key: cord-1024034-q301wed3 authors: Bozzani, Antonio; Arici, Vittorio; Ticozzelli, Giulia; Franciscone, Mila Maria; Ragni, Franco; Sterpetti, Antonio V. title: Reduced Vascular Practice And Increased Cardiovascular Mortality For Covid19 Negative Patients date: 2021-12-09 journal: J Surg Res DOI: 10.1016/j.jss.2021.11.014 sha: a54570ac93fa3fbc41690a645adb6593203b0715 doc_id: 1024034 cord_uid: q301wed3 OBJECTIVE: The aim of our study was to compare COVID19 and not-COVID19 related mortality rates in two Italian regions during the pandemic period when the same isolation rules and therapeutic approaches were introduced for all hospitals in Italy. Risk factors for not-COVID19 related deaths during the pandemic were analyzed; we tried to assess a possible correlation between reducing hospital visits and “deferrable” vascular operations and the increased cardiovascular mortality not related to COVID19 infection. METHODS: We analyzed COVID 19 and not-COVID 19 related mortality rates in two Italy regions in the period January 2020 - January 2021. We compared mortality rates during the pandemic period with those of the previous five years. We tried to determine the factors involved in increased mortality rates during the pandemic period. RESULTS: Despite the same isolation rules for people and the same therapeutic approaches for hospitals, mortality rates did not increase in the region Lazio where the pandemic was not severe. In the region Lombardy the mortality rate was doubled in comparison with the previous years and 50% of the increase was related with not-COVID19 deaths. CONCLUSIONS: The increase in mortality rates for not-COVID19 related deaths in the region Lombardy was connected to the generalized turmoil in the acute phase of an overwhelming pandemic, including diffuse stress, inadequate communications, reluctance to ask for medical help unless symptoms were severe, unexpected inadequate number of health workers, hospital and ICU beds. Reduced hospital visits may have had a fundamental role. In Italy more than 106,000 deaths from COVID 19 have been reported up to March 30 th 2021; 250 56 health workers died from COVID19 infection and 110,266 health workers were diagnosed positive 57 for COVID19 [1,2,3,4]. The pandemic has brought to unexpected consequences, including shortage 58 of medical personnel and reluctance from patients to ask for medical help unless symptoms were 59 severe [3,4,5]. Isolation rules were introduced for all hospitals in Italy including separate sections 60 for COVID19 patients, diffuse testing and specific measures for health workers and patients. 61 Admissions to hospitals were reduced, avoiding visits for not-urgent conditions and deferrable 62 elective surgeries [6, 7] . Often it is difficult to determine the difference between deferrable and not-63 deferrable procedures and urgent or not-urgent examinations in patients suffering from vascular 64 diseases. 65 The objective of our analysis was to identify the potential risk factors for increased cardiovascular 66 mortality not related with COVID19 infection during the pandemic. We tried to determine the 67 influence of deferring not-urgent visits and operations for patients with vascular disease; we 68 analyzed mortality rates in two Italian regions with different levels of severity of the pandemic 69 (high in Lombardy-low in Lazio) (Fig 1) . In both regions the same isolation rules for the general 70 population and the same therapeutic attitudes in hospitals were introduced during the acute phases 71 of the pandemic, when it was not clear the differences in regional levels of the pandemic. 78 The mortality data in Italy during the pandemic period March 2020-March 2021 were reviewed. 79 The analysis was based on the data reported by the national health institute (Istituto Superiore and laboratory evidence of COVID19 infection, without an alternative cause of death clearly not 88 referable to the COVID19 infection even if present (for example a trauma-related death) [8, 9] . All 89 laboratory tests to determine a probable COVID19 infection were performed in specialized regional 90 referral centers with a RT-PCR of the oropharyngeal swab. The number of patients who died during the period January -December 2020 were compared to the 94 mean number of patients who died in the previous 5 years (2015-2019). The isolation rules imposed by the Central Government for the general population and the 98 restrictions for hospitals to perform only urgent visits or operations were the same all over Italy, 99 independently from the level of the pandemic. Deferrable, elective operations were not performed. Outpatient visits were performed only for patients with severe symptoms and emergency 101 conditions. There was a spontaneous tendency in the general population to avoid medical facilities. As result even the number of not-COVID19 patients seen and admitted through the emergency 103 rooms of hospitals was significantly reduced. We analyzed the number of vascular outpatients visits Overall Mortality in Italy during the COVID19 pandemic. 119 During the pandemic 106779 deaths COVID19 infection related were reported in Italy. Mean age 120 was 81 years (Female 44% and Male 56%). Out of the total number, 30341 deaths were registered 121 in the region Lombardy (28.4%) and 6501 in the region Lazio (6.1%) ( Table 1) . 123 Table 1 shows the difference in overall mortality in the regions Lombardy and Lazio during the 124 pandemic. People older than 50 years of age had higher mortality rates in comparison with the 125 previous years. (Table 2 ,3,4). This increase was related with people dying from COVID19 infection 126 for its 50%. The remaining 50% of the increase in mortality was related with people not dying from 127 COVID19 infection (70% of these deaths were defined as consequence of cardiovascular events). During the overwhelming outbreaks, collection of data was inevitably inaccurate accurate. The (Table 2) . There were no significant differences in therapeutic attitude and hospital isolation rules between the 211 two examined Italian regions (Lombardy and Lazio). The only major difference was the level of the 212 pandemic severity. In Rome the pandemic had a low intensity and the medical system was adequate 213 without major deficits of hospital beds and equipment. In Pavia the pandemic was severe and in 214 the acute phase the workforce had limited capacity and the health care system was overwhelmed 215 with COVID-19 cases with problems respect to hospital and Intensive Care beds and equipment. J o u r n a l P r e -p r o o f Global vascular surgeons' experience, stressors, and 313 coping during the coronavirus disease 2019 pandemic Pattern of vascular 316 disease in Lombardy, Italy, during the first month of the COVID-19 outbreak Massive drop in elective and 320 urgent aortic procedures during the peak of the COVID-19 outbreak in Spanish multicenter analysis Acute limb ischemia in patients with COVID-19 pneumonia Reassessing the operative threshold for 326 abdominal aortic aneurysm repair in the context of COVID-19 Acute Thrombosis of Lower Limbs 329 Arteries in the Acute Phase and After Recovery From COVID19 26-Acute arterial and deep venous thromboembolism in COVID-19 333 patients: Risk factors and personalized therapy Telemedicine platforms and 336 their use in the coronavirus disease-19 era to deliver comprehensive vascular care Lombardy Covid-19 Vascular Study Group Regional Survey in Lombardy Endovascular Surgery 343 during COVID-19 Virus Pandemic as a Valid Alternative to Open Surgery Thrombin induces production of growth factors from aortic smooth muscle cells Medical Student Surgery Podcast During COVID-19 Positive Patients Who Underwent Surgery: A New York City Experience