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Canadian Journal of Cardiology

Health Care Implications of the COVID-19 Pandemic for the Cardiovascular Practitioner

  • Finlay A. McAlister
    Correspondence
    Corresponding author: Dr Finlay A. McAlister, 5-134C Clinical Sciences Building, University of Alberta, 11350 83 Avenue, Edmonton, Alberta T6G 2G3, Canada. Tel.: +1-780-492-9824; fax: +1-780-492-7277.
    Affiliations
    The Division of General Internal Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada

    The Alberta Strategy for Patient Oriented Research Support Unit, Edmonton, Alberta, Canada
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  • Harsh Parikh
    Affiliations
    Peter Munk Cardiac Center, Ted Rogers Centre for Heart Research, University of Toronto, Toronto, Ontario, Canada
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  • Douglas S. Lee
    Affiliations
    Peter Munk Cardiac Center, Ted Rogers Centre for Heart Research, University of Toronto, Toronto, Ontario, Canada

    ICES (formerly Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
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  • Harindra C. Wijeysundera
    Affiliations
    ICES (formerly Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada

    Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada

    Schulich Heart Program, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
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Published:December 05, 2022DOI:https://doi.org/10.1016/j.cjca.2022.11.014

      Abstract

      There has been substantial excess morbidity and mortality during the COVID-19 pandemic, not all of which was directly attributable to SARS-CoV-2 infection, and many non-COVID-19 deaths were cardiovascular. The indirect effects of the pandemic have been profound, resulting in a substantial increase in the burden of cardiovascular disease and cardiovascular risk factors, both in individuals who survived SARS-CoV-2 infection and in people never infected. In this report, we review the direct effect of SARS-CoV-2 infection on cardiovascular and cardiometabolic disease burden in COVID-19 survivors as well as the indirect effects of the COVID-19 pandemic on the cardiovascular health of people who were never infected with SARS-CoV-2. We also examine the pandemic effects on health care systems and particularly the care deficits caused (or exacerbated) by health care delayed or foregone during the COVID-19 pandemic. We review the consequences of: (1) deferred/delayed acute care for urgent conditions; (2) the shift to virtual provision of outpatient care; (3) shortages of drugs and devices, and reduced access to: (4) diagnostic testing, (5) cardiac rehabilitation, and (6) homecare services. We discuss the broader implications of the COVID-19 pandemic for cardiovascular health and cardiovascular practitioners as we move forward into the next phase of the pandemic.

      Résumé

      Durant la pandémie de COVID-19, les taux de surmorbidité et de surmortalité étaient considérables, mais pas toujours directement attribuables à l’infection par le SRAS-CoV-2, et de nombreux décès non liés à la COVID-19 étaient d’origine cardiovasculaire. La pandémie a eu de graves effets indirects qui ont augmenté sensiblement le fardeau des maladies vasculaires et les facteurs de risque cardiovasculaire, aussi bien chez les personnes qui ont survécu à une infection par le SRAS-CoV-2 que chez celles qui n’ont jamais contracté le virus. Nous examinons ici l’effet direct de l’infection par le SRAS-CoV-2 sur le fardeau des maladies cardiovasculaires et cardiométaboliques chez les survivants de la COVID-19, ainsi que les effets indirects de la pandémie sur la santé cardiovasculaire des personnes n’ayant jamais été infectées par le SRAS-CoV-2. Nous traitons aussi des effets de la pandémie sur les systèmes de soins de santé, en particulier des problèmes causés (ou exacerbés) par le report des soins ou le renoncement aux soins durant la pandémie. Nous passons en revue les conséquences : 1) du report ou du retard des soins dans les cas urgents; 2) de la transition vers la virtualisation des soins externes; 3) des pénuries de médicaments et d’appareils médicaux; ainsi que des difficultés d’accès : 4) aux tests diagnostiques, 5) aux services de réadaptation cardiaque et 6) aux soins à domicile. Nous présentons par ailleurs les conséquences globales de la pandémie de COVID-19 sur la santé cardiovasculaire et sur les praticiens en santé cardiovasculaire au moment où commence une nouvelle phase de la pandémie.
      Although the official death toll from SARS-CoV-2 infection was approximately 6 million by the summer of 2022, studies of all-cause mortality rate trends over time suggest that more than 18 million people died prematurely during the first 2 years of the pandemic.
      COVID-19 Excess Mortality Collaborators
      Estimating excess mortality due to the COVID-19 pandemic: a systematic analysis of COVID-19-related mortality, 2020-21.
      Many of these deaths were cardiovascular,
      COVID-19 Excess Mortality Collaborators
      Estimating excess mortality due to the COVID-19 pandemic: a systematic analysis of COVID-19-related mortality, 2020-21.
      and although the absolute number of in-hospital cardiovascular deaths decreased during the pandemic, cardiovascular deaths at home and in long-term care (LTC) facilities substantially increased.
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      Place and causes of acute cardiovascular mortality during the COVID-19 pandemic.
      In fact, deaths attributed to cardiac events or strokes have increased more than deaths for any other non-COVID-19 diagnosis during the pandemic.

      Statistics Canada. Leading Causes of Death, Total Population (Age Standardization Using 2011 Population). Available at: https://doi.org/10.25318/1310080101-eng. Accessed July 18, 2022.

