Impact of COVID‐19 pandemic on acute heart failure admissions and mortality: a multicentre study (COV‐HF‐SIRIO 6 study)

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Abstract

Aims

The coronavirus disease‐2019 (COVID‐19) pandemic has changed the landscape of medical care delivery worldwide. We aimed to assess the influence of COVID‐19 pandemic on hospital admissions and in‐hospital mortality rate in patients with acute heart failure (AHF) in a retrospective, multicentre study.

Methods and results

From 1 January 2019 to 31 December 2020, a total of 101 433 patients were hospitalized in 24 Cardiology Departments in Poland. The number of patients admitted due to AHF decreased by 23.4% from 9853 in 2019 to 7546 in 2020 ( P < 0.001). We noted a significant reduction of self‐referrals in the times of COVID‐19 pandemic accounting 27.8% ( P < 0.001), with increased number of AHF patients brought by an ambulance by 15.9% ( P < 0.001). The length of hospital stay was overall similar (7.7 ± 2.8 vs. 8.2 ± 3.7 days; P = not significant). The in‐hospital all‐cause mortality in AHF patients was 444 (5.2%) in 2019 vs. 406 (6.5%) in 2020 ( P < 0.001). A total number of AHF patients with concomitant COVID‐19 was 239 (3.2% of AHF patients hospitalized in 2020). The rate of in‐hospital deaths in AHF patients with COVID‐19 was extremely high accounting 31.4%, reaching up to 44.1% in the peak of the pandemic in November 2020.

Conclusions

Our study indicates that the COVID‐19 pandemic led to (i) reduced hospital admissions for AHF; (ii) decreased number of self‐referred AHF patients and increased number of AHF patients brought by an ambulance; and (iii) increased in‐hospital mortality for AHF with very high mortality rate for concomitant AHF and COVID‐19.

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Most cited references 20

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2016 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)Developed with the special contribution of the Heart Failure Association (HFA) of the ESC.

Piotr Ponikowski, Adriaan A. Voors, Stefan D. Anker … (2016)

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

Ovidio De Filippo, Fabrizio D’Ascenzo, Filippo Angelini … (2020)

To the Editor: To address the coronavirus (Covid-19) pandemic, 1 strict social containment measures have been adopted worldwide, and health care systems have been reorganized to cope with the enormous increase in the numbers of acutely ill patients. 2,3 During this same period, some changes in the pattern of hospital admissions for other conditions have been noted. The aim of the present analysis is to investigate the rate of hospital admissions for acute coronary syndrome (ACS) during the early days of the Covid-19 outbreak. In this study, we performed a retrospective analysis of clinical and angiographic characteristics of consecutive patients who were admitted for ACS at 15 hospitals in northern Italy. All the hospitals were hubs of local networks for treatment involving primary percutaneous coronary intervention. The study period was defined as the time between the first confirmed case of Covid-19 in Italy (February 20, 2020) and March 31, 2020. We compared hospitalization rates between the study period and two control periods: a corresponding period during the previous year (February 20 to March 31, 2019) and an earlier period during the same year (January 1 to February 19, 2020). The primary outcome was the overall rate of hospital admissions for ACS. We calculated incidence rates for the primary outcome by dividing the number of cumulative admissions by the number of days for each time period. Incidence rate ratios comparing the study period with each of the control periods were calculated with the use of Poisson regression. (Details regarding the study methods are provided in the Supplementary Appendix, available with the full text of this letter at NEJM.org.) Of the 547 patients who were hospitalized for ACS during the study period, 420 (76.8%) were males; the mean (±SD) age was 68±12 years. Of these patients, 248 (45.3%) presented with ST-segment elevation myocardial infarction (STEMI). The mean admission rate for ACS during the study period was 13.3 admissions per day. This rate was significantly lower than either the rate during the earlier period in the same year (total number of admissions, 899; 18.0 admissions per day; incidence rate ratio, 0.74; 95% confidence interval [CI], 0.66 to 0.82; P<0.001) or the rate during the previous year (total number of admissions, 756; 18.9 admissions per day; incidence rate ratio, 0.70; 95% CI, 0.63 to 0.78; P<0.001). The incidence rate ratios for individual ACS subtypes are presented in Table 1. After the national lockdown was implemented on March 8, 2020, 4 a further reduction in ACS admissions was reported. (Details regarding the full secondary analyses are provided in the Supplementary Appendix.) This report shows a significant decrease in ACS-related hospitalization rates across several cardiovascular centers in northern Italy during the early days of the Covid-19 outbreak. Recent data suggest a significant increase in mortality during this period that was not fully explained by Covid-19 cases alone. 5 This observation and data from our study raise the question of whether some patients have died from ACS without seeking medical attention during the Covid-19 pandemic.

