key: cord-344080-tru8kvxw
authors: Bhatt, Ankeet S.; Moscone, Alea; McElrath, Erin E.; Varshney, Anubodh S.; Claggett, Brian L.; Bhatt, Deepak L.; Januzzi, James L.; Butler, Javed; Adler, Dale S.; Solomon, Scott D.; Vaduganathan, Muthiah
title: Declines in Hospitalizations for Acute Cardiovascular Conditions During the COVID-19 Pandemic: A Multicenter Tertiary Care Experience
date: 2020-05-26
journal: J Am Coll Cardiol
DOI: 10.1016/j.jacc.2020.05.038
sha: 
doc_id: 344080
cord_uid: tru8kvxw

Abstract Background While patients with cardiovascular disease face excess risks of severe illness with coronavirus disease-2019 (COVID-19), there may be indirect consequences of the pandemic on this high-risk patient segment. Objectives To examine longitudinal trends in hospitalizations for acute cardiovascular conditions across a tertiary care healthcare system. Methods We tracked acute cardiovascular hospitalizations between January 1st, 2019 and March 31st, 2020. We estimated daily hospitalization rates using negative binomial models. Temporal trends in hospitalization rates were compared across the first 3 months of 2020, with the first 3 months of 2019 as a reference. Results From January 1, 2019 to March 31, 2020, 6,083 patients experienced 7,187 hospitalizations for primary acute cardiovascular reasons. There was 43.4% (27.4% to 56.0%) fewer estimated daily hospitalizations in March 2020 as compared with March 2019 (P<0.001). The daily rate of hospitalizations did not change throughout 2019 (-0.01% per day [-0.04% to +0.02%], P=0.50), January 2020 (-0.5% per day [-1.6% to +0.5%], P=0.31), or February 2020 (+0.7% per day [-0.6% to +2.0%], P=0.27). There was significant daily decline in hospitalizations in March 2020 (-5.9% per day [-7.6% to -4.3%], P<0.001). Length of stay was shorter (4.8 [2.4,8.3] days vs. 6.0 [3.1,9.6] days; P=0.003) and in-hospital mortality was not significantly different (6.2% vs. 4.4%; P=0.30) in March 2020 compared with March 2019. Conclusions During the first phase of the COVID-19 pandemic, there was a marked decline in acute cardiovascular hospitalizations and patients who were admitted had shorter lengths of stay. These data substantiate concerns that acute care of cardiovascular conditions may be delayed, deferred, or abbreviated during the COVID-19 pandemic.

The rapidly evolving coronavirus disease-2019 (COVID-19) pandemic has demanded major shifts in resource allocation worldwide. Healthcare systems have engaged in significant restructuring efforts in order to prepare for the expected surge of patients with illness, including repurposing of inpatient beds for dedicated special pathogen units and expanding intensive care unit (ICU) capacity. The pandemic has also led to deferral or cancellation of non-essential procedures, in-person patient visits, and routine diagnostic evaluations. Public messaging has focused around "stay-at-home" measures and appropriate physical distancing to mitigate transmission.

While patients with known cardiovascular disease are recognized to face excess risks of severe illness with COVID-19 (1) (2) , there may be an indirect impact of the pandemic on these high-risk patients, even among those without direct viral infection or exposure. Anecdotal reports have identified a lower volume of hospital presentations for non-COVID-19 illnesses during the pandemic. Initial data suggest declines in cardiac catheterization laboratory activations for STelevation myocardial infarction (STEMI), a condition which requires prompt in-hospital treatment and intervention to avoid significant morbidity and mortality (3) (4) (5) (6) . These early reports have raised concerns that similar reductions may be seen across other important acute cardiovascular conditions that require early in-hospital evaluation and treatment, including chest pain syndromes, heart failure (HF), and stroke/transient ischemic attack (TIA) among others, although this has not been well characterized. We therefore examined longitudinal trends in hospitalizations for acute cardiovascular conditions before and during the COVID-19 pandemic in a large, tertiary care integrated health system. Daily hospitalization rates for acute cardiovascular conditions were estimated using negative binomial models. Models were separately constructed for each month in 2020 to identify temporal changes in hospitalization rates. Temporal changes were analyzed across the first 3 months of 2019 for reference. Trends in hospitalization rates were analyzed for individual types of acute cardiovascular hospitalizations. Daily cardiovascular hospitalization rates were modeled as a continuous variable using restricted cubic splines; the number of knots were selected to minimize the Akaike information criterion. Values of P<0.05 were considered significant.

For comparative purposes, daily confirmed cases of COVID-19 in Massachusetts were extracted based on state records (7). The study was reviewed and approved by the Institutional Review Board of Mass General Brigham. All statistical analyses were performed using STATA 14.1 (College Station, TX, USA). Tableau software (Seattle, WA, USA) was used for geomapping using zip codes of patients' primary residences.

