The Impact of the COVID-19 Pandemic on Avoidance of Health Care, Symptom Severity, and Mental Well-Being in Patients With Coronary Artery Disease

Factors associated with ART interruption during the COVID-19 crisis in Burundi (the EPIC community-based research program)

With a national prevalence of 0.9%, Burundi is close to achieving UNAIDS' 2025 targets. Despite this, different types of crises periodically disrupt its HIV health services. The community-based program EPIC measured the impact of the COVID-19 health crisis on people living with HIV (PLHIV) in Burundi in 2021. Specifically, it assessed ART interruption and associated factors since the beginning of the pandemic. The study questionnaire was administered to PLHIV in three cities between October and November 2021. Participants were recruited using convenience sampling. Logistic regression models helped identify factors associated with ART interruption. Of the 317 respondents, 37 (11.7%) reported interruption. The majority (79.2%) self-identified as belonging to key populations. Interruption was significantly associated with: fewer HIV medical follow-up visits (adjusted Odds Ratio, aOR = 7.80, p = 0.001) and forced HIV status disclosure (aOR = 4.10, p = 0.004). It was inversely associated with multi-month ART dispensing (aOR = 0.36, p = 0.017) since the beginning of the pandemic and the perception of not having been sufficiently informed by the HIV medical team about the risk of COVID-19 infection (aOR = 0.11, p < 0.001). Our results highlight the importance of multi-month ART dispensing, enhanced communication, and voluntary disclosure of one's HIV status in preventing ART interruption in times of crises in Burundi.

Nutritional support team intervention in surgical ICUs and its effect on nutrition delivery and quality in critically ill patients

RATIONAL

Critically ill surgical patients pose one of the greatest challenges in achieving nutritional goals. Several published papers have demonstrated clear benefits when nutrition support (NS) is managed by a multidisciplinary nutrition support team (NST). We hypothesized that implementing a NST in a surgical intensive care unit (ICU) would increase the number of patients achieving their nutritional goals.

MATERIAL AND METHOD

Multicenter "BEFORE & AFTER" study. In the BEFORE phase, an audit of the previous state of NS was conducted in three ICUs without a NST.

INTERVENTION

Implementation of a NST and protocol. In the AFTER phase, a new audit of NS was conducted. Continuous variables (presented as mean ± SD or median Q1-Q3) were tested using the t-test and Mann-Whitney U test. Categorical variables (presented as frequencies and percentages) were assessed using the chi-square test. A binomial logistic regression model was performed, with independent variables introduced using a stepwise forward method. A difference was considered to be significant with a two-sided P-value <0.05. Statistical analysis was conducted using IBM-SPSS 26.

RESULTS

A total of 83 patients were included in the BEFORE phase, and 85 in the AFTER phase. The latter group showed a higher frequency of nutritional risk and malnutrition (SGA B+C odds ratio 2.314, 95% CI 1.164-4.600). Laparoscopy was more frequently utilized as a surgical technique in the AFTER phase. No differences were observed in ICU and hospital LOS or 90 days' survival rates. Two variables remained independent factors to predict NS achievement: NST implementation (odds ratio 3.582, 95% CI 1.733-7.404), and surgical technique (odds ratio 3.231, 95% CI 1.312-7.959).

CONCLUSION

NST positively impacts the chance of achieving NS goals in critically ill surgical patients.

Invasive Endotyping in Patients With Angina and No Obstructive Coronary Artery Disease: A Randomized Controlled Trial

BACKGROUND

We investigated the usefulness of invasive coronary function testing to diagnose the cause of angina in patients with no obstructive coronary arteries.

METHODS

Outpatients referred for coronary computed tomography angiography in 3 hospitals in the United Kingdom were prospectively screened. After coronary computed tomography angiography, patients with unobstructed coronary arteries, and who consented, underwent invasive endotyping. The diagnostic assessments included coronary angiography, fractional flow reserve (patient excluded if ≤0.80), and, for those without obstructive coronary artery disease, coronary flow reserve (abnormal <2.0), index of microvascular resistance (abnormal ≥25), and intracoronary infusion of acetylcholine (0.182, 1.82, and 18.2 μg/mL; 2 mL/min for 2 minutes) to assess for microvascular and coronary spasm. Participants were randomly assigned to disclosure of the results of the coronary function tests to the invasive cardiologist (intervention group) or nondisclosure (control group, blinded). In the control group, a diagnosis of vasomotor angina was based on medical history, noninvasive tests, and coronary angiography. The primary outcome was the between-group difference in the reclassification rate of the initial diagnosis on the basis of coronary computed tomography angiography versus the final diagnosis after invasive endotyping. The Seattle Angina Questionnaire summary score and Treatment Satisfaction Questionnaire for Medication were secondary outcomes.

