Implications of the COVID-19 Pandemic for Cardiovascular Disease and Risk-Factor Management

Psychosocial factors and associations with preventive cardiovascular screening among U.S adults: Findings from the National Health Interview Survey, 2023

OBJECTIVE

Structural and COVID-related factors have been linked with the decline in preventive health screenings among adults. However, associations between psychosocial factors and undergoing preventive cardiovascular screening are not fully known. The current study examined associations between psychosocial factors and preventive cardiovascular screening among U.S. adults.

METHODS

We used data from the 2023 National Health Interview Survey (N = 23,428). Data were collected from January to December from adults living in U.S. Preventive cardiovascular (CV) screening (i.e., blood pressure, cholesterol, or blood sugar level) was defined as no screening, and undergoing screening for any CV risk within the past year. Psychosocial factors were defined as discrimination, life satisfaction, and depression. Multivariable logistic regression models examined the associations between psychosocial factors and preventive cardiovascular screening, adjusted for sociodemographic characteristics.

RESULTS

Adults with diagnosis of depression (OR: 1.93, 95 % CI: 1.65-2.25) had higher odds of undergoing screening for any CV risk. Adults who experienced discrimination had lower odds of undergoing screening for cholesterol (OR: 0.77, 95 % CI: 0.71-0.84) and blood sugar level specifically (OR: 0.78, 95 % CI: 0.72-0.85), while life dissatisfaction was associated with lower odds of screening for blood pressure (OR: 0.76, 95 % CI: 0.58-0.99) and blood sugar level specifically (OR: 0.80, 95 % CI: 0.65-0.97).

CONCLUSIONS

Discrimination and life dissatisfaction were associated with decreased odds of undergoing specific preventive cardiovascular screening, and depression is associated with increased odds of undergoing any preventive cardiovascular screening. Equitable health care policies focused on addressing psychosocial factors are needed to increase preventive cardiovascular screening among U.S. adults.

Post-Telemedicine Acute Care for Undifferentiated High-Acuity Conditions: Is a Picture Worth a Thousand Words?

Objectives: Telemedicine use increased substantially with the COVID-19 pandemic. Understanding of the impact of telemedicine modality (video vs. phone) on post-telemedicine acute care for higher risk conditions is limited. Methods: We conducted a retrospective study of telemedicine visits, comparing video with telephone, for selected diagnoses with potentially higher illness acuity, evaluating post-telemedicine emergency department (ED) and hospitalization rates. In a large, multicenter cohort of adult patient-initiated primary care telemedicine visits from March 1, 2020, to July 31, 2021, we evaluated 7-day ED and hospitalization rates for higher acuity diagnostic categories (cardiac, gastrointestinal, and respiratory) by telemedicine modality, provider familiarity, and patient sociodemographic and clinical characteristics. Results: Among 431,705 telemedicine encounters, 128,129 (29.7%) were video visits and 303,576 (70.3%) were telephone visits. Adjusting for patient and appointment factors, telephone encounters for cardiac conditions were associated with significantly higher 7-day ED visit rates than video encounters (5.5% vs. 4.9%, respectively) but similar hospitalization rates (0.7% vs. 0.8%, respectively); for gastrointestinal conditions, post-telemedicine adjusted ED and hospitalization rates were comparable between telemedicine modalities (4.0% for ED and 1.2% vs. 1.3% for hospitalization, respectively); among respiratory conditions, video encounters were associated with higher ED and hospitalization rates than telephone encounters (ED: 5.9% after video vs. 5.2% after phone; hospitalization: 1.9% after video vs. 1.5% after phone). Telemedicine encounters with patients' own primary care provider (PCP) were associated with lower adjusted rates of ED use across all conditions and modalities. Conclusions: Short-term ED and hospitalization rates following primary care video or telephone visits for selected acute, high-risk conditions varied by condition and PCP familiarity. Nuanced use of video visits may confer benefits triaging to downstream acute care.

Use of Sodium-Glucose Cotransporter-2 Inhibitors in Adults Aged ≥65 Years With Type 2 Diabetes and Cardiovascular Disease: A Cross-sectional Study of Different Drug Funding Policies

OBJECTIVES

Sodium-glucose cotransporter-2 inhibitors (SGLT2is) provide heart and kidney benefits in adults with diabetes and cardiovascular disease (CVD). Public drug coverage policies for SGLT2is differ by province in Canada. In this study, we describe the potential effects of prior authorization/step therapy (PA/ST) and relatively high income-based deductibles, compared with regular benefit status with modest copay, on SGLT2i prescriptions in high-risk adults.

METHODS

This investigation was a cross-sectional study of adults ≥65 years of age with type 2 diabetes and CVD and taking at least 1 antihyperglycemic agent from 2019 to 2020. Using electronic medical record data obtained from primary care practices, we compared SGLT2i use (2019 to 2020) in Alberta (PA/ST, modest copay) and Manitoba (PA/ST, relatively high income-based deductible) vs Ontario (regular benefit status, modest copay). Poisson regression was used to adjust for confounders, including age, sex, glycated hemoglobin, and other medication use. Other diabetes medications were estimated as control cases.

RESULTS

We included 3,191 adults (average age 75 years, 31% women). SGLT2i use was lowest in Manitoba (15.6%), followed by Alberta (25.9%), and highest in Ontario (31.9%). After adjustment, compared with Ontario, SGLT2i prescriptions were lower in Alberta (prevalence ratio [PR] 0.80, 95% confidence interval [CI] 0.71 to 0.91, p<0.001) and Manitoba (PR 0.48, 95% CI 0.39 to 0.59, p<0.001).

CONCLUSIONS

PA/ST and relatively high deductibles are associated with reduced SGLT2i prescribing---PA/ST by approximately 20% in Alberta and Manitoba, and relatively high deductibles by an additional relative reduction of 40% in Manitoba. PA/ST and cost-sharing policies should be flexible and responsive to changing evidence of clinical benefit.

Impact of hospital outpatients' experiences of patient safety on fear of infection: a secondary analysis of national data

INTRODUCTION

Amid the COVID-19 pandemic, outpatients' concerns about infection risk have increased. It is crucial to understand the factors that contribute to this fear of infection to promote patient safety and encourage outpatients to seek proper follow-up treatment without fear. This study aims to understand the relationship between outpatients' experiences of patient safety and their fear of infection.

DESIGN

This was a secondary analysis of national data from the Healthcare Service Experience Survey in 2020.

SETTING AND PARTICIPANTS

A total of 4416 patients with experience using outpatient services in the past year were included in South Korea.

PRIMARY AND SECONDARY OUTCOME MEASURES

Demographic characteristics, fear of infection and safety experiences were assessed in the original survey. Fear of infection served as the dependent variable, with safety experiences-specifically, patient identification, preinjection explanations, hand hygiene, proper use of injection supplies, skin disinfection and adverse drug reactions-as the independent variables.

RESULTS

Approximately 14% of outpatients had a fear of infection when receiving medical care. The unadjusted model showed that all patient safety categories were determinants of fear of infection, and the multivariate logistic model identified hand hygiene and medication safety experiences as significant factors associated with fear of infection.

