Impact of the COVID-19 Pandemic on a Department of Cardiology

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Abstract

In December 2019, the first cases of SARS-CoV-2 were identified in China; shortly after, the World Health Organization (WHO) declared COVID-19 an international emergency, and by February 2020, more than 80 000 cases had been confirmed. (1) The disease is characterized by acute respiratory distress syndrome and subsequent cardiac damage by different mechanisms. (2) To briefly describe the impact of the pandemic on cardiac patients, we consecutively analyzed consultations, practices, and admissions in the Coronary Care Unit (CCU) of our center, Hospital Santojanni. This is a public hospital receiving nearly one million consultations per year, 59% of which correspond to residents of the City of Buenos Aires (CABA). Cardiac patient care was considered essential; therefore, the areas of cardiac admission were kept mostly free from COVID-19 patients. During the critical months, part of the healthcare team was assigned to work in COVID areas. Telecare for arrhythmias and heart failure began in May, but the medical office for prevention always remained with in-person consultations. The Interventional Cardiology and Electrophysiology Units continued working and adapted to protection standards established by the Ministry of Health. Cancellation of scheduled procedures increased with high COVID bed occupancy, in order to free up CCU beds and save healthcare resources. In the three medical offices analyzed, the 2020 overall drop rate in health care was 17% compared with 2019. A deficit of 1007 consultations was observed, with 4923 consultations in 2020 versus 5930 in 2019. When the exclusive in-person medical office for prevention was analyzed, an average drop rate of 62% was observed in the critical months, with a total of 1019 fewer consultations (– 31%) than in 2019. However, no difference was found in the medical offices that performed telecare. The top panel of Table 1 shows the total number consultations per quarter and the quarterly average, comparing 2019 and in 2020 in the in-person medical offices in 2019 that added telemedicine in 2020, and in those that maintained only in-person consultation. The analysis is repeated at the bottom panel of Table 1, taking into account only the last 3 quarters of each year, to assess specifically the impact of the pandemic. Regarding invasive procedures, there were fewer cardiac catheterizations (coronary angiography and coronary angioplasty). A total of 942 invasive procedures were performed in 2019 and 605 in 2020, that is, 36% fewer procedures, with an average reduction of 66% from April to July. A drop in the total number of coronary angioplasties, including primary percutaneous coronary intervention (PCI) in acute myocardial infarction (AMI), was also observed with respect to 2019. An annual drop of 21% was found in electrophysiology implants, with an average reduction of 46% from May to September 2020 (Table 2). There was a reduction in the number of cardiovascular patients hospitalized in 2020 in the CCU, and an increase in the number of patients referred from intensive care units. A decrease in hospitalizations due to acute myocardial infarction (AMI) with ST-segment elevation (STEMI) or non-ST-segment elevation (NSTEMI) was evidenced during 2020, and this difference was maximal in the critical months of COVID-19 bed occupancy. A total of 248 AMI patients were hospitalized in 2019, and 191 in 2020, a drop of 23%. This reduction was observed in both STEMI (122 in 2019 and 88 in 2020) and NSTEMI (126 in 2019 and 103 in 2020). Given that the center also receives referrals from the AMI network, the number of STEMI patients is higher than the number of patients hospitalized with this diagnosis, as some of them return to their referral centers after PCI. So, a total of 176 STEMI patients were hospitalized in 2019, and 116 in 2020 (a drop of 34%). The maelstrom of the pandemic should not prevent us from analyzing how we work. The CCU continues to receive patients with severe conditions, such as AMI or heart failure, with longer delays or treatment withdrawal. Considering the marked reduction of consultations in the critical periods of 2020, it is likely that the cardiovascular mortality rate has then increased, as described in international reports showing an increase in out-of-hospital events. (3) Especially, we observed a significant reduction in consultations and hospital admissions in the second quarter, when few COVID-19 cases were still being admitted. This was a "missed opportunity" for care, perhaps due to general health policies and center-specific reasons, among others. The same situation was described in other countries. (4, 5) Prolonged lockdown delayed transmission, but this situation was only used for the general hospital reorganization, when the care of patients with heart diseases could have been encouraged, as was timely expressed by different sectors of Argentine cardiology. (6) Experience shows, as we observed months later with a greater number of COVID-19 in patients, that cardiac patient care can be safely sustained. 2020 was a unique experience due to the pandemic; we observed a poorer care of patients with heart diseases and a possible increase in cardiovascular morbidity and mortality in the untreated population. In the City of Buenos Aires, the number of cases increased gradually in 2020, but a new wave of infections in 2021 might not be mitigated with social behavior. Our challenge will be to sustain quality of care without postponing patient medical attention to avoid the complications mentioned above.

Conflicts of interest none declared (See authors’ conflicts of interest forms on the website/ Supplementary material).
Ethical considerations
Not applicable