US Cath Labs and COVID-19: Pushed Procedures, Late STEMIs, and Paycheck Pain

US catheterization laboratories saw an “unprecedented” drop in cardiovascular interventions at the height of the COVID-19 pandemic and those deferred procedures tracked with regional COVID-19 burden, according to the results of a nationwide survey. Many cardiac cath lab (CCL) directors and interventionalists who took the survey also said they’d seen an increase in late-presenting STEMIs, and one in five said they’d seen an uptick in deaths among patients waiting for TAVR procedures.

“In the first national survey of CCL directors and interventional cardiologists about cardiac procedural deferral in the United States during the COVID-19 pandemic, we identified unprecedented large-scale procedural deferrals, plummeting procedural volumes, and negative impacts on patient outcomes,” Celina M. Yong, MD, MBA, MSc (Stanford University and VA Palo Alto Healthcare System, CA), and colleagues write in an early online publication of Catheterization and Cardiovascular Interventions.

Speaking with TCTMD, Yong pointed out that reduced volumes have been documented elsewhere—due to cancelled/deferred procedures, but also to hospital avoidance by patients. The impact of this on practice and patient outcomes has been unclear, she said.

“What concerns me most about our findings is that patients may inappropriately be deferring lifesaving procedures, out of fear of the COVID-19, to the point that it's a detriment to their health,” she said. “And as much as we, as physicians, may be focusing on making sure that there are no delays to getting the urgent procedures the patients need, if the patients themselves are not showing up because they're afraid, then I do think that as the months progress, we are going to start to see some of the long-term effects of patients not getting these procedures. And we're going to have to deal with those for a long time to come.”

Commenting on the survey results for TCTMD, Amer Ardati, MD (University of Illinois, Chicago), called them “fascinating,” adding that they call into focus many of the key issues that interventionalists have grappled with over the last few months. “The most pressing issues that they identify are the increase in late presentation for STEMI and an increase in the aortic stenosis mortality in patients awaiting TAVR. These are two of the areas where we clearly know our services provide improvement in morbidity and mortality, and it’s difficult to see us not [providing] our usual standard of care.”

Procedures Dropped as Infections Climbed

Yong et al developed the 20-question survey with input from the Society for Cardiovascular Angiography and Interventions (SCAI) and the American College of Cardiology (ACC) Interventional Council. It was then distributed to CCL directors and interventionalists using SCAI and ACC mailer lists in May 2020. After excluding responses from non-US-based physicians, investigators received 414 responses from 360 unique CCLs in 48 states. More than 90% of cath labs had “shelter-in-place” directives in place at that time, and 88% had those as far back as March 2020.

In aggregate, median monthly PCI volumes between March 15 and April 15 ranged from zero to 500, a reduction of 55% from 2019. The drop was even more dramatic for TAVR, where median monthly TAVR volumes ranged from zero to 40 during the study period, reflecting a 64% reduction from 2019.

We are so laser focused on finding a treatment or a vaccine for COVID-19, and yet we have proven treatments for heart attack, for example, that are lifesaving and we're not using them. Celina M. Yong

Patient workup also changed, with 62% of responders saying they were more likely to use alternate imaging studies for risk stratification including nuclear perfusion scanning (24%), coronary CT angiography (CTA; 22%), and stress echo (14%).

Whether some of these less-invasive tests will get more of a toehold as a result of COVID-19 remains to be seen, Yong said. Already at her hospital and elsewhere, she said, “people are already returning to what their prior practices were. I think that's partly because hospitals now know what's going on, we have more safety precautions in place, and testing has ramped up. So I think we are feeling more comfortable with managing the situation, even though we're still in the midst of an ongoing pandemic.”

To TCTMD, Ardati said he thinks different imaging modalities—CTA in particular—are likely here to stay. “The knock-on effect of this crisis is going to be that hospital systems are going to look inward at their preparedness to be flexible, to use alternative modalities. We certainly are. We noticed a deficiency in our CT angiography program, and we're in the process of seeing what we can do to improve our access to that technology to be more facile,” he said. “I think this in combination with the ISCHEMIA trial is going to be a tipping point.”

Same-day discharge will also get a leg up as a result of the pandemic, he predicted. “I think this is an opportunity where people who may have been sort of held back by institutional inertia or perceived discomfort with same-day discharge PCI are going to realize that it's actually feasible, it's safe, and it's cost saving.”

The survey also asked about COVID-19 burden, finding wide variations in the number of COVID-19-positive inpatients at any given time—ranging from zero to 800, yielding a mean of 16% (calculated as a proportion of confirmed patients per total beds). Not surprisingly, procedure deferrals also varied widely and typically tracked with a hospitals COVID-19 burden—the higher the burden, the more procedures deferred.

Making Do and Getting By

Other practice differences were also picked up in the survey. Several respondents noted that they were more likely to perform certain procedures at the bedside, such as pulmonary artery catheterization and pericardiocentesis, and nearly half said they’d seen an increase in same-day discharge. Of the centers offering 24-7 STEMI coverage (93% of the sample), 62% said they’d been more likely to use thrombolytics for STEMI in a patient with suspected or confirmed COVID-19, but just 10% of these said they were “significantly” more likely to do so. Here, too, use of thrombolytics tracked with a hospital’s overall COVID-19 burden.

What didn’t appear to track with disease burden was the reduction in STEMIs, which is widely believed to relate in large part to patients’ reluctance to go to hospital. When these were overlaid with US maps showing the burden of COVID-19 mortality, there was “no consistent overlap of areas with increased late presenting STEMIs and high COVID-19 burden regions,” they write.

“That, to me suggests that patients' fears may be driving behaviors more than actual risk, and if they're inappropriately deferring lifesaving procedures out of fear of COVID-19, that could be to the point where it's a detriment to their own health,” Yong said. The survey did not ask interventionalists to describe the types of late STEMI presentations that were seen, but Yong, like others before, predicted these will lead to increased volumes of patients presenting in the coming months with new wall motion abnormalities on echo and ECG changes as well as heart failure and arrhythmias, further down the road.

“We are so laser focused on finding a treatment or a vaccine for COVID-19, and yet we have proven treatments for heart attack, for example, that are lifesaving and we're not using them because people are so scared of COVID,” she said.

The data also reveal some more personal insights. Almost one-third of survey respondents said that at least one operator in their lab had tested positive for the virus. This “likely reflects community measures, but also raises the question of the degree to which hospital exposure could contribute,” they write. The likelihood of an operator testing positive was associated with age and gender, but not with a hospital’s overall COVID-19 burden.

Survey results also hint at some of the friction between frontline workers and hospital administrators over staff safety. At centers were universal testing was not available, 81% of respondents said they wanted more, with almost all respondents identifying hospital administration as a barrier, followed by patient willingness (93%), staff to perform swabs (90%), and test availability (32%).

Ardati, who highlighted these results for TCTMD, said, “I thought it was really interesting that a lot of respondents were concerned about administrative support for testing and for staffing around COVID testing. . . . That really signals an important gap between us as frontline providers and administrators in healthcare systems. Whether or not the perceived absence of testing or access to testing is valid, the fact that that divide exists shows a concerning lack of trust and cooperation between frontline workers and administrators.”

Pocketbooks also took a hit: 95% of interventionalists surveyed said that their salaries had dropped by a mean of 23% (maximum 70%) and 99% reported a drop in weekly RVUs (mean 46%, maximum 90%). Reassuringly, said Yong, the survey picked up no link between salary reductions and the degree of angiography or stable CAD PCI deferral. Nor were there patterns regarding the magnitude of salary reduction and the pace at which institutions were ramping back up.