CONCLUSIONS

This study revealed that patient safety experiences are associated with fear of infection in outpatient settings. Improving healthcare professionals' hand hygiene and managing adverse drug reactions are crucial for enhancing patient safety.

The effectiveness of continuous glucose monitoring with remote telemonitoring-enabled virtual educator visits in adults with non-insulin dependent type 2 diabetes: A randomized trial

AIMS

Estimate the effectiveness of continuous glucose monitoring (CGM) with remote telemonitoring-enabled virtual diabetes educator visits for improving glycemic management in adults with type 2 diabetes, not on insulin.

METHODS

Participants with type 2 diabetes, not on insulin, and HbA1c > 7.0 % were enrolled in an open-label randomized trial of 6 weeks of CGM with telemonitoring versus enhanced usual care. Both groups received educator visits. HbA1c was assessed at 12 weeks.

RESULTS

Of 105 participants (mean age 57.3 years, 49.5 % females, mean baseline HbA1c 8.0 %), 86 remained at follow-up. Change in HbA1c was -0.69 % (CGM) versus -0.33 % (enhanced usual care). Adjusting for baseline HbA1c, CGM was superior (0.65 % greater HbA1c reduction [95 % CI 0.17-1.12 %], p = 0.008). CGM participants were 92 % (RR = 1.92, 1.19-3.06, p = 0.007) more likely to have an HbA1c reduction ≥ 0.5 %, lost more weight (difference in weight reduction 2.17 kg, 0.22-4.11, p = 0.029) and were more satisfied with their treatment. No treatment-related adverse events were observed.

CONCLUSIONS

CGM with virtual diabetes educator visits is effective, safe, and acceptable in adults with type 2 diabetes not on insulin and should be considered as an alternative to drug therapy for improving blood glucose.

Effects of Mediterranean diets and nutrigenomics on cardiovascular health

The field of nutrigenomics studies the interaction between nutrition and genetics, and how certain dietary patterns can impact gene expression and overall health. The Mediterranean diet (MedDiet), characterized by a high intake of fruits, vegetables, whole grains, and healthy fats, has been linked to better cardiovascular health (CVH) outcomes. This review summarizes the current state of research on the effects of nutrigenomics and MedDiet on cardiovascular health. Results suggest that MedDiet, through its impact on gene expression, can positively influence CVH markers such as blood pressure, lipid profile, and inflammation. However, more research is needed to fully understand the complex interactions between genetics, nutrition, and CVH, and to determine the optimal dietary patterns for individualized care. The aim of this scientific review is to evaluate the current evidence on the effects of nutrigenomics and MedDiet on cardiovascular health. The review summarizes the available studies that have investigated the relationship between nutrition, genetics, and cardiovascular health, and explores the mechanisms by which certain dietary patterns can impact CVH outcomes. The review focuses on the effects of MedDiet, a dietary pattern that is rich in whole foods and healthy fats, and its potential to positively influence CVH through its impact on gene expression. The review highlights the limitations of current research and the need for further studies to fully understand the complex interplay between nutrition, genetics, and cardiovascular health.

Longitudinal study of the impact of the COVID-19 pandemic on diet and physical activity among Latinos of Mexican ancestry

BACKGROUND

The COVID-19 pandemic caused societal disruption in the United States and most of the world, affecting many aspects of life, including healthcare and health-related behaviors such as diet, food security, and physical activity. Communities with economic and health disparities may have been particularly affected. This study was undertaken to determine how conditions in the early pandemic (January, 2021-February, 2022) affected Latino patients of Mexican Ancestry at high risk of type 2 diabetes mellitus who participated in El Banco por Salud biobank project in Tucson, Arizona.

METHODS

Baseline, prepandemic measurements were available in 17, 21, and 60 patients with normal hemoglobin A1c (HbA1c), prediabetes, and type 2 diabetes, respectively.

RESULTS

People with healthy HbA1c were significantly younger, less obese, and had higher HDL cholesterol. HbA1c was unaffected by the pandemic in any group. Triglycerides, total and HDL cholesterol levels fell in all groups during the pandemic. Physical activity levels in all groups were remarkably low, with most reporting no engagement in any voluntary physical activity. Engagement in physical activity or its enjoyment was lower in patients with diabetes and prediabetes than in younger, less obese patients. Major diet differences were between men and women and were present before the pandemic. Women consumed significantly more vegetables, fruit, and salad than men. The only pandemic-related change in diet was a drop in egg consumption, possibly explaining the fall in total cholesterol.

CONCLUSION

Societal disruption during the COVID-19 pandemic had minimal effects on adverse health-related behaviors, cardiometabolic risk, or changes in glycemic control in a Latino community with diabetes and healthcare disparities in the Southwest US.

Negative effects of COVID-19 on the implantation rate of cardiac resynchronization therapy with defibrillator device

Introduction

COVID-19 drastically impacted the landscape of the United States' medical system. Limited data is available on the nationwide implantation trends in Cardiac Resynchronization Therapy Defibrillator (CRT-D) devices before and during the pandemic. We aimed to explore the impact of the COVID-19 pandemic on CRT-D insertion rates and adverse outcomes related to delays in care.

Methods and Results

We conducted a retrospective cross-sectional analysis using the National Inpatient Sample database between 2017 and 2020. Variables were identified using their ICD-10 codes. Inclusion criteria: age ≥ 18 years, presenting for a nonelective admission, primary diagnosis of hypertensive heart disease, hypertensive heart, chronic kidney disease, or heart failure, and underwent insertion of a CRT-D. Between 2017 and 2020, CRT-D devices were inserted during 23,635 admissions. On average, 6198 devices were implanted yearly from 2017 to 2019, with only 5040 devices being implanted in 2020. Additionally, reduced implantation rates were noted for every cohort of hospital size, location, and teaching status during this year. The year 2020 also had the highest average death rate at 1.39%, but this difference was statistically insignificant (adjusted Wald test p = .767), and COVID-19 was not associated with an increased risk of inpatient mortality (OR 0.22, 95% CI 0.03-1.82, p = .162).

Conclusion

The COVID-19 pandemic has affected all facets of the healthcare system, especially surgical volume rates. CRT-D procedures significantly decreased in 2020. This is the first retrospective study highlighting the trend of reduced rates of CRT-D implantation as a response to the COVID-19 pandemic.