RESULTS

Of 322 eligible patients, 250 (77.6%) underwent invasive endotyping; 19 (7.6%) had obstructive coronary disease, 127 (55.0%) had microvascular angina, 27 (11.7%) had vasospastic angina, 17 (7.4%) had both, and 60 (26.0%) had no abnormality. A total of 231 patients (mean age, 55.7 years; 64.5% women) were randomly assigned and followed up (median duration, 19.9 [12.6-26.9] months). The clinician diagnosed vasomotor angina in 51 (44.3%) patients in the intervention group and in 55 (47.4%) patients in the control group. After randomization, patients in the intervention group were 4-fold (odds ratio, 4.05 [95% CI, 2.32-7.24]; P<0.001) more likely to be diagnosed with a coronary vasomotor disorder; the frequency of this diagnosis increased to 76.5%. The frequency of normal coronary function (ie, no vasomotor disorder) was not different between the groups before randomization (51.3% versus 50.9%) but was reduced in the intervention group after randomization (23.5% versus 50.9%, P<0.001). At 6 and 12 months, the Seattle Angina Questionnaire summary score in the intervention versus control groups was 59.2±24.2 (2.3±16.2 change from baseline) versus 60.4±23.9 (4.6±16.4 change) and 63.7±23.5 (4.7±14.7 change) versus 66.0±19.3 (7.9±17.1 change), respectively, and not different between groups (global P=0.36). Compared with the control group, global treatment satisfaction was higher in the intervention group at 12 months (69.9±22.8 versus 61.7±26.9, P=0.013).

CONCLUSIONS

For patients with angina and no obstructive coronary arteries, a diagnosis informed by invasive functional assessment had no effect on long-term angina burden, whereas treatment satisfaction improved.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03477890.

Screening for - and prevalence of - anxiety and depression in cardiac rehabilitation in the post-COVID era. An observational study

BACKGROUND

Approximately 20-30% of patients with a cardiac disease suffer from anxiety and/or depression, leading to poor health outcomes. To identify this subgroup, clinical guidelines recommend screening for anxiety and depression in cardiac rehabilitation (CR). It is unknown how screening practice is delivered post-COVID.

METHODS

This observational study used data from the National Audit of Cardiac Rehabilitation from April 2018-March 2022. Descriptive statistics were used to assess screening rates and prevalence, while a multivariate logistic regression model was performed to analyse determinants for screening for anxiety and depression among patients participating in cardiac rehabilitation.

RESULTS

The population consisted of 245,705 patients, where 128,643 (52.4%) were screened and 117,062 (47.6%) were not. Patients attending CR during first year of COVID-19 were less likely to be screened. Patients with female gender, living alone, non-white ethnicity, living in the most deprived areas, current smoking, and physical inactivity were less likely to be screened, while patients who were revascularized, having an objective physical fitness test, and attending a certified CR center were more likely to be screened. For patients attending CR during COVID-19, the prevalence of anxiety and depression decreased significantly. For anxiety the prevalence dropped from 34.4% to 15.8%, for depression the prevalence dropped from 33.5% to 16.5%.

CONCLUSION

CR service provision was negatively impacted during COVID-19, leading to much lower screening for anxiety and depression in the CR setting. Prevalence of anxiety and depression decreased during COVID-19 for this population, possibly because psychologically affected patients refrained from attending CR.

The COVID-19 Pandemic and Coronary Heart Disease: the Next Surge

PURPOSE OF REVIEW

In this narrative review, we highlight different ways in which the COVID-19 pandemic has impacted coronary heart disease (CHD) burden and how a surge in morbidity and mortality may be expected in the near future. We also discuss potential solutions, and the direction subsequent research and corrective actions should take.

