Temporal trends in decompensated heart failure and outcomes during COVID-19: a multisite report from heart failure referral centres in London

Outcomes of Covid-19 among patients with ischemic heart disease: A propensity matched analysis

BACKGROUND

Prior research has linked cardiovascular diseases with higher COVID-19 mortality and worse hospital outcomes, particularly in severe heart failure. Large population-based data regarding the impact of pre-existing ischemic heart disease (IHD) on COVID-19 outcomes is not well established.

OBJECTIVE

To study the impact of COVID-19 infection on IHD hospital mortality and other outcomes.

METHODS

The study included a patient cohort from the 2020 and 2021 National Inpatient Sample (NIS) database. Propensity score matching was used to match the study cohort (COVID-19 with IHD) to controls (COVID-19 without IHD) using a 1:1 matching ratio. The outcomes analyzed were in-hospital mortality, rates of acute kidney injury (AKI), acute myocardial injury (AMI), cardiogenic shock, cardiac arrest, mechanical ventilation, tracheal intubation, pulmonary embolism (PE), ventricular tachycardia (VT), ventricular fibrillation (VF), length of stay (LOS), and total hospitalization charges.

RESULTS

A total of 2,532,652 patients met the inclusion criteria (1,199,008 females [47.3 %), predominantly Caucasian 1,456,203 (57.5 %); mean [SD] age 63, (5.4), including 29,315 (1.1 %) patients with a history of IHD. Following propensity matching, 4,772 COVID-19 patients with and without IHD were matched. IHD patients had higher rates of AMI (adjusted odds ratio (aOR) 3.75, 95 % CI 3.27-4.31, p < 0.001), cardiogenic shock (aOR 2.89, 95 % CI 1.60-5.19, p < 0.001), VT (aOR 3.26, 95 % CI 2.48-4.29, p < 0.001), and VF (aOR 2.23, 95 % CI 1.25-3.99, p < 0.001). The odds ratios of in-hospital mortality, AKI, PE, mechanical ventilation, tracheal intubation, and resource use were not significantly different.

CONCLUSION

A history of IHD does not impact COVID-19 mortality but increases the risk of in-hospital cardiac complications.

A nationwide, population-based study on specialized care for acute heart failure throughout the COVID-19 pandemic

AIMS

The COVID-19 pandemic disrupted the delivery of care for patients with heart failure (HF), leading to fewer HF hospitalizations and increased mortality. However, nationwide data on quality of care and long-term outcomes across the pandemic are scarce.

METHODS AND RESULTS

We used data from the National Heart Failure Audit (NHFA) linked to national records for hospitalization and deaths. We compared pre-COVID (2018-2019), COVID (2020), and late/post-COVID (2021-2022) periods. Data for 227 250 patients admitted to hospital with HF were analysed and grouped according to the admission year and the presence of HF with (HFrEF) or without reduced ejection fraction (non-HFrEF). The median age at admission was 81 years (interquartile range 72-88), 55% were men (n = 125 975), 87% were of white ethnicity (n = 102 805), and 51% had HFrEF (n = 116 990). In-hospital management and specialized cardiology care were maintained throughout the pandemic with an increasing percentage of patients discharged on disease-modifying medications over time (p < 0.001). Long-term outcomes improved over time (hazard ratio [HR] 0.92, 95% confidence interval [CI] 0.90-0.95, p < 0.001), mainly driven by a reduction in cardiovascular death. Receiving specialized cardiology care was associated with better long-term outcomes both for those who had HFrEF (HR 0.79, 95% CI 0.77-0.82, p < 0.001) and for those who had non-HFrEF (HR 0.87, 95% CI 0.85-0.90, p < 0.001).

CONCLUSIONS

Despite the disruption of healthcare systems, the clinical characteristics of patients admitted with HF were similar and the overall standard of care was maintained throughout the pandemic. Long-term survival of patients hospitalized with HF continued to improve after COVID-19, especially for HFrEF.

Differential Mortality Among Heart Failure Patients Across Different COVID-19 Surges in New York City

ABSTRACT

Learning from the healthcare system's response to the COVID-19 pandemic is essential to better prepare for potential future crises. We sought to assess mortality rates for patients admitted for acute decompensated heart failure (HF) and to analyze which factors demonstrated a statistically significant correlation with this primary endpoint. We performed a retrospective analysis of patients hospitalized with a primary diagnosis of acute decompensated HF within the New York City Health and Hospitals 11-hospital system across the different COVID surge periods. Mortality information was collected in 4,405 participants (mean [SD] age 70.54 [14.44] years, 1885 [42.87%] female).The highest mortality existed in the first surge (9.02%), then improved to near prepandemic levels (3.65%) in the second (3.91%) and third surges (5.94%, p < 0.0001). In-hospital mortality inversely correlated with receipt of a COVID-19 vaccination, but had no correlation with left ventricular ejection fraction or the number of vaccination doses. Mortality for acute decompensated HF patients improved after the first surge, suggesting that hospitals adequately adapted to provide quality care. As future infectious outbreaks may occur, emergency preparedness must ensure that adequate focus and resources remain for other clinical entities, such as HF, to ensure optimal care is delivered across all areas of illness.

Successful ECMO support for COVID-19-induced severe ARDS in patient after LVAD implantation

Ventricular assist devices are increasingly being used as a bridge to transplant in end stage heart failure patients. The Corona Virus Disease (COVID-19) pandemic had affected millions of people across the world, some of them with rapid progression to profound hypoxemia and development of acute respiratory distress syndrome (ARDS). Extracorporeal life support has been widely used in most severe respiratory failure cases, mostly as a veno-venous extracorporeal membrane oxygenation (ECMO). Right ventricle dysfunction does occur in almost 25% of patients with acute ARDS, and some groups of patients might have an increased risk of developing right ventricle (RV) failure. A case is described that involves a 22-year-old female patient who developed acute respiratory distress syndrome and right ventricle failure due to COVID-19 infection 6 months following left ventricle assist device (LVAD) implantation. The goal was to use a modified ECMO cannulation strategy to support the failing right ventricle and the patient's lungs. This was achieved with percutaneous cannulation of the pulmonary artery as an outflow cannula, while an inflow cannula was inserted into the femoral vein. Following 7 days of support, she was weaned from ECMO, and after an uneventful recovery, she was successfully discharged home. This case report shows that modified extracorporeal membrane oxygenation can be successfully used to support the failing ventricle and damaged lungs leading to full recovery in patients following LVAD implantation with severe ARDS and right ventricle failure.

The impact of the COVID-19 pandemic on delayed care of cardiovascular diseases in Europe: a systematic review

AIMS

Cardiovascular diseases (CVD) are the leading cause of death worldwide. The coronavirus disease 2019 (COVID-19) pandemic has disrupted healthcare systems, causing delays in essential medical services, and potentially impacting CVD treatment. This study aims to estimate the impact of the pandemic on delayed CVD care in Europe by providing a systematic overview of the available evidence.

