• Global Survey: Drastic Drop in Cardiovascular Diagnostic Testing During Pandemic Raises ‘Serious Concerns’

    A global survey of cardiovascular diagnostic care during the COVID-19 pandemic has signaled a “significant and abrupt reduction” in the number of procedures carried out, raising “serious concerns” for long-term adverse outcomes.

    The findings from 1.3 million cardiac diagnostic procedures were published in the Jan. 19 issue of the Journal of the American College of Cardiology.

    Although the pandemic is known to have adversely affected diagnosis and treatment of noncommunicable diseases, the effects on diagnostic care for cardiovascular disease have not previously been quantified, the researchers, led by Columbia University Irving Medical Center/New York-Presbyterian Hospital’s Andrew J. Einstein, MD, PhD, said.

    The survey is believed to be the first large-scale global assessment of the early impact of COVID-19 on worldwide cardiovascular diagnostic testing volumes.

    The International Atomic Energy Agency’s Noninvasive Cardiology Protocols Study Group conducted a worldwide survey into cardiovascular procedure volumes and safety practices resulting from COVID-19, with 909 inpatient and outpatient centers performing cardiac procedures in 108 countries submitting surveys.

    Globally, the survey found 678,638 cardiovascular disease diagnostic testing procedures were carried out in March 2019. This dropped by 42% to 394,625 between March 2019 and March 2020 – when many countries began lockdowns – and had fallen by 64% to 244,436 between March 2019 and April 2020.

    Procedure volume queries included transthoracic and transesophageal echocardiography, cardiac magnetic resonance (CMR), stress testing (stress electrocardiography, echocardiography, single-photon emission computed tomography, positron emission tomography [PET], and CMR), PET infection studies, coronary artery calcium scanning, coronary computed tomography angiography and invasive coronary angiography.

    In particular, transthoracic echocardiography decreased by 59%, transesophageal echocardiography by 76%, and stress tests by 78%, while coronary angiography (invasive or computed tomography) decreased 55% (p < 0.001 for each procedure).

    The drop in testing was most acutely felt in the world’s most economically challenged nations, the researchers added. Being located in a low-income or lower-middle-income country was associated with an extra 22% reduction in cardiac procedures and less availability of PPE and telehealth, in multivariable regression.

    Einstein and colleagues did note some limitations to the study, including that they only obtained procedure volumes during the pandemic in March and April 2020 – a period after the peak in China. In some Latin American countries and the United States, the peak came later, they added.

    Still, “these findings raise serious concerns for long-term adverse cardiovascular health outcomes resulting from decreased diagnosis,” said Einstein in an accompanying press release, published online Monday.

    The authors called for further research into the impact of patient behavior and limited access to diagnostic, preventive and therapeutic services on cardiovascular outcomes during and after the pandemic.

    Einstein added in the press statement: “Efforts to improve timely patient access to cardiovascular diagnosis in this and future pandemics, particularly in low- and middle-income countries, are warranted.”

    Decreased MI hospital admissions

    As Einstein and colleagues suggest, decreasing rates of cardiac testing could explain a rise in out-of-hospital cardiac arrests reported during the pandemic. Darryl P. Leong, MBBS, PhD, led an accompanying editorial suggesting that under-recognition of high-risk coronary disease and failure to provide appropriate treatments could be expected to increase myocardial infarction (MI) rates.

    Hospital admission rates for MI dropped during the same period, the editorialists – from the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario – noted.

    Still, they stressed that other factors may play a role in lower MI hospitalization rates, including patient reluctance to seek medical attention for fear of infection.

    “We cannot be certain that there is a direct causal link between reduced cardiac diagnostic procedures and excess cardiovascular mortality. However, it is clear that cardiac diagnostic procedures are another measure of the impact of COVID-19 on the delivery of health care.”

    The editorialists added that, although it is not known how long the pandemic will persist, it is “highly likely” it will continue for many months, “or even a year or two.”

    “This should prompt us to prepare for a protracted campaign against COVID-19,” they said. “An important part of these preparations will be the allocation of health care resources to minimize both COVID-19 and non-COVID-19 morbidity and mortality within countries and across countries.

    “This requires a global, national, and regional strategy that is more likely to be developed in countries where the health care systems are better organized and oriented toward public benefits.”

    The editorialists concluded: “Nobody will be safe until everybody is safe.”


    Einstein AJ, Shaw LJ, Hirschfeld C, et al. International Impact of COVID-19 on the Diagnosis of Heart Disease. J Am Coll Cardiol 2021;77:173-85.

    Leong DP, Eikelboom JW, Yusuf S. The Indirect Consequences of the Response to the COVID-19 Pandemic. J Am Coll Cardiol 2021;77:186-8.

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