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

Bernhard Metzler, Peter Siostrzonek, Ronald Binder … (2020)

We conducted a nationwide retrospective survey on the impact of COVID-19 on the diagnosis and treatment of acute cornary syndrome (ACS) from 2 to 29 March in Austria. Of the 19 public primary percutaneous coronary (PCI) centres contacted, 17 (90%) provided the number of admitted patients. During the study period, we observed a significant decline in the number of patients admitted to hospital due to ACS (Figure 1 ). Comparing the first and last calendar week, there was a relative reduction of 39.4% in admissions for ACS. In detail, from calendar week 10 to calendar week 13, the number of ST-segment elevation myocardial infarction (STEMI) patients admitted to all hospitals was 94, 101, 89, and 70, respectively. The number of non-STEMI patients declined even more markedly from 132 to 110, to 62, and to 67. Figure 1 Decline of acute coronary syndrome admissions in Austria since the outbreak of COVID-19. The absolute numbers of all ACS (blue bars), STEMI (orange bars), and NSTEMI (grey bars) admissions in Austria from calendar week 10 to calendar week 13 are shown. Abbreviations: STEMI, ST-segment elevation myocardial infarction; NSTEMI, non-ST-segment elevation myocardial infarction. The main finding of our retrospective observational study is an unexpected major decline in hospital admissions and thus treatment for all subtypes of ACS with the beginning of the COVID-19 outbreak in Austria and subsequent large-scale public health measures such as social distancing, self-isolation, and quarantining. Several factors might explain this important observation. The rigorous public health measures, which are undoubtedly critical for controlling the COVID-19 pandemic, may unintentionally affect established integrated care systems. Amongst others, patient-related factors could mean that infarct-related symptoms such as chest discomfort and dyspnoea could be misinterpreted as being related to an acute respiratory infection. Moreover, the strict instructions to stay at home as well as the fear of infection in a medical facility may have further prevented patients with an ACS from going to a hospital. Irrespective of the causes, the lower rate of admitted and therefore treated patients with ACS is worrisome and we are concerned that this might be accompanied by a substantial increase in early and late infarct-related morbidity and mortality. Our study does not provide data on mortality; however, considering the annual incidence of ACS in Austria (200/100 000/year = 17 600/year in 8.8 million habitants) 1 and taking into consideration sudden cardiac deaths and silent infarctions (one-third), there will remain ∼1000 ACS cases a month. The difference between the assumed number of ACS patients and the observed number in our study, i.e. 725 ACS patients in calendar weeks 10–13 is 275. According to these assumptions, 275 patients were not treated in March 2020. Based on data showing that the cardiovascular mortality of untreated ACS patients might be as high as 40% (as it was in the 1950s), 2 we can theoretically estimate 110 ACS deaths during this time frame. The number of deaths associated with this unintentional undersupply of guideline-directed ACS management is very alarming, particularly when considering that the official number of COVID-related deaths in Austria was 86 on 29 March. In conclusion, it seems likely that the COVID-19 outbreak is associated with a significantly lower rate of hospital admissions and thus, albeit unintended, treatment of ACS patients, which is most likely explained by several patient- and system-related factors. Every effort should be undertaken by the cardiology community to minimize the possible cardiac collateral damage caused by COVID-19.