METHODS AND RESULTS

PubMed, Embase, and Web of Science were searched until mid-September 2022 for studies focused on the impact of delayed CVD care due to the pandemic in Europe among adult patients. Outcomes were changes in hospital admissions, mortality rates, delays in seeking medical help after symptom onset, delays in treatment initiation, and change in the number of treatment procedures. We included 132 studies, of which all were observational retrospective. Results were presented in five disease groups: ischaemic heart diseases (IHD), cerebrovascular accidents (CVA), cardiac arrests (CA), heart failures (HF), and others, including broader CVD groups. There were significant decreases in hospital admissions for IHD, CVA, HF and urgent and elective cardiac procedures, and significant increases for CA. Mortality rates were higher for IHD and CVA.

CONCLUSION

The pandemic led to reduced acute CVD hospital admissions and increased mortality rates. Delays in seeking medical help were observed, while urgent and elective cardiac procedures decreased. Adequate resource allocation, clear guidelines on how to handle care during health crises, reduced delays, and healthy lifestyle promotion should be implemented. The long-term impact of pandemics on delayed CVD care, and the health-economic impact of COVID-19 should be further evaluated.

Telemedicine for the treatment of heart failure: new opportunities after COVID-19

ABSTRACT

During the Coronavirus Disease 2019 (COVID-19) pandemic, the epidemiology of heart failure significantly changed with reduced access to health system resources and a worsening of patients' outcome. Understanding the causes of these phenomena could be important to refine the management of heart failure during and after the pandemic. Telemedicine was associated with an improvement in heart failure outcomes in several studies; therefore, it may help in refining the out-of-hospital care of heart failure. In this review, the authors describe the changes in heart failure epidemiology during the COVID-19 pandemic; analyse available evidence on use and benefit of telemedicine during the pandemic and prepandemic periods; and discuss approaches to optimize the home-based or outpatient heart failure management in the future, beyond the pandemic.

Impact of COVID-19 on heart failure hospitalization and outcome in India - A cardiological society of India study (CSI-HF in COVID 19 times study - "The COVID C-HF study")

OBJECTIVES

The presentation and outcomes of acute decompensated heart failure (ADHF) during COVID times (June 2020 to Dec 2020) were compared with the historical control during the same period in 2019.

METHODS

Data of 4806 consecutive patients of acute HF admitted in 22 centres in the country were collected during this period. The admission patterns, aetiology, outcomes, prescription of guideline-directed medical therapy (GDMT) and interventions were analysed in this retrospective study.

RESULTS

Admissions for acute heart failure during the pandemic period in 2020 decreased by 20% compared to the corresponding six-month period in 2019, with numbers dropping from 2675 to 2131. However, no difference in the epidemiology was seen. The mean age of presentation in 2019 was 61.75 (±13.7) years, and 59.97 (±14.6) years in 2020. There was a significant decrease in the mean age of presentation (p = 0.001). Also. the proportion of male patients decreased significantly from 68.67% to 65.84% (p = 0.037). The in-hospital mortality for acute heart failure did not differ significantly between 2019 and 2020 (4.19% and 4.,97%) respectively (p = 0.19). The proportion of patients with HFrEF did not change in 2020 compared to 2019 (76.82% vs 75.74%, respectively). The average duration of hospital stay was 6.5 days.

CONCLUSION

The outcomes of ADHF patients admitted during the Covid pandemic did not differ significantly. The length of hospital stay remained the same. The study highlighted the sub-optimal use of GDMT, though slightly improving over the last few years.

Long-term reduction in the incidence of aplastic anemia and immune thrombocytopenia during the COVID-19 pandemic

Not available.

Ethnic differences in the indirect effects of the COVID-19 pandemic on clinical monitoring and hospitalisations for non-COVID conditions in England: a population-based, observational cohort study using the OpenSAFELY platform

Background

The COVID-19 pandemic disrupted healthcare and may have impacted ethnic inequalities in healthcare. We aimed to describe the impact of pandemic-related disruption on ethnic differences in clinical monitoring and hospital admissions for non-COVID conditions in England.

Methods

In this population-based, observational cohort study we used primary care electronic health record data with linkage to hospital episode statistics data and mortality data within OpenSAFELY, a data analytics platform created, with approval of NHS England, to address urgent COVID-19 research questions. We included adults aged 18 years and over registered with a TPP practice between March 1, 2018, and April 30, 2022. We excluded those with missing age, sex, geographic region, or Index of Multiple Deprivation. We grouped ethnicity (exposure), into five categories: White, Asian, Black, Other, and Mixed. We used interrupted time-series regression to estimate ethnic differences in clinical monitoring frequency (blood pressure and Hba1c measurements, chronic obstructive pulmonary disease and asthma annual reviews) before and after March 23, 2020. We used multivariable Cox regression to quantify ethnic differences in hospitalisations related to diabetes, cardiovascular disease, respiratory disease, and mental health before and after March 23, 2020.

Findings

Of 33,510,937 registered with a GP as of 1st January 2020, 19,064,019 were adults, alive and registered for at least 3 months, 3,010,751 met the exclusion criteria and 1,122,912 were missing ethnicity. This resulted in 14,930,356 adults with known ethnicity (92% of sample): 86.6% were White, 7.3% Asian, 2.6% Black, 1.4% Mixed ethnicity, and 2.2% Other ethnicities. Clinical monitoring did not return to pre-pandemic levels for any ethnic group. Ethnic differences were apparent pre-pandemic, except for diabetes monitoring, and remained unchanged, except for blood pressure monitoring in those with mental health conditions where differences narrowed during the pandemic. For those of Black ethnicity, there were seven additional admissions for diabetic ketoacidosis per month during the pandemic, and relative ethnic differences narrowed during the pandemic compared to the White ethnic group (Pre-pandemic hazard ratio (HR): 0.50, 95% confidence interval (CI) 0.41, 0.60, Pandemic HR: 0.75, 95% CI: 0.65, 0.87). There was increased admissions for heart failure during the pandemic for all ethnic groups, though highest in those of White ethnicity (heart failure risk difference: 5.4). Relatively, ethnic differences narrowed for heart failure admission in those of Asian (Pre-pandemic HR 1.56, 95% CI 1.49, 1.64, Pandemic HR 1.24, 95% CI 1.19, 1.29) and Black ethnicity (Pre-pandemic HR 1.41, 95% CI: 1.30, 1.53, Pandemic HR: 1.16, 95% CI 1.09, 1.25) compared with White ethnicity. For other outcomes the pandemic had minimal impact on ethnic differences.

