Diagnosis of cardiac disease plummets during COVID-19

A significant indirect effect of the COVID-19 pandemic was a sudden and sharp decrease in the number of cardiology diagnostic procedures performed worldwide, especially in lower-income countries.

A global survey of COVID-19's impact on heart disease diagnosis, conducted by the International Atomic Energy Agency (IAEA), found a 64% reduction in diagnostic 2020 procedures compared with 2019. The study results were published in the Journal of the American College of Cardiology in January.

The study included 909 inpatient and outpatient centers that perform cardiac diagnostic procedures in 108 countries.

"The study was amazing in terms of the worldwide participation," coauthor Dr. Cole Hirschfeld, of Columbia University Irving Medical Center/New York-Presbyterian Hospital, told Current Science Daily.

A primary reason for the study, Hirschfeld said, was that "early in the pandemic there were a number of reports talking about the reduction in health care-seeking behaviors during the lockdown periods to contain the virus spread. Nobody was showing up at the hospital for diagnostic imaging tests or emergency health services. People weren't even showing up at the hospital with heart attacks."

Hirschfeld said that cardiologists were concerned about the impact of this on cardiovascular disease patients, and in general. Cardiovascular disease is still, by far, the number one killer worldwide, he said, responsible for about 18 million deaths each year.

"What's going on? Where did all these people go? What's the long-term impact?" These are some of the questions the IAEA study sought to answer, Hirschfeld said.

The study findings were "extremely concerning," Hirschfeld said. "There was a reduction in the number of imaging procedures being done around the world. In March 2020, we found the reduction was 42% worldwide from April 2019, and in April 2020, it was 64%."

"Invasive procedures, things that required intubation or aerosolizing procedures had even greater reductions than those that were non-invasive. But in general we observed a sweeping decline across the board and consistent across all regions of the world," he said.

Another main result of the study was that "we found major differences between wealthier countries and economically challenged countries," Hirschfeld said. "Specifically, we reported an 81% decline in procedure volumes in low-income countries and a 77% decline in the low-middle-income countries, but only 62 and 63% in the upper-middle and high-income countries."

The study also found significant differences between wealthier and poorer countries in terms of availability of personal protective equipment (PPE) and use of telehealth technology. 

"Telehealth is a really important service in a pandemic, and zero percent of the facilities we surveyed in low-income countries reported utilizing telehealth services, compared with 60% of facilities in high-income countries," Hirschfeld said. 

Facilities in lower-income countries included those in Afghanistan, Nepal, Uganda and Niger, he said.

Lessening heart disease risks

When Current Science Daily asked Hirschfeld what could be done to lessen the risks of heart disease and undiagnosed heart disease during the pandemic, he emphasized the importance of telehealth technology in managing patient risk factors and follow up.

"Diagnostic imaging is extremely important, but the most important factor in battling heart disease is primary prevention and secondary prevention efforts. This means managing risk factors like diabetes, obesity, heart disease, smoking and lifestyle—all things that we do in our day-to-day practice, which has been very challenging throughout the pandemic," he said.

"From a societal perspective, we know that the pandemic has caused greater unemployment, social isolation, sedentary lifestyle, depression; all of these things are independent risks for heart disease," Hirschfeld said. "But there's good evidence, especially during the pandemic, from many studies showing that patient management through telehealth, text messaging programs, and other novel technologies can improve outcomes related to cardiovascular disease."

Hirschfeld said that his clinic at Columbia Presbyterian Hospital in New York City had nurses and medical assistants "reaching out to get in contact with patients to help monitor their blood sugars or blood pressure, and making sure that patients have a blood pressure cuff at home." 

Hirschfeld also comments that “as telehealth has become a leading platform for the delivery of health care during the pandemic, we must be cognizant of disparities and barriers related to access to telehealth services. Our study revealed that lower-income countries not only had the greatest decline in diagnostic cardiovascular procedures, but also lower utilization of telehealth for patient care.” 

"Telehealth requires internet, a capable device, and sufficient technology literacy, which has also been a major barrier to many of the patients we serve in our local community. Lack of technology affects the most vulnerable populations. One study even called the pandemic 'the great unequalizer,' in terms of telehealth,” Hirschfeld said. “But, in general, telehealth has been superbly helpful for a majority of our patients. It's a different level of healthcare than we’re used to, but it’s far better than nothing."

Long-term impact 

As for the future, Hirschfeld noted that major medical centers are "doing a good job of getting back to the capacities they had pre-pandemic, but it's harder for smaller clinics and more rural clinics to achieve that. They just don't have the same resources available."

"It is tough, and only time will tell what the long-term impact will be from reduced diagnostic testing, especially in the early stages of the pandemic," he said. "Many facilities have not increased hours or capacity to make up the tests that were missed. I'm not sure what the long-term impact will be, but I know it's concerning to many of us."

An accompanying editorial in the Journal of the American College of Cardiology reported that between March 1 and Aug. 1, 2020, the U.S. mortality rate from all causes was 20% higher than 2014 to 2020. 

"Of these excess deaths, 65% were directly attributed to COVID-19 and 35% to other causes. The large and rapid excess mortality is unprecedented in peace time, and the reasons for the excess non−COVID-19 mortality require exploration," the editorial stated.

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