Reduction in heart failure hospitalization rate during coronavirus disease 19 pandemic outbreak

Trends in outpatient and inpatient visits for separate ambulatory-care-sensitive conditions during the first year of the COVID-19 pandemic: a province-based study

Background

The COVID-19 pandemic led to global disruptions in non-urgent health services, affecting health outcomes of individuals with ambulatory-care-sensitive conditions (ACSCs).

Methods

We conducted a province-based study using Ontario health administrative data (Canada) to determine trends in outpatient visits and hospitalization rates (per 100,000 people) in the general adult population for seven ACSCs during the first pandemic year (March 2020-March 2021) compared to previous years (2016-2019), and how disruption in outpatient visits related to acute care use. ACSCs considered were chronic obstructive pulmonary disease (COPD), asthma, angina, congestive heart failure (CHF), hypertension, diabetes, and epilepsy. We used time series auto-regressive integrated moving-average models to compare observed versus projected rates.

Results

Following an initial reduction (March-May 2020) in all types of visits, primary care outpatient visits (combined in-person and virtual) returned to pre-pandemic levels for asthma, angina, hypertension, and diabetes, remained below pre-pandemic levels for COPD, and rose above pre-pandemic levels for CHF (104.8 vs. 96.4, 95% CI: 89.4-104.0) and epilepsy (29.6 vs. 24.7, 95% CI: 22.1-27.5) by the end of the first pandemic year. Specialty visits returned to pre-pandemic levels for COPD, angina, CHF, hypertension, and diabetes, but remained above pre-pandemic levels for asthma (95.4 vs. 79.5, 95% CI: 70.7-89.5) and epilepsy (53.3 vs. 45.6, 95% CI: 41.2-50.5), by the end of the year. Virtual visit rates increased for all ACSCs. Among ACSCs, reductions in hospitalizations were most pronounced for COPD and asthma. CHF-related hospitalizations also decreased, albeit to a lesser extent. For angina, hypertension, diabetes, and epilepsy, hospitalization rates reduced initially, but returned to pre-pandemic levels by the end of the year.

Conclusion

This study demonstrated variation in outpatient visit trends for different ACSCs in the first pandemic year. No outpatient visit trends resulted in increased hospitalizations for any ACSC; however, reductions in rates of asthma, COPD, and CHF hospitalizations persisted.

The impact of COVID-19 on heart failure admissions in Suriname-A call for action

Introduction

During the height of the COVID-19 pandemic, there was a worldwide reorganization of healthcare systems focusing on limiting the spread of the virus. The impact of these measures on heart failure (HF) admissions is scarcely reported in Low and Middle Income Countries (LMICs) including Suriname. We therefore assessed HF hospitalizations before and during the pandemic and call for action to improve healthcare access in Suriname through the development and implementation of telehealth strategies.

Methods

Retrospectively collected clinical (# hospitalizations per patient, in hospital mortality, comorbidities) and demographic (sex, age, ethnicity) data of people hospitalized with a primary or secondary HF discharge ICD10 code in the Academic Hospital Paramaribo (AZP) from February to December 2019 (pre-pandemic) and February to December 2020 (during the pandemic) were used for analysis. Data are presented as frequencies with corresponding percentages. T-tests were used to analyze continuous variables and the two-sample test for proportions for categorical variables.

Results

There was an overall slight decrease of 9.1% HF admissions (N pre-pandemic:417 vs N during the pandemic: 383). Significantly less patients (18.3%, p-value<0.00) were hospitalized during the pandemic (N: 249 (65.0%)) compared to pre-pandemic (N: 348 (83.3%)), while readmissions increased statistically significantly for both readmissions within 90 days (75 (19.6%) vs 55 (13.2%), p-value = 0.01) and readmissions within 365 days (122 (31.9%) vs 70 (16.7%), p-value = 0.00) in 2020 compared to 2019. Patients admitted during the pandemic also had significantly more of the following comorbidities: hypertension (46.2% vs 30.6%, p-value = 0.00), diabetes (31.9% vs 24.9%, p-value = 0.03) anemia (12.8% vs 3.1%, p-value = 0.00), and atrial fibrillation (22.7% vs 15.1%, p-value = 0.00).

Conclusion

HF admissions were reduced during the pandemic while HF readmissions increased compared to the pre-pandemic period. Due to in-person consultation restrictions, the HF clinic was inactive during the pandemic period. Distance monitoring of HF patients via telehealth tools could help in reducing these adverse effects. This call for action identifies key elements (digital and health literacy, telehealth legislation, integration of telehealth tools within the current healthcare sector) needed for the successful development and implementation of these tools in LMICs.