Interpretation

Our study suggests that ethnic differences in clinical monitoring and hospitalisations remained largely unchanged during the pandemic for most conditions. Key exceptions were hospitalisations for diabetic ketoacidosis and heart failure, which warrant further investigation to understand the causes.

Funding

LSHTM COVID-19 Response Grant (DONAT15912).

Clinical Pathways Guided by Remotely Monitoring Cardiac Device Data: The Future of Device Heart Failure Management?

Research examining the utility of cardiac device data to manage patients with heart failure (HF) is rapidly evolving. COVID-19 has reignited interest in remote monitoring, with manufacturers each developing and testing new ways to detect acute HF episodes, risk stratify patients and support self-care. As standalone diagnostic tools, individual physiological metrics and algorithm-based systems have demonstrated utility in predicting future events, but the integration of remote monitoring data with existing clinical care pathways for device HF patients is not well described. This narrative review provides an overview of device-based HF diagnostics available to care providers in the UK, and describes the current state of play with regard to how these systems fit in with current HF management.

The impact of COVID-19 on heart failure admissions in Suriname-A call for action

Introduction

During the height of the COVID-19 pandemic, there was a worldwide reorganization of healthcare systems focusing on limiting the spread of the virus. The impact of these measures on heart failure (HF) admissions is scarcely reported in Low and Middle Income Countries (LMICs) including Suriname. We therefore assessed HF hospitalizations before and during the pandemic and call for action to improve healthcare access in Suriname through the development and implementation of telehealth strategies.

Methods

Retrospectively collected clinical (# hospitalizations per patient, in hospital mortality, comorbidities) and demographic (sex, age, ethnicity) data of people hospitalized with a primary or secondary HF discharge ICD10 code in the Academic Hospital Paramaribo (AZP) from February to December 2019 (pre-pandemic) and February to December 2020 (during the pandemic) were used for analysis. Data are presented as frequencies with corresponding percentages. T-tests were used to analyze continuous variables and the two-sample test for proportions for categorical variables.

Results

There was an overall slight decrease of 9.1% HF admissions (N pre-pandemic:417 vs N during the pandemic: 383). Significantly less patients (18.3%, p-value<0.00) were hospitalized during the pandemic (N: 249 (65.0%)) compared to pre-pandemic (N: 348 (83.3%)), while readmissions increased statistically significantly for both readmissions within 90 days (75 (19.6%) vs 55 (13.2%), p-value = 0.01) and readmissions within 365 days (122 (31.9%) vs 70 (16.7%), p-value = 0.00) in 2020 compared to 2019. Patients admitted during the pandemic also had significantly more of the following comorbidities: hypertension (46.2% vs 30.6%, p-value = 0.00), diabetes (31.9% vs 24.9%, p-value = 0.03) anemia (12.8% vs 3.1%, p-value = 0.00), and atrial fibrillation (22.7% vs 15.1%, p-value = 0.00).

Conclusion

HF admissions were reduced during the pandemic while HF readmissions increased compared to the pre-pandemic period. Due to in-person consultation restrictions, the HF clinic was inactive during the pandemic period. Distance monitoring of HF patients via telehealth tools could help in reducing these adverse effects. This call for action identifies key elements (digital and health literacy, telehealth legislation, integration of telehealth tools within the current healthcare sector) needed for the successful development and implementation of these tools in LMICs.

The Evolving Phenotypes of Cardiovascular Disease during COVID-19 Pandemic

COVID-19 pandemic has negatively impacted the management of patients with acute and chronic cardiovascular disease: acute coronary syndrome patients were often not timely reperfused, heart failure patients not adequately followed up and titrated, atrial arrhythmias not efficaciously treated and became chronic. New phenotypes of cardiovascular patients were more and more frequent during COVID-19 pandemic and are expected to be even more frequent in the next future in the new world shaped by the pandemic. We therefore aimed to briefly summarize the main changes in the phenotype of cardiovascular patients in the COVID-19 era, focusing on new clinical challenges and possible therapeutic options.

The Impact of the COVID-19 Pandemic on Hospitalization Rates due to Prosthetic Valve Thrombosis

Background

Studies have shown a decline in the admission rates of various diseases during the COVID-19 pandemic. Prosthetic valve thrombosis (PVT) is a rare condition followed by surgical or transcatheter valvular interventions. Considering the lack of data on hospitalization rates due to PVT during the pandemic, this study evaluated the implications of the COVID-19 pandemic on PVT admissions and characteristics in a tertiary referral center.

Methods

Data from all the consecutive patients hospitalized due to PVT between February 2020 and February 2021 (the first year of the pandemic) were collected from medical records and compared clinically with the corresponding time before the pandemic (February 2019 through February 2020). Variables of interest included the number of hospitalization, patient and valve characteristics, diagnostic and management strategies, and in-hospital events.

Results

Forty patients (32.5% male, age: 54.0 [46.5-62.0 y] comprised the study population. We observed a considerable decline in hospitalization rates during the pandemic, from 31 to 9 patients. Admitted patients were 8 years younger, had a higher proportion of the New York Heart Association functional class III or IV symptoms (44.4% vs 22.6%), were more often treated with fibrinolysis (33.3% vs 22.6%) or surgical approaches (33.3% vs 22.6%), and were discharged 6 days sooner.

Conclusion

We described a reduction in PVT hospitalization. Patients presented with a higher proportion of severe dyspnea and had increased treatment with fibrinolysis/surgical approaches. These observations highlight the necessity of the active surveillance of patients with prosthetic valves by caregivers for timely diagnosis and appropriate management during the pandemic.

Reshaping care in the aftermath of the pandemic. Implications for cardiology health systems

In the last two years, the COVID-19 pandemic has undeniably changed everyday life and significantly reshaped the healthcare systems. Besides the direct effect on daily care leading to significant excess mortality, several collateral damages have been observed during the pandemic. The impact of the pandemic led to staff shortages, disrupted education, worse healthcare professional well-being, and a lack of proper clinical training and research. In this review we highlight the results of these important changes and how can the healthcare systems can adapt to prevent unprecedented events in case of future catastrophes.

Impact of COVID-19 on Cardiovascular Disease

Coronavirus disease 2019 (COVID-19) is a viral infection with the novel severe acute respiratory distress syndrome corona virus 2 (SARS-CoV-2). Until now, more than 670 million people have suffered from COVID-19 worldwide, and roughly 7 million death cases were attributed to COVID-19. Recent evidence suggests an interplay between COVID-19 and cardiovascular disease (CVD). COVID-19 may serve as a yet underappreciated CVD risk modifier, including risk factors such as diabetes mellitus or arterial hypertension. In addition, recent data suggest that previous COVID-19 may increase the risk for many entities of CVD to an extent similarly observed for traditional cardiovascular (CV) risk factors. Furthermore, increased CVD incidence and worse clinical outcomes in individuals with preexisting CVD have been observed for myocarditis, acute coronary syndrome, heart failure (HF), thromboembolic complications, and arrhythmias. Direct and indirect mechanisms have been proposed by which COVID-19 may impact CVD and CV risk, including viral entry into CV tissue or by the induction of a massive systemic inflammatory response. In the current review, we provide an overview of the literature reporting an interaction between COVID-19 and CVD, review potential mechanisms underlying this interaction, and discuss preventive and treatment strategies and their interference with CVD that were evaluated since the onset of the COVID-19 pandemic.

