Impact of the COVID-19 pandemic on cardiovascular mortality and catherization activity during the lockdown in central Germany: an observational study

Abstract

Aims During the COVID-19 pandemic, hospital admissions for cardiac care have declined. However, effects on mortality are unclear. Thus, we sought to evaluate the impact of the lockdown period in central Germany on overall and cardiovascular deaths. Simultaneously we looked at catheterization activities in the same region. Methods and results Data from 22 of 24 public health-authorities in central Germany were aggregated during the pandemic related lockdown period and compared to the same time period in 2019. Information on the total number of deaths and causes of death, including cardiovascular mortality, were collected. Additionally, we compared rates of hospitalization (n = 5178) for chronic coronary syndrome (CCS), acute coronary syndrome (ACS), and out of hospital cardiac arrest (OHCA) in 26 hospitals in this area. Data on 5,984 deaths occurring between March 23, 2020 and April 26, 2020 were evaluated. In comparison to the reference non-pandemic period in 2019 (deaths: n = 5832), there was a non-significant increase in all-cause mortality of 2.6% [incidence rate ratio (IRR) 1.03, 95% confidence interval (CI) 0.99–1.06; p = 0.16]. Cardiovascular and cardiac mortality increased significantly by 7.6% (IRR 1.08, 95%-CI 1.01–1.14; p = 0.02) and by 11.8% (IRR 1.12, 95%-CI 1.05–1.19; p < 0.001), respectively. During the same period, our data revealed a drop in cardiac catherization procedures. Conclusion During the COVID-19-related lockdown a significant increase in cardiovascular mortality was observed in central Germany, whereas catherization activities were reduced. The mechanisms underlying both of these observations should be investigated further in order to better understand the effects of a pandemic-related lockdown and social-distancing restrictions on cardiovascular care and mortality. Graphic abstract

Potential Relationship Between Lifestyle Changes and Incidence of Hospital Admissions for Acute Coronary Syndrome During the COVID-19 Lockdown

“…We cannot exclude that the reduction in STEMI admissions and higher in-hospital mortality did not reach statistical significance due to the small number of events. This would be in accord with the observed higher in-hospital mortality in patients admitted for cardiac catheterization during the COVID-19 pandemic compared with 2019 (58/1,801 vs. 55/3,030, p = 0.002), reported by Nef et al ( 6 ) This would support the theory of a phenomenal reduction in ACS incidence due to patients' denial to seek medical care under the fear of the pandemic. Nevertheless, an alternative scenario of “Life in a Standstill” where a real reduction of ACS incidence (mainly NSTEMI) could be related to lifestyle changes induced by lockdown measures also cannot be excluded.…”

“…The prevailing hypothetical explanations for this phenomenon include fear of contagion at the hospital, reassignment of medical services to care of COVID-19 patients, use of thrombolysis for STEMI in district hospitals, and STEMI misdiagnosis ( 1 – 7 ). All the above imply a false decrease in the incidence of ACS ( 8 – 10 ), which could potentially lead to a corresponding increase in cardiovascular and possibly all-cause morbidity and mortality ( 6 , 11 ). Indeed an alarming four times higher rate of out-of-hospital cardiac arrest was reported in New York City from 30 March to 5 April 2020, associated with an eight times higher mortality compared to the same period of the previous year ( 12 ).…”

“…Indeed an alarming four times higher rate of out-of-hospital cardiac arrest was reported in New York City from 30 March to 5 April 2020, associated with an eight times higher mortality compared to the same period of the previous year ( 12 ). Very recently Nef et al reported an 11.8% increase of cardiac mortality in 2020 compared to 2019 (IRR: 1.12, 95% CI: 1.05–1.19; p < 0.001), in central Germany (Hesse), suggesting that patients probably presented, or were referred too late to the hospitals ( 6 ).…”

“…The impact of this extremely unique situation on a population's lifestyle habits has not been studied. During the above lockdown periods a decrease in hospital admissions for acute coronary syndrome (ACS) has been observed ( 1 – 6 ). The prevailing explanatory theory on this observation is that patients may have avoided seeking medical help through fear of the pandemic, thus causing a false decrease in the rate of ACS.…”

COVID-19-Pandemie

“…In Deutschland zeigte eine populationsbasierte Analyse aus Hessen einen Anstieg der kardialen und kardiovaskulären Sterblichkeit während des Lockdowns im März und April 2020 von relativen 7,6 % (IRR [„incidence rate ratio“]: 1,08; 95 %-Konfidenzintervall [KI]: 1,01–1,14; p = 0,02) bzw. 11,8 % (IRR: 1,12; 95 %-KI: 1,05–1,19; p < 0,001; [ 32 ]).…”