Care-seeking for heart-related illness fell amid pandemic—with long-term fallout likely

Man having heart attack

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Rates of long-term major adverse cardiovascular events (CVEs) fell after the COVID-19 pandemic began in early 2020 and remained lower over the next year among commercially insured New England patients seeking care, and the incidence of congestive heart failure (CHF) and angina (chest pain) remained lower than expected.

A commentary, however, advises caution in interpreting the findings as indicating an actual drop in heart-related health problems. The study was published late last week in JAMA Health Forum.

A team led by a Duke University investigator mined administrative and claims data from Harvard Pilgrim Health Care from COVID-19 patients with commercial or Medicare Advantage insurance aged 35 years or older from Massachusetts, New Hampshire, Maine, and Connecticut from March 2017 to December 2021. Participants were of higher socioeconomic (SES) status than the rest of the states' population.

Specifically, the team compared prepandemic to pandemic rates of hospitalization for heart attack and stroke and visits to the emergency department (ED), observation unit, or hospital for CHF, angina, and transient ischemic attack (TIA), which is a stroke-like episode. The investigators also compared modeled to expected postpandemic trends.

The study authors noted that the pandemic and related public health measures disrupted healthcare access, which could have delayed time-sensitive cardiovascular disease (CVD) care, and that COVID-19 infection is tied to a higher incidence of heart failure, heart attack, and stroke.

"This pattern raised concerns that subsequent rates might increase beyond expected levels, but longer-term patterns are uncertain," they wrote. "New England was among the earliest- and hardest-hit regions during the pandemic."

Stroke, heart attack hospitalizations fell

After the pandemic began, hospitalizations for stroke initially declined 27.0%, remained lower than expected in February 2021 (−11.8%), and stayed low in December 2021 (−27.3%). Admissions for heart attack dropped 27.8% but were not statistically different than expected by January 2021.

CHF episodes at first dipped 26.1%, were still lower than expected in March 2021 (−15.8%), and stayed low in December 2021 (−22.1%). Angina episodes also remained lower, while TIA episodes were not statistically different than expected in August 2020.

Composite major CVEs fell 26.6% in April 2020 and stayed below expected levels in March (−9.6%) and December (−19.8%).

"Factors explaining these trends could include lack of patient presentation during the 21-month follow-up, cardiovascular deaths outside the medical system, COVID-19–related deaths of people at risk for high-acuity CVEs, decrease in overdiagnosis due to lower emergency department and hospital volumes, heart failure management at home, and reductions in adverse events," the researchers wrote. "Further studies are needed to identify and quantify such factors."

The authors cautioned that the findings may not be generalizable to other US regions, non-commercially insured patients, or those of lower SES.

"For example, Massachusetts was unusual for experiencing no increase in cardiovascular deaths during the first 2 pandemic months," they wrote. "Additional research may examine regions with lower concentrations of clinicians, lower SES, and higher CVD burden. This study, combined with future studies, could help policymakers and insurers anticipate changes in major health outcomes during periods of limited health care access."

'Tsunami' of heart disease likely

In a related commentary, Rishi Wadhera, MD, MPP, MPhil, of Beth Israel Deaconess Medical Center and Harvard Medical School, warned not to interpret the drop in cardiovascular hospitalizations as a decline in the actual incidence of CVEs, "given the sharp increase in population-level cardiovascular deaths that occurred during the pandemic, which erased nearly a decade of progress."

Together, these spillover effects may have severe and far-reaching repercussions for cardiovascular morbidity and mortality long after the pandemic is over.

Many adults, Wadhera said, experienced disrupted outpatient care, preventive screenings, and treatment for chronic conditions such as high blood pressure and diabetes, along with worsening social determinants of health such as unemployment and other financial hardships.

"Together, these spillover effects may have severe and far-reaching repercussions for cardiovascular morbidity and mortality long after the pandemic is over," he wrote. "Clinicians, health systems, and public health leaders will need to prepare for the tsunami of cardiovascular risk factors and diseases that will likely emerge in the years that follow the pandemic."

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