Characteristics, Treatment Patterns, and Clinical Outcomes After Heart Failure Hospitalizations During the COVID-19 Pandemic, March to October 2020

OBJECTIVE

To compare clinical characteristics, treatment patterns, and 30-day all-cause readmission and mortality between patients hospitalized for heart failure (HF) before and during the coronavirus disease 2019 (COVID-19) pandemic.

PATIENTS AND METHODS

The study was conducted at 16 hospitals across 3 geographically dispersed US states. The study included 6769 adults (mean age, 74 years; 56% [5033 of 8989] men) with cumulative 8989 HF hospitalizations: 2341 hospitalizations during the COVID-19 pandemic (March 1 through October 30, 2020) and 6648 in the pre-COVID-19 (October 1, 2018, through February 28, 2020) comparator group. We used Poisson regression, Kaplan-Meier estimates, multivariable logistic, and Cox regression analysis to determine whether prespecified study outcomes varied by time frames.

RESULTS

The adjusted 30-day readmission rate decreased from 13.1% (872 of 6648) in the pre-COVID-19 period to 10.0% (234 of 2341) in the COVID-19 pandemic period (relative risk reduction, 23%; hazard ratio, 0.77; 95% CI, 0.66 to 0.89). Conversely, all-cause mortality increased from 9.7% (645 of 6648) in the pre-COVID-19 period to 11.3% (264 of 2341) in the COVID-19 pandemic period (relative risk increase, 16%; number of admissions needed for one additional death, 62.5; hazard ratio, 1.19; 95% CI, 1.02 to 1.39). Despite significant differences in rates of index hospitalization, readmission, and mortality across the study time frames, the disease severity, HF subtypes, and treatment patterns remained unchanged (P>0.05).

CONCLUSION

The findings of this large tristate multicenter cohort study of HF hospitalizations suggest lower rates of index hospitalizations and 30-day readmissions but higher incidence of 30-day mortality with broadly similar use of HF medication, surgical interventions, and devices during the COVID-19 pandemic compared with the pre-COVID-19 time frame.

The Impact of COVID-19 Pandemic on Hospitalization and Interventional Procedures for Cardiovascular Diseases during the First Wave in Italy

Coronavirus disease 2019 (COVID-19) has been responsible for an epidemic of devastating proportion, and it has represented a challenge for worldwide healthcare systems with the need of resources reallocation in order to face epidemic spread. Italy was one of the hardest hit countries by COVID-19, and the Italian government adopted strict rules to contain the spread of the COVID-19 pandemic, such as national lockdown and home quarantine; moreover, the Italian healthcare system had to rapidly re-organize the diagnostic and therapeutic pathways, with a reallocation of health resources and hospital beds, in order to manage COVID-19 patients. The aim of the present review is to provide an overview of the effects of the first pandemic wave on cardiovascular assistance in Italy with the purpose of evaluating the strengths and weaknesses of the Italian health system.

Cardiovascular disease and COVID-19, a deadly combination: A review about direct and indirect impact of a pandemic

Coronavirus disease 2019 (COVID-19) is known to present with respiratory symptoms, which can lead to severe pneumonia and respiratory failure. However, it can have multisystem complications such as cardiovascular manifestations. The cardiovascular manifestations reported comprise myocarditis, cardiogenic shock, arrhythmias, pulmonary embolism, deep vein embolism, acute heart failure, and myocardial infarction. There is also an indirect impact of the pandemic on the management of cardiovascular care that has been shown clearly in multiple publications. In this review, we summarize the deadly relation of COVID-19 with cardiovascular events and the wider impact on several cardiovascular care areas by the pandemic situation

Heart failure during the COVID-19 pandemic: clinical, diagnostic, management, and organizational dilemmas

The coronavirus 2019 (COVID-19) infection pandemic has affected the care of patients with heart failure (HF). Several consensus documents describe the appropriate diagnostic algorithm and treatment approach for patients with HF and associated COVID-19 infection. However, few questions about the mechanisms by which COVID can exacerbate HF in patients with high-risk (Stage B) or symptomatic HF (Stage C) remain unanswered. Therefore, the type of HF occurring during infection is poorly investigated. The diagnostic differentiation and management should be focused on the identification of the HF phenotype, underlying causes, and subsequent tailored therapy. In this framework, the relationship existing between COVID and onset of acute decompensated HF, isolated right HF, and cardiogenic shock is questioned, and the specific management is mainly based on local hospital organization rather than a standardized model. Similarly, some specific populations such as advanced HF, heart transplant, patients with left ventricular assist device (LVAD), or valve disease remain under investigated. In this systematic review, we examine recent advances regarding the relationships between HF and COVID-19 pandemic with respect to epidemiology, pathogenetic mechanisms, and differential diagnosis. Also, according to the recent HF guidelines definition, we highlight different clinical profile identification, pointing out the main concerns in understudied HF populations.