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      Age-adjusted mortality rates and age and risk-associated contributions to change in heart disease and stroke mortality, 2011-2019 and 2019-2020.
      Despite assumptions that excess mortality during the COVID-19 pandemic was largely among older individuals, even in developed nations more than 50% of quality-adjusted life years lost have been in people younger than 65 years.
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      Measuring the COVID-19 mortality burden in the United States: a microsimulation study.
      Moreover, less than half of those who died had evidence of SARS-CoV-2 infection.
      COVID-19 Excess Mortality Collaborators
      Estimating excess mortality due to the COVID-19 pandemic: a systematic analysis of COVID-19-related mortality, 2020-21.
      ,
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      All-cause excess mortality and COVID-19-related mortality among US adults aged 25-44 years, March-July 2020.
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      Excess mortality, COVID-19 and health care systems in Canada.
      Fortunately, the Omicron variant, although far more transmissible than earlier variants, causes less severe disease than previous variants of concern.
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      • Jing S.
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      • Wang H.
      Infectivity versus fatality of SARS-CoV-2 mutations and influenza.
      Thus, we appear to have entered an endemic phase with SARS-CoV-2, but we will have to continue to factor the numerous effects of the COVID-19 pandemic into health care projections and planning for many years to come. In this report, we examine the direct, secondary, and tertiary effects of the COVID-19 pandemic on health care systems (Table 1), highlight some of the care deficits that have arisen, and discuss the broader implications for cardiovascular health and cardiovascular practitioners as we move forward.
      Table 1The effects of the COVID-19 pandemic for cardiovascular patients and practitioners
      Direct (primary) effect of SARS-CoV-2 infection on cardiovascular disease burden in COVID-19 survivors
      • Acute cardiovascular complications from COVID-19 (myocarditis, acute coronary syndromes, microvascular thromboses, arrhythmias, pericarditis)
      • Therapies for COVID-19 with cardiovascular side effects and/or potentially interact with cardiovascular medications
      • Increased long-term risks for various chronic cardiovascular conditions (heart failure, scar-related arrhythmias, myocardial fibrosis, accelerated atherosclerosis)
      • Increased frequency of cardiometabolic diseases (such as diabetes mellitus) and chronic kidney disease
      Secondary effects: care deficits caused (or exacerbated) by health care delayed or foregone during the COVID-19 pandemic
      • Reduced outpatient care and shift to virtual care resulting in:
      • Deferred/delayed cardiovascular risk factor optimization
      • Suboptimal chronic disease management
      • Deferred/delayed acute care for urgent conditions resulting in:
      • Increased out-of-hospital events
      • Worsened in-hospital outcomes
      • Reduced rates of diagnostic testing resulting in:
      • Shrinking procedural waiting lists but poorer outcomes
      • Reduced access to home care and long-term care services resulting in system backlogs
      • Reduced access to cardiac rehabilitation services resulting in deferred/delayed secondary prevention
      • Shortages of drugs and devices resulting in suboptimal treatment
      Indirect (tertiary) effects: increased future cardiovascular disease burden in people who did not have COVID-19
      • Pandemic-related stressors
      • Socioeconomic upheaval
      • Increased social isolation and mental health issues
      • Worsened physical activity profiles
      • Increased alcohol consumption
      • Exacerbation of existing deficiencies and inequities in health care
      • Exacerbation of health human resource shortages
      • More cases of influenza and respiratory syncytial virus infections in coming seasons because of immunity debt

      Direct Effect of SARS-CoV-2 Infection on Future Cardiovascular Disease Burden

      Early in the COVID-19 pandemic it became apparent that SARS-CoV2 infection was associated with a wide range of acute cardiovascular complications, including myocarditis, acute coronary syndromes, microvascular thromboses, arrhythmias, and pericarditis.
      • Driggin E.
      • Madhavan M.V.
      • Bikdeli B.
      • et al.
      Cardiovascular considerations for patients, health care workers, and health systems during the COVID-19 pandemic.
      In addition, a number of the therapies used to treat COVID-19 have cardiovascular side effects and/or potentially interact with cardiovascular medications.
      • Driggin E.
      • Madhavan M.V.
      • Bikdeli B.
      • et al.
      Cardiovascular considerations for patients, health care workers, and health systems during the COVID-19 pandemic.
      Further, there is now increasing recognition of elevated long-term risks for a variety of chronic cardiovascular conditions (ischemic and nonischemic) in survivors of SARS-CoV-2 infection, even in those with no previous cardiovascular disease or comparatively mild COVID-19 symptoms.
      • Driggin E.
      • Madhavan M.V.
      • Bikdeli B.
      • et al.
      Cardiovascular considerations for patients, health care workers, and health systems during the COVID-19 pandemic.
      The relative risks of chronic cardiovascular conditions developing in COVID-19 survivors are similar across patient subgroups defined by baseline characteristics (absolute risks are obviously higher in those with higher baseline risk); however, relative risks are higher in patients who had more severe COVID-19 disease.
      • Xie Y.
      • Xu E.
      • Bowe B.
      • Al-Aly Z.
      Long-term cardiovascular outcomes of COVID-19.
      • Sidik S.M.
      Heart disease after COVID: what the data say.
      • Salah H.M.
      • Fudim M.
      • O’Neil S.T.
      • Manna A.
      • Chute C.G.
      • Caughey M.C.
      Post-recovery COVID-19 and incident heart failure in the National COVID Cohort Collaborative (N3C) study.
      The current best estimate is that those who survive their acute SARS-CoV-2 infection exhibit an approximately 55% relative increase in the risk of major adverse cardiovascular events in the next year: an extra 23.5 deaths, myocardial infarcts, or strokes per 1000 COVID-19 survivors.
      • Xie Y.
      • Xu E.
      • Bowe B.
      • Al-Aly Z.
      Long-term cardiovascular outcomes of COVID-19.
      As well, there are subsequent increases in atrial fibrillation (71% relative increase, or 11 more cases per 1000 survivors), ventricular arrhythmias (84% relative increase, 4 extra events per 1000), and heart failure (72% increase, 12 additional cases per 1000 patients) after SARS-CoV-12 infection of any severity.
      • Xie Y.
      • Xu E.
      • Bowe B.
      • Al-Aly Z.
      Long-term cardiovascular outcomes of COVID-19.
      Notably, the risks are even higher in patients who survive a COVID-19 hospitalization, even after adjusting for demographic characteristics, cardiovascular risk factors, and established cardiovascular disease (45% increase in heart failure with 23 additional cases per 1000 patients in the US National COVID Cohort Collaborative study). Of course, this is undoubtedly an underestimate of myocardial damage because ongoing myocardial inflammation on cardiac magnetic resonance imaging is commonly reported after COVID-19 infection.
      • Huang L.
      • Zhao P.
      • Tang D.
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      Cardiac involvement in patients recovered from COVID-2019 identified using magnetic resonance imaging.
      It has been estimated that there have been an additional 30,000 extra strokes and up to 110,000 extra acute myocardial infarctions in the United States in COVID survivors in 2020 and 2021.
      • Sidik S.M.
      Heart disease after COVID: what the data say.
      SARS-CoV-2 targets multiple cells that express angiotensin converting enzyme 2, including pulmonary alveolar epithelial cells, nasal goblet secretory cells, pancreatic β-cells, gastrointestinal epithelial cells, astrocytes in the brain, and renal proximal tubules and podocytes. Many of these noncardiac targets are important in cardiometabolic health, and organ dysfunction induced by SARS-CoV-2 does result in an increased frequency of cardiometabolic diseases in survivors.
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      • Birkenfeld A.L.
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      Global pandemics interconnected — obesity, impaired metabolic health and COVID-19.
      For example, new diabetes (mostly type 2) has been documented in 0.8% of nonhospitalized COVID-19 survivors, 5.7% of hospitalized patients, and 8.9% of those with COVID-19 who survived intensive care unit stays.
      • Xie Y.
      • Al-Aly Z.
      Risks and burdens of incident diabetes in long COVID: a cohort study.
      Of the numerous other manifestations of postacute COVID syndrome that have been described so far, the increased frequency of chronic kidney disease due to direct renal injury from SARS-CoV-2 infection in survivors is also of particular relevance to cardiovascular practitioners.
      • Copur S.
      • Berkkan M.
      • Basile C.
      • Tuttle K.
      • Kanbay M.
      Post-acute COVID-19 syndrome and kidney diseases: what do we know?.
      Thus, health care systems around the world must be prepared to deal with a substantial increase in the burden of cardiovascular disease in individuals who survived SARS-CoV-2 infection.