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Author and article information

Contributors

Małgorzata Ostrowska:

ORCID: https://orcid.org/0000-0002-3377-2950

m.ostrowska@cm.umk.pl

Journal

Journal ID (nlm-ta): ESC Heart Fail

Journal ID (iso-abbrev): ESC Heart Fail

Journal ID (doi): 10.1002/(ISSN)2055-5822

Journal ID (publisher-id): EHF2

Title: ESC Heart Failure

Publisher: John Wiley and Sons Inc. (Hoboken )

ISSN (Electronic): 2055-5822

Publication date (Electronic): 16 November 2021

Publication date PMC-release: 16 November 2021

Electronic Location Identifier: 10.1002/ehf2.13680

Affiliations

[ ¹ ] Department of Cardiology and Internal Medicine, Collegium Medicum Nicolaus Copernicus University 9 Skłodowskiej‐Curie Street Bydgoszcz 85‐094 Poland

[ ² ] Department of Cardiology Marian Zyndram‐Kościałkowski Ministry of Interior and Administration Hospital Białystok Poland

[ ³ ] II Department of Cardiology, Chair of Cardiology, Cardiac Surgery and Vascular Diseases Medical University of Lodz Lodz Poland

[ ⁴ ] Department of Cardiology Hospital of the Ministry of Interior and Administration Rzeszów Poland

[ ⁵ ] 1st Department of Cardiology, Collegium Medicum Jan Kochanowski University Kielce Poland

[ ⁶ ] Department of Cardiology and Internal Medicine, School of Medicine, Collegium Medicum University of Warmia and Mazury Olsztyn Poland

[ ⁷ ] Department of Cardiology and Cardiac Surgery 10th Military Hospital and Polyclinic Bydgoszcz Poland

[ ⁸ ] Department of Cardiology Independent Public Healthcare in Przeworsk Przeworsk Poland

[ ⁹ ] Cardiology Department Pope John Paul II District Hospital in Zamość Zamosc Poland

[ ¹⁰ ] Cardiology Department Medical Care Center Jaroslaw Poland

[ ¹¹ ] Department of Cardiology and Internal Diseases, Institute of Maritime and Tropical Medicine Medical University of Gdańsk Gdynia Poland

[ ¹² ] Department of Cardiology Tertiary Care Hospital Ciechanów Poland

[ ¹³ ] Department of Cardiology Masovian Rehabilitation Center “STOCER”, Dr. Włodzimierz Roefler Hospital Pruszków Poland

[ ¹⁴ ] Department of Cardiology District Hospital Tuchola Poland

[ ¹⁵ ] Department of Cardiology Dr. Emil Warmiński Tertiary Care Municipal Hospital Bydgoszcz Poland

[ ¹⁶ ] Department of Invasive Cardiology Central Clinical Hospital of the Ministry of Interior and Administration Warsaw Poland

[ ¹⁷ ] Mossakowski Medical Research Centre Polish Academy of Science Warsaw Poland

[ ¹⁸ ] Department of Cardiology Polish Hospitals Kędzierzyn‐Koźle Poland

[ ¹⁹ ] Department of Cardiology and Intensive Cardiac Care Unit District Polyclinic Hospital Toruń Poland

[ ²⁰ ] Department of Cardiology Medical University in Białystok Białystok Poland

[ ²¹ ] Department of Cardiology and Cardiac Intensive Care Tertiary Care Municipal Hospital Toruń Poland

[ ²² ] Cardiology Subdivision of Heart Failure St. Elizabeth Hospital Biała Poland

[ ²³ ] Department of Cardiology, Interventional Cardiology and Electrophysiology with Cardiac Intensive Care Unit Tertiary Care Hospital Grudziądz Poland

[ ²⁴ ] 1st Department of Physiology, Institute of Medical Sciences University of Opole, Cardiology Center of Kluczbork SCANMED SA Opole Poland

[ ²⁵ ] Department of Cardiology Polish Hospitals Sztum Poland

[ ²⁶ ] 2nd Department of Cardiology, Collegium Medicum Jagiellonian University Cracow Poland

[ ²⁷ ] Department of Cardiology Center of Postgraduate Medical Education, Grochowski Hospital Warsaw Poland

[ ²⁸ ] 3rd Department of Cardiology, Silesian Center for Heart Diseases, Faculty of Medicine in Zabrze Medical University of Silesia Zabrze Poland

[ ²⁹ ] 1st Department of Cardiology Medical University of Gdansk Gdansk Poland

[ ³⁰ ] 1st Department of Cardiology Jagiellonian University Medical College Krakow Poland