Developing effective strategies to optimize physical activity and cardiorespiratory fitness in the long Covid population- The need for caution and objective assessment

The Post Covid-19 Condition (commonly known as Long Covid) has been defined by the World Health Organisation as occurring in individuals with a history of probable or confirmed SARS CoV 2 infection, usually within 3 months from the onset of acute Covid-19 infection with symptoms that last for at least two months which cannot be explained by an alternative diagnosis. Long Covid is associated with over two hundred recognised symptoms and affects tens of millions of people worldwide. Widely reported reductions in quality of life(QoL) and functional status are caused by extremely sensitive and cyclical symptom profiles that are augmented following exposure to physical, emotional, orthostatic, and cognitive stimuli. This manifestation prevents millions of people from engaging in routine activities of daily living (ADLs) and has important health and well-being, social and economic impacts. Post-exertional symptom exacerbation (PESE) (also known as post-exertional malaise) is an exacerbation in the severity of fatigue and other symptoms following physical, emotional, orthostatic and cognitive tasks. Typically, this will occur 24-72 h after "over-exertion" and can persist for several days and even weeks. It is a hallmark symptom of Long Covid with a reported prevalence of 86%. The debilitating nature of PESE prevents patients from engaging in physical activity which impacts functional status and QoL. In this review, the authors present an update to the literature relating to PESE in Long Covid and make the case for evidence-based guidelines that support the design and implementation of safe rehabilitation approaches for people with Long Covid. This review also considers the role of objective monitoring to quantify a patient's response to external stimuli which can be used to support the safe management of Long Covid and inform decisions relating to engagement with any stimuli that could prompt an exacerbation of symptoms.

Adjuvants in COVID-19 vaccines: innocent bystanders or culpable abettors for stirring up COVID-heart syndrome

COVID-19 infection is a multi-system clinical disorder that was associated with increased morbidity and mortality. Even though antiviral therapies such as Remdesvir offered modest efficacy in reducing the mortality and morbidity, they were not efficacious in reducing the risk of future infections. So, FDA approved COVID-19 vaccines which are widely administered in the general population worldwide. These COVID-19 vaccines offered a safety net against future infections and re-infections. Most of these vaccines contain inactivated virus or spike protein mRNA that are primarily responsible for inducing innate and adaptive immunity. These vaccines were also formulated to contain supplementary adjuvants that are beneficial in boosting the immune response. During the pandemic, clinicians all over the world witnessed an uprise in the incidence and prevalence of cardiovascular diseases (COVID-Heart Syndrome) in patients with and without cardiovascular risk factors. Clinical researchers were not certain about the underlying reason for the upsurge of cardiovascular disorders with some blaming them on COVID-19 infections while others blaming them on COVID-19 vaccines. Based on the literature review, we hypothesize that adjuvants included in the COVID-19 vaccines are the real culprits for causation of cardiovascular disorders. Operation of various pathological signaling events under the influence of these adjuvants including autoimmunity, bystander effect, direct toxicity, anti-phospholipid syndrome (APS), anaphylaxis, hypersensitivity, genetic susceptibility, epitope spreading, and anti-idiotypic antibodies were partially responsible for stirring up the onset of cardiovascular disorders. With these mechanisms in place, a minor contribution from COVID-19 virus itself cannot be ruled out. With that being said, we strongly advocate for careful selection of vaccine adjuvants included in COVID-19 vaccines so that future adverse cardiac disorders can be averted.

Changes in Health Care Access and Preventive Health Screenings by Race and Ethnicity

Importance

The COVID-19 pandemic led to unprecedented disruptions in health care. Little is known about whether health care access and preventive health screenings among US adults have recovered to prepandemic levels, and how patterns varied by race and ethnicity.

Objective

To evaluate health care access and preventive health screenings among eligible US adults in 2021 and 2022 compared with prepandemic year 2019, overall and by race and ethnicity.

Design, Setting, and Participants

This cross-sectional study used data from US adults aged 18 years or older who participated in the National Health Interview Survey in 2021 and 2022. Survey weights provided by the National Health Interview Survey were used to generate nationally representative estimates. Data were analyzed from May 23 to November 13, 2023.

Main Outcomes and Measures

Measures of health care access included the proportion of adults with a usual place for care, those with a wellness visit, and those who delayed or did not receive medical care due to cost within the past year. Preventive health screening measures included eligible adults who received blood pressure, cholesterol, or blood glucose screening within the past year (2021), as well as colorectal, cervical, breast, and prostate cancer screenings based on US Preventive Services Task Force guidelines.

Results

The unweighted study population included 89 130 US adults. The weighted population included 51.6% females; 16.8% Hispanic, 5.9% non-Hispanic Asian (hereafter, Asian), 11.8% non-Hispanic Black (hereafter, Black), 62.8% non-Hispanic White (hereafter, White) individuals; and 2.9% individuals of other races and ethnicities (including American Indian, Alaska Native, Native Hawaiian or other Pacific Islander, or multiracial). After adjusting for age and sex, having a usual place for health care did not differ among adults in 2021 or 2022 vs 2019 (adjusted rate ratio [ARR] for each year, 1.00; 95% CI, 0.99-1.01). However, fewer participants had wellness visits in 2022 compared with 2019 (ARR, 0.98; 95% CI, 0.97-0.99), with the most pronounced decline among Asian adults (ARR, 0.95; 95% CI, 0.92-0.98). In addition, adults were less likely to delay medical care (ARR, 0.79; 95% CI, 0.73-0.87) or to not receive care (ARR, 0.76; 95% CI, 0.69-0.83) due to cost in 2022 vs 2019. Preventive health screenings in 2021 remained below 2019 levels (blood pressure: ARR, 0.95 [95% CI, 0.94-0.96]; blood glucose: ARR, 0.95 [95% CI, 0.93-0.96]; and cholesterol: ARR, 0.93 [95% CI, 0.92-0.94]). Eligible adults were also significantly less likely to receive colorectal cancer screening (ARR, 0.88; 95% CI, 0.81-0.94), cervical cancer screening (ARR, 0.86; 95% CI, 0.83-0.89), breast cancer screening (ARR, 0.93; 95% CI, 0.90-0.97), and prostate cancer screening (ARR, 0.86 [0.78-0.94]) in 2021 vs 2019. Asian adults experienced the largest relative decreases across most preventive screenings, while Black and Hispanic adults experienced large declines in colorectal cancer screening (ARR, 0.78; 95% CI, 0.67-0.91) and breast cancer screening (ARR, 0.83; 95% CI, 0.75-0.91), respectively. Differences in preventive screening rates across years persisted after additional adjustment for socioeconomic factors (income, employment status, and insurance coverage).

Conclusions and Relevance

Results of this cohort study suggest that, in the US, wellness visits and preventive health screenings have not returned to prepandemic levels. These findings support the need for public health efforts to increase the use of preventive health screenings among eligible US adults.

Cardiovascular disease risk management during COVID-19: in-person vs virtual visits

OBJECTIVES

Limited research has assessed how virtual care (VC) affects cardiovascular disease (CVD) risk management, especially in community clinic settings. This study assessed change in community clinic patients' CVD risk management during the COVID-19 pandemic and CVD risk factor control among patients who had primarily in-person or primarily VC visits.

STUDY DESIGN

Retrospective interrupted time-series analysis.

METHODS

Data came from an electronic health record shared by 52 community clinics for index (March 1, 2019, to February 29, 2020) and follow-up (July 1, 2020, to February 28, 2022) periods. Analyses compared follow-up period changes in slope and level of population monthly means of 10-year reversible CVD risk score, blood pressure (BP), and hemoglobin A1c (HbA1c) among patients whose completed follow-up period visits were primarily in person vs primarily VC. Propensity score weighting minimized confounding.