      Indirect Effects of the COVID-19 Pandemic on Future Cardiovascular Disease Burden

      We are likely to see higher than normal rates of influenza and other respiratory viruses in the coming seasons (assuming universal masking and social distancing protocols remain discontinued) due to the “immunity debt” accrued over the past 2 seasons (ie, low exposure rates in the general population to these other viral pathogens leading to a paucity of protective immunity). Because we already know that influenza or respiratory virus outbreaks are associated with upswings in cardiovascular hospitalizations and deaths, this immunity debt is likely to further exacerbate the increasing burden from cardiovascular disease in the near future.
      • Behrouzi B.
      • Araujo Campoverde M.V.
      • Liang K.
      • et al.
      Influenza vaccination to reduce cardiovascular morbidity and mortality in patients with COVID-19: JACC State-of-the-Art Review.
      Furthermore, we must also prepare for an increased burden of cardiovascular disease even in those who never had COVID-19 due to pandemic-related stressors (a systematic review of 58 studies confirmed that natural disasters were often followed by upswings in cardiometabolic risks and events)
      • De Rubeis V.
      • Lee J.
      • Anwer M.S.
      • et al.
      Impact of disasters, including pandemics, on cardiometabolic outcomes across the life-course: a systematic review.
      and the numerous unintended consequences of the pandemic public health restrictions.
      • Gonzalez D.
      • Karpman M.
      • Kenney G.M.
      • Zuckerman S.
      Delayed and forgone health care for nonelderly adults during the COVID-19 pandemic: findings from the September 11-28 Coronavirus Tracking Survey.
      These unintended consequences included socioeconomic upheaval, increased social isolation and mental health issues, decreased physical activity but increased caloric and alcohol consumption resulting in exacerbation of the obesity epidemic,
      • Freiberg A.
      • Schubert M.
      • Romero Starke K.
      • Hegewald J.
      • Seidler A.
      A rapid review on the influence of COVID-19 lockdown and quarantine measures on modifiable cardiovascular risk factors in the general population.
      and care deficits caused (or exacerbated) by the pandemic.
      As a result of public health advice to reduce contacts, patient fear of exposure, and restricted access to health care providers, there was also a substantial decrease in health care interactions during the COVID-19 pandemic, especially in the first year. Although volumes have returned to (and in some cases now exceed) prepandemic levels, there are a myriad of consequences arising from the health care delayed or forgone during the COVID-19 pandemic. An analysis of data from the US Coronavirus Tracking Survey showed that 33% of American adults with 1 chronic health condition and 46% of those with multiple chronic conditions reported delayed or forgone health care during the first year of the pandemic.
      • Gonzalez D.
      • Karpman M.
      • Kenney G.M.
      • Zuckerman S.
      Delayed and forgone health care for nonelderly adults during the COVID-19 pandemic: findings from the September 11-28 Coronavirus Tracking Survey.
      Of those who reported delayed/forgone care, 23% believed it had worsened their health condition(s), 15% believed it caused new limitations in their ability to work, and 21% described new limitations in their ability to do other daily activities (Fig. 1).
      • Gonzalez D.
      • Karpman M.
      • Kenney G.M.
      • Zuckerman S.
      Delayed and forgone health care for nonelderly adults during the COVID-19 pandemic: findings from the September 11-28 Coronavirus Tracking Survey.
      In an earlier report in the Canadian Journal of Cardiology,
      • Lau D.
      • McAlister F.A.
      Implications of the COVID-19 pandemic for cardiovascular disease and risk-factor management.
      we argued that these secondary and tertiary effects of the pandemic on cardiovascular health were likely to far exceed the primary effects directly related to SARS-CoV-2 infection (Fig. 2) and in the remainder of this report we explore the emerging evidence on pandemic-induced care deficits relevant to the cardiovascular practitioner.
      Figure thumbnail gr1
      Figure 1Effect of delayed or foregone health care during the COVID-19 pandemic, as reported by American adults in September 2020. ADL, activity of daily living. Modified from Gonzalez et al.
      • Gonzalez D.
      • Karpman M.
      • Kenney G.M.
      • Zuckerman S.
      Delayed and forgone health care for nonelderly adults during the COVID-19 pandemic: findings from the September 11-28 Coronavirus Tracking Survey.
      with permission from Urban Institute.
      Figure thumbnail gr2
      Figure 2Effects of the COVID-19 pandemic on cardiovascular (CV) morbidity and mortality. Modified from Lau and McAlister
      • Lau D.
      • McAlister F.A.
      Implications of the COVID-19 pandemic for cardiovascular disease and risk-factor management.
      with permission from Elsevier.