From January 1, 2019 to March 31, 2020, 6,083 unique patients experienced 7,187 hospitalizations for primary acute cardiovascular reasons. Hospitalized patients had primary residences spanning 26 states in the continental US (Figure 1) . Of all hospitalizations, 2,933 (40.8%) had primary admission diagnoses of HF, followed by 2,217 (30.8%) for chest pain syndromes/ACS, 1,566 (21.2%) for stroke, and 471 (6.6%) for other select acute cardiovascular conditions. Overall, 2,076 (28.9%) admissions were to hospitals other than the two large academic teaching hospitals in the health system.

Baseline demographic profiles of patients were compared between those admitted in March 2020 to patients admitted prior to March 2020 and to patients admitted in March 2019 ( Table 1 ). There were no significant differences in age, sex, and race distribution between groups; approximately 80% of admitted patients were white. While the volume of (Figure 4 ).

In this temporal analysis of over 7,000 hospitalizations, a marked decline in total hospitalizations was observed for acute cardiovascular conditions in a large, tertiary care Although patients admitted during the COVID-19 pandemic had comparable demographic characteristics, length of stay was shorter. In-hospital mortality was also numerically higher in patients admitted during the COVID-19 pandemic, suggesting greater severity of illness.

Presentations for HF, chest pain syndromes, and stroke are considered urgent and often require early invasive or pharmacological therapy in addition to careful inpatient monitoring to avoid associated morbidity and mortality. While prior analyses have described temporal changes in STEMI-related cardiac catheterization laboratory activations (3) (4) , to our knowledge, this is the largest and among the first descriptions of the change in a broad range of cardiovascular hospitalizations during the COVID-19 pandemic.

Beyond the concerning likelihood that patients are remaining at home with acute cardiovascular diseases, other reasons for these recent trends should be investigated. It is plausible there is a true population-level reduction in cardiovascular events necessitating healthcare attention. Ecological factors such as shifts in dietary patterns (for instance, decreased consumption of high-sodium, fast food intake (8) ) and reduced exposure to ambient air pollution (9) may contribute to reduced daily risks. In addition, the emergence and widespread adoption of more accessible forms of communication between patients and their providers, including telemedicine(10), may be able to avert certain lower-acuity hospitalizations. Finally, the expected decline in ambulatory cardiovascular visits, outpatient testing, and deferral of elective procedures may have contributed to the lower rate of hospitalizations, as these often may serve as points of referral for inpatient hospitalization.

Patient and provider aversion to seeking care in medical centers with documented or suspected COVID-19 patients, a notion that has been well captured in the lay media (11) (12) (13) (14) , represents a more concerning reason for our observed findings. These behaviors may be substantiated by "stay-at-home" messaging from major associations, governmental bodies, and media outlets, potentially leading to patients delaying or deferring hospital admission for acute cardiovascular conditions. Recent evidence has demonstrated marked reductions in the rates of hospitalization for ACS during the pandemic in Austria and Italy (5, 15) . Our analysis supports and extends the findings in these European countries to a U.S. health system. In addition, our analysis provides evidence that hospitalization rates for other acute cardiovascular hospitalizations, such as HF and stroke, may be similarly reduced during the COVID-19

pandemic. The trend toward increased in-hospital mortality in March 2020 compared with earlier time periods also raises concerns that patients admitted for acute cardiovascular conditions during the COVID-19 pandemic may present later in their acute illness and therefore may have higher acuity. Indeed, provisional death counts from the Centers for Disease Control already show trends toward excess mortality in Massachusetts. From February 1, 2020 to April 11, 2020, there have been 13,615 all-cause deaths reported thus far, which is 1% greater than expected based on the average number of deaths across the same weeks in 2017-2019 (16) , and these findings are likely conservative due to underreporting of more recent deaths (17) . Early global reports from areas affected earlier in the COVID-19 pandemic corroborate this experience and further suggest that the majority of excess mortality may actually be due to causes not directly related to infection with severe acute respiratory syndrome coronavirus 2 (18) . Emerging data from the Lombardy region of Italy found substantial increases in out of hospital cardiac arrests during the COVID-19 pandemic as compared with 2019 (19) . Potential missed acute cardiovascular events may add to the composite detrimental effects of the COVID-19 pandemic on this high-risk patient segment (20) .

Reasons for the observed shorter lengths of stay in patients admitted in March 2020 are likely multifactorial. There may be pressure from both patients and providers for early discharge, given concerns of heightened COVID-19 exposure risk in healthcare settings. In addition, given declines in elective cardiovascular procedures, wait times for certain necessary procedures may be reduced, facilitating earlier discharges.

Importantly, this study examines trends in acute cardiovascular hospitalizations across a large, integrated health system with broad patient membership across multiple states. In addition, the health system consists of care entities spanning the spectrum of clinical care facilities, from large urban academic centers to smaller, more rural community hospitals, improving the generalizability of our findings. In addition, seasonal variations in acute cardiovascular admissions were accounted for by comparing daily hospitalization rates to month-matched controls from 2019, highlighting a clear divergence in March 2020 from typical temporal fluctuations in acute cardiovascular admissions that can be expected, for example, due to declines in cardiopulmonary illnesses at the end of the seasonal influenza season.

