Hospitalization deficit of in- and outpatient cases with cardiovascular diseases and utilization of cardiological interventions during the COVID-19 pandemic: Insights from the German-wide helios hospital network

Continued decline in the incidence of myocardial infarction beyond the COVID-19 pandemic: a nationwide study of the Swedish population aged 60 and older during 2015-2022

The number of myocardial infarctions declined during the early COVID-19 pandemic but mechanisms behind these declines are poorly understood. COVID-19 infection is also associated with an increased risk of myocardial infarction which could lead to higher incidence rates in the population. This study aims to shed light on the seemingly paradoxical relationship between COVID-19 and myocardial infarction occurrence on the population level by exploring long-term trends in incidence rates, case fatality, and proportion of patients dying before reaching a hospital. Our work is based on a linkage of administrative registers covering the entire population aged 60 + in Sweden. Considering both long-term trends since 2015 and seasonal variability, we compared observed incidence, case fatality, and proportions of patients hospitalized to expected values during 2020-2022. Despite more than 200 laboratory-confirmed COVID-19 cases per 1000 inhabitants by the end of 2022, incidence rates of myocardial infarction continued to decline, thus following the long-term trend observed already before 2020. During the first pandemic wave there was an additional incidence decline corresponding to 13% fewer myocardial infarctions than expected. This decline was neither accompanied by increasing case fatality nor by lower shares of patients being hospitalized. We found no increase in the population-level incidence of myocardial infarction despite large-scale exposure to COVID-19, which suggests that the effect of COVID-19 on myocardial infarction risk is not substantial. Increased pressure on the Swedish health care system has not led to increased risks or poorer outcomes for patients presenting with acute myocardial infarction.

Predictors of worse outcome after postponing non-emergency cardiac interventions during the COVID-19 pandemic

OBJECTIVE

Deferral of non-emergency cardiac procedures is associated with increased early emergency cardiovascular hospitalisation. This study aimed to identify predictors of worse clinical outcome after deferral of non-emergency cardiovascular interventions.

METHODS

This observational case-control study included consecutive patients whose non-emergency cardiac intervention has been postponed during COVID-19-related lockdown between 19 March and 30 April 2020 (n=193). Cox regression was performed to identify predictors of the combined 1-year end point emergency cardiovascular hospitalisation and death. All patients undergoing non-emergency interventions in the corresponding time period 2019 served as control group (n=216).

RESULTS

The combined end point of death and emergency cardiovascular hospitalisation occurred in 70 (36.3%) of 193 patients with a postponed cardiovascular intervention. The planned intervention was deferred by a median of 23 (19-36) days. Arterial hypertension (HR 2.27; 95% CI 1.00 to 5.12; p=0.049), chronic kidney disease (HR 1.89; 95% CI 1.03 to 3.49; p=0.041) as well as severe valvular heart disease (HR 3.08; 95% CI 1.68 to 5.64; p<0.001) were independent predictors of death or emergency hospitalisation. Kaplan-Maier estimators of the combined end point were 31% in patients with arterial hypertension, 56% in patients with severe valvular heart disease and 77% with both risk factors (HR 12.4, 95% CI 3.8 to 40.7; p<0.001) and only 9% in patients without these risk factors (log rank p<0.001). N-terminal pro-B-type natriuretic peptide (NT-proBNP) cut-point of ≥1109 pg/mL best predicts the occurrence of primary end point event in deferred patients (area under the curve 0.71; p<0.001; sensitivity 63.8%, specificity 69.4%).

CONCLUSION

Our results suggest that patients with either arterial hypertension, chronic kidney or severe valvular heart disease are at very high risk for emergency hospitalisation and increased mortality in case of postponed cardiac interventions even in supposed stable clinical status. Risk seems to be even higher in patients suffering from a combination of these conditions. If the ongoing or future pandemics force hospitals again to postpone cardiac interventions, the biomarker NT-proBNP is an applicable parameter for outpatient monitoring to identify those at risk for adverse cardiovascular events.