Increased national mortality in acute myocardial infarction hospitalization during the COVID-19 pandemic

This retrospective study describes the effect of the COVID-19 pandemic on epidemiologic trends and highlights disparities in outcomes among acute myocardial infarction (AMI) hospitalizations. The National Inpatient Sample database from 2016 to 2020 was searched for hospitalizations of adult patients with AMI as a principal diagnosis using Clinical Classifications Software Refined codes. The admission rate for each calendar year was obtained as admission per 1000 adults hospitalized. The primary outcome was a comparison of inpatient mortality, and the secondary outcomes were the length of hospital stay and total hospital charge between prepandemic and pandemic years. During the pandemic (2020), the admission rate for AMI was 31.1 admissions per 1000 adults hospitalized compared to 33.4 admissions in 2019 (prepandemic) (P  < 0.001). When compared to the prepandemic admissions, those admitted during the pandemic had a lower mean age (66.5 ± 13.2 vs 66.9 ± 13.4, P  < 0.001), with more women (36.3% vs 37.3%, P  < 0.001). The inpatient mortality during the pandemic was 5.0% compared to 4.5% in 2019 (P  < 0.001). Mortality increased 12.0% in women vs 9.5% in men, 13.2% in Blacks vs 8.9% in Whites, and 6.5% in low-income vs 4.3% in high-income household hospitalizations. In conclusion, our study showed a statistically significant reduction in AMI admission rates during the pandemic and an increase in inpatient mortality. There were significant disparities in the increase in mortality across sociodemographic groups.

Characteristics, Treatment Patterns, and Clinical Outcomes After Heart Failure Hospitalizations During the COVID-19 Pandemic, March to October 2020

OBJECTIVE

To compare clinical characteristics, treatment patterns, and 30-day all-cause readmission and mortality between patients hospitalized for heart failure (HF) before and during the coronavirus disease 2019 (COVID-19) pandemic.

PATIENTS AND METHODS

The study was conducted at 16 hospitals across 3 geographically dispersed US states. The study included 6769 adults (mean age, 74 years; 56% [5033 of 8989] men) with cumulative 8989 HF hospitalizations: 2341 hospitalizations during the COVID-19 pandemic (March 1 through October 30, 2020) and 6648 in the pre-COVID-19 (October 1, 2018, through February 28, 2020) comparator group. We used Poisson regression, Kaplan-Meier estimates, multivariable logistic, and Cox regression analysis to determine whether prespecified study outcomes varied by time frames.

RESULTS

The adjusted 30-day readmission rate decreased from 13.1% (872 of 6648) in the pre-COVID-19 period to 10.0% (234 of 2341) in the COVID-19 pandemic period (relative risk reduction, 23%; hazard ratio, 0.77; 95% CI, 0.66 to 0.89). Conversely, all-cause mortality increased from 9.7% (645 of 6648) in the pre-COVID-19 period to 11.3% (264 of 2341) in the COVID-19 pandemic period (relative risk increase, 16%; number of admissions needed for one additional death, 62.5; hazard ratio, 1.19; 95% CI, 1.02 to 1.39). Despite significant differences in rates of index hospitalization, readmission, and mortality across the study time frames, the disease severity, HF subtypes, and treatment patterns remained unchanged (P>0.05).

CONCLUSION

The findings of this large tristate multicenter cohort study of HF hospitalizations suggest lower rates of index hospitalizations and 30-day readmissions but higher incidence of 30-day mortality with broadly similar use of HF medication, surgical interventions, and devices during the COVID-19 pandemic compared with the pre-COVID-19 time frame.

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.

Heart failure: an update from the last years and a look at the near future

In the last years, major progress occurred in heart failure (HF) management. Quadruple therapy is now mandatory for all the patients with HF with reduced ejection fraction. Whilst verciguat is becoming available across several countries, omecamtiv mecarbil is waiting to be released for clinical use. Concurrent use of potassium-lowering agents may counteract hyperkalaemia and facilitate renin-angiotensin-aldosterone system inhibitor implementations. The results of the EMPagliflozin outcomE tRial in Patients With chrOnic heaRt Failure With Preserved Ejection Fraction (EMPEROR-Preserved) trial were confirmed by the Dapagliflozin in Heart Failure with Mildly Reduced or Preserved Ejection Fraction (DELIVER) trial, and we now have, for the first time, evidence for treatment of also patients with HF with preserved ejection fraction. In a pre-specified meta-analysis of major randomized controlled trials, sodium-glucose co-transporter-2 inhibitors reduced all-cause mortality, cardiovascular (CV) mortality, and HF hospitalization in the patients with HF regardless of left ventricular ejection fraction. Other steps forward have occurred in the treatment of decompensated HF. Acetazolamide in Acute Decompensated Heart Failure with Volume Overload (ADVOR) trial showed that the addition of intravenous acetazolamide to loop diuretics leads to greater decongestion vs. placebo. The addition of hydrochlorothiazide to loop diuretics was evaluated in the CLOROTIC trial. Torasemide did not change outcomes, compared with furosemide, in TRANSFORM-HF. Ferric derisomaltose had an effect on the primary outcome of CV mortality or HF rehospitalizations in IRONMAN (rate ratio 0.82; 95% confidence interval 0.66-1.02; P = 0.070). Further options for the treatment of HF, including device therapies, cardiac contractility modulation, and percutaneous treatment of valvulopathies, are summarized in this article.

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.

Prognostic relevance of demographic factors in cardiac magnetic resonance-proven acute myocarditis: A cohort study

Aim

Acute myocarditis (AM) is a heterogeneous condition with variable estimates of survival. Contemporary criteria for the diagnosis of clinically suspected AM enable non-invasive assessment, resulting in greater sensitivity and more representative cohorts. We aimed to describe the demographic characteristics and long-term outcomes of patients with AM diagnosed using non-invasive criteria.