The Mutual Relationship among Cardiovascular Diseases and COVID-19: Focus on Micronutrients Imbalance

Micronutrients are ions and vitamins humbly required by the human body. They play a main role in several physiological mechanisms and their imbalance is strongly associated with potentially-fatal complications. Micronutrient imbalance is associated with many cardiovascular diseases, such as arrythmias, heart failure, and ischemic heart disease. It has been also observed in coronavirus disease 2019 (COVID-19), particularly in most severe patients. The relationship between cardiovascular diseases and COVID-19 is mutual: the latter triggers cardiovascular disease onset and worsening while patients with previous cardiovascular disease may develop a more severe form of COVID-19. In addition to the well-known pathophysiological mechanisms binding COVID-19 and cardiovascular diseases together, increasing importance is being given to the impact of micronutrient alterations, often present during COVID-19 and able to affect the balance responsible for a good functioning of the cardiovascular system. In particular, hypokalemia, hypomagnesemia, hyponatremia, and hypocalcemia are strongly associated with worse outcome, while vitamin A and D deficiency are associated with thromboembolic events in COVID-19. Thus, considering how frequent the cardiovascular involvement is in patients with COVID-19, and how it majorly affects their prognosis, this manuscript provides a comprehensive review on the role of micronutrient imbalance in the interconnection between COVID-19 and cardiovascular diseases.

Changes in Acute Myocardial Infarction, Stroke, and Heart Failure Hospitalizations During COVID-19 Pandemic in Tuscany-An Interrupted Time Series Study

Objectives: We evaluate the impact of the COVID-19 pandemic on unplanned hospitalization rates for patients without COVID-19, including their length of stay, and in-hospital mortality, overall, and for acute myocardial infarction (AMI), stroke, and heart failure in the Tuscany region of Italy. Methods: We carried out a population-based controlled interrupted time series study using segmented linear regression with an autoregressive error term based on admissions data from all public hospitals in Tuscany. The primary outcome measure was weekly hospitalization rates; secondary outcomes included length of stay, and in-hospital mortality. Results: The implementation of the pandemic-related mitigation measures and fear of infection was associated with large decreases in inpatient hospitalization rates overall (-182 [-234, -130]), unplanned hospitalization (-39 [-51, -26]), and for AMI (-1.32 [-1.98, -0.66]), stroke (-1.51 [-2.56, -0.44]), and heart failure (-8.7 [-11.1, -6.3]). Average length of stay and percent in-hospital mortality for select acute medical conditions did not change significantly. Conclusion: In Tuscany, Italy, the COVID-19 pandemic was associated with large reductions in hospitalization rates overall, as well as for heart failure, and the time sensitive conditions of AMI and stroke during the months January to July 2020.

Clinical Support through Telemedicine in Heart Failure Outpatients during the COVID-19 Pandemic Period: Results of a 12-Months Follow Up

Background: Heart failure (HF) patients are predisposed to recurrences and disease destabilizations, especially during the COVID-19 outbreak period. In this scenario, telemedicine could be a proper way to ensure continuous care. The purpose of the study was to compare two modalities of HF outpatients’ follow up, the traditional in-person visits and telephone consultations, during the COVID-19 pandemic period in Italy. Methods: We conducted an observational study on consecutive HF outpatients. The follow up period was 12 months, starting from the beginning of the COVID-19 Italy lockdown. According to the follow up modality, and after the propensity matching score, patients were divided into two groups: those in G1 (n = 92) were managed with traditional in-person visits and those in G2 (n = 92) were managed with telephone consultation. Major adverse cardiovascular events (MACE) were the primary endpoints. Secondary endpoints were overall mortality, cardiovascular death, cardiovascular hospitalization, and hospitalization due to HF. Results: No significant differences between G1 and G2 have been observed regarding MACE (p = 0.65), cardiovascular death (p = 0.39), overall mortality (p = 0.85), hospitalization due to acute HF (p = 0.07), and cardiovascular hospitalization (p = 0.4). Survival analysis performed by the Kaplan–Meier method also did not show significant differences between G1 and G2. Conclusions: Telephone consultations represented a valid option to manage HF outpatients during COVID-19 pandemic, comparable to traditional in-person visits.