Hospital admissions and deaths due to acute cardiovascular events during the COVID-19 pandemic in residents of long-term care facilities

Hospital admissions due to acute cardiovascular events dropped during the COVID-19 pandemic in the general population; however, evidence for residents of long-term care facilities (LTCF) is sparse. We investigated rates of hospital admissions and deaths due to myocardial infarction (MI) and stroke in LTCF residents during the pandemic. Our nationwide cohort study used claims data. The sample comprised 1,140,139 AOK-ensured LTCF residents over 60 years of age (68.6% women; age 85.3 ± 8.5 years) from the largest statutory health insurance in Germany (AOK), which is not representative for all LTCF residents. We included MI and stroke admission and compared numbers of in-hospital deaths from January 2020 to end of April 2021 (i.e., during the first three waves of the pandemic) with the number of incidences in 2015-2019. To estimate incidence risk ratios (IRR), adjusted Poisson regression analyses were applied. During the observation period (2015-2021), there were 19,196 MI and 73,953 stroke admissions. MI admissions declined in the pandemic phase by 22.5% (IRR = 0.68 [CI 0.65-0.72]) compared to previous years. This decline was slightly more pronounced for NSTEMI than for STEMI. MI fatality risks remained comparable across years (IRR = 0.97 [CI95% 0.92-1.02]). Stroke admissions dropped by 15.1% (IRR = 0.75 [CI95% 0.72-0.78]) in the pandemic. There was an elevated case fatality risk for haemorrhagic stroke (IRR = 1.09 [CI95% 1.03-1.15]) but not for other stroke subtypes compared to previous years. This study provides first evidence of declines in MI and stroke admissions and in-hospital deaths among LTCF residents during the pandemic. The figures are alarming given the acute nature of the conditions and the vulnerability of the residents.

Deferral of Non-Emergency Cardiovascular Interventions Triggers Increased Cardiac Emergency Admissions-Analysis of the COVID-19 Related Lockdown

BACKGROUND

Data on the relation between non-emergency and emergency cardiac admission rates during the COVID-19 lockdown and post-lockdown period are sparse.

METHODS

Consecutive cardiac patients admitted to our tertiary heart center between 1 January and 30 June 2020 were included. The observation period of 6 months was analyzed in total and divided into three defined time periods: the pre-lockdown (1 January-19 March), lockdown (20 March-19 April), and post-lockdown (20 April-30 June) period. These were compared to the reference periods 2019 and 2022 using daily admission rates and incidence rate ratios (IRR).

RESULTS

Over the observation period from 1 January to 30 June, cardiac admissions (including non-emergency and emergency) were comparable between 2019, 2020, and 2022 (n = 2889, n = 2952, n = 2956; p = 0.845). However, when compared to the reference period 2019, non-emergency admissions decreased in 2020 (1364 vs. 1663; p = 0.02), while emergency admissions significantly increased (1588 vs. 1226; p < 0.001). Further analysis of the lockdown period revealed that non-emergency admissions dropped by 82% (IRR 0.18; 95%-CI 0.14-0.24; p < 0.001) and 42% fewer invasive cardiac interventions were performed (p < 0.001), whereas the post-lockdown period showed a 52% increase of emergency admissions (IRR 1.47; 95%-CI 1.31-1.65; p < 0.001) compared to 2019.

CONCLUSIONS

We demonstrate a drastic surge of emergency cardiac admissions post-COVID-19 related lockdown suggesting that patients who did not keep their non-emergency appointment had to be admitted as an emergency later on.

Temporal trends in cardiovascular care: Insights from the COVID-19 pandemic

In response to the ongoing COVID-19 pandemic, public health care measures have been implemented to limit spread of the contagion and ensure adequate healthcare resource allocation. Correlating with these measures are observed changes in the incidence and outcomes of cardiovascular conditions in the absence of COVID-19 infection. The pandemic has resulted in a reduction in acute coronary syndrome, heart failure and arrhythmia admissions but with worsened outcomes in those diagnosed with these conditions. This is concerning of an underdiagnosis of cardiovascular diseases during the pandemic. Furthermore, cardiovascular services and investigations have decreased to provide healthcare allocation to COVID-19 related services. This threatens an increasing future prevalence of cardiovascular morbidity in healthcare systems that are still adapting to the challenges of a continuing pandemic. Adaption of virtual training and patient care delivery platforms have been shown to be useful, but adequate resources allocation is needed to ensure effectiveness in vulnerable populations.

Impact analysis of heart failure across European countries: an ESC-HFA position paper

Heart failure (HF) is a long-term clinical syndrome, with increasing prevalence and considerable healthcare costs that are further expected to increase dramatically. Despite significant advances in therapy and prevention, mortality and morbidity remain high and quality of life poor. Epidemiological data, that is, prevalence, incidence, mortality, and morbidity, show geographical variations across the European countries, depending on differences in aetiology, clinical characteristics, and treatment. However, data on the prevalence of the disease are scarce, as are those on quality of life. For these reasons, the ESC-HFA has developed a position paper to comprehensively assess our understanding of the burden of HF in Europe, in order to guide future policies for this syndrome. This manuscript will discuss the available epidemiological data on HF prevalence, outcomes, and human costs-in terms of quality of life-in European countries.

