Fewer Diagnostic Tests, Higher CV Mortality During COVID-19 Pandemic

Two new studies—one focused on the United States, the second global in scope—are highlighting the impact the COVID-19 pandemic has had on patients with known or suspected cardiovascular disease.

In the first, US investigators confirm what has long been suspected: that the number of deaths from ischemic and hypertensive heart disease increased in 2020. Compared with shifts in 2019, increases in death due to ischemic heart and hypertensive disease in 2020 were 11 and 17% larger, respectively, perhaps attributable to delays in patients seeking care.

“If you look at some of the data that’s come out, hospitalizations for heart attacks and cath lab activations for STEMI, just as an example, dropped by more than 40% in many parts of the country in April and May,” lead investigator Rishi Wadhera, MD (Beth Israel Deaconess Medical Center, Boston, MA), told TCTMD. “These concerning patterns suggested that some patients with urgent cardiovascular conditions might be avoiding necessary care at hospitals and potentially not doing well at home because of fear of contracting the virus. Things have evolved so quickly, but we sometimes forget that in March and April, we just didn’t know a lot about the virus. There was a lot of fear in the air about stepping out into the community, and more so about coming into a hospital.”

In the global analysis, more than 900 inpatient and outpatient centers reported performing fewer invasive and noninvasive diagnostic procedures for heart disease, including the use of echocardiography, stress testing, and coronary angiography. The abrupt reduction in cardiovascular diagnostic imaging was most pronounced in some of the world’s poorer regions.

There was a lot of fear in the air about stepping out into the community, and more so about coming into a hospital. Rishi Wadhera

“The first step for cardiovascular disease is identifying it,” lead investigator Andrew Einstein, MD, PhD (NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY), told TCTMD. “The various imaging tests we do, from echocardiograms to diagnostic caths to stress testing, really helps us identify and characterize patient’s heart disease enough to frame treatment. If patients aren’t going through the system as they traditionally do and not getting this vital testing, the concern is that this will have implications in terms of the short-term diagnosis of very serious disease, as well as the long-term management of patients who get missed by the system.”

Both studies were published January 11, 2021, in the Journal of the American College of Cardiology.

New York City Sees Largest Increase in Mortality

At the peak of the pandemic, as people were asked to shelter in place and to only leave home for emergency reasons, hospitals saw a sharp decline in the number of patients diagnosed and treated for STEMI and other cardiovascular diseases, a phenomenon that has been attributed to patients’ fear of contracting SAR-CoV-2 during hospitalization. Given this, investigators evaluated whether population-level deaths due to cardiovascular causes increased during the COVID-19 pandemic.

Using data from the National Center for Health Statistics, they measured the rate of death due to cardiovascular causes in the US between March 18 and June 2, 2020, and the period immediately preceding the pandemic (January 1 to March 17, 2020). Investigators compared the relative change in deaths per 100,000 patients in 2020 (the prepandemic period versus the pandemic) against the relative change in death rates over the same two time periods in 2019.

Death Rates With COVID-19 Pandemic: 2020 vs 2019

Compared with the changes observed in 2019, New York City had the largest relative increase in the number of deaths caused by ischemic heart disease. Overall, there was a 139% increase in ischemic heart disease deaths per 100,000 persons in 2020 compared with the relative change seen in 2019. Similarly, there was a 164% relative increase in deaths from hypertensive disease. Outside the city, there was a 44% increase in ischemic heart disease deaths in New York State, a 45% increase in ischemic deaths in New Jersey, a 23% increase in Michigan, and an 11% increase in Illinois compared with patterns in 2019. There was no increase observed in Massachusetts or Louisiana, two other states struck hard by the pandemic.

Deaths from hypertensive disease increased in New York State, New Jersey, Michigan, and Illinois in 2020, although the increase wasn’t as large as that observed in New York City. For the most part, there was no other change in the relative rate of death from other diseases, such as heart failure or cerebrovascular disease, in the overall population or in the different regions.   