Impact of SARS-CoV-2 Outbreak on Emergency Department Presentation and Prognosis of Patients with Acute Myocardial Infarction: A Systematic Review and Updated Meta-Analysis

We performed an updated meta-analysis to robustly quantify admission trends of patients with ST-segment elevation MI (STEMI) and non-ST-segment elevation MI (NSTEMI) during the first wave of the pandemic and to characterize on a large basis the risk profile and early prognosis. Studies having the same observation period for the comparison between SARS-CoV-2 outbreak in 2020 versus control period in 2019 were included. Primary endpoints were the relative variation of hospital admissions, the difference of in-hospital mortality for STEMI and NSTEMI. Secondary were: mortality according to countries, income levels and data quality; cardiogenic shock, mechanical complications, door-to-balloon time, time from symptom onset to first medical contact, left ventricular ejection fraction (LVEF) and troponin. In total, 61 observational studies with 125,346 patients were included. Compared with 2019, during the pandemic for STEMI were observed: a 24% reduction of hospitalizations with an impact on early survival (OR = 1.33 in-hospital mortality); the time from symptom onset to first medical contact was 91.31 min longer, whereas door-to-balloon time was increased (+5.44 min); after STEMI, the rate of cardiogenic shock was 33% higher; LVEF at discharge was decreased (−3.46); elevated high-sensitivity troponin levels (1.52) on admission. For NSTEMI, in the COVID-19 period, we observed a 31% reduction of hospitalizations and higher in-hospital deaths (OR = 1.34). The highest mortality rates among countries were: Italy OR = 3.71 (high income), Serbia OR = 2.15 (upper middle) and Pakistan OR = 1.69 (lower middle). Later hospital presentation was associated with larger infarctions, as well as with increased cardiogenic shock and in-hospital mortality.

Continuous Decline in Myocardial Infarction and Heart Failure Hospitalizations during the First 12 Months of the COVID-19 Pandemic in Israel

Background: A decline in cardiovascular hospitalizations was observed during the initial phases of the COVID-19 pandemic. We examine the continuous effect of the COVID-19 pandemic in reducing cardiovascular hospitalization and associated mortality rates during the first year of the pandemic in Israel. Methods: We conduct a retrospective cohort study using the data of Clalit Health Services, the largest healthcare organization in Israel. We divide the Corona year into six periods (three lockdowns and three post-lockdowns) and compare the incidence rates of cardiovascular hospitalizations and 30-day all-cause mortality during each period to the previous three years. Results: The number of non-STEMI hospitalizations during the first year of the pandemic was 13.7% lower than the average of the previous three years (95% CI 11–17%); STEMI hospitalizations were 15.7% lower (95% CI 13–19%); CHF (Congestive heart failure) hospitalizations were 23.9% lower (95%, CI 21–27%). No significant differences in 30-day all-cause mortality rates were observed among AMI (acute myocardial infarction) patients during most of the periods, whereas the annual 30-day all-cause mortality rate among CHF patients was 23% higher. Conclusions: AMI and CHF hospitalizations were significantly lower during the first year of the pandemic relative to 2017–9. Mortality rates were higher in the case of CHF patients but not in the case of AMI patients, possibly due to a change in the clinical acuity of patients arriving at the hospitals. We conclude that targeted public health messaging should be implemented together with proactive monitoring, in order to identify residual disability in patients who may have received non-optimal treatment during the pandemic.

Association of chronic heart failure with mortality in old intensive care patients suffering from Covid-19

Aims

Chronic heart failure (CHF) is a major risk factor for mortality in coronavirus disease 2019 (COVID‐19). This prospective international multicentre study investigates the role of pre‐existing CHF on clinical outcomes of critically ill old (≥70 years) intensive care patients with COVID‐19.

