COVID Highlights Poor Outcomes in Hospitalised CLI Patients

Liam Davenport

August 31, 2021

Although the reorganisation of angioplasty services in response to COVID-19 did not lead to a worsening of outcomes, the pandemic underlined the poor survival outcomes of patients with critical limb ischemia (CLI) treated in hospital, reveals a UK study.

Christian Heiss, professor of cardiovascular medicine, University of Surrey, Guildford, and colleagues studied nearly 200 patients who underwent endovascular revascularisation for symptomatic lower extremity peripheral artery disease between 2018 and 2021.

Dividing them into pre-COVID and COVID period patients, they found that the proportion of patients treated as day cases increased by 32%, and the time between being referred to undergoing angioplasty fell by 8 days on average.

The time to wound healing, major amputation or death did not change between the pre-COVID and COVID periods.

However, hospitalised patients had a significantly shorter median survival than those treated as day cases across both periods, at just over 5 months versus more than a year.

The research was presented at the European Society of Cardiology Congress (ESC) 2021 on August 27.

Very High Mortality Rates

"While adapting to COVID restrictions, we maintained a safe and effective angioplasty service, while shortening waiting times," said Prof Heiss.

However, "independent of COVID, our data confirmed very high mortality rates in hospitalised patients…as compared to day cases," he continued.

This "indicates that CLI needs to be treated much earlier and more aggressively to avoid hospitalisation and mortality".

He told Medscape News UK that he was "struck" by the higher mortality in hospitalised CLI patients, especially as "on average" patients treated as day cases and those treated in hospital "did not really differ".

"One thing that also struck me is when you look at the cause of death," cardiovascular causes were not the most common either pre- or during COVID, rather "it was more inflammatory" in nature.

Prof Heiss also emphasised that hospitalised patients did not tend to die within 30 days. "The 30-day mortality was the same" as that for day cases, he continued, "they just died over the next half year".

Patient Safety

Professor Susanna Price, who was not involved in the study, said it is not surprising that there was a shift to day cases during the COVID pandemic, as "you wouldn’t have got in to hospital, particularly in wave one, unless you really needed to be there, and you wouldn’t have wanted to".

"The message I wouldn’t want patients to get," added Prof Price, professor of practice in cardiology and intensive care, Royal Brompton Hospital, London, "is that if you come into hospital you’re more likely to die".

"If you need to be in hospital, the reason that you’re not going to survive is not because [the] care is worse."

She told Medscape News UK that "the confounders would have been massive" as the patients "who came in during COVID…really needed to be there, especially in the first wave".

"So they would have been sicker than normal."

Prof Price added: "When one looks at how healthcare systems have reorganised [in response to COVID-19], this is going to be a long-term reconfiguration", with the question: "How do we make sure our cardiac patients are safe?"

Retrospective Analysis

Prof Heiss explained that, to examine the impact of COVID-19 on angioplasty services and outcomes, the team conducted a retrospective analysis of consecutive patients.

They looked at two groups of patients: 120 patients treated in the pre-COVID period between August 2018 and February 2020; and 72 patients treated during the COVID period between March 2020 and February 2021.

There was no difference between the patient groups in terms of their age at an average age of 75 years versus 74 years, presence of diabetes at 60% versus 61%, and the presence of CLI at 92% versus 96%.

There were also no significant differences in the lesion length, the type of procedure performed and its technical success. No patients experienced any major procedural complications.

However, the proportion of patients treated in hospital versus as a day case with same day discharge shifted dramatically between the pre-COVID and COVID periods.

Before the pandemic struck, 40% of patients were treated as a day case with same day discharge, while 16% were overnight day cases, 14% involved planned hospitalisation and 31% were the result of an emergency admission.

The arrival of COVID-19 saw 72% of patients treated as day cases with same day discharge, while 10% were treated as overnight day cases and 18% underwent angioplasty following an emergency admission. There were no planned hospitalisations.

It is also notable that the waiting time to have a day case procedure, whether same day discharge or overnight, fell significantly between the pre-COVID and COVID periods, from an average of 23 days to 15 days (p=0.006).

Overall, the percentage of outpatients treated within 14 days of referral increased from 39% to 63%, and the proportion of hospitalised patients treated within 5 days of referral rose from 47% to 54%.

Study Findings

The team found that one-year crude mortality across all patients decreased between the pre-COVID and COVID periods, from 23% to 15%, although Kaplan-Meier analysis revealed the difference was not significant for either day case (p=0.445) or hospitalised patients (p=0.655).

Overall median survival was 368 days, and was affected by neither the COVID period nor the time to procedure.

However, the team found that amputation-free survival was significantly worse in hospitalised patients compared with those treated as day cases, at a median survival of 155 days versus 368 days (p<0.001).

The main causes of death in the pre-COVID period were:

  • Sepsis (41%)

  • Pneumonia (22%)

  • Cardiac causes (11%)

  • COVID pneumonia (11%)

  • Stroke (7%)

In the COVID period, the primary causes of death were:

  • COVID pneumonia (37%)

  • Cardiac causes (27%)

  • Pneumonia, sepsis and stroke (all in 9%).

Among patients who survived, the median time to wound healing was 168 days, which was identical to that seen across the whole patient group.

No funding declared.

No relevant financial relationships declared.

ESC Congress 2021: Abstract Impact of COVID-19 on angioplasty service and outcome of patients treated for critical limb ischaemia. Presented 27 August.


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