RESULTS

There were 10,028 in-person and 6593 VC patients in CVD risk analyses, 9874 in-person and 5390 VC patients in BP analyses, and 8221 in-person and 4937 VC patients in HbA1c analyses. The VC group was more commonly younger, female, White, and urban. Mean reversible CVD risk, mean systolic BP, and percentage of BP measurements that were 140/90 mm Hg or higher increased significantly from index to follow-up periods in both groups. Rate of change between these periods was the same for all outcomes in both groups, regardless of care modality.

CONCLUSIONS

Among community clinic patients with CVD risk, receiving a majority of care in person vs a majority of care via VC was not significantly associated with longitudinal trends in reversible CVD risk score or key CVD risk factors.

Impact of the COVID-19 Pandemic on Stroke Subtype Presentation in Patients Without COVID-19 Infection

BACKGROUND & AIMS

It is unknown if the COVID-19 pandemic and public health measures had an immediate impact on stroke subtypes and etiologies in patients not infected with COVID-19. We aimed to evaluate if the proportion of non-COVID-19-related stroke subtypes (ischemic vs. hemorrhagic) and etiologies (cardioembolic, atherosclerosis, small vessel disease, and others) during the pandemic's first wave were different from prepandemic.

METHODS

For this retrospective cohort study, we included patients without COVID-19 with ischemic or hemorrhagic stroke at two large Canadian stroke centers between March-May 2019 (prepandemic cohort) and March-May 2020 (pandemic cohort). Proportions of stroke subtypes and etiologies were compared between cohorts using chi-square tests.

RESULTS

The prepandemic cohort consisted of 234 stroke patients and the pandemic cohort of 207 stroke patients. There were no major differences in baseline characteristics. The proportions of ischemic versus hemorrhagic stroke were similar (ischemic stroke: 77% prepandemic vs. 75% pandemic; hemorrhagic stroke:12% prepandemic vs. 14% pandemic; p > 0.05). There were no differences in etiologies, except for a decreased proportion of ischemic stroke due to atherosclerosis in the pandemic cohort (26% prepandemic vs. 15% pandemic; difference: 10.6%, 95%CI: 1.4-19.7; p = 0.03). Notably, during the pandemic, the cause of ischemic stroke was more often unknown because of incomplete work-up (13.3% prepandemic vs. 28.2% pandemic, difference: 14.9%, 95%-CI: 5.7-24.2; p = <0.01).

CONCLUSIONS

In this study, the pandemic had no clear effect on stroke subtypes and etiologies suggesting a limited impact of the pandemic on stroke triggers. However, the shift from atherosclerosis toward other causes warrants further exploration.

Drivers of telemedicine in primary care clinics at a large academic medical centre

BACKGROUND

COVID-19 disrupted healthcare routines and prompted rapid telemedicine implementation. We investigated the drivers of visit modality selection (telemedicine versus in-person) in primary care clinics at an academic medical centre.

METHODS

We used electronic medical record data from March 2020 to May 2022 from 13 primary care clinics (N = 21,031 new, N = 207,292 return visits), with 55% overall telemedicine use. Hierarchical logistic regression and cross-validation methods were used to estimate the variation in visit modality explained by the patient, clinician and visit factors as measured by the mean-test area under the curve (AUC).

RESULTS

There was significant variation in telemedicine use across clinicians (ranging from 0-100%) for the same visit diagnosis. The strongest predictors of telemedicine were the clinician seen for new visits (mean AUC of 0.79) and the primary visit diagnosis for return visits (0.77). Models based on all patient characteristics combined accounted for relatively little variation in modality selection, 0.54 for new and 0.58 for return visits, respectively. Amongst patient characteristics, males, patients over 65 years, Asians and patient's with non-English language preferences used less telemedicine; however, those using interpreter services used significantly more telemedicine.

CONCLUSION

Clinician seen and primary visit diagnoses were the best predictors of visit modality. The distinction between new and return visits and the minimal impact of patient characteristics on visit modality highlights the complexity of clinical care and warrants research approaches that go beyond linear models to uncover the emergent causal effects of specific technology features mediated by tasks, people and organisations.

Health Care Access and Cardiovascular Risk Factor Management Among Working-Age US Adults During the Pandemic

BACKGROUND

Low-income working-age US adults disproportionately experienced health care disruptions at the onset of the coronavirus disease 2019 pandemic. Little is known about how health care access and cardiovascular risk factor management changed as the pandemic went on or if patterns differed by state Medicaid expansion status.

METHODS

Cross-sectional data from the behavioral risk factor surveillance system were used to compare self-reported measures of health care access and cardiovascular risk factor management among US adults aged 18 to 64 years in 2021 (pandemic) to 2019 (prepandemic) using multivariable Poisson regression models. We assessed differential changes between low-income (<138% federal poverty level) and high-income (>400% federal poverty level) working-age adults by including an interaction term for income group and year. We then evaluated changes among low-income adults in Medicaid expansion versus nonexpansion states using a similar approach.

RESULTS

The unweighted study population included 80 767 low-income and 184 136 high-income adults. Low-income adults experienced improvements in insurance coverage (relative risk [RR], 1.10 [95% CI, 1.08-1.12]), access to a provider (RR, 1.12 [95% CI, 1.09-1.14]), and ability to afford care (RR, 1.07 [95% CI, 1.05-1.09]) in 2021 compared with 2019. While these measures also improved for high-income adults, gains in coverage and ability to afford care were more pronounced among low-income adults. However, routine visits (RR, 0.96 [95% CI, 0.94-0.98]) and cholesterol testing (RR, 0.93 [95% CI, 0.91-0.96]) decreased for low-income adults, while diabetes screening (RR, 1.01 [95% CI, 0.95-1.08]) remained stable. Treatment for hypertension (RR, 1.05 [95% CI, 1.02-1.08]) increased, and diabetes-focused visits and insulin use remained stable. These patterns were similar for high-income adults. Across most outcomes, there were no differential changes between low-income adults residing in Medicaid expansion versus nonexpansion states.

CONCLUSIONS

In this national study of working-age adults in the United States, measures of health care access improved for low- and high-income adults in 2021. However, routine outpatient visits and cardiovascular risk factor screening did not return to prepandemic levels, while risk factor treatment remained stable. As many coronavirus disease-era safety net policies come to an end, targeted strategies are needed to protect health care access and improve cardiovascular risk factor screening for working-age adults.

The Impact of COVID-19 on Hypertension and Hypertension Medication Adherence Among Underrepresented Racial and Ethnic Groups: A Scoping Review

PURPOSE OF REVIEW

To conduct a scoping review of articles which examined the impact of COVID-19 on HTN and HTN medication adherence among underrepresented racial/ethnic minorities.

RECENT FINDINGS

Seven studies were included in this review and impact of COVID-19 was examined at 4 levels: patient, provider, health system and society. The results indicated that patient level factors, such as high unemployment and inequitable access to telemedicine due to society factors- lack of access to high-speed Internet and variation in the offering of telehealth by health systems, were most impactful on adherence. Additionally, provider level clinical inertia may have further impacted adherence to HTN medication. Our review showed that the COVID-19 pandemic did not introduce new barriers but exacerbated preexisting barriers. Ongoing efforts are needed to change policies at the state and local levels to dismantle inequities in underrepresented communities to ensure access to health care with telemedicine to promote health equity.