Methods and results

Patients with pre‐existing CHF were subclassified as having ischaemic or non‐ischaemic cardiac disease; patients with a documented ejection fraction (EF) were subclassified according to heart failure EF: reduced (HFrEF, n = 132), mild (HFmrEF, n = 91), or preserved (HFpEF, n = 103). Associations of heart failure characteristics with the 30 day mortality were analysed in univariate and multivariate logistic regression analyses. Pre‐existing CHF was reported in 566 of 3917 patients (14%). Patients with CHF were older, frailer, and had significantly higher SOFA scores on admission. CHF patients showed significantly higher crude 30 day mortality [60% vs. 48%, P < 0.001; odds ratio 1.87, 95% confidence interval (CI) 1.5–2.3] and 3 month mortality (69% vs. 56%, P < 0.001). After multivariate adjustment for confounders (SOFA, age, sex, and frailty), no independent association of CHF with mortality remained [adjusted odds ratio (aOR) 1.2, 95% CI 0.5–1.5; P = 0.137]. More patients suffered from pre‐existing ischaemic than from non‐ischaemic disease [233 vs. 328 patients (n = 5 unknown aetiology)]. There were no differences in baseline characteristics between ischaemic and non‐ischaemic disease or between HFrEF, HFmrEF, and HFpEF. Crude 30 day mortality was significantly higher in HFrEF compared with HFpEF (64% vs. 48%, P = 0.042). EF as a continuous variable was not independently associated with 30 day mortality (aOR 0.98, 95% CI 0.9–1.0; P = 0.128).

Conclusions

In critically ill older COVID‐19 patients, pre‐existing CHF was not independently associated with 30 day mortality.

Trial registration number: NCT04321265.

Economic Issues in Heart Failure in the United States

The cost of heart failure care is high owing to the cost of hospitalization and chronic treatments. Heart failure treatments vary in their benefit and cost. The cost effectiveness of therapies can be determined by comparing the cost of treatment required to obtain a certain benefit, often defined as an increase in 1 year of life. This review was sponsored by the Heart Failure Society of America and describes the growing economic burden of heart failure for patients and the health care system in the United States. It also provides a summary of the cost effectiveness of drugs, devices, diagnostic tests, hospital care, and transitions of care for patients with heart failure. Many medications that are no longer under patent are inexpensive and highly cost-effective. These include angiotensin-converting enzyme inhibitors, beta-blockers and mineralocorticoid receptor antagonists. In contrast, more recently developed medications and devices, vary in cost effectiveness, and often have high out-of-pocket costs for patients.

History of Heart Failure in Patients Hospitalized Due to COVID-19: Relevant Factor of In-Hospital Complications and All-Cause Mortality up to Six Months

Background: Patients with heart failure (HF) are at high risk of unfavorable courses of COVID-19. The aim of this study was to evaluate characteristics and outcomes of COVID-19 patients with HF. Methods: Data of patients hospitalized in a tertiary hospital in Poland between March 2020 and May 2021 with laboratory-confirmed COVID-19 were analyzed. The study population was divided into a HF group (patients with a history of HF) and a non-HF group. Results: Out of 2184 patients (65 ± 13 years old, 50% male), 12% had a history of HF. Patients from the HF group were older, more often males, had more comorbidities, more often dyspnea, pulmonary and peripheral congestion, inflammation, and end-organ damage biomarkers. HF patients had longer and more complicated hospital stay, with more frequent acute HF development as compared with non-HF. They had significantly higher mortality assessed in hospital (35% vs. 12%) at three (53% vs. 22%) and six months (72% vs. 47%). Of 76 (4%) patients who developed acute HF, 71% died during hospitalization, 79% at three, and 87% at six months. Conclusions: The history of HF identifies patients with COVID-19 who are at high risk of in-hospital complications and mortality up to six months of follow-up.

OUP accepted manuscript

Aims

During the coronavirus disease 2019 (COVID-19) pandemic, important changes in heart failure (HF) event rates have been widely reported, but few data address potential causes for these changes; several possibilities were examined in the GUIDE-HF study.

Methods and results

From 15 March 2018 to 20 December 2019, patients were randomized to haemodynamic-guided management (treatment) vs. control for 12 months, with a primary endpoint of all-cause mortality plus HF events. Pre-COVID-19, the primary endpoint rate was 0.553 vs. 0.682 events/patient-year in the treatment vs. control group [hazard ratio (HR) 0.81, P = 0.049]. Treatment difference was no longer evident during COVID-19 (HR 1.11, P = 0.526), with a 21% decrease in the control group (0.536 events/patient-year) and no change in the treatment group (0.597 events/patient-year). Data reflecting provider-, disease-, and patient-dependent factors that might change the primary endpoint rate during COVID-19 were examined. Subject contact frequency was similar in the treatment vs. control group before and during COVID-19. During COVID-19, the monthly rate of medication changes fell 19.2% in the treatment vs. 10.7% in the control group to levels not different between groups (P = 0.362). COVID-19 was infrequent and not different between groups. Pulmonary artery pressure area under the curve decreased −98 mmHg-days in the treatment group vs. −100 mmHg-days in the controls (P = 0.867). Patient compliance with the study protocol was maintained during COVID-19 in both groups.