      Effect of the COVID-19 pandemic on outpatient care: deferred/delayed cardiovascular risk factor optimization and suboptimal chronic disease management

      In addition to the initial reduction in volume, outpatient care shifted from an almost exclusively in-person model prepandemic to a mixed model very rapidly after the onset of the COVID-19 pandemic,
      • Glazier R.H.
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      Shifts in office and virtual primary care during the early COVID-19 pandemic in Ontario, Canada.
      • Baum A.
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      Reduced in-person and increased telehealth outpatient visits during the COVID-19 pandemic.
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      Impact of telemedicine on the management of heart failure patients during coronavirus disease 2019 pandemic.
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      Association between primary care practice telehealth use and acute care visits for ambulatory care-sensitive conditions during COVID-19.

      McAlister FA, Hsu Z, Dong Y, Tsuyuki RT, van Walraven C, Bakal J. The frequency and type of outpatient visits for patients with cardiovascular ambulatory care sensitive conditions during the COVID19 pandemic and subsequent outcomes: a retrospective cohort study. J Am Heart Assoc, in press. doi:10.1161/JAHA.122.027922.

      • Alexander G.C.
      • Tajanlangit M.
      • Heyward J.
      • Mansour O.
      • Qato D.M.
      • Stafford R.S.
      Use and content of primary care office-based vs telemedicine care visits during the COVID-19 pandemic in the US.
      • Yuan N.
      • Pevnick J.M.
      • Botting P.G.
      • et al.
      Patient use and clinical practice patterns of remote cardiology clinic visits in the era of COVID-19.
      • Wosik J.
      • Clowse M.E.B.
      • Overton R.
      • et al.
      Impact of the COVID-19 pandemic on patterns of outpatient cardiovascular care.
      • Yuan N.
      • Botting P.G.
      • Elad Y.
      • et al.
      Practice patterns and patient outcomes after widespread adoption of remote heart failure care.
      • McAlister F.A.
      • Hsu Z.
      • Dong Y.
      • van Walraven C.
      • Bakal J.
      Changes in Outpatient Care Patterns and Subsequent Outcomes During the COVID-19 Pandemic: A Retrospective Cohort Analysis From a Single Payer Healthcare System.
      and the implications of this shift are still being investigated. Although 2 studies

      McAlister FA, Hsu Z, Dong Y, Tsuyuki RT, van Walraven C, Bakal J. The frequency and type of outpatient visits for patients with cardiovascular ambulatory care sensitive conditions during the COVID19 pandemic and subsequent outcomes: a retrospective cohort study. J Am Heart Assoc, in press. doi:10.1161/JAHA.122.027922.

      ,
      • Wosik J.
      • Clowse M.E.B.
      • Overton R.
      • et al.
      Impact of the COVID-19 pandemic on patterns of outpatient cardiovascular care.
      reported that virtual visits for patients with a variety of cardiovascular diagnoses were associated with fewer subsequent emergency department visits and hospitalizations, another
      • Yuan N.
      • Botting P.G.
      • Elad Y.
      • et al.
      Practice patterns and patient outcomes after widespread adoption of remote heart failure care.
      showed higher rates of emergency department visits, hospitalization, or death for heart failure patients after virtual visits compared with in-person visits. All 3 of those studies were observational and thus could only show association and not causation, and without randomized trial evidence it is impossible to declare one type of outpatient encounter superior to another. However, it does seem clear that virtual visits are associated with less risk factor screening, diagnostic testing, or medication intensification than in-person visits.

      McAlister FA, Hsu Z, Dong Y, Tsuyuki RT, van Walraven C, Bakal J. The frequency and type of outpatient visits for patients with cardiovascular ambulatory care sensitive conditions during the COVID19 pandemic and subsequent outcomes: a retrospective cohort study. J Am Heart Assoc, in press. doi:10.1161/JAHA.122.027922.