Reduction in Hospital Admissions for Cardiovascular Diseases (CVDs) during the Coronavirus Disease 2019 (COVID-19) Pandemic: A Retrospective Study from a Southern Italian Region in the Year 2020

(1) Background: The COVID-19 pandemic has indirect consequences for healthcare for other diseases, known as collateral damage. This situation heavily affects healthcare systems, causing changes in patterns of hospital admission. During the peak of the coronavirus disease 2019 pandemic, numerous studies reported a reduction in admissions for acute coronary syndrome. The aim of this study was to evaluate the incidence of admissions for cardiovascular diseases in Abruzzo, a region of Southern Italy, in the year 2020 and compare it to the two previous years (2018−2019). (2) Methods: This retrospective study was conducted in Abruzzo, Italy. The monthly number of admissions in the year 2020 was compared to a control period made from the average number of events that occurred in the previous two years (2018−2019). (3) Results: A global reduction in hospital admissions for all the cardiovascular diseases (CVDs) considered was observed. In particular, compared to the control period, in 2020, the number of admissions for ST-segment elevation myocardial infarction (STEMI) was lower by 34 (hospitalization rate ratio, HRR, 0.93; p < 0.001), the number of non-ST-segment-elevation myocardial infarctions (N-STEMI) was lower by 154.5 (HRR 0.89; p < 0.001), the number for acute coronary syndrome (ACS) was 340 lower (HRR 0.90; p < 0.001) and the number for heart failure (HF) was 1424.5 lower than during the control period (HRR 0.73; p < 0.001). (4) Conclusions: The results of this study show the impact of COVID-19 on admissions for CVDs, suggesting the need for strategic measures to overcome the burden of hospitalizations in future years.

The Impact of the COVID-19 Pandemic on Hospital Services for Patients with Cardiac Diseases: A Scoping Review

This study aims to assess the impact of the COVID-19 pandemic on hospital cardiac care, as assessed by performance indicators. Scoping review methodology: performance indicators were extracted to inform on changes in care during January-June 2020. Database searches yielded 6277 articles, of which 838 met the inclusion criteria. After full-text screening, 94 articles were included and 1637 indicators were retrieved. Most of the indicators that provided information on changes in the number of admissions (n = 118, 88%) signaled a decrease in admissions; 88% (n = 15) of the indicators showed patients' delayed presentation and 40% (n = 54) showed patients in a worse clinical condition. A reduction in diagnostic and treatment procedures was signaled by 95% (n = 18) and 81% (n = 64) of the indicators, respectively. Length of stay decreased in 58% (n = 21) of the indicators, acute coronary syndromes treatment times increased in 61% (n = 65) of the indicators, and outpatient activity decreased in 94% (n = 17) of the indicators related to outpatient care. Telehealth utilization increased in 100% (n = 6). Outcomes worsened in 40% (n = 35) of the indicators, and mortality rates increased in 52% (n = 31). All phases of the pathway were affected. This information could support the planning of care during the ongoing pandemic and in future events.

The influence of the 2020 COVID-19 pandemic on the implantation rates of cardiac implantable electronic devices in Germany: changes between 2020 Q1-Q3 and 2019 Q1-Q3

Aim

During the early phase of the COVID-19 pandemic, hospital admissions for several medical and surgical conditions have declined. Few data are available with respect to elective cardiac implantable electronic devices (CIEDs) implantation. The aim of the present study was to determine the impact of the COVID-19 pandemic on the monthly CIED implantation rates in Germany.

Methods and Results

The monthly rates of CIED implantation for the 2019 pre- and 2020 pandemic periods were retrieved from the “Institute für das Entgeltsystem im Krankenhaus” (InEK) using OPS codes to identify pacemakers (PMs), implantable cardioverter/defibrillators (ICDs) and cardiac resynchronisation therapy (CRT) systems. Compared with 2019, the COVID-19 pandemic was associated with an overall decline of CIED implantation rates of -2.6%, reaching -22,9% in April 2020. Stratified by device type, the patterns of implantation were similar between PMs and ICDs, with maximal declines of -24.3% and -23.2% in April, respectively. Thereafter, the implantation rates gradually increased before stabilizing to rates similar to those observed in 2019. CRT implantation rates also declined in the early pandemic wave, but the overall 2020 rates increased by +4.3% likely driven by an increase of +16.5% (June to September). All observed percentage differences of monthly device type related implantation rates demonstrated a statistical significance.

Conclusions

The COVID-19 pandemic had a significant impact on the implantation of CIEDs in Germany. A differential pattern of resource utilization was observed with a catch-up effect for PMs and ICDs. The implantation rates of CRT also declined, but they increased rapidly and remained higher than those of 2019.

