Two reports today in the Journal of the American College of Cardiology reveal large increases in deaths due to ischemic heart disease and high blood pressure in some US regions and dramatic drops in cardiovascular diagnostic testing internationally at the start of the COVID-19 pandemic, possibly fueled by fear of contracting the virus and delays caused by healthcare systems overwhelmed by coronavirus patients.

First surge hit NYC, other areas hard

Led by researchers from Beth Israel Deaconess Medical Center and Harvard Medical School, the first report, an observational study, compared weekly death data from the US National Center for Health Statistics from Jan 1 to Jun 2, 2020 with those from the same period in 2019.

From Jan 1 to Jun 2, 2020, 397,042 Americans died of cardiovascular causes, with deaths due to ischemic heart disease rising 11% across the nation relative to before. Of the 397,042 deaths, 199,311 occurred before the pandemic, from Jan 1 to Mar 17, 2020, and 197,731 occurred during the pandemic, from Mar 18 to Jun 2, 2020.

Deaths due to high blood pressure increased 17% over the same period, but no difference was observed for heart failure, cerebrovascular disease, or other circulatory conditions.

The largest relative increase in deaths caused by ischemic heart disease over 2019 (139%) occurred in New York City, with more modest increases observed in the rest of New York state (relative ratio of change, 1.44), New Jersey (1.45), Michigan (1.23), and Illinois (1.11). Neither Massachusetts nor Louisiana saw an increase.

A large relative increase in deaths due to high blood pressure also occurred in New York City (164%), with smaller increases in the rest of New York State (relative ratio of change, 1.28), New Jersey (1.88), Michigan (1.16), and Illinois (1.30). New Jersey was the only state that saw an increase in deaths due to cerebrovascular disease (1.28), while New York City was the only area with an increase in deaths caused by other diseases of the circulatory system (1.65). No states experienced an increase in deaths from heart failure.

The authors noted that recent studies have suggested large increases in deaths during the pandemic that can’t be explained by COVID-19 alone and that hospitalizations for emergent cardiovascular conditions such as heart attack, heart failure, and stroke have fallen steeply since the first phase of the pandemic.

“It is unlikely that these changes reflect a true reduction in the incidence of cardiovascular events,” the authors wrote. “Instead, our findings suggest that patients with acute coronary syndromes who require emergent treatment may be avoiding medical care and dying at home, possibly because of concerns about contracting the virus in a hospital setting, and consistent with reports that deaths at home have risen dramatically in areas of the United States hardest hit by COVID-19.”

They added that the patterns observed may also be at least partly due to cardiovascular complications of undiagnosed COVID-19 infection, an issue that needs further study.

Lead author Rishi Wadhera, MD, MPP, MPhil, said in a Beth Israel Deaconess Medical Center news release that the study results suggest an indirect toll of the pandemic on patients with cardiovascular diseases.

“Overall, our data highlight the urgent need to improve public health messaging and rapidly expand health care system resources to ensure that patients with emergent conditions seek and receive medical care—particularly in regions currently experiencing a sharp rise in COVID-19 cases,” he said.

Poorer nations see biggest declines in procedures

The second study, led by researchers at Columbia University, involved analyzing results of a worldwide survey conducted by the International Atomic Energy Agency evaluating changes in numbers of cardiovascular procedures and safety practices caused by the COVID-19 pandemic.

Data on noninvasive and invasive testing, availability of personal protective equipment (PPE), and pandemic-related testing practices were obtained from 909 participating hospitals and clinics in 108 countries for March and April 2020 and compared with those from March 2019.

Cardiovascular procedure volumes fell by 42% from March 2019 to March 2020 and by 64% from March 2019 to April 2020. Specifically, rates of transthoracic echocardiography imaging dropped 59%, transesophageal echocardiography fell 76%, and stress tests declined 78%, with little variation between different types of stress tests. Invasive or computed tomographic coronary angiography fell 55%.

After multivariable regression analysis, hospitals and clinics in countries with lower gross domestic product, reflecting a less robust economy, saw substantially larger declines in procedure volumes. Those in low- and lower-middle–income countries were linked to another 22% reduction in cardiovascular procedure volumes and less access to PPE and telemedicine services.

The authors said the study findings spark serious concerns about cardiovascular outcomes over the long term after a time of delayed or missed diagnoses. “Efforts to improve timely patient access to cardiovascular diagnosis in this and future pandemics, particularly in low- and middle-income countries, are warranted,” they wrote.

The authors also called for further research into the effects of patient behavior and reduced access to diagnostic, preventive, and therapeutic services on heart patient outcomes during and after the pandemic.

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