Prevalence of plasma lipid abnormalities and associated risk factors among Iranian adults based on the findings from STEPs survey 2021

The study aimed to estimate the prevalence of lipid abnormalities in Iranian adults by demographic characterization, geographical distribution, and associated risk factors using national and sub-national representative samples of the STEPs 2021 survey in Iran. In this population-based household survey, a total of 18,119 individuals aged over 25 years provided blood samples for biochemical analysis. Dyslipidemia was defined by the presence of at least one of the lipid abnormalities of hypertriglyceridemia (≥ 150 mg/dL), hypercholesterolemia (≥ 200 mg/dL), high LDL-C (≥ 130 mg/dL), and low HDL-C (< 50 mg/dL in women, < 40 mg/dL in men), or self-reported use of lipid-lowering medications. Mixed dyslipidemia was characterized as the coexistence of high LDL-C with at least one of the hypertriglyceridemia and low HDL-C. The prevalence of each lipid abnormality was determined by each population strata, and the determinants of abnormal lipid levels were identified using a multiple logistic regression model. The prevalence was 39.7% for hypertriglyceridemia, 21.2% for hypercholesterolemia, 16.4% for high LDL-C, 68.4% for low HDL-C, and 81.0% for dyslipidemia. Hypercholesterolemia and low HDL-C were more prevalent in women, and hypertriglyceridemia was more prevalent in men. The prevalence of dyslipidemia was higher in women (OR = 1.8), obese (OR = 2.8) and overweight (OR = 2.3) persons, those residents in urban areas (OR = 1.1), those with inappropriate physical activity (OR = 1.2), patients with diabetes (OR = 2.7) and hypertension (OR = 1.9), and participants with a history (OR = 1.6) or familial history of CVDs (OR = 1.2). Mixed dyslipidemia prevalence was 13.6% in women and 11.4% in men (P < 0.05). The prevalence of lipid abnormalities was highly heterogeneous among provinces, and East Azarbaijan with 85.3% (81.5-89.1) and Golestan with 68.5% (64.8-72.2) had the highest and lowest prevalence of dyslipidemia, respectively. Although the prevalence of high cholesterol and LDL-C had a descending trend in the 2016-2021 period, the prevalence of dyslipidemia remained unchanged. There are modifiable risk factors associated with dyslipidemia that can be targeted by the primary healthcare system. To modify these risk factors and promote metabolic health in the country, action plans should come to action through a multi-sectoral and collaborative approach.

The COVID-19 pandemic and temporal change in metabolic risk factors for cardiovascular disease: A natural experiment within the HELIUS study

The coronavirus disease 2019 (COVID-19) pandemic, including the restrictive measures taken to reduce the spread of the virus, negatively affected people's health behavior. We explored whether the pandemic also had an effect on metabolic risk factors for cardiovascular disease (CVD) in women and men. We conducted a natural experiment, using data from 6962 participants without CVD at baseline (2011-2015) of six ethnic groups of the HELIUS study in Amsterdam, the Netherlands. We studied whether participants whose follow-up measurements were taken within the 11 months before the pandemic (control group) differed from those whose measurements were taken taken within 6 months after the first lockdown (exposed group). Using sex-stratified linear regressions with inverse probability weighting, we compared changes in baseline- and follow-up data between the control and exposed group in six metabolic risk factors: systolic and diastolic blood pressure (SBP, DBP), total cholesterol (TC), fasting plasma glucose (FPG), hemoglobin A1c (HbA1c), and estimated glomerular filtration rate (eGFR). Next, we explored the mediating effect of changes in body-mass index (BMI), alcohol, smoking, depressive symptoms and negative life events at follow-up. We observed less favorable changes in SBP (+1.12mmHg for women, +1.38mmHg for men), DBP (+0.85mmHg, +0.80mmHg) and FPG (only in women, +0.12 mmol/L) over time in the exposed group relative to the control group. Conversely, changes in HbA1c (-0.65 mmol/mol, -0.84 mmol/mol) and eGFR (+1.06 mL/min, +1.04 mL/min) were more favorable in the exposed compared to the control group, respectively. Changes in SBP, DBP, and FPG were partially mediated by changes in behavioral factors, in particular BMI and alcohol consumption. Concluding, the COVID-19 pandemic, in particular behavioral changes associated with restrictive lockdown measures, may have negatively affected several CVD risk factors, in both women and men.

Emergency Visits or Hospitalizations for Cardiovascular Diagnoses in the Post-Acute Phase of COVID-19

Background

Prior studies of COVID-19 cardiovascular sequelae include diagnoses made within 4 weeks, but the World Health Organization definition for "postacute phase" is >3 months.

Objectives

The purpose of this study was to determine which cardiovascular diagnoses in the postacute phase of COVID-19 are associated with SARS-CoV-2 infection.

Methods

Retrospective cohort study of all adults in Alberta who had a positive SARS-CoV-2 reverse transcription polymerase chain reaction test between March 1, 2020 and June 30, 2021, matched (by age, sex, Charlson Comorbidity score, and test date) with controls who had a negative reverse transcription polymerase chain reaction test.

Results

The 177,892 patients with laboratory confirmed SARS-CoV-2 infection (mean age 42.7 years, 49.7% female) were more likely to visit an emergency department (5.7% vs 3.3%), be hospitalized (3.4% vs 2.1%), or die (1.3% vs 0.4%) within 1 month than matched test-negative controls. After 3 months, cases were significantly more likely than controls to have an emergency department visit or hospitalization for diabetes mellitus (1.5% vs 0.7%), hypertension (0.6% vs 0.4%), heart failure (0.2% vs 0.1%), or kidney injury (0.3% vs 0.2%). In the 6,030 patients who had survived a hospitalization for COVID-19, postacute phase risks were substantially greater for diabetes mellitus (9.5% vs 3.0%, adjusted odds ratio [aOR]: 3.16 [95% CI: 2.43-4.12]), hypertension (3.5% vs 1.4%, aOR: 2.89 [95% CI: 1.97-4.23]), heart failure (2.1% vs 0.7%, aOR: 3.16 [95% CI: 1.88-5.29]), kidney injury (3.1% vs 0.8%, aOR: 2.70 [95% CI: 1.71-4.28]), bleeding (1.5% vs 0.5%, aOR: 3.40 [95% CI: 1.83-6.32]), and venous thromboembolism (0.8% vs 0.3%, aOR: 3.60 [95% CI: 1.59-8.13]).

Conclusions

Clinicians should screen COVID-19 survivors for diabetes mellitus, hypertension, heart failure, and kidney dysfunction in the postacute phase.

