COVID’s Indirect Toll on the Heart

COVID-19 has had an indirect toll on heart health around the world, as cardiovascular testing volumes plummeted and cardiovascular deaths rose in 2020, researchers found.

CDC data revealed that in the first U.S. coronavirus epicenters like New York, the number of people who died from ischemic heart disease and hypertension increased dramatically after mid-March compared with historical controls from the year before.

It remains unclear whether the excess deaths were related to people avoiding necessary medical care for fear of contracting SARS-CoV-2 or reflected other factors, such as undiagnosed COVID-19, according to study authors led by Rishi Wadhera, MD, MPP, MPhil, of Beth Israel Deaconess Medical Center and Harvard Medical School in Boston, reporting in the Journal of the American College of Cardiology (JACC).

However, the theory of avoidance of care would be consistent with the finding that cardiac testing centers in 108 countries were seeing sharp decreases in cardiac diagnostic procedures by the summer, as reported in the same issue of JACC by another group.

“Clearly, the overwhelming priority should be emphasizing the importance of public health measures to prevent the spread of COVID-19. … Such a strategy may allow the economy, schools, and less urgent but important health services, including selective cardiac diagnostic tests, to be provided to a limited extent,” according to an accompanying editorial.

“This calls for a coordinated national strategy in all countries and enhanced collaborative efforts internationally to contain COVID-19. Nobody will be safe until everybody is safe,” wrote Darryl Leong, MBBS, PhD, and colleagues at McMaster University’s Population Health Research Institute in Hamilton, Ontario.

More Cardiovascular Deaths

The start of the pandemic brought an abrupt increase in certain types of cardiovascular deaths in the U.S., according to an observational cohort study.

Cardiovascular mortality jumped more from the period immediately before to after COVID-19 started surging in the country (Jan. 1-March 17 vs March 18-June 2, 2020) than it did between the same two periods in 2019, Wadhera and colleagues found.

Study authors highlighted especially large increases in death from ischemic heart disease (ratio of relative change in deaths per 100,000: 1.11, 95% CI 1.04-1.18) and deaths caused by hypertensive disease (1.17 per 100,000, 95% CI 1.09-1.26) in 2020.

By contrast, hospitalizations and cardiac catheterization laboratory activations for heart attacks were down substantially in 2020. It is “unlikely” that the lower case volumes “reflect a true reduction in the incidence of cardiovascular events,” the investigators said.

“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 wrote.

“Collectively, these data offer a retrospective reminder of what could transpire for acutely ill patients who elect to shelter in place while enduring the natural history of their disease processes,” agreed Michael Young, MD, and two colleagues of Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire.

Alternatively, the increased heart-related deaths could be explained by cardiovascular sequelae of undiagnosed COVID-19. The study excluded deaths with underlying causes of COVID-19, but it is possible that some COVID-19 deaths were misclassified as cardiovascular deaths or that a portion of cardiovascular deaths were related to COVID-19, Wadhera’s group acknowledged.

“Regardless, this simply provides further impetus for policymakers to expand the capability and availability for widespread, rapid-return testing for COVID-19,” Young’s group commented in another accompanying editorial.

For their study, the authors relied on weekly death data from the CDC’s National Center for Health Statistics.

After COVID hit in 2020, New York City showed the largest increase in deaths caused by ischemic heart disease (ratio of relative change in deaths per 100,000 2.39, 95% CI 1.39-4.09) and hypertensive disease (2.64 per 100,000, 95% CI 1.52-4.56) over historical baseline from 2019. The surge of deaths related to these conditions was more modest in the rest of New York State as well as New Jersey, Michigan, and Illinois.

There was no significant change in death from heart failure, cerebrovascular disease, or other diseases of the circulatory system, the investigators found.

“Overall, our data highlight the urgent need to improve public health messaging, communication, and education to ensure that patients with emergent conditions seek and receive medical care, particularly in regions that are currently experiencing surges or resurgences of COVID-19 cases,” Wadhera and colleagues said.

“From this publication, we see the importance for continued study of the ancillary effects of COVID-19, whether they be related to cardiovascular health, mental health, substance abuse, domestic violence, or homelessness,” according to Young’s group.

More research should prioritize finding how vulnerable populations in particular are affected by the pandemic, they noted.

Cardiovascular Disease Diagnosis Down

In a separate study, hospitals reported in a survey that the first wave of COVID-19 brought an abrupt drop in cardiovascular diagnostic testing across the globe — especially in lower-income countries.

Cardiac testing volumes decreased by 42% from March 2019 to March 2020, or 64% from March 2019 to April 2020, reported a group led by Andrew Einstein, MD, PhD, of Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York City.

Survey participants reported significant decreases in:

• Transthoracic echocardiography (59%)
• Transesophageal echocardiography (76%)
• Stress tests (78%)
• Coronary angiography (invasive or CT, 55%)

Testing decreases were most prominent in the Middle East and Latin America. Only the Far East countries were able to bounce back by April 2020.

Ultimately, the lower the GDP of a given country, the greater the reductions in cardiac testing, availability of PPE, and telehealth use, according to Einstein’s team.

“The cumulative impact of the current pandemic will likely result in consequences in delayed cardiovascular diagnosis that, if persistent, may not only erase prior population declines for this condition, but also hasten premature morbidity and mortality for millions of patients from low- to high-income countries alike,” study authors concluded.

Even so, cardiac testing is not necessary to find most at-risk individuals, if they have home blood pressure monitoring machines and body scales, Leong and colleagues’ editorial pointed out.

“This calls for more emphasis on developing efficient systems of telehealth, especially in poorer countries or in remote settings in all countries. Such transformative health systems can provide sustainable low-cost care, even after the epidemic has receded. It may also stimulate reconsideration of whether the current levels of diagnostic testing in some countries are appropriate and may lead to more selective use,” the editorialists suggested.

The study was based on a survey conducted by the International Atomic Energy Agency. By June 10, 2020, completed responses were collected from 909 unique responders at inpatient and outpatient centers performing cardiac diagnostic procedures in 108 countries.

Einstein and colleagues warned of potential nonresponse bias given that 2,596 people had opened the survey link. In addition, procedural volumes were not measured but self-reported instead.

In light of the study’s limitations, Leong and colleagues warned against drawing causal links between reduced cardiac diagnostic procedures and excess cardiovascular mortality.

“However, it is clear that cardiac diagnostic procedures are another measure of the impact of COVID-19 on the delivery of health care,” they wrote.