Patients may be “dying at home” without seeking medical care because of concerns about contracting COVID-19 in a hospital setting, researchers warned, after finding a rise in deaths caused by ischemic heart disease and hypertensive diseases in the U.S. during the pandemic.
Researchers from Beth Israel Deaconess Medical and Harvard Medical School, Boston, led by Rishi K. Wadhera, MD, MPP, MPhil, conducted an observational cohort study using data from the National Center for Health Statistics (NCHS) on deaths caused by cardiovascular issues from March 18, 2020, through June 2, 2020.
They found that U.S. deaths caused by ischemic heart disease and hypertensive diseases rose – at least in the early stages of the pandemic – and said this was probably caused by patient fears over entering hospitals, increased strain on healthcare systems and cardiovascular sequelae of the infection.
The results were published in the Jan. 19 issue of the Journal of the American College of Cardiology.
The direct toll of the novel coronavirus disease in the U.S. has been substantial, the authors said, but noted that concerns have also arisen over the indirect effects of the pandemic on higher-risk patients with chronic medical conditions, such as cardiovascular disease.
They cited reports of rising mortality rates during the pandemic that cannot be accounted for by COVID-19 alone and highlighted data showing sharp declines in hospitalization for acute cardiovascular conditions. It is unlikely that the drop in hospitalizations reflects a true reduction in the incidence of cardiovascular events, the researchers said.
“These patterns have raised concern that patients may be avoiding hospitals because of fear of contracting severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2)” – the virus that causes COVID-19.
In response to concerns that patients were choosing to delay or avoid care for emergencies including heart attacks, the American College of Cardiology issued a statement urging people to seek medical help if needed.
Wadhera and colleagues, therefore, set out to find whether population-level deaths due to cardiovascular disease (ischemic heart disease, heart failure, hypertensive diseases, cerebrovascular disease and other diseases of the circulatory system) changed in the U.S. after the onset of the pandemic compared to the same period in 2019, and whether those changes were bigger in states with high initial infection surges.
The observational cohort study used NCHS weekly death data on the 397,042 cardiovascular deaths between January 1, 2020, and June 2, 2020. Deaths with an underlying cause of COVID-19 were excluded to examine the potential “indirect” pandemic effect. The 2020 data were compared with the same period in 2019 by looking at the ratio of the relative change in deaths per 100,000.
For cardiovascular deaths in 2020, there was no overall numerical increase between the pre-pandemic period (January 1, 2020, through March 17, 2020) at 199,311 cardiovascular deaths, and during the pandemic period – after states issued stay-at-home orders – when 197,731 deaths occurred.
However, comparing rates of ischemic heart disease in the 2020 period with 2019, there was a national increase in deaths after the onset of the pandemic (ratio of the relative change in deaths per 100,000 in 2020 vs. the relative change in 2019: 1.11; 95% confidence interval [CI]: 1.04 to 1.18).
The researchers also observed an increase in deaths caused by hypertensive disease (1.17, 95% CI: 1.09 to 1.26), but not for heart failure (0.97; 95% CI: 0.92 to 1.01), cerebrovascular disease (1.03; 95% CI: 0.99 to 1.07) or other diseases of the circulatory system (0.99; 95% CI: 0.95 to 1.04).
The rise in deaths caused by ischemic heart disease and hypertensive diseases was more pronounced in some of the U.S. states that experienced early surges of COVID-19 cases.
Of the regions that saw an initial COVID-19 surge, New York City, New York state (excluding New York City), New Jersey, Michigan and Illinois experienced significant increases in deaths due to ischemic heart disease and hypertensive diseases.
In particular, New York City saw a 139% increase (ratio of the relative change in deaths in 100,000 in 2020 vs. the relative change in 2019: 2.39; 95% CI: 1.39 to 4.09) and 164% rise (2.64, 95% CI: 1.52 to 4.56) respectively.
In the same relative change terms, New York state saw an increase in deaths caused by ischemic heart disease by 1.44 (95% CI: 1.16 to 1.79), New Jersey by 1.45 (95% CI: 1.22 to 1.73), Michigan by 1.23 (95% CI: 1.07 to 1.41), and Illinois by 1.11 (95%CI: 1.04 to 1.19).
The other two states that had early high influx of COVID-19 infections – Louisiana and Massachusetts – did not see a change in cardiovascular deaths.
The researchers did note some limitations to the study, including that data may be incomplete owing to reporting delays, that control group data were missing and that COVID-19 could still have been a contributing cause of death for these cardiovascular cases. The patterns may, in part, reflect the cardiovascular sequelae of undiagnosed COVID-19, they clarified.
However, Wadhera stressed in an accompanying press statement released online on Monday, “Our findings suggest that the pandemic may have had an indirect toll on patients with cardiovascular disease, potentially due to the avoidance of hospitals out of fear of exposure to the virus, increased health care system strain, and the deferral of semi-elective procedures and care.”
Further studies are now needed to clarify the extent to which cardiovascular death rates are affected by hospital avoidance over fear of contracting the virus, deferred outpatient and procedural care, strain imposed on healthcare systems and by disease related to undiagnosed COVID-19 infection, the researchers urged.
“U.S. public health officials and policymakers should improve public health messaging to encourage patients with acute conditions to seek medical care,” Wadhera added.
Editorialists led by Michael N. Young, MD, of Dartmouth-Hitchcock Medical Center, New Hampshire, commended the researchers for the data.
“Prolonged delays in outpatient testing, procedures, and follow-up may impose unanticipated burdens on the access to and delivery of care with uncertain long-term implications,” they said in an accompanying editorial.
“It is possible that we will inherit a population of COVID survivors with long-term lung injury, cardiomyopathy, and venous thromboembolic disease.”
Wadhera RK, Shen C, Gondi S, et al. Cardiovascular Deaths During the COVID-19 Pandemic in the United States. J Am Coll Cardiol 2021;77:159-69.
Young MN, Iribarne A, Malenka D. COVID-19 and Cardiovascular Health: This Is a Public Service Announcement. J Am Coll Cardiol;2021;77:170-2.