Conclusion

During COVID-19, the primary event rate decreased in the controls and remained low in the treatment group, resulting in an effacement of group differences that were present pre-COVID-19. These outcomes did not result from changes in provider- or disease-dependent factors; pulmonary artery pressure decreased despite fewer medication changes, suggesting that patient-dependent factors played an important role in these outcomes.

Clinical Trials.gov: NCT03387813

Key questions

What factors explain the loss of treatment effect and reduction in heart failure events during COVID-19?

Key findings

The treatment effect change was not due to COVID-19-related events. Patient management was sustained but not intensified during COVID-19. Patient status improved during COVID-19 and pulmonary artery pressure reduced in both groups.

Take home message

Patient behaviour probably improved during COVID-19, given that patient status and pulmonary artery pressure improved during COVID-19 despite fewer medication changes and without increased contact from providers.

Impact of COVID-19 on Heart Failure Hospitalizations

The Novel Coronavirus Disease 2019 (COVID-19) pandemic has transformed individual lives and societal framework on a global scale, and in no other sector is this more evident than healthcare. Herein, we aim to describe the impact of the current COVID-19 pandemic and its associated restrictions on heart failure (HF) admissions. In this retrospective cohort study, we obtained administrative data for patients with a primary discharge diagnosis of HF (identified by ICD-10 code) with discharge dates ranging from January 2019 to November 2020. The study is comprised of 2 distinct sub-cohorts: HF admissions during the COVID-19 pandemic (case) period from March 2020 to October 2020 and corresponding control period during the previous year (March 2019 to December 2019). Primary outcome analysis involved comparison of total and daily HF admissions and secondary outcomes included hospital Length of Stay (LOS) and 30-day readmissions. The number of total HF admissions and average daily admissions were significantly lower in 2020 compared to 2019 (774 vs. 864; p < 0.001 and 3.17 vs. 3.53 days; p < 0.001), respectively. Average length of stay was significantly higher between March and October 2020 relative to the same months in 2019 (6.05 vs. 5.25 days; p < 0.001). Thirty-day readmission rates were also significantly higher in March–October 2020 compared to the same months in 2019 (20.6% vs. 19.1%; p < 0.001). During the pandemic, both readmission rates and length of stay for HF-related admissions were significantly impacted. The COVID-19 pandemic significantly impacted HF-related admissions as well as associated LOS and 30-day readmissions. High-risk patients should be identified carefully, and timely and appropriate treatment should be provided.

Late phase of COVID-19 pandemic in General Cardiology. A position paper of the ESC Council for Cardiology Practice

Cardiovascular (CV) engagement in coronavirus disease 2019 (COVID-19) is a huge determinant of prognosis during the acute phase of the disease. However, little is known about the potential chronic implications of the late phase of COVID-19 and about the appropriate approach to these patients. Heart failure, type 1 and type 2 myocardial infarction, arrhythmias, myocarditis, pulmonary fibrosis, and thrombosis have been shown to be related to severe acute respiratory syndrome coronavirus 2 infection, and a 'long COVID-19' illness has been recognized with fatigue, chest pain, and dyspnoea among the most frequent symptoms reported after discharge from hospital. This paper focuses on some open questions that cardiologists are going to face during the next months in a general cardiology outpatient clinic, in particular how to evaluate a 'post-COVID' patient during follow-up of CV complications of the acute phase and how to manage new CV symptoms that could be the consequence, at least in part, of heart/vessels and/or lung involvement of the previous virus infection. Present symptoms and signs, history of previous CV disease (both preceding COVID-19 and occurring during viral infection), and specific laboratory and imaging measurements during the acute phase may be of interest in focusing on how to approach the clinical evaluation of a post-COVID patient and how to integrate in our standard of care the new information on COVID-19, possibly in a multidisciplinary view. Dealing with the increased COVID-associated CV risk burden and becoming acquainted with potential new e-cardiology approaches aimed at integrating the cardiology practice are relevant new challenges brought by severe acute respiratory syndrome coronavirus 2 infection and its sequelae.