Psycho-Cardiological Disease in COVID-19 Era

During the coronavirus disease 2019 (COVID-19) pandemic, panic and public health responses, including self-monitored quarantine and lockdown of the city, have severely impacted mental health and caused depression or anxiety in citizens. Psycho-cardiology indicates that psychological factor plays an important role in coronary heart disease (CHD). COVID-19, depression and CHD can co-exist and deleteriously affect each other, leading to worse progression and prognosis. Delays in medical consultation and treatment have become more common than before the pandemic, inducing more cardiovascular (CV) events and sequelae. COVID-19 survivors have been identified to have more psycho-cardiological symptoms compared with non-COVID-19 controls. Undoubtedly, diet alterations and sedentary lifestyles during the pandemic will cause and aggravate psycho-cardiological diseases. Some frequently used cardiovascular drugs were found to associate with changes in depression. With the advent of the post-pandemic era, although the acute damage of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is gradually declining, the psycho-cardiological diseases related to the novel coronavirus are becoming increasingly prominent. So it is an important issue for us to explore the pathogenesis, clinical manifestations and corresponding preventive measures of this aspect.

COVID-19 and the cardiovascular system: a study of pathophysiology and interpopulation variability

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in humans can lead to various degrees of tissue and organ damage, of which cardiovascular system diseases are one of the main manifestations, such as myocarditis, myocardial infarction, and arrhythmia, which threaten the infected population worldwide. These diseases threaten the cardiovascular health of infected populations worldwide. Although the prevalence of coronavirus disease 2019 (COVID-19) has slightly improved with virus mutation and population vaccination, chronic infection, post-infection sequelae, and post-infection severe disease patients still exist, and it is still relevant to study the mechanisms linking COVID-19 to cardiovascular disease (CVD). This article introduces the pathophysiological mechanism of COVID-19-mediated cardiovascular disease and analyzes the mechanism and recent progress of the interaction between SARS-CoV-2 and the cardiovascular system from the roles of angiotensin-converting enzyme 2 (ACE2), cellular and molecular mechanisms, endothelial dysfunction, insulin resistance, iron homeostasis imbalance, and psychosocial factors, respectively. We also discussed the differences and mechanisms involved in cardiovascular system diseases combined with neocoronavirus infection in different populations and provided a theoretical basis for better disease prevention and management.

The Impact of COVID-19 on the Social Determinants of Cardiovascular Health

Cardiovascular disease is the leading noncommunicable disease and cause of premature mortality globally. Despite well established evidence of a cause-effect relationship between modifiable lifestyle behaviours and the onset of risk of chronic disease, preventive approaches to curtail increasing prevalence have been ineffective. This has undoubtedly been exacerbated by the response to COVID-19, which saw widespread national lockdowns implemented to reduce transmission and alleviate pressure on strained health care systems. A consequence of these approaches was a well documented negative impact on population health in the context of both physical and mental well-being. Although the true extent of the impact of the COVID-19 response on global health has yet to be fully realised or understood, it seems prudent to review effective preventative and management strategies that have yielded positive outcomes across the spectrum (ie, from individual to society). There is also a clear need to heed lessons learned from the COVID-19 experience in the power of collaboration and how this can be used in the design, development, and implementation of future approaches to address the longstanding burden of cardiovascular disease.

Real-World Attainment of Low-Density Lipoprotein Cholesterol Goals in Patients at High Risk of Cardiovascular Disease Treated with High-Intensity Statins: The TERESA Study

Despite steady improvements in cardiovascular disease (CVD) prevention, a scarce proportion of patients achieve the recommended LDL-C goals, even under high-intensity lipid-lowering therapy (LLT). Our study aimed to evaluate the attainment rate of LDL-C targets recommended by the 2019 European guidelines, and to characterize potential factors associated with LDL-C goal achievement and change patterns in LLT. We conducted a retrospective, observational study on patients treated with high-intensity atorvastatin or rosuvastatin ± ezetimibe at cardiology and internal medicine clinics across Spain. It included 1570 evaluable patients (median age: 62 years; established CVD: 77.5% [myocardial infarction: 34.3%]; and 85.8% at very high cardiovascular risk). Rosuvastatin ± ezetimibe was the LLT in 52.2% of patients, and atorvastatin ± ezetimibe in 47.8%. LLT had been modified in 36.8% of patients (side effects: 10%), being the most common switch from atorvastatin- to rosuvastatin-based treatment (77.2%). The risk-based LDL-C goal attainment rate was 31.1%, with 78.2% high-risk and 71.7% very high-risk patients not achieving the recommended LDL-C targets. Established CVD and familial hypercholesterolemia were significantly associated with the non-achievement of LDL-C goals. Although having limitations, this study shows that the guideline-recommended LDL-C goal attainment rate is still suboptimal despite using high-intensity statin therapy in a real-world setting in Spain.

Atteinte des cibles thérapeutiques pour le diabète de type 2 en 2015 et 2020 en médecine de soins primaires au Canada

Contexte:

Une vérification du degré d’atteinte des cibles thérapeutiques pour le diabète de type 2 au Canada s’impose afin d’en documenter l’évolution et d’identifier les sousgroupes auprès desquels il est plus urgent d’intervenir. Nous avons voulu estimer la fréquence à laquelle les cas suivis en soins primaires atteignaient leurs cibles thérapeutiques (c.-a-d., HbA1c ≤ 7,0 %, tension artérielle (TA) < 130/80 mm Hg et cholestérol à lipoprotéines de basse densité [LDL-C] < 2,00 mmol/L), le recours aux statines et aux inhibiteurs de l’enzyme de conversion de l’angiotensine (IECA) ou aux bloqueurs des récepteurs de l’angiotensine (BRA) conformément aux lignes directrices, et les effets de l’âge et du sexe.

Méthodes:

Nous avons réalisé une étude transversale auprès de 32 503 et 44 930 adultes atteints de diabète au Canada le 30 juin 2015 et le 30 juin 2020, respectivement, à l’aide des données tirées des dossiers médicaux électroniques (DME) des milieux de soins primaires de 5 provinces. Nous avons regroupé l’atteinte des cibles thérapeutiques pour le diabète selon l’âge et le sexe et comparé les groupes à l’aide d’analyses de régression logistique en tenant compte des comorbidités cardiovasculaires.

Résultats:

En 2020, les taux cibles d’HbA1c ont été atteints par 63,8 % des femmes et 58,9 % des hommes. Les cibles de TA et de LDL-C ont été atteintes par 45,6 % et 45,8 % des femmes et par 43,1 % et 59,4 % des hommes, respectivement. Les 3 cibles thérapeutiques ont été atteintes par 13,3 % des femmes et 16,5 % des hommes. Globalement, 45,3 % et 54,0 % des femmes et des hommes, respectivement, ont utilisé des statines; 46,5 % des femmes ont utilisé des inhibiteurs de l’ECA ou des BRA, contre 51,9 % des hommes. À l’exception de la TA et des taux d’HbA1c chez les femmes, l’atteinte des cibles a été moindre chez les patientes plus jeunes. L’atteinte de la cible de LDL-C et l’utilisation de statines et d’IECA ou de BRA ont été moindres chez les femmes de toutes les catégories d’âge. Entre 2015 et 2020, l’atteinte des cibles a augmenté pour l’HbA1c, est demeurée constante pour le LDL-C et a diminué pour la TA; l’utilisation des statines et des IECA ou des BRA a aussi diminué.

