-188. Article 1, Article 2, Editorial 1, Editorial 2

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