Methods and results

A total of 199 patients with cardiac magnetic resonance (CMR)-confirmed AM were included. The majority (n = 130, 65%) were male, and the average age was 39 ± 16 years. Half of the patients were White (n = 99, 52%), with the remainder from Black and Minority Ethnic (BAME) groups. The most common clinical presentation was chest pain (n = 156, 78%), with smaller numbers presenting with breathlessness (n = 25, 13%) and arrhythmias (n = 18, 9%). Patients admitted with breathlessness were sicker and more often required inotropes, steroids, and renal replacement therapy (p < 0.001, p < 0.001, and p = 0.01, respectively). Over a median follow-up of 53 (IQR 34-76) months, 11 patients (6%) experienced an adverse outcome, defined as a composite of all-cause mortality, resuscitated cardiac arrest, and appropriate implantable cardioverter defibrillator (ICD) therapy. Patients in the arrhythmia group had a worse prognosis, with a nearly sevenfold risk of adverse events [hazard ratio (HR) 6.97; 95% confidence interval (CI) 1.87-26.00, p = 0.004]. Sex and ethnicity were not significantly associated with the outcome.

Conclusion

AM is highly heterogeneous with an overall favourable prognosis. Three-quarters of patients with AM present with chest pain, which is associated with a benign prognosis. AM presenting with life-threatening arrhythmias is associated with a higher risk of adverse events.

Heart failure during the COVID-19 pandemic: clinical, diagnostic, management, and organizational dilemmas

The coronavirus 2019 (COVID-19) infection pandemic has affected the care of patients with heart failure (HF). Several consensus documents describe the appropriate diagnostic algorithm and treatment approach for patients with HF and associated COVID-19 infection. However, few questions about the mechanisms by which COVID can exacerbate HF in patients with high-risk (Stage B) or symptomatic HF (Stage C) remain unanswered. Therefore, the type of HF occurring during infection is poorly investigated. The diagnostic differentiation and management should be focused on the identification of the HF phenotype, underlying causes, and subsequent tailored therapy. In this framework, the relationship existing between COVID and onset of acute decompensated HF, isolated right HF, and cardiogenic shock is questioned, and the specific management is mainly based on local hospital organization rather than a standardized model. Similarly, some specific populations such as advanced HF, heart transplant, patients with left ventricular assist device (LVAD), or valve disease remain under investigated. In this systematic review, we examine recent advances regarding the relationships between HF and COVID-19 pandemic with respect to epidemiology, pathogenetic mechanisms, and differential diagnosis. Also, according to the recent HF guidelines definition, we highlight different clinical profile identification, pointing out the main concerns in understudied HF populations.

Increased Mortality in Patients With Acutely Decompensated Heart Failure During the COVID-19 Pandemic in Toronto, Canada

Background

Methods

Results

Conclusions

Longer Hospitalizations and Higher In-Hospital Mortality for Acute Heart Failure during the COVID-19 Pandemic in Larger vs. Smaller Cardiology Departments: Subanalysis of the COV-HF-SIRIO 6 Multicenter Study

Background

The coronavirus disease-2019 (COVID-19) pandemic is surging across Poland, leading to many direct deaths and underestimated collateral damage. We aimed to compare the influence of the COVID-19 pandemic on hospital admissions and in-hospital mortality in larger vs. smaller cardiology departments (i.e., with ≥ 2000 vs. < 2000 hospitalizations per year in 2019).

Methods

We performed a subanalysis of the COV-HF-SIRIO 6 multicenter retrospective study including all patients hospitalized in 24 cardiology departments in Poland between January 1, 2019 and December 31, 2020, focusing on patients with acute heart failure (AHF) and COVID-19.

Results

Total number of hospitalizations was reduced by 29.2% in larger cardiology departments and by 27.3% in smaller cardiology departments in 2020 vs. 2019. While hospitalizations for AHF were reduced by 21.8% and 25.1%, respectively. The length of hospital stay due to AHF in 2020 was 9.6 days in larger cardiology departments and 6.6 days in smaller departments (p < 0.001). In-hospital mortality for AHF during the COVID-19 pandemic was significantly higher in larger vs. smaller cardiology departments (10.7% vs. 3.2%; p < 0.001). In-hospital mortality for concomitant AHF and COVID-19 was extremely high in larger and smaller cardiology departments accounting for 31.3% vs. 31.6%, respectively.

Conclusions

During the COVID-19 pandemic longer hospitalizations and higher in-hospital mortality for AHF were observed in larger vs. smaller cardiology departments. Reduced hospital admissions and extremely high in-hospital mortality for concomitant AHF and COVID-19 were noted regardless of department size.

Cardiovascular Damage in COVID-19: What We Know Two Years Later

PURPOSE OF THE REVIEW

The Coronavirus disease 2019 (COVID-19) pandemic has profoundly influenced cardiological clinical and basic research in the past two years. In the present review, we summarize the current knowledge on myocardial involvement in COVID-19, providing an overview on the incidence, the pathogenetic mechanisms, and the clinical implications of cardiac injury in this setting.

RECENT FINDINGS

The possibility of heart involvement in patients with COVID-19 has received great attention since the beginning of the pandemic. After more than two years, several steps have been taken in understanding the mechanisms and the incidence of cardiac injury during COVID-19 infection. Similarly, studies globally have clarified the implications of co-existing heart disease and COVID-19. Severe COVID-19 infection may be complicated by myocardial injury. To date, a direct damage from the virus has not been demonstrated. The presence of myocardial injury should be systematically assessed for a prognostication purpose and for possible therapeutic implications.

The collateral damage of COVID-19 to cardiovascular services: a meta-analysis

AIMS

The effect of the COVID-19 pandemic on care and outcomes across non-COVID-19 cardiovascular (CV) diseases is unknown. A systematic review and meta-analysis was performed to quantify the effect and investigate for variation by CV disease, geographic region, country income classification and the time course of the pandemic.

METHODS AND RESULTS

From January 2019 to December 2021, Medline and Embase databases were searched for observational studies comparing a pandemic and pre-pandemic period with relation to CV disease hospitalisations, diagnostic and interventional procedures, outpatient consultations, and mortality. Observational data were synthesised by incidence rate ratios (IRR) and risk ratios (RR) for binary outcomes and weighted mean differences for continuous outcomes with 95% confidence intervals. The study was registered with PROSPERO (CRD42021265930). A total of 158 studies, covering 49 countries and 6 continents, were used for quantitative synthesis. Most studies (80%) reported information for high-income countries (HICs). Across all CV disease and geographies there were fewer hospitalisations, diagnostic and interventional procedures, and outpatient consultations during the pandemic. By meta-regression, in low-middle income countries (LMICs) compared to HICs the decline in ST-segment elevation myocardial infarction (STEMI) hospitalisations (RR 0.79, 95% confidence interval [CI] 0.66-0.94) and revascularisation (RR 0.73, 95% CI 0.62-0.87) was more severe. In LMICs, but not HICs, in-hospital mortality increased for STEMI (RR 1.22, 95% CI 1.10-1.37) and heart failure (RR 1.08, 95% CI 1.04-1.12). The magnitude of decline in hospitalisations for CV diseases did not differ between the first and second wave.