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      • Mansour O.
      • Qato D.M.
      • Stafford R.S.
      Use and content of primary care office-based vs telemedicine care visits during the COVID-19 pandemic in the US.
      • Yuan N.
      • Pevnick J.M.
      • Botting P.G.
      • et al.
      Patient use and clinical practice patterns of remote cardiology clinic visits in the era of COVID-19.
      • Wosik J.
      • Clowse M.E.B.
      • Overton R.
      • et al.
      Impact of the COVID-19 pandemic on patterns of outpatient cardiovascular care.
      • Yuan N.
      • Botting P.G.
      • Elad Y.
      • et al.
      Practice patterns and patient outcomes after widespread adoption of remote heart failure care.
      • McAlister F.A.
      • Hsu Z.
      • Dong Y.
      • van Walraven C.
      • Bakal J.
      Changes in Outpatient Care Patterns and Subsequent Outcomes During the COVID-19 Pandemic: A Retrospective Cohort Analysis From a Single Payer Healthcare System.
      Delayed detection or deferred management of cardiovascular risk factors (such as hypertension or dyslipidemia) and the economic and psychosocial upheaval associated with the pandemic and public health responses has undoubtedly led to poorer cardiovascular risk factor control, which will cause future increases in the frequency of cardiovascular events. Although early evidence has shown a marked reduction in cardiovascular risk factor screening and management, as well as medication intensification for chronic conditions such as hypertension or heart failure during the pandemic,

      McAlister FA, Hsu Z, Dong Y, Tsuyuki RT, van Walraven C, Bakal J. The frequency and type of outpatient visits for patients with cardiovascular ambulatory care sensitive conditions during the COVID19 pandemic and subsequent outcomes: a retrospective cohort study. J Am Heart Assoc, in press. doi:10.1161/JAHA.122.027922.

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      • Tajanlangit M.
      • Heyward J.
      • Mansour O.
      • Qato D.M.
      • Stafford R.S.
      Use and content of primary care office-based vs telemedicine care visits during the COVID-19 pandemic in the US.
      • Yuan N.
      • Pevnick J.M.
      • Botting P.G.
      • et al.
      Patient use and clinical practice patterns of remote cardiology clinic visits in the era of COVID-19.
      • Wosik J.
      • Clowse M.E.B.
      • Overton R.
      • et al.
      Impact of the COVID-19 pandemic on patterns of outpatient cardiovascular care.
      • Yuan N.
      • Botting P.G.
      • Elad Y.
      • et al.
      Practice patterns and patient outcomes after widespread adoption of remote heart failure care.
      outcome differences resulting from these care patterns are yet to fully manifest. Of course, this problem is not unique to cardiovascular medicine and many other preventative services (such as vaccinations or cancer screening) were deferred during the pandemic, and evidence is already beginning to emerge of adverse clinical outcomes as a result.
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      It should be noted that training future cardiovascular health care professionals to use telehealth technologies, although of paramount importance, poses unique challenges because of variations among institutions in communication platforms that need to be addressed.
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      Effect of the COVID-19 pandemic on acute care: deferred/delayed acute care for urgent conditions and worsened in-hospital outcomes

      A number of studies in other jurisdictions confirm reports from the Canadian Institute for Health Information
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      even those for acute cardiovascular diagnoses,
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      The effect of the COVID-19 pandemic on emergency department visits for serious cardiovascular conditions.
      and hospitalizations for non-COVID conditions and surgeries decreased markedly during the pandemic.
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      The median decrease in cardiovascular service utilization in a systematic review of 33 studies (64 services) was 29% in the first 2 quarters after onset of the pandemic.
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      Trends in hospitalizations for ambulatory care-sensitive conditions during the COVID-19 pandemic.
      Concerningly, the hesitation to seek care was not limited to elective care; Czeisler and colleagues estimated that approximately 41% of US adults avoided medical care during the pandemic because of concerns about COVID-19, including 12% who avoided urgent or emergency care.
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      There was substantial inequity in terms of this care deficit, with a disproportionate burden on women, ethnic minorities, those in lower socioeconomic strata specifically without health insurance, and those with greater medical comorbidity and disability.
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      • et al.
      Delay or avoidance of medical care because of COVID-19-related concerns - United States, June 2020.
      Multiple lines of evidence suggest that outcomes in patients with cardiovascular disease have worsened during the pandemic due to this reluctance to go to acute care centres. For example, studies have shown a twofold increase in the proportion of patients with acute myocardial infarction or ischemic stroke who refuse emergency service transportation to the hospital,
      • Chew N.W.S.
      • Ow Z.G.W.
      • Teo V.X.Y.
      • et al.
      The global effect of the COVID-19 pandemic on STEMI care: a systematic review and meta-analysis.
      ,
      • Clodfelder C.
      • Cooper S.
      • Edwards J.
      • et al.
      Delayed care in myocardial infarction and ischemic stroke patients during the COVID-19 pandemic.
      and the most alarming upstream consequence are rates of out-of-hospital cardiac arrest that have increased by almost 50%, indicative of patients ignoring even very severe symptoms.
      • Wong L.E.
      • Hawkins J.E.
      • Langness S.
      • Murrell K.L.
      • Iris P.
      • Sammann A.
      Where Are All the Patients? Addressing Covid-19 Fear to Encourage Sick Patients to Seek Emergency Care.
      • Marijon E.
      • Karam N.
      • Jost D.
      • et al.
      Out-of-hospital cardiac arrest during the COVID-19 pandemic in Paris, France: a population-based, observational study.
      • McVaney K.E.
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      The relationship of large city out-of-hospital cardiac arrests and the prevalence of COVID-19.
      Although data from multiple jurisdictions, including Canada, have shown a decrease in cardiovascular hospitalization volumes during the pandemic, outcomes have also been worse for patients who are hospitalized, with in-hospital mortality increases of > 50%, even independent of possible COVID-19 coinfection.
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      • et al.
      Cumulative hospitalization deficit for cardiovascular disorders in Germany during the COVID-19 pandemic: insights from the German-wide Helios hospital network.
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      • Johnson D.Y.
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      Impact of the COVID-19 pandemic on patients without COVID-19 with acute myocardial infarction and heart failure.
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      • Nielsen P.B.
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      • et al.
      Hospital admission and mortality rates for non-covid diseases in Denmark during covid-19 pandemic: nationwide population based cohort study.