Acute heart failure in elderly patients: a review of invasive and non-invasive management

Acute heart failure (AHF) is a major cause of unplanned hospitalisations in the elderly and is associated with high mortality. Its prevalence has grown in the last years due to population aging and longer life expectancy of chronic heart failure patients. Although international societies have provided guidelines for the management of AHF in the general population, scientific evidence for geriatric patients is often lacking, as these are underrepresented in clinical trials. Elderly have a different risk profile with more comorbidities, disability, and frailty, leading to increased morbidity, longer recovery time, higher readmission rates, and higher mortality. Furthermore, therapeutic options are often limited, due to unfeasibility of invasive strategies, mechanical circulatory support and cardiac transplantation. Thus, the in-hospital management of AHF should be tailored to each patient's clinical situation, cardiopulmonary condition and geriatric assessment. Palliative care should be considered in some cases, in order to avoid unnecessary diagnostics and/or treatments. After discharge, a strict follow-up through outpatient clinic or telemedicine is can improve quality of life and reduce rehospitalisation rates. The aim of this review is to offer an insight on current literature and provide a clinically oriented, patient-tailored approach regarding assessment, treatment and follow-up of elderly patients admitted for AHF.

Myocardial Tissue Characterization in Heart Failure with Preserved Ejection Fraction: From Histopathology and Cardiac Magnetic Resonance Findings to Therapeutic Targets

Heart failure with preserved ejection fraction (HFpEF) is a complex clinical syndrome responsible for high mortality and morbidity rates. It has an ever growing social and economic impact and a deeper knowledge of molecular and pathophysiological basis is essential for the ideal management of HFpEF patients. The association between HFpEF and traditional cardiovascular risk factors is known. However, myocardial alterations, as well as pathophysiological mechanisms involved are not completely defined. Under the definition of HFpEF there is a wide spectrum of different myocardial structural alterations. Myocardial hypertrophy and fibrosis, coronary microvascular dysfunction, oxidative stress and inflammation are only some of the main pathological detectable processes. Furthermore, there is a lack of effective pharmacological targets to improve HFpEF patients' outcomes and risk factors control is the primary and unique approach to treat those patients. Myocardial tissue characterization, through invasive and non-invasive techniques, such as endomyocardial biopsy and cardiac magnetic resonance respectively, may represent the starting point to understand the genetic, molecular and pathophysiological mechanisms underlying this complex syndrome. The correlation between histopathological findings and imaging aspects may be the future challenge for the earlier and large-scale HFpEF diagnosis, in order to plan a specific and effective treatment able to modify the disease's natural course.

Home delivery of the communicator for remote monitoring of cardiac implantable devices: A multicenter experience during the covid-19 lockdown

Background

During the COVID‐19 pandemic in‐person visits for patients with cardiac implantable electronic devices should be replaced by remote monitoring (RM), in order to prevent viral transmission. A direct home‐delivery service of the RM communicator has been implemented at 49 Italian arrhythmia centers.

Methods

According to individual patient preference or the organizational decision of the center, patients were assigned to the home‐delivery group or the standard in‐clinic delivery group. In the former case, patients received telephone training on the activation process and use of the communicator. In June 2020, the centers were asked to reply to an ad hoc questionnaire to describe and evaluate their experience in the previous 3 months.

Results

RM was activated in 1324 patients: 821 (62%) received the communicator at home and the communicator was activated remotely. Activation required one additional call in 49% of cases, and the median time needed to complete the activation process was 15 min [25th‐75th percentile: 10–20]. 753 (92%) patients were able to complete the correct activation of the system. At the time when the questionnaire was completed, 743 (90%) communicators were regularly transmitting data. The service was generally deemed useful (96% of respondents) in facilitating the activation of RM during the COVID‐19 pandemic and possibly beyond.

Conclusions

Home delivery of the communicator proved to be a successful approach to system activation, and received positive feedback from clinicians. The increased use of a RM protocol will reduce risks for both providers and patients, while maintaining high‐quality care.

Reduction of Emergency Calls and Hospitalizations for Cardiac Causes: Effects of Covid-19 Pandemic and Lockdown in Tuscany Region

Introduction: Containment measures were established to flatten the curve of COVID-19 contagion in order to avoid a crash of the healthcare system. However, these measures influenced the rate of hospitalization of cardiac patients. In this study, we aimed to analyse the impact of COVID-19 and the effects of lockdown measures on hospital admissions and alerts of emergency medical system (EMS) for cardiac causes in the Tuscany region.

Methods: An observational, retrospective analysis from Italian Tuscany region was conducted. We evaluated consecutive patients contacting EMS or admitted to the 39 Emergency Departments (EDs) in Tuscany for cardiac causes in the first trimester of 2020. Data were compared with the same period in 2018/19.