CONCLUSIONS

There was substantial global collateral CV damage during the COVID-19 pandemic with disparity in severity by country income classification.

Hospitalizations for Cardiovascular Diseases During the Early Stage of the COVID-19 Pandemic in Japan

Background: Although reductions in hospitalizations for myocardial infarction and heart failure have been reported during the period of COVID-19 pandemic restrictions, it is unclear how the overall number of hospitalizations for cardiovascular disease (CVD) treatment changed in the early stages of the pandemic.

Methods and Results: We analyzed the records of 574 certified hospitals affiliated with the Japanese Circulation Society and retrieved data from April 2015 to March 2020. Records were obtained from the nationwide Japanese Registry of All Cardiac and Vascular Diseases–Diagnosis Procedure Combination database. A quasi-Poisson regression model was used to estimate the number of hospitalizations for CVD treatment. Between January and March 2020, when the number of COVID-19 cases was relatively low in Japan, the actual/estimated number of hospitalizations for acute CVD was 18,233/21,634 (84.3%), whereas the actual/estimated number of scheduled hospitalizations was 16,921/19,066 (88.7%). The number of hospitalizations for acute heart failure and scheduled hospitalizations for valvular disease and aortic aneurysm were 81.1%, 84.6%, and 83.8% of the estimated values, respectively. A subanalysis that considered only facilities without hospitalization restrictions did not alter the results for these diseases.

Conclusions: The spread of COVID-19 was associated with a decreased number of hospitalizations for CVD in Japan, even in the early stages of the pandemic.

From Oral to Subcutaneous Furosemide: The Road to Novel Opportunities to Manage Congestion

The steadily rising prevalence of heart failure (HF) and the associated increase in health care expenditures represent a significant burden for patients, caregivers, and society. Ambulatory management of worsening congestion is a complex undertaking that requires diuretic escalation, yet clinical success is often hindered by the progressively declining bioavailability of oral agents. Once beyond a threshold, patients with acute on chronic HF often require hospital admission for intravenous diuresis. A novel, pH neutral formulation of furosemide that is administered by a biphasic drug delivery profile (80 mg total over 5 ​hours) via an automated, on-body infusor was designed to overcome these limitations. Early studies have shown that it has equivalent bioavailability with comparable diuresis and natriuresis to the intravenous formulation, leads to significant decongestion, and improvement in quality of life. It was shown to be safe and is well tolerated by patients. Although there is one ongoing clinical trial, available data have demonstrated the potential to shift hospital-administered, intravenous diuresis to the outpatient setting. Reduction in the need for recurrent hospital admissions would be highly desirable by most patients with chronic HF and would lead to a significant reduction in health care expenditures. In this article, we describe the rationale and evolution of this novel PH neutral formulation of furosemide administered subcutaneously, summarize its pharmacokinetic and pharmacodynamic profiles, and review emerging clinical trials demonstrating its clinical safety, efficacy, and potential to reduce health care expenditures.

ESC guidance for the diagnosis and management of cardiovascular disease during the COVID-19 pandemic: part 2-care pathways, treatment, and follow-up

AIMS

Since its emergence in early 2020, the novel severe acute respiratory syndrome coronavirus 2 causing coronavirus disease 2019 (COVID-19) has reached pandemic levels, and there have been repeated outbreaks across the globe. The aim of this two part series is to provide practical knowledge and guidance to aid clinicians in the diagnosis and management of cardiovascular (CV) disease in association with COVID-19.

METHODS AND RESULTS

A narrative literature review of the available evidence has been performed, and the resulting information has been organized into two parts. The first, which was reported previously, focused on the epidemiology, pathophysiology, and diagnosis of CV conditions that may be manifest in patients with COVID-19. This second part addresses the topics of: care pathways and triage systems and management and treatment pathways, both of the most commonly encountered CV conditions and of COVID-19; and information that may be considered useful to help patients with CV disease (CVD) to avoid exposure to COVID-19.

CONCLUSION

This comprehensive review is not a formal guideline but rather a document that provides a summary of current knowledge and guidance to practicing clinicians managing patients with CVD and COVID-19. The recommendations are mainly the result of observations and personal experience from healthcare providers. Therefore, the information provided here may be subject to change with increasing knowledge, evidence from prospective studies, and changes in the pandemic. Likewise, the guidance provided in the document should not interfere with recommendations provided by local and national healthcare authorities.

The impact of the COVID-19 pandemic on heart failure management: Global experience of the OPTIMIZE heart failure care network

During the COVID-19 pandemic, reductions in heart failure (HF) hospitalizations have been widely reported, and there is an urgent need to understand how HF care has been reorganized in countries with different infection levels, vaccination rates and healthcare services. The OPTIMIZE Heart Failure Care program has a global network of investigators in 42 countries, with first-hand experience of the impact of the pandemic on HF management in different care settings. The national coordinators were surveyed to assess: 1) the challenges of the COVID-19 pandemic for continuity of HF care, from both a hospital and patient perspective; 2) the organizational changes enacted to ensure continued HF care; and 3) lessons learned for the future of HF care. Contributions were obtained from 37 national coordinators in 29 countries. We summarize their input, highlighting the issues raised and using the example of three very different settings (Italy, Brazil, and Taiwan) to illustrate the similarities and differences across the OPTIMIZE program.

Co-Management of COVID-19 and Heart Failure During the COVID-19 Pandemic: Lessons Learned

The COVID pandemic has brought many new challenges worldwide, which has impacted on patients with chronic conditions. There is an increasing evidence base suggesting an interaction between chronic heart failure (HF) and COVID-19, and in turn the prognostic impact of co-existence of the two conditions. Patients with existing HF appear more prone to develop severe complications on contracting COVID-19, but the exact prevalence in patients with mild symptoms of COVID-19 not requiring hospital admission is poorly investigated. In addition, hospitalization rates for acute HF over the pandemic period appear reduced compared to previous periods. Several key issues remain rather unaddressed and, importantly, a specific algorithm focused on diagnostic differentiation between HF and acute respiratory distress syndrome, a severe complication of COVID-19, is still lacking. Furthermore, recent data suggests potential interaction existing between HF treatment and some anti-viral anti-inflammatory drugs prescribed during the infection, raising some doubts about a universal treatment strategy for all patients with COVID-19. With this manuscript, we aim to review the current literature in this field in light of growing understanding of COVID-19 in the setting of the HF population, its associated morbidity and mortality burden, and the impact on healthcare systems. We hope that this may stimulate a discussion to guarantee a better, more tailored delivery of care for patients with HF in the setting of concomitant COVID-19 infection.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.