[ ³¹ ] Department of Interventional Cardiology, Institute of Cardiology Jagiellonian University Medical College, John Paul II Hospital Krakow Poland

[ ³² ] Department of Cardiology Poznan University of Medical Sciences Poznan Poland

[ ³³ ] Department of Heart Failure and Transplantology National Institute of Cardiology Warsaw Poland

[ ³⁴ ] Department of Coronary Artery Disease and Heart Failure, Institute of Cardiology Jagiellonian University Medical College Krakow Poland

[ ³⁵ ] Department of Preventive Medicine and Education Medical University of Gdansk Gdansk Poland

[ ³⁶ ] Department of Cardiology Pomeranian Medical University Szczecin Poland

Author notes

[*] [* ] Correspondence to: Małgorzata Ostrowska, MD, PhD, Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, 9 Skłodowskiej‐Curie Street, 85‐094 Bydgoszcz, Poland. Tel: +48 52 5854023; Fax: +48 52 5854024. Email: m.ostrowska@ 123456cm.umk.pl

Author information

Jacek Kubica https://orcid.org/0000-0001-8250-754X

Małgorzata Ostrowska https://orcid.org/0000-0002-3377-2950

Wioleta Stolarek https://orcid.org/0000-0002-7235-0734

Michał Kasprzak https://orcid.org/0000-0002-3465-4163

Klaudyna Grzelakowska https://orcid.org/0000-0001-6175-2191

Aldona Kubica https://orcid.org/0000-0002-4608-0881

Piotr Adamski https://orcid.org/0000-0001-9719-0987

Przemysław Podhajski https://orcid.org/0000-0003-0525-1557

Eliano Pio Navarese https://orcid.org/0000-0002-2355-4589

Leszek Gromadziński https://orcid.org/0000-0002-8827-4203

Paweł Grzelakowski https://orcid.org/0000-0002-9514-4941

Andrzej Kleinrok https://orcid.org/0000-0001-6276-5525

Marek Koziński https://orcid.org/0000-0002-6460-4802

Agnieszka Pawlak https://orcid.org/0000-0001-9032-9130

Bożena Sobkowicz https://orcid.org/0000-0002-3297-3320

Stanisław Bartuś https://orcid.org/0000-0003-4508-3551

Andrzej Budaj https://orcid.org/0000-0002-6395-2098

Mariusz Gąsior https://orcid.org/0000-0001-6775-1392

Marcin Gruchała https://orcid.org/0000-0003-4901-2291

Jarosław Drożdż https://orcid.org/0000-0002-0732-2104

Miłosz Jaguszewski https://orcid.org/0000-0002-2555-593X

Jacek Legutko https://orcid.org/0000-0002-2945-3674

Maciej Lesiak https://orcid.org/0000-0003-2630-5016

Przemysław Leszek https://orcid.org/0000-0003-4529-2687

Jadwiga Nessler https://orcid.org/0000-0002-5076-5816

Anna Tomaszuk‐Kazberuk https://orcid.org/0000-0003-0153-0356

Agnieszka Tycińska https://orcid.org/0000-0001-7855-7261

Tomasz Zdrojewski https://orcid.org/0000-0001-6015-8561

Jarosław Kaźmierczak https://orcid.org/0000-0001-6090-8377

Article

Publisher ID: EHF213680 Other ID: ESCHF-21-00663

DOI: 10.1002/ehf2.13680

PMC ID: 8652676

PubMed ID: 34786869

SO-VID: 3ce8ca32-c9bf-43bd-8ac8-3416f807ea60

License:

This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

History

Date revision received : 27 September 2021

Date received : 28 June 2021

Date accepted : 05 October 2021

Page count

Figures: 2, Tables: 4, Pages: 8, Words: 2218

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details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_JATSPMC version:6.0.9 mode:remove_FC converted:08.12.2021

Keywords: heart failure,covid‐19,in‐hospital mortality,hospitalization

Data availability:

Keywords: heart failure, covid‐19, in‐hospital mortality, hospitalization

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Impact of COVID‐19 pandemic on acute heart failure admissions and mortality: a multicentre study (COV‐HF‐SIRIO 6 study)

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Wiley: Novel Coronavirus COVID-19

Most cited references 20

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

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

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Cited by 16

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