key: cord-0699225-0x0hnzwr
authors: Colivicchi, Furio; Di Fusco, Stefania Angela; Magnanti, Massimo; Cipriani, Manlio; Imperoli, Giuseppe
title: The impact of the COVID-19 pandemic and Italian lockdown measures on clinical presentation and management of acute heart failure
date: 2020-05-14
journal: J Card Fail
DOI: 10.1016/j.cardfail.2020.05.007
sha: c3d623788bcf8bf08a4388b945d12576a359e4a2
doc_id: 699225
cord_uid: 0x0hnzwr

nan

Dear Editor, COVID-19 has rapidly evolved into a pandemic with a major impact on worldwide health. 1 As of April 21, 2020, approximately 183,957 cases of COVID-19 and 24,648 deaths have been confirmed in Italy. 2 Following the COVID-19 outbreak at the end of February 2020, the Italian government implemented extraordinary measures to minimize the spread of infection. 3 We describe the impact of the current COVID-19 pandemic and the consequent Italian lockdown measures on the clinical presentation and management of acute heart failure (AHF) in patients without COVID-19.

We analyzed clinical records of consecutive patients reporting to the emergency department (ED) of San Filippo Neri Hospital in Rome, Italy for AHF between February 20 and April 20, 2020. All patients with evidence of COVID-19 were excluded. Collected data were compared with those of patients with AHF reporting to the same ED between February 20 and April 20, 2019. AHF diagnosis was made according to ESC criteria. 4 The local ethics committee had previously authorized the collection of anonymous data from patients with AHF .

Group differences for continuous data were examined by unpaired Student t test or by Mann-Whitney 2-sample test, as appropriate. For categorical variables, group differences were examined by χ2 or Fisher exact test, as appropriate. A stepwise logistic regression analysis was performed.

The model was built using variables that showed a p value <0.10 in univariate analysis. The significance within the model was evaluated with the Wald statistical test. A two-sided p value of <0.05 was considered significant.

After the COVID-19 outbreak, the number of ED visits was 2711, vs. 6060 in 2019 (55% reduction). The number of patients with AHF decreased by 49%, from 127 to 64 (Table 1) . Patients with AHF during the pandemic were older, more frequently male, and with worsening rather than new-onset heart failure requiring admission to the intensive care unit (ICU). These patients also showed a higher prevalence of atrial fibrillation, ischemic heart disease, diabetes mellitus, severe renal dysfunction, and reduced ventricular function. In-hospital all-cause mortality for was 17.2% in 2020 and 6.3% in 2019, with an odds ratio of 3.1 (95% CI 1.1-8.1, p=0.022).

The following features were independent predictors of in-hospital mortality: age (hazard ratio [HR] per 5-year increase: 1.3; 95% CI 1.1-1.8, p=0.002); admission to ICU (HR: 2.1; 95% CI 1.7-3.4, p=0.001); systolic blood pressure <100 mmHg on admission (HR: 1.7; 95% CI 1.2-2.7, p=0.03); admission during the COVID-19 pandemic (HR: 2.7; 95% CI 1.2-6.9, p=0.01).

The COVID-19 outbreak in Italy has been associated with a 40-60% reduction in ED visits, 5,6 with similar trends observed in other countries. 7 Our study confirms that the COVID-19 pandemic led to a decline in overall ED visits, paired with a 49% decrease in patients with AHF. The AHF cohort without COVID-19 presenting to the ED during the pandemic had a higher prevalence of high-risk features and in-hospital mortality. Presentation due to AHF during the pandemic was an independent predictor of in-hospital mortality in patients without COVID-19.

Patients with heart disease who contract COVID-19 are considered at higher risk of worse outcomes and advised to be extremely careful. 8 Consequently, these patients may avoid hospitals and seek alternative management. Previous reports have highlighted areas of concern for patients requiring cardiac care during the COVID-19 outbreak, including delays in presentation and treatment. 9 Our study shows that during the COVID-19 pandemic, patients with AHF often reported to the ED after significant clinical deterioration possibly due to several different barriers to appropriate care.

Primary-care services have been overwhelmed by COVID-19 cases, making it difficult to manage other healthcare needs, including the worsening of chronic conditions such as AHF. 3, 6 It would be important to know how patients with AHF were managed at home and their outcomes. However, these issues are beyond the scope of the current study. Patients with AHF may have been left without proper guidance that would have directed them to EDs sooner. The COVID-19 pandemic has disrupted most consolidated approaches to heart disease management, including AHF. 6, 9 Stakeholders should be aware that the risks of delayed access to hospital care for AHF could be even higher than those posed by COVID-19. Moreover, a significant re-engineering of healthcare services should be considered. The implementation of modern communication systems may overcome several emerging problems in the post-COVID-19 era. 10 Online real-time consultations with primary-care physicians and specialists may effectively circumvent the need for patient travel.

None. 

Updated information on COVID 19 pandemia

COVID-19 and Italy: what next?

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)

Delayed access or provision of care in Italy resulting from fear of COVID-19

Being a cardiologist at the time of SARS-COVID-19: is it time to reconsider our way of working?

How the COVID-19 Pandemic May Reshape US Hospital Design. The Heart.org, Medscape Cardiology

For people with heart failure, covid-19 presents a challenge. The BMJ Opinion

Virtual Visits for Care of Patients with Heart Failure in the Era of COVID-19: A Statement from the Heart Failure Society of America