A Comparative Analysis of In-Hospital Mortality per Disease Groups in Germany Before and During the COVID-19 Pandemic From 2016 to 2020

IMPORTANCE

Throughout the ongoing SARS-CoV-2 pandemic, it has been critical to understand not only the viral disease itself but also its implications for the overall health care system. Reports about excess mortality in this regard have mostly focused on overall death counts during specific pandemic phases.

OBJECTIVE

To investigate hospitalization rates and compare in-hospital mortality rates with absolute mortality incidences across a broad spectrum of diseases, comparing 2020 data with those of prepandemic years.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective, cross-sectional, multicentric analysis of administrative data from 5 821 757 inpatients admitted from January 1, 2016, to December 31, 2020, to 87 German Helios primary to tertiary care hospitals.

EXPOSURES

Exposure to SARS-CoV-2.

MAIN OUTCOMES AND MEASURES

Administrative data were analyzed from January 1, 2016, to March 31, 2021, as a consecutive sample for all inpatients. Disease groups were defined according to International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10; German modification) encoded main discharge diagnoses. Incidence rate ratios (IRRs) for hospital admissions and hospital mortality counts, as well as relative mortality risks (RMRs) comparing 2016-2019 with 2020 (exposure to the SARS-CoV-2 pandemic), were calculated with Poisson regression with log-link function.

RESULTS

Data were examined for 5 821 757 inpatients (mean [SD] age, 56.4 [25.3] years; 51.5% women), including 125 807 in-hospital deaths. Incidence rate ratios for hospital admissions were associated with a significant reduction for all investigated disease groups (IRR, 0.82; 95% CI, 0.79-0.86; P < .001). After adjusting for age, sex, the Elixhauser Comorbidity Index score, and SARS-CoV-2 infections, RMRs were associated with an increase in infectious diseases (RMR, 1.28; 95% CI, 1.21-1.34; P < .001), musculoskeletal diseases (RMR, 1.19; 95% CI, 1.04-1.36; P = .009), and respiratory diseases (RMR, 1.09; 95% CI, 1.05-1.14; P < .001) but not for the total cohort (RMR, 1.00; 95% CI, 0.99-1.02; P = .66). Regarding in-hospital mortality, IRR was associated with an increase within the ICD-10 chapter of respiratory diseases (IRR, 1.28; 95% CI, 1.13-1.46; P < .001) in comparing 2020 with 2016-2019, in contrast to being associated with a reduction in IRRs for the overall cohort and several other subgroups. After exclusion of patients with SARS-CoV-2 infections, IRRs were associated with a reduction in absolute in-hospital mortality for the overall cohort (IRR, 0.78; 95% CI, 0.72-0.84; P < .001) and the subgroup of respiratory diseases (IRR, 0.83; 95% CI, 0.74-0.92; P < .001).

CONCLUSIONS AND RELEVANCE

This cross-sectional study of inpatients from a multicentric German database suggests that absolute in-hospital mortality for 2020 across disease groups was not higher compared with previous years. Higher IRRs of in-hospital deaths observed in patients with respiratory diseases were likely associated with individuals with SARS-CoV-2 infections.

Expected and observed in-hospital mortality in heart failure patients before and during the COVID-19 pandemic: Introduction of the machine learning-based standardized mortality ratio at Helios hospitals

BACKGROUND

Reduced hospital admission rates for heart failure (HF) and evidence of increased in-hospital mortality were reported during the COVID-19 pandemic. The aim of this study was to apply a machine learning (ML)-based mortality prediction model to examine whether the latter is attributable to differing case mixes and exceeds expected mortality rates.

METHODS AND RESULTS

Inpatient cases with a primary discharge diagnosis of HF non-electively admitted to 86 German Helios hospitals between 01/01/2016 and 08/31/2020 were identified. Patients with proven or suspected SARS-CoV-2 infection were excluded. ML-based models were developed, tuned, and tested using cases of 2016-2018 (n = 64,440; randomly split 75%/25%). Extreme gradient boosting showed the best model performance indicated by a receiver operating characteristic area under the curve of 0.882 (95% confidence interval [CI]: 0.872-0.893). The model was applied on data sets of 2019 and 2020 (n = 28,556 cases) and the hospital standardized mortality ratio (HSMR) was computed as the observed to expected death ratio. Observed mortality rates were 5.84% (2019) and 6.21% (2020), HSMRs based on an individual case-based mortality probability were 100.0 (95% CI: 93.3-107.2; p = 1.000) for 2019 and 99.3 (95% CI: 92.5-106.4; p = .850) for 2020. Within subgroups of age or hospital volume, there were no significant differences between observed and expected deaths. When stratified for pandemic phases, no excess death during the COVID-19 pandemic was observed.

