COVID-19 Had Broad Global Effects on CV Care, Review Affirms

COVID-19 has had a major impact on the delivery of cardiovascular services around the world, particularly in low- and middle-income countries already lagging behind their higher-income counterparts, a systematic review and meta-analysis shows.

During the early part of the pandemic, there were global declines in hospitalizations for various CVDs, diagnostic and interventional procedures, and outpatient visits, researchers led by Ramesh Nadarajah, MBBS (Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, England), report.

“There was clear detrimental effect on cardiovascular services. There was nowhere that managed to escape this issue,” Nadarajah told TCTMD.

Even so, countries outside of Europe and North America—home to the majority of the world’s population—experienced steeper reductions in hospitalizations and primary PCIs for STEMI and worse short-term outcomes for certain conditions.

The analysis, published online this week in the European Heart Journal, “provides, to date, the most-comprehensive summary of the effect of the COVID-19 pandemic on CV services and individuals with CV disease,” the authors write, noting that there are insufficient data from low- and middle-income countries. “Notwithstanding this, we provide synthesized evidence that the COVID-19 pandemic resulted in substantial global collateral CV damage.”

Expanding the Scope

After the emergence and worldwide spread of SARS-CoV-2, lockdowns and public health messaging encouraging people to stay home to prevent transmission and protect healthcare workers contributed to declining numbers of hospitalizations and procedures related to non-COVID-19 diagnoses, including CVD. Early on, for instance, hospitals in multiple countries reported substantial drops in STEMI presentations. Far-reaching impacts on the delivery of care have been documented since then in numerous studies—often focusing on specific conditions or the experience of single healthcare systems.

In this new paper, Nadarajah and colleagues aimed for a broader, more-global look at the impact of COVID-19, delving into what happened across multiple types of CVD, geographic regions, countries of different income levels, and the first two waves of the pandemic. Their review and meta-analysis encompassed 158 studies with data from 49 countries and six continents. Most of the studies (59%) were conducted in Europe, with another 18% coming out of North America. Overall, 80% of the research was performed in high-income countries.

A consistent picture emerged, with fewer hospitalizations across conditions (STEMI, NSTEMI, heart failure, unstable angina, and arrhythmia). Reductions in diagnostic and interventional procedures within a variety of CV specialties and in outpatient consultations, despite a substantial increase in telemedicine visits, were also seen during the early part of the pandemic compared with normal times.

Of note, the drop in admissions was similar during the first and second waves of infection. That’s surprising, said Nadarajah, who expected to see less of an impact during the second wave after increased efforts were made to encourage people to come to the hospital if they were having a medical emergency even during the pandemic. “It’s very likely that this is an indicator that messaging just didn’t really get through to people,” he said.

I think it’s probably the tip of the iceberg, and I think it’s very likely the pandemic only reinforced and exaggerated the preexisting disparities. Ramesh Nadarajah

The most-robust data came from studies of the impact on ACS management. COVID-19 was associated with significant reductions in admissions for STEMI (incidence rate ratio [IRR] 0.78; 95% CI 0.72-0.85), NSTEMI (IRR 0.66; 95% CI 0.60-0.72), and unstable angina (IRR 0.80; 95% CI 0.66-0.98).

There were declines of similar magnitude when it came to the overall number of PCIs for STEMI and NSTEMI during the pandemic, although the proportion of patients who underwent revascularization after being hospitalized did not change. Overall door-to-balloon times remained consistent on the background of COVID-19, but the interval between symptom onset and first medical contact, on average, grew by more than an hour (weighted mean difference 69.45 min).

Lower-Income Countries Bear the Brunt

Though COVID-19 affected the delivery of cardiovascular services around the world, the impact was more strongly felt in low- and middle-income countries, which saw more-dramatic reductions in STEMI hospitalizations and in use of PCI in STEMI and NSTEMI patients compared with higher-income areas. These nations also were the only ones to have a significant increase in use of thrombolysis as a treatment for STEMI (relative risk [RR] 2.70; 95% CI 1.07-6.86). There were significantly longer door-to-balloon and symptom-to-first medical contact times compared with the prepandemic period only outside of Europe and North America.

These disparities in management appeared to have an effect on early patient outcomes, as low- and middle-income countries—but not high-income nations—had significantly higher rates of in-hospital mortality for STEMI (RR 1.22; 95% CI 1.10-1.37) and heart failure (RR 1.08; 95% CI 1.04-1.12) during the pandemic period.

Nadarajah noted that high-quality data on other conditions were less available from lower-income parts of the world, and said these types of differences based on country-level income probably apply to other areas of care as well. “I think it’s probably the tip of the iceberg, and I think it’s very likely the pandemic only reinforced and exaggerated the preexisting disparities between care received for heart diseases in high-income countries and low- to middle-income countries.”

Taking Steps to Address Future Waves, Crises

In emailed comments to TCTMD, senior author Chris Gale, MBBS, PhD (Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds), cautioned that the pandemic-related damage “will continue to accrue unless mitigation strategies are speedily implemented.”

For instance, “the deferral of interventional procedures, especially for structural heart disease, leaves many patients at high risk of adverse outcomes,” he said. “There is little doubt that there will continue to be deaths and illness that would not have otherwise occurred. Urgent action is needed to address the burden of cardiovascular disease left in the wake of the pandemic.”

Nadarajah agreed that the decline in both procedures and outpatient visits “is leaving a large number of people with significant and severe and acutely threatening cardiovascular conditions untreated.”

Moving forward, then, “we have to be better at reinforcing those services and protecting those services,” he said, adding that “we probably need to start making some changes in the way we manage our healthcare so that we are better protected if there is a future wave.”

An acceleration of digital transformation in medicine will streamline pathways and make care more accessible to patients, Nadarajah said. Moreover, clinicians need to improve the ways they prioritize patients to ensure that those with the highest-risk conditions are treated in the shortest time.

“We’re still getting out of the fog of the pandemic, and I think these lessons are helpful as we move forward to hopefully push policy makers, push governments, push funding bodies to help us try and alleviate some of the detrimental impact that the pandemic had upon our services,” Nadarajah said.

And to address the relative dearth of data from low- and middle-income countries, he and his colleagues say that “a global living collaborative network focusing on CV care during the pandemic at an institutional level could be established, and internationally harmonized CV data available in a responsive fashion could enable a ‘global barometer’ of the consequences of the pandemic as well as the opportunity to prepare for future major health crises.”