Graphical Abstract: Impact of the 'waves' of the COVID-19 pandemic on cardiovascular care.
In late 2019, local media outlets began sporadic reporting of a small group of individuals infected with a novel virus originating from the Wuhan province of China. As severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) spread rapidly across continents, we witnessed slowing of commercial activities, a collapse in capital markets, and an abrupt shift fin work patterns. In tandem, unprecedented strains were placed on healthcare systems globally, including contending with uncertainties regarding emergency and intensive care needs and capacity and availibility of personal protective equipment. The resultant situation forced health systems to decide how they might best care for their local communities, including those with and without SARS-CoV-2 infection.
During the early pandemic, several reports from diverse health systems cited a decline in hospitalizations for conditions that otherwise would necessitate emergency or urgent inpatient care.[1,2] These included several cardiovascular diseases, such as ST-segment elevation myocardial infarction (STEMI), stroke, and acute decompensated heart failure (HF). Perhaps influenced by perceived capacity contrainsts, fear of contracting coronavirus disease 2019 (COVID-19), and strong 'stay at home' public health messaging, patients seemed reluctant to present (or be admitted to) hospitals worldwide when they developed worrisome symptoms. Even the lay press caught wind of this trend, with the New York Times asking, 'Where have all the heart attacks gone?'
In this issue of the European Heart Journal, Nadarajah et al. expand our perspective on the breadth of collateral effects of the COVID-19 pandemic on patients with cardiovascular disease. Systematically synthesizing data from 158 studies across 49 countries and six continents, this analysis serves as one of the most extensive studies of the global impact of the pandemic on cardiovascular healthcare utilization. The authors found consistent drops in hospitalizations for several acute cardiovascular conditions, including a 22% decline in STEMI and a 33% decline in non-STEMI and HF hospitalizations during the pandemic compared with pre-pandemic levels. Reductions in these acute cardiovascular hospitalizations appeared broadly consistent across global geographic regions, with the notable exception of more significant declines in STEMI among low- and middle-income countries compared to higher income countries. Among studies reporting these data, the authors also found an estimated 60 min increase in the time from symptom onset to first medical contact in patients with STEMI, though door-to-needle times remained similar. In-hospital mortality for STEMI and HF was higher during the pandemic. Such data help quantify the magnitude of the secondary effects of the COVID-19 pandemic as a result of deferred acute cardiovascular care.
How do we make sense of these sobering data and, more importantly, how can health systems learn from these experiences for the future? Notably, this study uses a pre-pandemic comparator group to assess changes in hospitalizations and mortality; natural seasonal changes in hospitalization/mortality rates are not fully accounted for in this analysis. Including a month-matched control as a secondary comparator may have further strengthened the findings. However, the degree of hospitalization reduction observed would be unlikely to be driven by seasonal changes alone. Geographic variation during pandemic waves and differences in viral strains, infectivity, and virulence may further complicated interpretation of these pooled data.
Acknowledging these limitations, these data highlight the need for appropriate, structured, and consistent messaging surrounding seeking emergency acute cardiovascular care during a public health emergency. While the COVID-19 pandemic represented an unexpected disruption in care delivery, strong 'stay at home' messaging aimed at the general public may have added collateral damage. These data are particularly worrisome in the context of (i) a rise in cardiovascular mortality during the pandemic and (ii) reports of increased out-of-hospital cardiac arrests. The observed higher in-hospital mortality rates are likely to be related to several potential factors. For example, delays in care may have led to higher acuity at hospital presentation; on the other hand, effective triage of lower risk patients to non-hospital settings may have also increased in-hospital acuity. While appropriate, mitigation messaging attempts underscoring the importance of seeking prompt attention if experiencing symptoms of heart attack, stroke or HF, or other serious illness may have come too late or may have further confused patients, leading to decision paralysis about whether to seek emergency care. During future perturbations of care, more apparent separation of public health messaging (physical distancing and protective masks) from acute illness messaging (continued capacity and safety of emergency facilities) may improve our ability to curtail viral spread while ensuring care needs are not delayed.
However, acute COVID-19 infection and the secondary impact of deferred acute cardiovascular care may only contribute to a small portion of the overall legacy of the pandemic on cardiovascualr caret. Further 'waves' may be imminent and more longstanding; for example, the pandemic may have also disrupted chronic cardiovascular preventative care. Reduced willingness or access to clinical laboratories for biomarker assessment may have reduced recognition of poorly controlled hyperlipidaemia or blood glucose levels, leading to longer latency periods of poorly controlled cardiovascular risk factors. The abrupt shift from ambulatory to virtual care similarly may have led to less frequent blood pressure monitoring and initiation of antihypertensive therapies. Likewise, for high-risk conditions such as HF, for which multiple evidence-based, therapies exist, the pandemic may have deepened therapeutic inertia and slowed attempts to implement comprehensive disease-modifying treatment as early as possible. This tertiary impact of the pandemic may, in turn, lead to a greater number of downstream cardiovascular events that could have been potentially averted. Quaternary effects are probably not fully realized and include the long-term effects of mental, social, and economic hardship that the pandemic has levied. Structured identification of these residual waves of the pandemic and prospectively developed mitigation strategies will prove essential as care teams grapple with the unpleasant legacy this pandemic continues to hold.
Are there any silver linings or lessons that we can take forward? Notably, the accelerated adoption of telehealth and digital health solutions may utimately be a boon for innovation in care delivery. The forced adoption of virtual communicati on necessitated by the pandemic may, in turn, increase access and bring us closer to our patients. As coverage, reimbursement, and staffing models evolve, telemedicine may allow for more effective triage of lower risk patients that can be appropriately managed outside inpatient settings. In addition, technology may also improve clinicians' abilities to provide better population-level care and create new distribution avenues for effective implementation and dissemination science. Recent programmes have demonstrated that care for atherosclerotic vascular disease, hypertension, and HF can be optimized via remote platforms.[7–9] Importantly, technology may have the added benefit of better educating, engaging, and empowering patients to take greater ownership over their care and responsible use may allow for reinforcement of healthy behaviors between clinical encounters. These applications hold significant promise in therapeutic medication adherence and other health promotion behaviours. Further leveraging digital health tools across research, clinical care, and implementation science efforts must utimately strike the balance of promoting population-level health management while reducing 'sludge' and lessening burden on clinicians.
Overall, the work by Nadarajah et al. highlights yet another example of the far-reaching effects of the COVID-19 pandemic, extending well beyond those who have contracted the virus itself. As the clinical community grapples with continued surges while trying to forge a new normal, emerging data suggest that there will be a long-lasting legacy of cardiovascular disease in the wake of the COVID-19 pandemic, with many waves yet to hit the shore.
Eur Heart J. 2022;43(33):3179-3181. © 2022 Oxford University Press
Copyright 2007 European Society of Cardiology. Published by Oxford University Press. All rights reserved.