RECENT FINDINGS

COVID-19 has been implicated in the development and worsening of CHD via acute and chronic mechanisms in the form of plaque rupture, destabilization, and sustenance of a chronic inflammatory state leading to long COVID syndrome and increased rates of myocardial infarction. However, indirectly the pandemic is likely to further escalate the CHD burden through poor health behaviors such as tobacco consumption, reduced physical activity, economic devastation and its associated sequelae, and regular cardiac care interruptions and delays. COVID-19 has increased the total CHD burden and will require extensive resource allocation and multifaceted strategies to curb future rise.

Heart team consultations for patients with severe coronary artery disease or valvular heart disease in the era of the COVID-19 pandemic: a single-center experience

Introduction

The Heart Team (HT) as a group of experienced specialists is responsible for optimal decision-making for high-risk cardiac patients. The aim of this study was to investigate the impact of the COVID-19 pandemic on HT functioning.

Methods

In this retrospective, single-center study, we evaluated the cooperation of HT in terms of the frequency of meetings, the number of consulted patients, and the trends in choosing the optimal treatment strategies for complex individuals with severe coronary artery disease (CAD) or valvular heart disease (VHD) before and during the COVID-19 pandemic in Poland.

Results

From 2016 to May 2022, 301 HT meetings were held, and a total of 4,183 patients with severe CAD (2,060 patients) or severe VHD (2,123 patients) were presented. A significant decrease in the number of HT meetings and consulted patients (2019: 49 and 823 vs. 2020: 44 and 542 and 2021: 45 and 611, respectively, P < 0.001) as well as changes in treatment strategies-increase of conservative, reduction of invasive (2019: 16.7 and 51.9 patients/month vs. 2020: 20.4 and 24.8 patients/month and 2021:19.3 and 31.6 patients/month, respectively, P < 0.001)-were demonstrated with the spread of the COVID-19 pandemic. As the pandemic slowly receded, the observed changes began to return to the pre-pandemic trends.

Conclusions

The COVID-19 pandemic resulted in a decrease in the number of HT meetings and consulted patients and significant reduction of invasive procedures in favor of conservative management. Further studies should be aimed to evaluate the long-term implications of this phenomenon.

Distinct Features of Vascular Diseases in COVID-19

The Coronavirus Disease 2019 (COVID-19) pandemic was declared in early 2020 after several unexplained pneumonia cases were first reported in Wuhan, China, and subsequently in other parts of the world. Commonly, the disease comprises several clinical features, including high temperature, dry cough, shortness of breath, and hypoxia, associated with findings of interstitial pneumonia on chest X-ray and computer tomography. Nevertheless, severe forms of acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) are not limited to the respiratory tract but also may be extended to other systems, including the cardiovascular system. The bi-directional relationship between atherosclerosis and COVID-19 is accompanied by poor prognosis. The immune response hyperactivation due to SARS-CoV-2 infection causes an increased secretion of cytokines, endothelial dysfunction, and arterial stiffness, which promotes the development of atherosclerosis. Also, due to the COVID-19 pandemic, access to healthcare amenities was reduced, resulting in increased morbidity and mortality in patients at risk. Furthermore, as lockdown measures were largely adopted worldwide, the sedentary lifestyle and the increased consumption of processed nutrients or unhealthy food increased, and in the consequence, we might observe even 70% of overweight and obese population. Altogether, with the relatively low ratio of vaccinated people in many countries, and important health debt appeared, which is now and will be for next decade a large healthcare challenge. However, the experience gained in the COVID-19 pandemic and the new methods of patients' approaching have helped the medical system to overcome this crisis and will hopefully help in the case of new possible epidemics.