      Effect of the COVID-19 pandemic on diagnostic testing: shrinking procedural waiting lists but poorer outcomes

      Above and beyond acute conditions, the delays in ambulatory care as well as reduced access to diagnostic testing have also affected chronic cardiovascular conditions such as heart failure. In the National Health System in the United Kingdom, approximately one-third of heart failure patients reported subjective deterioration during the pandemic.
      • Hammersley D.J.
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      • Lota A.S.
      • et al.
      Direct and indirect effect of the COVID-19 pandemic on patients with cardiomyopathy.
      The magnitude of the reductions in cardiovascular diagnostic capacity has been substantial—a study of 909 institutions across 108 counties showed a > 60% decrease in all noninvasive cardiac studies (such as stress electrocardiogram, echocardiography, and single-photon emission computed tomography).
      • Hirschfeld C.B.
      • Shaw L.J.
      • Williams M.C.
      • et al.
      Impact of COVID-19 on cardiovascular testing in the United States versus the rest of the world.
      However, these upstream barriers have had a counterintuitive effect on procedural wait lists for percutaneous coronary intervention or coronary artery bypass grafting.
      • Tam D.Y.
      • Qiu F.
      • Manoragavan R.
      • et al.
      The impact of the COVID-19 pandemic on cardiac procedure wait list mortality in Ontario, Canada.
      Although volumes of procedures performed were low in the early part of the pandemic, because of closure of facilities from redeployment of health human resources or reallocation of beds for COVID-19 patients, even when cardiovascular capacity was restored, the actual wait lists were surprisingly shorter.
      • Tam D.Y.
      • Qiu F.
      • Manoragavan R.
      • et al.
      The impact of the COVID-19 pandemic on cardiac procedure wait list mortality in Ontario, Canada.
      These patients were “missing” because of the upstream care deficit. For example, a patient who has not been diagnosed by their family physician/cardiologist, nor completed testing because of barriers at those stops of care, cannot get on the procedural wait list. This has implications for how to address the decrease in procedure volumes from the prepandemic era because measures to increase procedural capacity without similar efforts to address upstream barriers in diagnostic testing and access to ambulatory care will not be successful.
      • Graham M.M.
      • Simpson C.S.
      The indirect impact of COVID-19 on cardiac care and outcomes: lessons from a stretched system.
      This is an important contradistinction to the strategies currently being proposed by the Canadian Medical Association and policy makers to address wait lists for orthopaedic, cancer, or cataract surgeries.
      Canadian Medical Association
      A Struggling System: Understanding the Health Care Impacts Of The Pandemic.
      The cumulative effect of each of these care deficits is excess cardiovascular mortality and morbidity, particularly among our frailest and sickest patients.
      • Wijeysundera H.C.
      • Abdel-Qadir H.
      • Qiu F.
      • et al.
      Relationship of frailty with excess mortality during the COVID-19 pandemic: a population-level study in Ontario, Canada.
      Because of the poor outcomes for untreated or partially treated cardiovascular disease, the estimates of excess mortality from delays in treatment are sobering. For example, estimates for England suggest between 49,932 and 99,865 excess cardiovascular deaths just in the first year of the pandemic due to indirect pandemic effects from reductions in referrals, diagnostic testing, and treatment services.
      • Banerjee A.
      • Chen S.
      • Pasea L.
      • et al.
      Excess deaths in people with cardiovascular diseases during the COVID-19 pandemic.
      The substantial magnitude of these indirect effects is reinforced when temporal trends of overall excess mortality and that of COVID-related deaths are evaluated, which show persistent excess mortality during the periods in between pandemic waves, even when direct COVID-19 deaths were comparatively low.
      • Wijeysundera H.C.
      • Abdel-Qadir H.
      • Qiu F.
      • et al.
      Relationship of frailty with excess mortality during the COVID-19 pandemic: a population-level study in Ontario, Canada.

      Effect of the COVID-19 pandemic on home care and LTC services: reduced access leading to system backlogs

      Deaths from SARS-CoV-2 infection disproportionately affected residents of LTC homes, especially early in the pandemic. In Canada, LTC residents accounted for 3% of all COVID-19 cases but 43% of COVID-19 deaths (Fig. 3),
      Canadian Institute for Health Information
      Impact of COVID-19 on Canada’s Health Care Systems.
      although vaccinations have significantly helped reduce these numbers. This population is at high risk because of their advanced age and multiple comorbidities, but also socioeconomic factors including lack of access to testing, less personal protective equipment, difficulty maintaining social distancing, and a precariously employed workforce that can transmit the virus across LTC sites.
      • Lee D.S.
      • Ma S.
      • Chu A.
      • et al.
      Predictors of mortality among long-term care residents with SARS-CoV-2 infection.
      ,
      • Stall N.
      • Sinha S.
      Why nursing homes are so vulnerable to COVID-19 catastrophe.
      Additionally, these nursing home residents were at even greater risk of delayed/deferred acute care than community-dwelling elderly: transfers from LTC to hospitals were substantially reduced for chronic obstructive pulmonary disease (by 58%), pneumonia (by 52%), and heart failure (by 41%), compared with prepandemic rates (Fig. 4).
      Canadian Institute for Health Information
      Impact of COVID-19 on Canada’s Health Care Systems.
      Despite this, the wait times for LTC beds and home care services, which were problems well before the pandemic, have worsened and the number of patients who require altered level of care in-hospital has increased.
      • Estabrooks C.A.
      • Straus S.E.
      • Flood C.M.
      • et al.
      Restoring trust: COVID-19 and the future of long-term care in Canada.
      Moreover, because of the negative effect of COVID-19 on LTC facilities, an increasing proportion of Canadians are expressing the wish to avoid LTC for themselves and their loved ones, which will exacerbate this issue further.
      • Marie-Louise Leroux
      • Bertrand Achou
      • Franca Glenzer
      • Lee Minjoon
      • De Donder Philippe
      Canadians Want Home Care, Not Long-Term Care Facilities, After COVID-19.
      The resulting shortage in acute care beds will undoubtedly have negative consequences for patients with cardiovascular disease who require hospitalization for evaluation or management in the future.
      Figure thumbnail gr3
      Figure 3Canadian long-term care (LTC) resident COVID-19 deaths vs COVID-19 community deaths to August 15, 2021. Reproduced from the Canadian Institute for Health Information
      • Moynihan R.
      • Johansson M.
      • Maybee A.
      • et al.
      Covid-19: an opportunity to reduce unnecessary healthcare.
      with permission.
      Figure thumbnail gr4
      Figure 4Changes in transfers of long-term care residents to hospital during the pandemic, according to reason for transfer, March 2020 to June 2021. Reproduced from the Canadian Institute for Health Information
      • Moynihan R.
      • Johansson M.
      • Maybee A.
      • et al.
      Covid-19: an opportunity to reduce unnecessary healthcare.
      with permission.
      With regard to home care services, the volume of home care assessments plummeted early in the pandemic, with more than 60,000 deferred new assessments (44% decline) between March and June 2020.
      Canadian Medical Association
      A Struggling System: Understanding the Health Care Impacts Of The Pandemic.
      Correcting for this backlog and other negative effects of the pandemic on the frequency and intensity of home care service provision will likely take years to address and in the meantime frail cardiovascular patients will exhibit poorer outcomes and our ability to manage them in their home setting will be impaired.

