key: cord-1025505-8l7jlvvj
authors: Oikonomou, Evangelos; Aznaouridis, Konstantinos; Barbetseas, John; Charalambous, Georgios; Gastouniotis, Ioannis; Fotopoulos, Vasileios; Gkini, Konstantia-Paraskevi; Katsivas, Apostolos; Koudounis, Georgios; Koudounis, Panagiotis; Koutouzis, Michael; Lamprinos, Dimitrios; Lazaris, Evangelos; Lazaris, Efstathios; Lazaros, George; Marinos, George; Platogiannis, Nikolaos; Platogiannis, Dimitrios; Siasos, Gerasimos; Terentes-Printzios, Dimitrios; Theodoropoulou, Alexandra; Theofilis, Panagiotis; Toutouzas, Konstantinos; Tsalamandris, Sotiris; Tsiafoutis, Ioannis; Vavouranakis, Manolis; Vogiatzi, Georgia; Zografos, Theodoros; Baka, Eleni; Tousoulis, Dimitris; Vlachopoulos, Charalambos
title: Hospital attendance and admission trends for cardiac diseases during the COVID-19 outbreak and lockdown in Greece
date: 2020-08-18
journal: Public Health
DOI: 10.1016/j.puhe.2020.08.007
sha: aff676a3afd028635ba3b39d3ba99cfe0010a45e
doc_id: 1025505
cord_uid: 8l7jlvvj

Abstract Objectives The COVID-19 outbreak, along with implementation of lockdown and strict public movement restrictions, in Greece have affected hospital visits and admissions. We aimed to investigate trends for cardiac diseases admissions during the outbreak of the pandemic and possible associations with the applied restrictive measures. Study Design Retrospective observational study. Methods Data for 4,970 patients admitted via the cardiology Emergency Department (ED) across 3 large volume urban hospitals in Athens and 2 regional/rural hospitals from 3rd February 2020 and up to 12th April was recorded. Data from the equivalent (for COVID-19 outbreak) time period of 2019 and from the post lockdown time period were also collected. Results A falling trend of cardiology ED visits and hospital admissions starting from the week that the restrictive measures due to COVID-19 were implemented was observed. Compared to the pre-COVID-19 outbreak time period, ACS [145 (29/week) vs. 60 (12/week), -59%, p<.001], STEMI [46 (9.2/week) vs. 21 (4.2/week), -54%, p=.002] and NSTE-ACS [99 cases (19.8/week) vs. 39 (7.8/week), -60% p<.001] were reduced at the COVID-19 outbreak time period. Reductions were also noted for heart failure worsening and arrhythmias. The ED visits in the post-lockdown period were significantly higher compared to the COVID-19 outbreak time period (1,511 vs 660; p<0.05). Conclusion Our data show significant drops in cardiology visits and admissions during the COVID-19 outbreak. Whether this results from restrictive measures or depicts a true reduction of cardiac disease cases warrants further investigation.

have been recorded, as well as a significant lag between symptom onset and first 32 medical contact, suggesting that patients are reluctant to seek medical care 1 . While 33 anecdotal reports are many, true registries of cardiac visits to hospitals and admissions 34 are scarce. In Spain, there was a 40% decrease in patients treated with percutaneous 35 coronary intervention (PCI) for STEMI 2 , corroborated by similar decreases from data 36 in catheterization laboratories in the United States of America (USA) 3 .

This observed reduction could be attributed to misdiagnosis in the setting of 38 healthcare overload, reluctance to seek medical help in an environment that is 39 perceived to precipitate infection, hindered access due to strict movement restrictions 40 during lockdown, or to a true paradoxical reduction of acute cardiovascular events, 41 possibly due to beneficial changes in lifestyle.

The course of the pandemic in Greece merits particular attendance. Lockdown Hospital, Athens) and 2 are regional hospitals of the National health system outside 56 Athens metropolitan area (Kalamata General Hospital and Trikala General Hospital). 57 We opted for representativeness including both University and non-University, as 58 well as metropolitan and regional hospitals. Data were collected for the period from 59 3 rd February 2020 and up to 13 th April (pre-and during pandemia outbreak) and from 60 the equivalent (COVID-19 outbreak) time period of 2019. Following the lifting of 61 restrictive measures we also collected data from an equivalent (4/5/2020 -7/6/2020) 62 time period (post lockdown period).

Based on an ad hoc design form, we collected demographic data (such as age and 64 gender), as well as patients' medical history, the reason of the visit, and diagnosis of (presented as mean ± SD) were tested for normality of distribution with Kolmogorov-72 Smirnov test and by visual inspection of P-P plots. A Student's t-test was used to test 73 for differences between 2 categories of normally distributed continuous data.

Differences between categorical variables were tested by forming contingency tables 75 and performing χ2-tests. Adjustment for multiple comparisons was performed as We observed a falling trend of cardiology ED visits and admissions starting from 95 the week that the restrictive measures due to COVID-19 were implemented. As it is 96 shown in Table 1 and Figure 1A , the cumulative visits at the pre-COVID-19 Table 2 ) and in all age ranges (>65 years as well as in 126 younger subjects) (Supplementary Table 3) . 127 To further validate our findings, we analyzed cardiology ED visits and cardiology Compared to the COVID-19 lockdown period, in the post-lockdown period a 135 significant increase was observed in cardiology ED visits and cardiology department 136 admissions, especially for ACS cases. As shown in Table 1 and Figure 1A , the 137 cumulative visits in the post-lockdown period was higher than the COVID-19 We performed a separate (exploratory) analysis for regional hospitals outside 

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This research did not receive any specific grant from funding agencies in the public, 215 commercial, or not-for-profit sectors.