key: cord-0817221-j8ogxt4x authors: Einstein, Andrew J.; Shaw, Leslee J.; Hirschfeld, Cole; Williams, Michelle C.; Villines, Todd C.; Better, Nathan; Vitola, Joao V.; Cerci, Rodrigo; Dorbala, Sharmila; Raggi, Paolo; Choi, Andrew D.; Lu, Bin; Sinitsyn, Valentin; Sergienko, Vladimir; Kudo, Takashi; Nørgaard, Bjarne Linde; Maurovich-Horvat, Pál; Campisi, Roxana; Milan, Elisa; Louw, Lizette; Allam, Adel H.; Bhatia, Mona; Malkovskiy, Eli; Goebel, Benjamin; Cohen, Yosef; Randazzo, Michael; Narula, Jagat; Pascual, Thomas N.B.; Pynda, Yaroslav; Dondi, Maurizio; Paez, Diana title: International Impact of COVID-19 on the Diagnosis of Heart Disease date: 2021-01-19 journal: J Am Coll Cardiol DOI: 10.1016/j.jacc.2020.10.054 sha: e289382a73959a9446da45dc21065ed69d3272d9 doc_id: 817221 cord_uid: j8ogxt4x BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has adversely affected diagnosis and treatment of noncommunicable diseases. Its effects on delivery of diagnostic care for cardiovascular disease, which remains the leading cause of death worldwide, have not been quantified. OBJECTIVES: The study sought to assess COVID-19’s impact on global cardiovascular diagnostic procedural volumes and safety practices. METHODS: The International Atomic Energy Agency conducted a worldwide survey assessing alterations in cardiovascular procedure volumes and safety practices resulting from COVID-19. Noninvasive and invasive cardiac testing volumes were obtained from participating sites for March and April 2020 and compared with those from March 2019. Availability of personal protective equipment and pandemic-related testing practice changes were ascertained. RESULTS: Surveys were submitted from 909 inpatient and outpatient centers performing cardiac diagnostic procedures, in 108 countries. Procedure volumes decreased 42% from March 2019 to March 2020, and 64% from March 2019 to April 2020. Transthoracic echocardiography decreased by 59%, transesophageal echocardiography 76%, and stress tests 78%, which varied between stress modalities. Coronary angiography (invasive or computed tomography) decreased 55% (p < 0.001 for each procedure). In multivariable regression, significantly greater reduction in procedures occurred for centers in countries with lower gross domestic product. Location in a low-income and lower–middle-income country was associated with an additional 22% reduction in cardiac procedures and less availability of personal protective equipment and telehealth. CONCLUSIONS: COVID-19 was associated with a significant and abrupt reduction in cardiovascular diagnostic testing across the globe, especially affecting the world’s economically challenged. Further study of cardiovascular outcomes and COVID-19–related changes in care delivery is warranted. . Delay in the delivery of these essential services will affect health outcomes and potentially reverse the declines observed in cardiovascular event rates over the past several decades (7) . However, to date, the magnitude of the worldwide impact of COVID-19 on cardiovascular procedural volumes as well as changes in testing patterns and modality utilization have not been quantified. The mission of the International Atomic Energy Agency (IAEA) Division of Human Health includes supporting member states as they confront the burden of cardiovascular diseases, cancer, malnutrition, and other health conditions through the use of appropriate prevention, diagnostic testing, and treatment. The impact of COVID-19 on the worldwide delivery of cardiovascular care is of particular importance to the IAEA and its goal of promoting equitable global cardiovascular care. Quantifying the early impact of COVID-19 on cardiovascular testing volumes and modality utilization across a large, diverse range of countries and world regions is also important for ongoing and future studies aiming to assess the impact of the pandemic on long-term cardiovascular disease-related outcomes and to define specific needs for recovery of effective cardiovascular care delivery. Such information can also inform strategic interventions targeted at planning for and responding to future outbreaks (8, 9) . Therefore, in an The 8-page online survey, including changes in practice performance and procedure numbers, was emailed to participants via various organizations and completed by June 10, 2020. A total of 909 participants from 108 countries were included in the final analysis. Outpatient physician practice 3 (7) 1 (2) 1 (1) 15 (7) 3 (5) CENTERS. Data were obtained from 909 inpatient and outpatient centers in 108 countries, of which 846 centers in 106 countries provided data on procedure volumes. Figure 1 details the iterative exclusion criteria applied to select the final sample, and characteristics of these centers are summarized in Table 1 The bar graph demonstrates the reduction in the number of each procedure type for the entire world between March 2019, March 2020, and April 2020. DEVELOPMENT. We observed a significant difference in procedure reduction between economically challenged and wealthier countries, with COVIDassociated reduction in cardiac diagnostic procedures more prominent for the world's economically challenged ( Figure 5 ). In the 4 low-income countries participating in the survey, overall reduction in procedures was 81%, and in lower-middle-income countries a reduction of 77% was noted. In contrast, procedural volume reduction was 62% in upper- (68) 680 (75) Values are n (%). COVID ¼ coronavirus disease. The future role of the United States in global health: emphasis on cardiovascular disease Global Health and the Future Role of the United States World Health Organization. Disease burden and mortality estimates Cardiovascular risk and events in 17 low-, middle-, and highincome countries COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU). Available at Investing in global health for our future COVID-19 kills at home: the close relationship between the epidemic and the increase of out-of-hospital cardiac arrests Maintaining Essential Health Services: Operational Guidance for the COVID-19 Context. Interim Guidance 1 World Bank country and lending groups Current worldwide nuclear cardiology practices and radiation exposure: results from the 65 country IAEA Nuclear Cardiology Protocols Cross-Sectional Study (INCAPS) Society of Cardiovascular Computed Tomography guidance for use of cardiac computed tomography amidst the COVID-19 pandemic American College of Cardiology ASE Statement on protection of patients and echocardiography service providers during the 2019 novel coronavirus outbreak: endorsed by the American College of Cardiology Guidance and best practices for reestablishment of nonemergent care in nuclear cardiology laboratories during the coronavirus disease 2019 (COVID-19) pandemic: an information statement from ASNC, IAEA, and SNMMI Utilization and appropriateness of transthoracic echocardiography in response to the COVID-19 pandemic Hospital inpatient only 65 81 75 63 87 75 32 74 78 74 72 72 67 38 66 Hospital inpatient and outpatient 57 75 63 61 68 52 58 78 84 82 73 75 53 73