The reason for the spike in ischemic and hypertensive disease deaths is likely multifactorial, said Wadhera. With fear of hospitals, patients might have delayed too long, he said, noting there have been reports that the number of at-home deaths spiked during the early part of the pandemic, particularly in hard-hit cities. Additionally, healthcare systems in these regions were overwhelmed and experiencing strain when COVID-19 swamped their emergency departments and ICUs.

“That strain might have diminished access to timely care, which led to delays in the [emergency medical services] response times and stretched hospitals so thin that it affected patients with non-COVID-19-related illness,” he said. “At the same time, there are a lot of procedures in cardiology that are semi-elective, like TAVR, and these patients might not have done well because of delays caused by the pandemic.”

Finally, it’s also possible that some of these deaths might be attributable to the CV complications of undiagnosed COVID-19. While they excluded patients with COVID-19, testing was fairly limited in that early phase of the pandemic. As for how things might play out in the second half of 2020, Wadhera said that state health departments and local healthcare systems have done an excellent job getting the message out that patients with emergent conditions should come to the hospital if needed.

“I think it’s provided patients with some much-needed reassurance that hospitals are safe places for care when you need it, even in the midst of the pandemic,” said Wadhera. This might help minimize the indirect tolls of the pandemic in the second part of 2020, he said.

Reduction in Diagnostic Procedures

For the second study, Einstein and colleagues sought to address COVID-19’s impact on testing volume. To do so, the researchers sent surveys to 909 inpatient and outpatient centers performing diagnostic procedures in 108 countries. Cardiac diagnostic procedures declined by 64% overall from March 2019 to April 2020, and this reduction in testing was most pronounced in the Middle East and Latin America.

The concern is that this will have implications in terms of the short-term diagnosis of very serious disease, as well as the long-term management of patients who get missed by the system. Andrew Einstein

Across the globe, diagnostic testing declined 79% in Africa, 68% in Eastern Europe, 52% in Southeast Asia and the Pacific, 84% in the Middle East and South Asia, 82% in Latin America, 69% in Western Europe, 35% in the Far East, and 68% in Canada and the US. Use of transthoracic echocardiography was reduced 59%, all stress testing by 78%, and invasive angiography by 57%. Additionally, CT angiography, coronary artery calcium screening, cardiac MR imaging, and transesophageal echocardiography were reduced by 54%, 71%, 64%, and 76%, respectively. For stress testing, all imaging procedures, including nuclear, single-photon emission computerized tomography, ECG, echocardiography, positron emission tomography, and cardiac MR, were reduced during the pandemic.

When stratified by economic development, diagnostic imaging was slashed by 81% in low-income countries and 77% in lower-middle-income countries during the pandemic. For the upper-middle and high-income countries, diagnostic testing volumes were reduced 62% and 63%, respectively.

“Low- and middle-income countries were really hit the hardest,” said Einstein. “If you don’t have much reserve capacity or your healthcare system is held together tenuously and you put a shock to it as the COVID-19 pandemic has done, it creates a situation where it’s just hard to deliver essential cardiovascular services.”

To TCTMD, Einstein said the early need to contain and limit the spread of SAR-CoV-2 led to the cancelation of elective procedures in some countries, although this wasn’t universal. For example, the survey showed that some outpatient activities were cancelled in 83% of centers with cardiac diagnostic testing capability whereas all outpatient procedures were cancelled in 45% of centers. However, extended hours or new weekend hours for testing during reopening were uncommon. When they reopened, nearly all facilities responded with new practices, such as physical distancing, requiring masks, symptom screening, temperature checks, and limited visitors. One in five centers reported shortages of surgical masks, 52% cited shortages of high-filtration masks, 27% lacked gowns, and 39% were short on eye shields.

At the moment, it’s unlikely that the various hospitals and centers have caught up with all the patients who have missed tests, said Einstein. A delayed cardiovascular diagnosis could hasten cardiovascular morbidity and mortality, and potentially erase some of the population-level declines in CVD and CVD-related mortality, say the researchers.