CONCLUSION

Applying an ML algorithm to calculate expected inpatient mortality based on administrative data, there was no excess death above expected event rates in HF patients during the COVID-19 pandemic.

Heart failure in COVID-19: the multicentre, multinational PCHF-COVICAV registry

Aims

We assessed the outcome of hospitalized coronavirus disease 2019 (COVID‐19) patients with heart failure (HF) compared with patients with other cardiovascular disease and/or risk factors (arterial hypertension, diabetes, or dyslipidaemia). We further wanted to determine the incidence of HF events and its consequences in these patient populations.

Methods and results

International retrospective Postgraduate Course in Heart Failure registry for patients hospitalized with COVID‐19 and CArdioVascular disease and/or risk factors (arterial hypertension, diabetes, or dyslipidaemia) was performed in 28 centres from 15 countries (PCHF‐COVICAV). The primary endpoint was in‐hospital mortality. Of 1974 patients hospitalized with COVID‐19, 1282 had cardiovascular disease and/or risk factors (median age: 72 [interquartile range: 62–81] years, 58% male), with HF being present in 256 [20%] patients. Overall in‐hospital mortality was 25% (n = 323/1282 deaths). In‐hospital mortality was higher in patients with a history of HF (36%, n = 92) compared with non‐HF patients (23%, n = 231, odds ratio [OR] 1.93 [95% confidence interval: 1.44–2.59], P < 0.001). After adjusting, HF remained associated with in‐hospital mortality (OR 1.45 [95% confidence interval: 1.01–2.06], P = 0.041). Importantly, 186 of 1282 [15%] patients had an acute HF event during hospitalization (76 [40%] with de novo HF), which was associated with higher in‐hospital mortality (89 [48%] vs. 220 [23%]) than in patients without HF event (OR 3.10 [2.24–4.29], P < 0.001).

Conclusions

Hospitalized COVID‐19 patients with HF are at increased risk for in‐hospital death. In‐hospital worsening of HF or acute HF de novo are common and associated with a further increase in in‐hospital mortality.

Stockpiled personal protective equipment and knowledge of pandemic plans as predictors of perceived pandemic preparedness among German general practitioners

BACKGROUND

The COVID-19 pandemic significantly changed the work of general practitioners (GPs). At the onset of the pandemic in March 2020, German outpatient practices had to adapt quickly. Pandemic preparedness (PP) of GPs may play a vital role in their management of a pandemic.

OBJECTIVES

The study aimed to examine the association in the stock of seven personal protective equipment (PPE) items and knowledge of pandemic plans on perceived PP among GPs.

METHODS

Three multivariable linear regression models were developed based on an online cross-sectional survey for the period March-April 2020 (the onset of the pandemic in Germany). Data were collected using self-developed items on self-assessed PP and knowledge of a pandemic plan and its utility. The stock of seven PPE items was queried. For PPE items, three different PPE scores were compared. Control variables for all models were gender and age.

RESULTS

In total, 508 GPs were included in the study; 65.16% believed that they were very poorly or poorly prepared. Furthermore, 13.83% of GPs were aware of a pandemic plan; 40% rated those plans as beneficial. The stock of FFP-2/3 masks, protective suits, face shields, safety glasses, and medical face masks were mostly considered completely insufficient or insufficient, whereas disposable gloves and disinfectants were considered sufficient or completely sufficient. The stock of PPE was significantly positively associated with PP and had the largest effect on PP; the association of the knowledge of a pandemic plan was significant but small. PPE scores did not vary considerably in their explanatory power. The assessment of a pandemic plan as beneficial did not significantly affect PP.

CONCLUSION

The stock of PPE seems to be the determining factor for PP among German GPs; for COVID-19, sufficient masks are the determining factor. Knowledge of a pandemic plans play a secondary role in PP.

Remote proctoring for high-risk coronary interventions with mechanical circulatory support during COVID-19 pandemic and beyond

Remote proctoring by advanced digital technologies may help to overcome pandemic, geographic, and resource-related constraints for mentoring and educating interventional cardiology skills. We present a case series of patients undergoing high-risk percutaneous coronary intervention (HR-PCI) with mechanical circulatory support (MCS) guided by remote proctoring to gain insights into a streaming technology platform with regard to video/audio quality, visibility of all structural and imaging details, and delay in transmission. According to our experience, remote proctoring appears to be a reliable, quick, and resource-conserving way to disseminate, educate and improve MCS-supported HR-PCI with implications far beyond the COVID-19 pandemic.