Increased Risk of Death in Cardiac Wait List Patients Seen Early in Pandemic

By Linda Carroll

October 01, 2021

NEW YORK (Reuters Health) - During the early months of COVID-19, the number of heart-disease patients referred for, and getting, cardiovascular procedures dropped and wait list mortality rose, according to a new study from Canada.

An analysis of healthcare data from more than 584,000 patients referred for procedures between January 2014 and September 2020, of whom 37,718 were referred early in the pandemic, shows the risk for all-cause mortality during 2020 rose nearly two-fold, researchers report in the Canadian Journal of Cardiology.

Early in the pandemic, "there were clear impacts on patients with non-COVID conditions, and these were substantial," said senior author Dr. Harindra C. Wijeysundera of the Schulich Heart Program, Sunnybrook Health Sciences Centre, in Toronto.

"During the pandemic, there was a 'care deficit' in that patients were not making their way onto wait-lists, and those that were getting on the wait-list for cardiac procedures were sicker and did worse," he told Reuters Health by email. "We have to ensure that the entire care continuum from diagnosis by primary care, access to diagnostic testing, specialists and procedures, is maintained. Our study shows that the delays to therapy are at all levels of this continuum, both upstream (diagnosis) and downstream (treatment)."

To take a closer look at how the pandemic might have impacted the care of heart-disease patients, Dr. Wijeysundera and his colleagues used population and clinical databases housed at ICES, Canada's largest health-services research institute.

The researchers identified a cohort of patients older than 18 who were referred for one of four commonly performed cardiac procedures: percutaneous coronary intervention (PCI), isolated coronary-artery bypass grafting (CABG), valve surgery (aortic, mitral, or tricuspid), or transcatheter aortic-valve implantation (TAVI) from January 1, 2014 to September 30, 2020.

During the early pandemic months, there was a significant decline in the number of referrals and procedures completed compared with the prepandemic period. The greatest drop was for PCI, with 970 fewer weekly referrals after accounting for secular trends and weekly seasonality.

Wait times for procedures were shorter during the pandemic. Nevertheless, all-cause mortality increased in patients referred for PCI and CABG during the pandemic versus before, with cumulative wait list mortality of 0.29% versus 0.17% (P<0.001) and 0.64% versus 0.59% (P=0.054), respectively.

In adjusted analysis, the corresponding hazard ratios were 1.83 (95% confidence interval, 1.47 to 2.27) and 1.96 (95% CI, 1.28 to 3.01). Mortality did not change significantly after adjustment for those referred for valve surgery or TAVI.

Things may have been even worse in the U.S. than in Canada where there is universal access to healthcare, said Dr. Erin Michos, an associate professor of cardiology at the Johns Hopkins School of Medicine, in Baltimore, who was not involved in the study.

"Here, there are disparities in access to care in those under age 65," she said. "Often healthcare is tied to employment and loss of employment means loss of health care access. Many lost their jobs during the pandemic."

The results of the Canadian study are not surprising, since it was done during the pre-vaccination period, Dr. Michos told Reuters Health by phone.

"Interestingly, despite shorter waiting times there was increased mortality with PCI and CABG," she added. "It's likely that by the time people sought medical attention there was probably a much more advanced disease process."

The decrease in referrals was unlikely to be due to there being fewer heart attacks, Dr. Michos said. "It's more likely that people were afraid to go to the hospital to seek care. So by the time they came to get medical care, they were much sicker."

"It's been reported across the U.S. and Europe that during the pandemic there were decreased admissions for heart attacks and stroke," Dr. Michos said.

An important message to get across is that patients should not delay care even during a pandemic, Dr. Michos said. "We should emphasize that patients should seek care for chest pain and acute neurological symptoms."

SOURCE: and Canadian Journal of Cardiology, online September 29, 2021.