Big Downturn in CVD Procedures Seen During COVID-19’s First Wave

Cardiovascular procedures for coronary lesions and failing aortic valves declined significantly when COVID-19 struck the United States last year, but the decrease in procedural volume did not affect all patients equally, according to a new study.

When procedural volumes decreased in early 2020, women, the elderly, those insured by Medicare, and Asian or Black individuals appeared to be disproportionately affected by the downturn, report researchers.

Lead investigator Celina M. Yong, MD, MSc, MBA (VA Palo Alto Health Care System/Stanford University, CA), said the COVID-19 pandemic has been an “unprecedented natural experiment” that required researchers to understand what happens when there are broad procedure deferrals on such a large scale.

“We thought it was important to look back over the different COVID phases to really understand what was going on in terms of procedural volumes and potential impacts on patient outcomes after cardiovascular procedures,” she said. The findings, she added, also emphasize the importance of “making sure that the disparities in healthcare don’t widen because of the pandemic.”

Senior investigator Ty J. Gluckman, MD (Providence Heart Institute, Portland, OR), also stressed the importance of learning from COVID-19, particularly when it comes to addressing critical questions about healthcare delivery.  

“What [steps] do you take as a healthcare delivery system going forward in the event that you should ever see something like this again, where we need to make significant efforts to curb our procedural volumes?” he said. “How do you proactively protect against the inequitable distribution of access to these types of procedures going forward? This analysis highlights the indirect consequences of the pandemic and should reinforce efforts to make sure that health inequities are not perpetuated.”

Coronary and Structural Procedures Decline

The new study, published online June 26, 2021, in the American Heart Journal, is an analysis of 36,152 cardiovascular procedures, defined as either PCI (69%), CABG surgery (13%), TAVI (10%), or surgical aortic valve replacement (8%), performed at 30 hospitals in six states as part of the Providence St. Joseph Health and Stanford Healthcare systems. The study period ranged from December 2, 2018, to June 28, 2020, but investigators specifically focused on one of the first major phases of the pandemic, which they defined as a 4-week period surrounding the nadir of procedural volumes and labeled the COVID I period (March 15 to April 11, 2020). 

Procedural volumes bottomed out in late March, with the number of cases beginning to slide downward at a rate of 21% per week starting from the last week in February. Prior to the pandemic, the weekly volume of all CVD procedures was 465 cases per week, reaching a nadir of 210 cases per week on March 29, 2020. After this, volumes once again began to increase at a rate of 15 cases per week, peaking again in May 2020. In the recovery period, defined as April 12 to June 28 and known as COVID II, the average weekly volume was 359 cases, which was 23% lower than in the prepandemic period.

Compared with the pre-COVID phase, patients treated in COVID I were younger, more likely to be male, and less likely to be Black or Asian. The proportion of patients with Medicare insurance decreased from 60% pre-COVID to 53% during COVID I, but the proportion with Medicare increased once again to 60% in COVID II. In terms of comorbidities, there was no difference across the phases, but more patients with heart failure were treated during COVID I compared with the prepandemic phase.

Gluckman noted that in the COVID II recovery period, the distribution of patients by age, race/ethnicity, sex, and insurance status normalized to what it was before the pandemic. What’s not known is whether those disproportionately affected by the decline in volume—the patients who missed procedures during COVID-19’s first wave—have reengaged with the healthcare system. 

Importantly, there was no significant difference in the rate of risk-adjusted in-hospital mortality during the COVID I and II periods (versus the prepandemic phase) for any of the four procedures. For patients undergoing PCI, the acuity of cases changed with the pandemic, with the proportion of STEMI and NSTE ACS cases increasing in the active COVID I period and the proportion of stable CAD cases declining. The complexity of revascularization cases was mostly unchanged across the pandemic phases, although there was a trend toward more complex procedures.

“These findings are helpful for reassuring patients that they can safely receive the cardiovascular care they need,” said Yong. “Even during the worst periods of the pandemic when staff were being reassigned and we were severely under-resourced, we were still able to sustain quality of care.”

Gluckman added that the study represents two different healthcare systems, and while it skews westward, it’s a good example of research groups coming together during a pandemic to address critical questions about cardiovascular care.

Declines Began Before National Mandates

Back in March 2020, numerous organizations began to issue statements to help physicians prepare for the disruptions wrought by COVID-19. For example, the American College of Cardiology and the Society for Cardiovascular Angiography and Interventions released a joint statement offering direction on everything from patient selection to resource allocation. At most centers, elective cases went on hold, but primary PCI was still considered the best option for patients with STEMI.

Yong said that procedural volumes began to decline before the publication of the consensus statements. PCI and TAVR procedures began to slow down as early as mid-February, say the researchers, while CABG surgery began to decline slightly after March 1, 2020. All three procedures began to recover to normal procedural volumes during the COVID II phase. SAVR, on the other hand, declined over time throughout the study period and this was unaltered in the different pandemic phases.

“Our national societies worked really fast to publish consensus statements, along with federal mandates that accompanied shelter-in-place orders,” said Yong. “Yet when we looked at the inflection points for the declines in procedural volumes, they predated the mandates by as much as a month. It raises the question as to how much patient behavior was driving the decline in procedures as opposed to provider-driven national recommendations.”  

The reason this is important, she said, is because as the country bounces back from the worst of the pandemic, it’s important to overcome patient fears and/or anxieties about coming to hospitals. The present study suggests that procedural volumes are returning to normal, but the “tail” of the pandemic studied in the present analysis is relatively short.

“We know these procedures save lives and improve outcomes,” she said. “So the question now is how can we best help our patients understand the importance of resuming care for their cardiovascular disease, and overcome any remaining barriers to doing so?”