COVID-19 Continues to Burden General Practitioners: Impact on Workload, Provision of Care, and Intention to Leave

General practitioners (GPs), already in a profession with a high workload, have been at the frontline of providing COVID-19-related healthcare in addition to routine care. Our study examined the impact of pandemic-related consultations and changes in practice organization on GPs' current workload and provision of healthcare in summer 2021 (May 2021-July 2021) and early 2022 (January 2022-February 2022). In total, 143 German GPs participated in an online survey in the summer of 2021. Of these, 51 GPs participated in the follow-up survey in 2022. Most GPs perceived an increase in consultation frequency, consultation times, and workload since the pandemic outbreak. Increased consultation times were related to the reduced provision of medical care to other patients with chronic diseases. More SARS-CoV-2 vaccination consultations were associated with reduced home visits, acute consultation times, and cancer screenings. A quarter of GPs considered leaving their job. Pandemic-related bureaucracy, restricted access to therapy and rehabilitation services specialized on COVID-19, unreliable vaccine deliveries, mandatory telematics-infrastructure implementation, and frequent changes in official regulations were the main reasons reported for dissatisfaction. Our results provide insights into how the pandemic continues to burden GPs' work routines and how better working conditions in times of high demand could be achieved in future pandemics.

The long-term impact of the COVID-19 pandemic on primary and specialized care provision and disease recognition in Germany

Background

The COVID-19 pandemic and the imposed lockdowns severely affected routine care in general and specialized physician practices.

Objective

To describe the long-term impact of the COVID-19 pandemic on the physician services provision and disease recognition in German physician practices and perceived causes for the observed changes.

Design

Observational study based on medical record data and survey data of general practitioners and specialists' practices.

Participants

996 general practitioners (GPs) and 798 specialist practices, who documented 6.1 million treatment cases for medical record data analyses and 645 physicians for survey data analyses.

Main measures

Within the medical record data, consultations, specialist referrals, hospital admissions, and documented diagnoses were extracted for the pandemic (March 2020-September 2021) and compared to corresponding pre-pandemic months in 2019. The additional online survey was used to assess changes in practice management during the COVID-19 pandemic and physicians' perceived main causes of affected primary and specialized care provision.

Main results

Hospital admissions (GPs: -22% vs. specialists: -16%), specialist referrals (-6 vs. -3%) and recognized diseases (-9 vs. -8%) significantly decreased over the pandemic. GPs consultations initially decreased (2020: -7%) but compensated at the end of 2021 (+3%), while specialists' consultation did not (-2%). Physicians saw changes in patient behavior, like appointment cancellation, as the main cause of the decrease. Contrary to this, they also mentioned substantial modifications of practice management, like reduced (nursing) home visits (41%) and opening hours (40%), suspended checkups (43%), and delayed consultations for high-risk patients (71%).

Conclusion

The pandemic left its mark on primary and specialized healthcare provision and its utilization. Both patient behavior and organizational changes in practice management may have caused decreased and non-compensation of services. Evaluating the long-term effect on patient outcomes and identifying potential improvements are vital to better prepare for future pandemic waves.

Using the NYHA Classification as Forecasting Tool for Hospital Readmission and Mortality in Heart Failure Patients with COVID-19

During the COVID-19 pandemic, it was observed that patients with heart disease are more likely to be hospitalized and develop severe COVID-19. Cardiac disease takes the top position among patient comorbidities, heart failure (HF) prevalence reaching almost 5% in the general population older than 35 years in Romania. This retrospective study aimed to determine the potential use of the NYHA classification for HF in hospitalized patients with COVID-19 as prognostic tool for in-hospital mortality, length of hospitalization, and probability of rehospitalization for HF decompensation. We observed that patients with advanced HF had a history of significantly more comorbid conditions that are associated with worse disease outcomes than the rest of patients classified as NYHA I and II. However, regardless of existing diseases, NYHA III, and, especially, NYHA IV, patients were at greatest risk for mortality following SARS-CoV-2 infection. They required significantly longer durations of hospitalization, ICU admission for mechanical ventilation, and developed multiple severe complications. NYHA IV patients required a median duration of 20 days of hospitalization, and their in-hospital mortality was as high as 47.8%. Cardiac biomarkers were significantly altered in patients with SARS-CoV-2 and advanced HF. Although the study sample was small, all patients with NYHA IV who recovered from COVID-19 required a rehospitalization in the following month, and 65.2% of the patients at initial presentation died during the next six months. The most significant risk factor for mortality was the development of severe in-hospital complications (OR = 4.38), while ICU admission was the strongest predictor for rehospitalization (OR = 5.19). Our result highlights that HF patients continue to be vulnerable post SARS-CoV-2 infection. Physicians and policymakers should consider this population’s high likelihood of hospital readmissions when making discharge, hospital capacity planning, and post-discharge patient monitoring choices.