      Effect of the COVID-19 pandemic on cardiac rehabilitation services: deferred/delayed secondary prevention

      Despite the well established benefits of cardiac rehabilitation for secondary prevention in patients with coronary disease or heart failure,
      Canadian Institute for Health Information
      COVID-19’s impact on long-term care.
      at the start of the COVID-19 pandemic many cardiovascular rehabilitation programs were closed, which resulted in negative outcomes for the vulnerable population.
      • Piepoli M.F.
      • Hoes A.W.
      • Agewall S.
      • et al.
      2016 European guidelines on cardiovascular disease prevention in clinical practice: the Sixth Joint Task Force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of 10 societies and by invited experts) developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR).
      ,
      • Yeo T.J.
      • Wang Y.T.L.
      • Low T.T.
      Have a heart during the COVID-19 crisis: making the case for cardiac rehabilitation in the face of an ongoing pandemic.
      Although in-person rehabilitation is the gold standard, even pre-COVID the European Society of Cardiology guidelines raised the possibility of home-based rehabilitation with or without telemonitoring.
      Canadian Institute for Health Information
      COVID-19’s impact on long-term care.
      Systematic reviews have proven that telerehabilitation is superior to no rehabilitation and noninferior to in-person rehabilitation for improving functional capacity and quality of life for all patients, including those with heart failure and coronary disease.
      • Marzolini S.
      • Ghisi G.L.M.
      • Hébert A.A.
      • Ahden S.
      • Oh P.
      Cardiac rehabilitation in Canada during COVID-19.
      ,
      • Cavalheiro A.H.
      • Silva Cardoso J.
      • Rocha A.
      • Moreira E.
      • Azevedo L.F.
      Effectiveness of tele-rehabilitation programs in heart failure: a systematic review and meta-analysis.
      Although some have enthusiastically advocated for that option during the pandemic,
      • Ramachandran H.J.
      • Jiang Y.
      • Tam W.W.S.
      • Yeo T.J.
      • Wang W.
      Effectiveness of home-based cardiac telerehabilitation as an alternative to phase 2 cardiac rehabilitation of coronary heart disease: a systematic review and meta-analysis.
      it should still be acknowledged that there are no definitive data on the effectiveness of home-based rehabilitation programs vs centre-based ones, and this is a clear research need that the COVID-19 pandemic has highlighted.

      Scherrenberg M, Wilhelm M, Hansen D, et al. The future is now: a call for action for cardiac telerehabilitation in the COVID-19 pandemic from the secondary prevention and rehabilitation section of the European Association of Preventive Cardiology [e-pub ahead of print]. Eur J Prev Cardiol. 2020:2047487320939671. doi:10.1177/2047487320939671

      Effect of the COVID-19 pandemic on shortages of drugs and devices: undertreatment