Interprétation:

L’atteinte des cibles de TA et l’utilisation des statines, des IECA et des BRA ont diminué entre 2015 et 2020 et étaient sous-optimales dans tous les groupes. Une amélioration à grande échelle de la qualité des soins s’impose pour promouvoir un traitement du diabète fondé sur des données probantes.

Noncompliance with Hypertension Treatment and Related Factors among Kumamoto Earthquake Victims Who Experienced the COVID-19 Pandemic during Postearthquake Recovery Period

Survivors of the Kumamoto earthquake of 2016 experienced the coronavirus disease (COVID-19) outbreak while carrying additional burdens that might bring inadequate coping. This cross-sectional survey aimed to identify untreated and interrupted consultations among those with hypertension and related factors and to identify the disaster's long-term effects. Of the 19,212 earthquake survivors who had moved to permanent housing, 7367 (4196 women and 3171 men, mean age 61.8 ± 17.3 years) completed a self-administered questionnaire. The prevalence of hypertension was 41.4%. The results of the logistic regression analysis with the significant independent variables in the bivariate analysis were: reduced income due to COVID-19 (AOR = 3.23, 95%CI = 2.27-4.58) and poor self-rated health (AOR = 2.49, 95%CI = 1.72-3.61) were associated with a risk of untreated or discontinued treatment. Moreover, living in rental, public or restoration public housing was also significantly associated with a higher risk of hypertension noncompliance (AOR = 1.92, 95%CI = 1.20-3.07; AOR = 2.47, 95%CI = 1.38-4.42; AOR = 4.12, 95%CI = 1.14-14.90). These results suggest that changes due to COVID-19, the extent of self-rated health and the type of permanent housing influence the hypertension consulting behaviour of earthquake survivors during recovery. It is crucial to implement long-term public support for the mental health, income and housing concerns of the survivors.

Achievement of treatment targets among patients with type 2 diabetes in 2015 and 2020 in Canadian primary care

BACKGROUND

An update on the degree to which patients with type 2 diabetes in Canada achieve treatment targets is needed to document progress and identify subgroups that need attention. We sought to estimate the frequency with which patients managed in primary care met treatment targets (i.e., HbA1c ≤ 7.0%, blood pressure < 130/80 mm Hg and low-density lipoprotein cholesterol [LDL-C] < 2.00 mmol/L), guideline-based use of statins and of angiotensin-convertingenzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), and the effects of patient age and sex.

METHODS

We conducted a cross-sectional study of 32 503 and 44 930 adults with diabetes in Canada on June 30, 2015, and 2020, respectively, using electronic medical record data from primary care practices across 5 provinces. We grouped achievement of diabetes targets by age and sex, and compared between groups using logistic regression with adjustment for cardiovascular comorbidities.

RESULTS

In 2020, target HbA1c levels were achieved for 63.8% of women and 58.9% of men. Blood pressure and LDL-C targets were achieved for 45.6% and 45.8% of women, and for 43.1% and 59.4% of men, respectively. All 3 treatment targets were achieved for 13.3% of women and 16.5% of men. Overall, 45.3% and 54.0% of women and men, respectively, used statins; 46.5% of women used ACE inhibitors or ARBs, compared with 51.9% of men. With the exception of blood pressure and HbA1c levels among women, target achievement was lower among younger patients. Achievement of the LDL-C target, statin use and ACE inhibitor or ARB use were lower among women at any age. From 2015 to 2020, target achievement increased for HbA1c, remained consistent for LDL-C and declined for blood pressure; use of statins and of ACE inhibitors or ARBs also declined.

INTERPRETATION

Target achievement for blood pressure and use of statins and of ACE inhibitors and ARBs declined between 2015 and 2020, and was suboptimal in all patient groups. Widespread quality improvement is needed to increase evidence-based therapy for people with diabetes.

The effect of SARS-CoV-2 infection on cardiac function in post-COVID-19 survivors: A systematic review and meta-analysis

The longitudinal trajectories of cardiac structure and function following SARS-CoV-2 infection are unclear. Therefore, this meta-analysis aims to elucidate the effect of SARS-CoV-2 infection on cardiac function in coronavirus disease 2019 (COVID-19) survivors after recovery. PubMed/MEDLINE, CENTRAL, and EMBASE were systematically searched for articles published up to 1st August 2022. A systematic review and meta-analysis were performed to calculate the pooled effects size and 95% confidence interval of each outcome. A total of 21 studies including 2394 individuals (1436 post-COVID-19 cases and 958 controls) were included in the present meta-analysis. The pooled analyses compared with control groups showed a significant association between post-COVID-19 and reduced left ventricular ejection fraction (LV EF), LV end-diastolic volume (LV EDV), LV stroke volume (LV SV), mitral annular plane systolic excursion (MAPSE), global longitudinal strain, right ventricular EF (RV EF), RV EDV, RV ESV, RV SV, tricuspid annular plane systolic excursion, and increased LV mass. Subgroup analysis based on the severity of COVID-19 in the acute phase and subsequent chronic outcomes revealed that LV EF, MAPSE, RV EF, and RV ESV only decreased in studies including patients with a history of intensive care unit admission. Cardiac impairment after SARS-CoV-2 infection persisted in recovered COVID-19 patients even after 1 year. Future studies are warranted to determine the biological mechanisms underlying the long-term cardiovascular consequences of COVID-19.

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

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.

Patterns of statin adherence in primary cardiovascular disease prevention during the pandemic

Background: Study of medication adherence patterns can help identify patients who would benefit from effective interventions to improve adherence. Objectives: To identify and compare groups of statin users based on their adherence patterns before and during the COVID-19 pandemic, to characterize the profile of users in each group, and to analyze predictors of distinct adherence patterns. Methods: Participants of the CARhES (CArdiovascular Risk factors for HEalth Services research) cohort, comprising individuals aged >16 years, residing in Aragón (Spain), with hypertension, diabetes mellitus and/or dyslipidemia, took part in this observational longitudinal study. Individuals who began statin therapy during January-June 2019 were selected and followed up until June 2021. Those with a cardiovascular event before or during follow-up were excluded. Data were obtained from healthcare system data sources. Statin treatment adherence during the implementation phase was estimated bimonthly using the Continuous Medication Availability (CMA9) function in the AdhereR package. Group-based trajectory models were developed to group statin users according to their adherence pattern during July 2019-June 2021. Group characteristics were compared and predictors of each adherence pattern were analyzed using multinomial logistic regression. Results: Of 15,332 new statin users, 30.8% had a mean CMA9 ≥80% for the entire study period. Four distinct adherence patterns were identified: high adherence (37.2% of the study population); poor adherence (35.6%); occasional use (14.9%); and gradual decline (12.3%). The latter two groups included users who showed a change in adherence (increase or decrease) during the pandemic emergence. Users with suboptimal adherence were likely to be younger, not pensioners, not institutionalized, with low morbidity burden and a low number of comorbidities. Female sex and switching between statins of different intensity increased the likelihood of belonging to the occasional use group, in which improved adherence coincided with the pandemic. Conclusion: We identified four distinct adherence patterns in a population of new statin users; two of them modified their adherence during the pandemic. Characterization of these groups could enable more effective distribution of resources in future similar crisis and the routine implementation of patient-centered interventions to improve medication adherence.

