As Cardiac Procedures Plummet, Concerns Mount for COVID-19’s Collateral Damage

All major cardiac and cardiothoracic procedures across England were radically curtailed in the first few months of the COVID-19 pandemic, new numbers confirm, and should serve as a wake-up call for regions now facing a second wave of infections, study authors say. Otherwise, they warn, collateral damage in the form of soaring morbidity and mortality due to untreated conditions may swamp the rate of death and disability due directly to SARS-CoV-2.

“Although difficult to quantify, the indirect burden of COVID-19 on morbidity and mortality of patients with cardiovascular disease whose interventions were deferred may exceed the direct effect of the infection in terms of mortality,” write Mohamed O. Mohamed, MRCP (Keele University, Stoke-on-Trent, England), and colleagues in the European Heart Journal – Quality of Care and Clinical Outcomes.

We need to think more holistically about which patients, and which procedures, need to be undertaken so as to minimize the impact on outcomes. Mamas Mamas

Steep procedure declines for cardiac and other conditions have become a hallmark of the COVID-19 pandemic, sometimes the result of hospital avoidance by patients. But when it comes to elective procedures, the drop stems largely from policy decisions to avoid prolonged admissions, free up beds and resources, preserve personal protective equipment, protect staff by avoiding aerosol-generating procedures, and prioritize ICUs for severely ill COVID-19 patients. Now is the time to carefully consider the unintended consequences of these decisions, write Mohamed et al. They give the example of untreated symptomatic aortic stenosis, which has been shown to carry a 1-year mortality risk as high as 44% and, untreated, puts patients at higher risk of COVID-19 mortality.

Procedures Drop, Waiting Lists Soar

Mohamed et al examined the number of inpatient and outpatient cardiothoracic procedures across England between January 1 and May 30, extracted from the Hospital Episode Statistics database for the years 2018, 2019, and 2020. Compared with monthly averages for the pre-COVID period, ending in February 2020, total procedures were down by 45,501 during the period of March to May 2020. Lower rates of cardiac caths and device implantations made up the bulk of the missing procedures, numerically, whereas valve surgeries and other types of structural heart interventions had the largest relative difference in volumes.

Of note, 30-day mortality rates were no different for procedures undertaken during the early months of the pandemic as compared with prior periods, with the exception of cardiac device implantation, where mortality rates rose from 1.4% to 2.0% (OR 1.35; 95% CI 1.15-1.58) and cardiac catheterizations, where the death rate increased from 1.1% to 1.6% (OR 1.25; 95% CI 1.07-1.47).

“Further work is required to define the cause of the increases in mortality in these patient groups, particularly whether the deaths were related to procedural complications or COVID-19 in the community,” investigators write.

Regional analyses and surveys of specific procedures have found similar trends, as did a nationwide survey of US cath labs that flagged the negative consequences for patients, including an increase in mortality among patients with aortic stenosis awaiting care. Celina M. Yong, MD, MBA (Stanford University and VA Palo Alto Health Care System, CA), who led the US analysis, told TCTMD that this latest study by Mohamed and colleagues has important US implications as well.

“While the COVID-19 mortality burden is horrifying in itself, this study and many others are starting to reveal the profound indirect impact of COVID-19 on patients who are dying during this pandemic without ever contracting the virus—simply because they are not receiving the lifesaving procedures they would normally receive for their heart,” Yong said.

She added that the US numbers suggest the most-acute patients are being prioritized during COVID, which might be the reason for the higher mortality seen for certain procedures in Mohamed et al’s data as well. “But we still need to find out the degree to which other specific factors may make a procedure during this time truly higher risk so we can appropriately mitigate them,” Yong said in an email.  

Thinking Holistically

Speaking with TCTMD, study co-author Mamas Mamas, BMBCh, DPhil (Keele University), stressed that there are important messages in the UK data as hospitals brace for a second wave of COVID-19 admissions.

While the COVID-19 mortality burden is horrifying in itself, this study and many others are starting to reveal the profound indirect impact of COVID-19 on patients who are dying during this pandemic without ever contracting the virus. Celina M. Yong

“First and foremost,” he said, cardiologists need to think beyond “their own pet areas of interest” to consider which procedures should take priority. “We need to think more holistically about which patients, and which procedures, need to be undertaken so as to minimize the impact on outcomes. So patients, for example, waiting for treatment of critical aortic stenosis: that will be a much greater priority than someone waiting for an elective cardiac catheterization.”

Some degree of restructuring of treatment modalities will also be needed, he suggested, even if guidelines would be applied differently in “normal” times. Some examples include aortic stenosis patients at low risk for surgery getting percutaneous valve replacement and even left-main CAD patients—currently a contentious area in the context of EXCEL and the disputed left-main guidelines—who might, during COVID-19, be better served by PCI rather than surgery, given the need to get them in and out of the hospital as swiftly as possible.

“A final takeaway is thinking more broadly around how we could change the way that we investigate patients,” Mamas said, “perhaps moving from a more-invasive strategy, say, diagnostic cardiac catheterization, to a noninvasive strategy where there may be a greater capacity—for example, cardiac CT.”

He pointed out that in the UK the majority of diagnostic workups for coronary disease are already being done by cardiac CT. “But for other healthcare systems, particularly in the United States, I think that they really do need to think very strongly about the limited capacity in their laboratories and think as a group of healthcare professionals as to how this can be utilized most effectively for the highest-risk patients.”

The researchers proposed several other “contingency measures” worth considering in the UK if the current backlog is to be addressed. These include introducing 7-day services at major centers, more collaboration with private healthcare institutions, and enticing retired physicians back into the profession to ease the caseload for others. “This is even more crucial in the event of further resurgence of COVID-19 outbreaks that would further increase the pressure on healthcare systems and continually growing waiting lists,” they write.

Yong pointed out to TCTMD that the UK study did not show a dramatic difference in procedures or outcomes by race, but “this may not be the same in the US and needs to be studied. Especially as we resume cardiovascular procedural treatments while the pandemic continues, we need to do everything we can to narrow the existing health disparities due to COVID-19.”