      Although drug shortages were common around the world even before 2019, the COVID-19 pandemic exacerbated many of these concerns because of increased demand for drugs used for COVID-19 therapies (such as steroids, hydroxychloroquine, antivirals) and drugs for supportive care (especially anaesthetics such as propofol, midazolam, fentanyl, rocuronium), as well as decreased supply as drug-supplying countries decreased their exports to prioritize their citizens, and pharmacies and hospitals began stockpiling medications.
      • Epstein E.
      • Patel N.
      • Maysent K.
      • Taub P.R.
      Cardiac rehab in the COVID era and beyond: mHealth and other novel opportunities.
      Each of these factors contributed to the scarcity of essential, lifesaving medications, which affected many countries around the world, but especially low-income countries in Africa and Asia.
      • Shuman A.G.
      • Fox E.R.
      • Unguru Y.
      COVID-19 and drug shortages: a call to action.
      ,
      • Das M.
      Lebanon faces critical shortage of drugs.
      Thankfully, with massive global collaboration efforts including the 4-level mitigation strategy established by the World Health Organization, as well as local efforts at government and pharmacy levels, many of these shortages have been addressed.
      • Faiva E.
      • Hashim H.T.
      • Ramadhan M.A.
      • et al.
      Drug supply shortage in Nigeria during COVID-19: efforts and challenges.
      ,
      • Lau B.
      • Tadrous M.
      • Chu C.
      • Hardcastle L.
      • Beall R.F.
      COVID-19 and the prevalence of drug shortages in Canada: a cross-sectional time-series analysis from April 2017 to April 2022.
      As a result of decreased supply, increased financial constraints, increased stress, decreased outpatient visits, and misinformation (the infodemic), adherence to many chronic medications has significantly decreased since the start of the pandemic.
      • Shukar S.
      • Zahoor F.
      • Hayat K.
      • et al.
      Drug shortage: causes, impact, and mitigation strategies.
      As health care providers, it would behoove us to inquire about adherence disruptions and provide prompt, nonjudgemental, reinitiation of medications where necessary.
      • Shukar S.
      • Zahoor F.
      • Hayat K.
      • et al.
      Drug shortage: causes, impact, and mitigation strategies.
      In addition to drugs, the COVID-19 pandemic also caused a shortage in devices including personal protective equipment, ventilators, COVID-19 testing supplies, and even blood collection tubes.
      • Clement J.
      • Jacobi M.
      • Greenwood B.N.
      Patient access to chronic medications during the Covid-19 pandemic: evidence from a comprehensive dataset of US insurance claims.
      ,
      • Ranney M.L.
      • Griffeth V.
      • Jha A.K.
      Critical supply shortages - the need for ventilators and personal protective equipment during the Covid-19 pandemic.
      This was because of increased demand as well as decreased supply from major global suppliers such as China due to factory shutdowns. Many countries around the globe were particularly affected by this, especially Italy, Spain, and parts of the United States.
      • Clement J.
      • Jacobi M.
      • Greenwood B.N.
      Patient access to chronic medications during the Covid-19 pandemic: evidence from a comprehensive dataset of US insurance claims.
      ,
      U.S. Food & Drug Administration
      Medical Device Shortages During the COVID-19 Public Health Emergency.
      Although the device shortage issue has abated to a large degree, it did trigger the need for international cooperation in the trade of medical supplies, a proactive backup approach at first signs of shortages, and innovative approaches such as 3D printing of medical supplies, all of which are likely to stay for the long term.
      • Bown C.P.
      How COVID-19 medical supply shortages led to extraordinary trade and industrial policy.

      Effect of the COVID-19 pandemic on exacerbating existing deficiencies in health care and health human services

      The COVID-19 pandemic also highlighted the inequities in health care access, particularly with respect to primary care for disadvantaged communities, and the structural deficits in the health care workforce that already existed prepandemic.
      • Tarfaoui M.
      • Nachtane M.
      • Goda I.
      • Qureshi Y.
      • Benyahia H.
      3D printing to support the shortage in personal protective equipment caused by COVID-19 pandemic.
      Indeed, all of the care deficits outlined previously are more pronounced in disadvantaged groups. Several recent studies have shown the negative effects of the pandemic on health care workers and have raised concerns about further increases in shortages of physicians and nurses. The Canadian Medical Association’s 2021 National Physician Health Survey
      • Blumenthal D.
      • Fowler E.J.
      • Abrams M.
      • Collins S.R.
      Covid-19 - implications for the health care system.
      indicated that physician burnout nearly doubled (up to 53%) during the pandemic and nearly half of physicians are planning to reduce their workload in the near future, mirroring reports from the Canadian Nurses Association
      Canadian Medical Association
      Physician Burnout Nearly Doubles During Pandemic.
      and the Association of American Medical Colleges.
      Canadian Nurses Association
      Governments Must Work Together to Combat Nurse Burnout, CNA, CFNU Say.

      Concluding Thoughts and Looking Forward

      During the pandemic, COVID-19 was the third leading cause of death in Canada, behind only cancer and cardiovascular disease. Although much attention has been focused on COVID-19 entering an “endemic phase,” as recently pointed out by Professor Katzourakis in Nature: “a disease can be endemic and both widespread and deadly” (he cited the example of 2 endemic infectious diseases—malaria and tuberculosis—that killed more than 2 million people in 2020).
      AAMC
      AAMC Report Reinforces Mounting Physician Shortage.
      In addition to the direct morbidity and mortality attributable to SARS-CoV-2 infection, the indirect effects of the pandemic have been profound, and cardiovascular conditions are one of the early bellweathers for these effects. The background incidence of cardiovascular disease has at the very least been constant over this period, but has more likely increased because of the increased burden of cardiovascular risk factors in COVID-19 survivors and pandemic-related stressors. Although Canada performed better than most other countries in the first 2 years of the pandemic on metrics such as number of infections, number of deaths, or proportion fully vaccinated,
      • Katzourakis A.
      COVID-19: endemic doesn’t mean harmless.
      our ability to address the care deficits described in this article will determine how we fare in the next phase of the pandemic. To do so, we need to learn from the natural experiment of reduced care induced by the pandemic to identify which elements of deferred care proved unnecessary and prioritize only interventions of proven efficacy and cost effectiveness.
      • Razak F.
      • Shin S.
      • Naylor C.D.
      • Slutsky A.S.
      Canada’s response to the initial 2 years of the COVID-19 pandemic: a comparison with peer countries.
      ,
      • Sorenson C.
      • Japinga M.
      • Crook H.
      Building a better health care system post-Covid-19: steps for reducing low-value and wasteful care.
      As pointed out by Abraham Maslow, “to a man with a hammer, everything looks like a nail,” and thus choosing which services to prioritize will require input from a broader constituency than just physicians. Indeed, the need for timely and explicit communication between health care providers, government and other policy makers, industry, and the public cannot be understated.

      Funding Sources

      None.

      Disclosures

      D.S.L. is the Ted Rogers Chair in Heart Function Outcomes, University Health Network. H.C.W. is a Canada Research Chair in Structural Heart Disease Policy and Outcomes.

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