STRUCTURE

Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

ESC guidance for the diagnosis and management of cardiovascular disease during the COVID-19 pandemic: part 2-care pathways, treatment, and follow-up

AIMS

Since its emergence in early 2020, the novel severe acute respiratory syndrome coronavirus 2 causing coronavirus disease 2019 (COVID-19) has reached pandemic levels, and there have been repeated outbreaks across the globe. The aim of this two part series is to provide practical knowledge and guidance to aid clinicians in the diagnosis and management of cardiovascular (CV) disease in association with COVID-19.

METHODS AND RESULTS

A narrative literature review of the available evidence has been performed, and the resulting information has been organized into two parts. The first, which was reported previously, focused on the epidemiology, pathophysiology, and diagnosis of CV conditions that may be manifest in patients with COVID-19. This second part addresses the topics of: care pathways and triage systems and management and treatment pathways, both of the most commonly encountered CV conditions and of COVID-19; and information that may be considered useful to help patients with CV disease (CVD) to avoid exposure to COVID-19.

CONCLUSION

This comprehensive review is not a formal guideline but rather a document that provides a summary of current knowledge and guidance to practicing clinicians managing patients with CVD and COVID-19. The recommendations are mainly the result of observations and personal experience from healthcare providers. Therefore, the information provided here may be subject to change with increasing knowledge, evidence from prospective studies, and changes in the pandemic. Likewise, the guidance provided in the document should not interfere with recommendations provided by local and national healthcare authorities.

Heart Failure Quality of Care and In-Hospital Outcomes During the COVID-19 Pandemic Findings from the Get With The Guidelines-Heart Failure Registry

Aims

To assess heart failure (HF) in‐hospital quality of care and outcomes before and during the COVID‐19 pandemic.

Methods and results

Patients hospitalized for HF with ejection fraction (EF) <40% in the American Heart Association Get With The Guidelines©‐HF (GWTG‐HF) registry during the COVID‐19 pandemic (3/1/2020–4/1/2021) and pre‐pandemic (2/1/2019–2/29/2020) periods were included. Adherence to HF process of care measures, in‐hospital mortality, and length of stay (LOS) were compared in pre‐pandemic vs. pandemic periods and in patients with vs. without COVID‐19. Overall, 42 004 pre‐pandemic and 37 027 pandemic period patients (median age 68, 33% women, 58% White) were included without observed differences across clinical characteristics, comorbidities, vital signs, or EF. Utilization of guideline‐directed medical therapy at discharge was comparable across both periods, with rates of implantable cardioverter defibrillator (ICD) placement or prescription lower during the pandemic (vs. pre‐pandemic period). In‐hospital mortality (3.0% vs. 2.5%, p <0.0001) and LOS (mean 5.7 vs. 5.4 days, p <0.0004) were higher during the pandemic vs. pre‐pandemic. The highest in‐hospital mortality during the pandemic was observed among patients hospitalized in the Northeast region (3.4%). Among patients concurrently diagnosed with COVID‐19 (n = 549; 1.5%), adherence to ICD placement or prescription, prescription of aldosterone antagonist or angiotensin‐converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor–neprilysin inhibitor at discharge were lower, and in‐hospital mortality (8.2% vs. 3.0%, p <0.0001) and LOS (mean 7.7 vs. 5.7 days, p <0.0001) were higher than those without COVID‐19.

Conclusion

Among GWTG‐HF participating hospitals, patients hospitalized for HF with reduced EF during the pandemic received similar care quality but experienced higher in‐hospital mortality than the pre‐pandemic period.

Continuous Decline in Myocardial Infarction and Heart Failure Hospitalizations during the First 12 Months of the COVID-19 Pandemic in Israel

Background: A decline in cardiovascular hospitalizations was observed during the initial phases of the COVID-19 pandemic. We examine the continuous effect of the COVID-19 pandemic in reducing cardiovascular hospitalization and associated mortality rates during the first year of the pandemic in Israel. Methods: We conduct a retrospective cohort study using the data of Clalit Health Services, the largest healthcare organization in Israel. We divide the Corona year into six periods (three lockdowns and three post-lockdowns) and compare the incidence rates of cardiovascular hospitalizations and 30-day all-cause mortality during each period to the previous three years. Results: The number of non-STEMI hospitalizations during the first year of the pandemic was 13.7% lower than the average of the previous three years (95% CI 11–17%); STEMI hospitalizations were 15.7% lower (95% CI 13–19%); CHF (Congestive heart failure) hospitalizations were 23.9% lower (95%, CI 21–27%). No significant differences in 30-day all-cause mortality rates were observed among AMI (acute myocardial infarction) patients during most of the periods, whereas the annual 30-day all-cause mortality rate among CHF patients was 23% higher. Conclusions: AMI and CHF hospitalizations were significantly lower during the first year of the pandemic relative to 2017–9. Mortality rates were higher in the case of CHF patients but not in the case of AMI patients, possibly due to a change in the clinical acuity of patients arriving at the hospitals. We conclude that targeted public health messaging should be implemented together with proactive monitoring, in order to identify residual disability in patients who may have received non-optimal treatment during the pandemic.

Patients hospitalised with heart failure across different waves of the COVID-19 pandemic show consistent clinical characteristics and outcomes

BACKGROUND

During the first wave of the COVID-19 pandemic, admissions for cardiovascular disease, including Heart Failure (HF), were reduced. Patients hospitalised for HF were sicker and with increased in-hospital mortality. So far, whether following waves had a different impact on HF patients is unknown.

METHODS

All consecutive patients hospitalised for acute heart failure during three different COVID-19 related national lockdowns were analysed. The lockdown periods were defined according to Government guidelines as 23/3/2020 to 4/7/2020 (First Lockdown), 4/11/2020 to 2/12/2020 (Second Lockdown) and 5/1/2021 to 28/2/2021 (Third Lockdown).

RESULTS

Overall, 184 patients hospitalised for HF were included in the study, 95 during the 1st lockdown, 30 during the 2nd lockdown and 59 during the 3rd lockdown. Across the three groups had comparable clinical characteristics, comorbidities and cardiovascular risk factors. Specialist in-hospital care was uninterrupted during the pandemic showing comparable mortality rates (p = 0.10). Although medical therapy for HF was comparable between the three lockdowns, a significantly higher proportion of patients received Angiotensin Receptor-Neprilysin Inhibitors (ARNI) in the second and third lockdowns (p < 0.001).

CONCLUSIONS

Although public health approaches changed throughout the pandemic, the clinical characteristics and outcomes of HF patients were consistent across different waves. For patients hospitalised in the subsequent waves, a more rapid optimization of medical therapy was observed during hospitalization. Particular attention should be devoted to prevent collateral cardiovascular damage during public health emergencies.