Results: The alerts of EMS for cardiac causes significantly decrease in 2020 and the highest difference between 2018/19 and 2020 was found immediately after national lockdown (Δ = −47.4%, p < 0.001). The number of admissions for chest pain in the EDs also decreased, with a maximum difference of −67.6% (p < 0.001) vs. 2018/19. The number of hospital accesses for acute coronary syndromes, atrial fibrillation, and heart failure in the EDs significantly decreased in 2020 as compared to 2018/19 (maximum Δ = −58.9%, p < 0.001; maximum Δ = −63.0%, p < 0.001; maximum Δ = −72.7%, p < 0.001, respectively).

Conclusions: A significant decrease in the contacts to EMS for cardiac causes and in cardiac diagnoses was observed during the first trimester of 2020. Fear of contagion has likely played a relevant role. The lesson learnt from first wave of COVID-19 pandemic suggests that appropriate public information strategies and re-education of people are essential.

Cardiology Department Policy in Japan After Coronavirus Disease-2019 (COVID-19) - Descriptive Summary of 2nd Nationwide Survey by the Japanese Circulation Society

Background: Cardiovascular department restriction policies on procedures resulting from the COVID-19 pandemic have not been fully evaluated.

Methods and Results: We performed a retrospective analysis of a nationwide survey performed by the Japanese Circulation Society in August 2020. The total response rate was 48.9% (651/1,331). The rate of restriction of cardiovascular procedures peaked in April. Exacerbations of heart failure due to hospital restrictions were noted in 43.8% of departments.

Conclusions: Many departments restricted their cardiological procedures, and this rate changed according to the pandemic situation. The exacerbation of cardiovascular disease resulting from pandemic restrictions should not be ignored.

Ischemic Heart Disease Pathophysiology Paradigms Overview: From Plaque Activation to Microvascular Dysfunction

Ischemic heart disease still represents a large burden on individuals and health care resources worldwide. By conventions, it is equated with atherosclerotic plaque due to flow-limiting obstruction in large-medium sized coronary arteries. However, clinical, angiographic and autoptic findings suggest a multifaceted pathophysiology for ischemic heart disease and just some cases are caused by severe or complicated atherosclerotic plaques. Currently there is no well-defined assessment of ischemic heart disease pathophysiology that satisfies all the observations and sometimes the underlying mechanism to everyday ischemic heart disease ward cases is misleading. In order to better examine this complicated disease and to provide future perspectives, it is important to know and analyze the pathophysiological mechanisms that underline it, because ischemic heart disease is not always determined by atherosclerotic plaque complication. Therefore, in order to have a more complete comprehension of ischemic heart disease we propose an overview of the available pathophysiological paradigms, from plaque activation to microvascular dysfunction.

Reduction in heart failure hospitalization rate during coronavirus disease 19 pandemic outbreak

AIMS

The recent coronavirus disease 19 (COVID-19) pandemic outbreak forced the adoption of restraint measures, which modified the hospital admission patterns for several diseases. The aim of the study is to investigate the rate of hospital admissions for heart failure (HF) during the early days of the COVID-19 outbreak in Italy, compared with a corresponding period during the previous year and an earlier period during the same year.

METHODS AND RESULTS

We performed a retrospective analysis on HF admissions number at eight hospitals in Italy throughout the study period (21 February to 31 March 2020), compared with an inter-year period (21 February to 31 March 2019) and an intra-year period (1 January to 20 February 2020). The primary outcome was the overall rate of hospital admissions for HF. A total of 505 HF patients were included in this survey: 112 during the case period, 201 during intra-year period, and 192 during inter-year period. The mean admission rate during the case period was 2.80 admissions per day, significantly lower compared with intra-year period (3.94 admissions per day; incidence rate ratio, 0.71; 95% confidence interval [CI], 0.56-0.89; P = 0.0037), or with inter-year (4.92 admissions per day; incidence rate ratio, 0.57; 95% confidence interval, 0.45-0.72; P < 0.001). Patients admitted during study period were less frequently admitted in New York Heart Association (NYHA) Class II compared with inter-year period (P = 0.019). At covariance analysis NYHA class was significantly lower in patients admitted during inter-year control period, compared with patients admitted during case period (P = 0.014).

CONCLUSIONS

Admissions for HF were significantly reduced during the lockdown due to the COVID-19 pandemic in Italy.