Despite these strengths, this analysis has several important limitations. First, reliance on administrative coding may have led to misclassification of primary reasons for hospitalization.

Particularly, patients presenting with cardiopulmonary symptoms may have been coded for suspected COVID-19 disease or to nonspecific diagnoses despite a presentation ultimately more consistent with HF or chest pain syndromes. This issue may be amplified by the initial lack of rapid turnaround COVID-19 testing capabilities and diagnostic tools. This misclassification may have contributed to the trends toward lower hospitalizations for acute cardiovascular conditions as COVID-19 cases rose in Massachusetts, though would be unlikely to fully account for the substantial magnitude of reductions observed and similar reductions were seen in stroke, which generally has distinct symptomatology to that of COVID-19. Second, concurrent illness with COVID-19 among patients with cardiovascular disease may also contribute to the observed numerically higher in-hospital mortality rate, though formal diagnostic codes for COVID-19

were only introduced in April 1, 2020 so could not be captured in this experience. Third, this analysis does not include emergency department presentations and therefore does not assess total initial presentations to the hospital for acute cardiovascular conditions. Fourth, it is possible that patients may have traveled outside of the region to less densely populated areas or may have been directed to other medical centers, though the health system cares for a broad geographic population and did not have any formal guidance for diversion to alternative centers. In addition, estimates during the period of this study in Massachusetts show adequate floor bed and ICU capacity, reducing the likelihood of need for transfer to alternative centers (21) . Fifth, our study had a low proportion of non-white patients, and given reports of that certain racial groups are disproportionately affected by COVID-19 (22) , this issue requires dedicated study in more diverse healthcare settings. Finally, we were not able to ascertain cause-specific mortality. (24) . While reasons for the observed decline in hospitalizations are likely multifactorial, educational platforms and formal guidance for high-risk patients regarding when to seek emergency care are needed. This high-risk population should be longitudinally followed to determine the potential impact of the COVID-19 pandemic on longterm cardiovascular health, including among patients not directly exposed to or infected with severe acute respiratory syndrome coronavirus 2.

Competency in Systems Based Practice: Health systems must plan for potential deferred or delayed care due to the COVID-19 pandemic in the intra-pandemic and post-pandemic periods.

Translational Outlook: Reasons for shifts in behavioral patterns of high-risk cardiovascular patients during large societal perturbations such as pandemics require further investigation.

Translational Outlook: Educational platforms and further guidance for high-risk patients with cardiovascular disease regarding when to seek emergency care are needed. 

Clinical Characteristics of Coronavirus Disease 2019 in China

COVID-19) and Cardiovascular Disease

Reduction in ST-Segment Elevation Cardiac Catheterization Laboratory Activations in the United States during COVID-19 Pandemic

sobre la actividad asistencial en cardiología intervencionista en España | Artículo original

Decline of acute coronary syndrome admissions in Austria since the outbreak of COVID-19: the pandemic response causes cardiac collateral damage

ST-Segment Elevation in Patients with Covid-19 -A Case Series

Archive of COVID-19 cases in Massachusetts

Evidence for an independent and cumulative effect of postprandial hypertriglyceridemia and hyperglycemia on endothelial dysfunction and oxidative stress generation: effects of short-and long-term simvastatin treatment

A time-to-event analysis on air pollutants with the risk of cardiovascular disease and mortality: A systematic review and meta-analysis of 84 cohort studies

COVID-19: An Unintended Force for Medical Revolution?

Empty non-coronavirus beds raise fears that sickest are avoiding NHS [Internet]. Financial Times

Where Have All the Heart Attacks Gone?

Hospital admissions for strokes appear to have plummeted, a doctor says, a possible sign people are afraid to seek critical help

Patients with heart attacks, strokes and even appendicitis vanish from hospitals

Reduced Rate of Hospital Admissions for ACS during Covid-19 Outbreak in Northern Italy

Provisional Death Counts for Coronavirus Disease

Timeliness of Death Certificate Data for Mortality Surveillance and Provisional Estimates

Covid-19's death toll appears higher than official figures suggest. The Economist

Out-of-Hospital Cardiac Arrest during the Covid-19 Outbreak in Italy

The Untold Toll -The Pandemic's Effects on Patients without Covid-19

Hospital Bed Availability

COVID-19 and African Americans

3548 -116th Congress

Postacute Care Preparedness for COVID-19: Thinking Ahead

The red line represents the cumulative number of confirmed Coronavirus Disease-2019 (COVID-19) cases in Massachusetts. Red arrows demarcate key dates in the COVID-19 pandemic in Massachusetts (MA). TIA = transient ischemic attack