Profile Trends of Non-COVID Patients Admitted to the Cardiac Intensive Care Unit during the 2020 COVID Pandemic

Background

During the COVID-19 outbreak, numerous reports indicated a higher mortality rate among cardiovascular patients. We investigated how this trend applied to patients admitted to the cardiac intensive care unit (CICU).

Methods

We retrospectively compared CICU patients admitted during the initial peak of the COVID outbreak between February and May 2020 (Covid Era, CE group) to a control group in pre-pandemic time in 2019. We interviewed patients to determine the symptom onset time and the time interval between symptomology and hospital arrival.

Results

The data of 292 patients were used in the analysis (119 patients in the CE group and 173 in the control group). CE patients had a higher incidence of ischemic heart disease (IHD) (p<.03), heart failure (p<.04), and psychiatric disorders (p<.001). During COVID time, more patients were hospitalized with myocarditis (OR: 26.45), arrhythmias (OR: 2.88), and new heart failure (HF) (p<.001) and less with STEMI (OR: 0.39; 95% CI: 0.24–0.63). Fewer PCIs were performed in the CE group (p<.001), with an overall lower success rate (p<.05) than reported in the control group. Patients in the CE group reported a longer period between symptom onset to hospital arrival (p<.001, χ2 = 12.42). The six-month survival rate was significantly lower in CE patients (χ2 = 7.01, P = 0.008).

Conclusions

Among CICU patients admitted to our center during the initial period of the COVID pandemic, STEMI events were less frequent while cases of newly diagnosed HF sharply increased. Patients waited longer after symptom onset before seeking medical care during the pandemic. The delay may have resulted in clinical deterioration that could explain the high mortality rate and the new HF admission rate.

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.

2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). With the special contribution of the Heart Failure Association (HFA) of the ESC

Document Reviewers: Rudolf A. de Boer (CPG Review Coordinator) (Netherlands), P. Christian Schulze (CPG Review Coordinator) (Germany), Magdy Abdelhamid (Egypt), Victor Aboyans (France), Stamatis Adamopoulos (Greece), Stefan D. Anker (Germany), Elena Arbelo (Spain), Riccardo Asteggiano (Italy), Johann Bauersachs (Germany), Antoni Bayes-Genis (Spain), Michael A. Borger (Germany), Werner Budts (Belgium), Maja Cikes (Croatia), Kevin Damman (Netherlands), Victoria Delgado (Netherlands), Paul Dendale (Belgium), Polychronis Dilaveris (Greece), Heinz Drexel (Austria), Justin Ezekowitz (Canada), Volkmar Falk (Germany), Laurent Fauchier (France), Gerasimos Filippatos (Greece), Alan Fraser (United Kingdom), Norbert Frey (Germany), Chris P. Gale (United Kingdom), Finn Gustafsson (Denmark), Julie Harris (United Kingdom), Bernard Iung (France), Stefan Janssens (Belgium), Mariell Jessup (United States of America), Aleksandra Konradi (Russia), Dipak Kotecha (United Kingdom), Ekaterini Lambrinou (Cyprus), Patrizio Lancellotti (Belgium), Ulf Landmesser (Germany), Christophe Leclercq (France), Basil S. Lewis (Israel), Francisco Leyva (United Kingdom), AleVs Linhart (Czech Republic), Maja-Lisa Løchen (Norway), Lars H. Lund (Sweden), Donna Mancini (United States of America), Josep Masip (Spain), Davor Milicic (Croatia), Christian Mueller (Switzerland), Holger Nef (Germany), Jens-Cosedis Nielsen (Denmark), Lis Neubeck (United Kingdom), Michel Noutsias (Germany), Steffen E. Petersen (United Kingdom), Anna Sonia Petronio (Italy), Piotr Ponikowski (Poland), Eva Prescott (Denmark), Amina Rakisheva (Kazakhstan), Dimitrios J. Richter (Greece), Evgeny Schlyakhto (Russia), Petar Seferovic (Serbia), Michele Senni (Italy), Marta Sitges (Spain), Miguel Sousa-Uva (Portugal), Carlo G. Tocchetti (Italy), Rhian M. Touyz (United Kingdom), Carsten Tschoepe (Germany), Johannes Waltenberger (Germany/Switzerland) All experts involved in the development of these guidelines have submitted declarations of interest. These have been compiled in a report and published in a supplementary document simultaneously to the guidelines. The report is also available on the ESC website www.escardio.org/guidelines For the Supplementary Data which include background information and detailed discussion of the data that have provided the basis for the guidelines see European Heart Journal online.

OUP accepted manuscript

Aims

During the coronavirus disease 2019 (COVID-19) pandemic, important changes in heart failure (HF) event rates have been widely reported, but few data address potential causes for these changes; several possibilities were examined in the GUIDE-HF study.

Methods and results

From 15 March 2018 to 20 December 2019, patients were randomized to haemodynamic-guided management (treatment) vs. control for 12 months, with a primary endpoint of all-cause mortality plus HF events. Pre-COVID-19, the primary endpoint rate was 0.553 vs. 0.682 events/patient-year in the treatment vs. control group [hazard ratio (HR) 0.81, P = 0.049]. Treatment difference was no longer evident during COVID-19 (HR 1.11, P = 0.526), with a 21% decrease in the control group (0.536 events/patient-year) and no change in the treatment group (0.597 events/patient-year). Data reflecting provider-, disease-, and patient-dependent factors that might change the primary endpoint rate during COVID-19 were examined. Subject contact frequency was similar in the treatment vs. control group before and during COVID-19. During COVID-19, the monthly rate of medication changes fell 19.2% in the treatment vs. 10.7% in the control group to levels not different between groups (P = 0.362). COVID-19 was infrequent and not different between groups. Pulmonary artery pressure area under the curve decreased −98 mmHg-days in the treatment group vs. −100 mmHg-days in the controls (P = 0.867). Patient compliance with the study protocol was maintained during COVID-19 in both groups.

Conclusion

During COVID-19, the primary event rate decreased in the controls and remained low in the treatment group, resulting in an effacement of group differences that were present pre-COVID-19. These outcomes did not result from changes in provider- or disease-dependent factors; pulmonary artery pressure decreased despite fewer medication changes, suggesting that patient-dependent factors played an important role in these outcomes.

Clinical Trials.gov: NCT03387813

Key questions

What factors explain the loss of treatment effect and reduction in heart failure events during COVID-19?

Key findings

The treatment effect change was not due to COVID-19-related events. Patient management was sustained but not intensified during COVID-19. Patient status improved during COVID-19 and pulmonary artery pressure reduced in both groups.

Take home message

Patient behaviour probably improved during COVID-19, given that patient status and pulmonary artery pressure improved during COVID-19 despite fewer medication changes and without increased contact from providers.