Increased Mortality in Patients With Acutely Decompensated Heart Failure During the COVID-19 Pandemic in Toronto, Canada

Background

Methods

Results

Conclusions

Differences in Treating Patients with Palpitations at the Primary Healthcare Level Using Telemedical Device Savvy before and during the COVID-19 Pandemic

Background: Palpitations are one of most common reasons why a patient visits a general practitioner (GP) and is referred to a cardiologist. Coronavirus disease 2019 (COVID-19) has been associated with new-onset arrhythmias, which are difficult to diagnose at the primary healthcare level during pandemic-related lockdown periods. Methods: A total of 151 patients with a complaint of heart rhythm disorder were included from before and during the COVID-19 pandemic, as well as after the start of vaccination, in this cohort retrospective study. We used a telemedical device—namely, a personal electrocardiographic (ECG) sensor called Savvy—to investigate heart rhythm in patients. The primary outcome of the study was to evaluate the number of actual heart rhythm disorder patients and any differences that infection with or vaccination for COVID-19 had on patients handled in a primary healthcare setting. Results: We found a heart rhythm disorder in 8.6% of patients before the COVID-19 pandemic and in 15.2–17.9% of patients during the COVID-19 pandemic, where the difference was statistically significant (p = 0.002). During the COVID-19 pandemic, we found a heart rhythm disorder in almost 50% of patients that had tested positive for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 virus) more than one month ago. After the vaccinations started, we also found a heart rhythm disorder in almost 50% of non-vaccinated patients. Conclusions: Using a telemedical approach or remote consultation is a useful method, at the primary healthcare level, for diagnosing and treating patients with palpitations during times of lockdown.

Nationwide Initiation of Cardiovascular Risk Treatments During the COVID-19 Pandemic in France: Women on a Slippery Slope?

Objectives

This study examines the initiation of prescribed medication treatments for cardiovascular risk (antihypertensives, lipid-lowering drugs, oral anticoagulants in atrial fibrillation, and smoking cessation medications) during the COVID-19 pandemic in the French population.

Methods

For each year between 2017 and 2021, we used the French National Insurance Database to identify the number of people with at least one reimbursement for these medications but no reimbursement in the previous 12 months. We computed incidence rate ratios (IRRs) between 2017–2019 and, respectively 2020 and 2021 using Poisson regression adjusted for age and 2017–2019 time trends. We recorded the number of lipid profile blood tests, Holter electrocardiograms, and consultations with family physicians or cardiologists.

Results

In 2020, IRR significantly decreased for initiations of antihypertensives (−11.1%[CI95%, −11.4%;−10.8%]), lipid-lowering drugs (−5.2%[CI95%, −5.5%;−4.8%]), oral anticoagulants in atrial fibrillation (−8.6%[CI95%, −9.1%;−8.0%]), and smoking cessation medications (−50.9%[CI95%, −51.1%;−50.7%]) compared to 2017–2019. Larger decreases were found in women compared to men except for smoking cessation medications, with the sex difference increasing with age. Similar analyses comparing 2021 to 2017–2019 showed an increase in the initiation of lipid-lowering drugs (+ 11.6%[CI95%, 10.7%;12.5%]) but even lower rates for the other medications, particularly in women. In addition, the 2020 number of people visiting a family physician or cardiologist decreased by 8.4 and 7.4%. A higher decrease in these visits was observed in those over 65 years of age compared to those under 65 years of age. A greater use of teleconsultation was found in women.

Conclusion

The COVID-19 pandemic heavily impacted the initiation of medication treatments for cardiovascular risk in France, particularly in women and people over 65 years.

Emergency Department Management of Hypertension in the Context of COVID-19

PURPOSE OF REVIEW

This review describes the relationship between COVID-19 and hypertension (HTN), and considerations for emergency medicine providers in the management of hypertensive patients during the COVID-19 pandemic.

RECENT FINDINGS

Hypertensive patients with COVID-19 have a higher risk of severe disease/complications, hospitalizations, intensive care unit (ICU) admissions, and mortality than non-hypertensive patients. Studies have also shown the importance of consideration of various demographic factors (such as older age) and socioeconomic factors that may confound these relationships. Despite concerns at the start of the pandemic that RAAS inhibiting antihypertension medications may contribute to worsened outcomes in COVID-19 patients, subsequent research has shown that use of ACEi/ARBs is associated with neutral or even improved COVID-19 outcomes. Socioeconomic factors must also be considered including patients' potential delay of health care due to fear of contracting COVID-19, loss of health insurance, and barriers to accessing primary care appointments for post-ED follow-up care. While there is mixed evidence on biological considerations for HTN care during the COVID-19 pandemic, the pandemic has undoubtedly been a major stressor and barrier to effective chronic disease management. Emergency medicine and other providers should consider this when evaluating acute care patients with a history of HTN or newly elevated blood pressure.

The influence of the pandemic on fear of contagion, blood pressure management and adherence to medication in hypertensive older adults in Turkey

The study was conducted to identify the impact of the pandemic on hypertensive older people's COVID-19 fear, blood pressure control, and medication adherence. In this descriptive, correlational study, mean medication adherence was taken as 45.6 ± 6.06% based on the literature, with a 5% margin of error, and the sample size was determined as 292 with 95% confidence interval and 80% power. Data were collected from 419 older individuals using a sociodemographic information form, an infodemic-related questionnaire, Fear of COVID-19 Scale, and Medication Adherence Self-Efficacy Scale via Google Forms. The data were analyzed using IBM SPSS Statistics 23 software via independent sample t test, one-way variance analysis, χ² analysis, and the Pearson correlation coefficient. It was found that, rather than avoiding hospitals during a pandemic, one out of two older people had had their blood pressure checked. One out of every five had abnormal/uncontrolled blood pressure during the pandemic. The infodemic was found to increase concern levels, and those with high fear scores had abnormal/uncontrolled levels of blood pressure. Moreover, a low-level positive correlation was found between medication adherence and the level of fear of COVID-19. As the pandemic continues, older people with hypertension need support in terms of monitoring blood pressure and medication adherence as well as increased awareness about the pandemic.

Post-ST-Segment Elevation Myocardial Infarction Follow-Up Care During the COVID-19 Pandemic and the Possible Benefit of Telemedicine: An Observational Study

Background: Infectious control measures during the COVID-19 pandemic have led to the propensity toward telemedicine. This study examined the impact of telemedicine during the pandemic on the long-term outcomes of ST-segment elevation myocardial infarction (STEMI) patients.

Methods: This study included 288 patients admitted 1 year before the pandemic (October 2018–December 2018) and during the pandemic (January 2020–March 2020) eras, and survived their index STEMI admission. The follow-up period was 1 year. One-year primary safety endpoint was all-cause mortality. Secondary safety endpoints were cardiac readmissions for unplanned revascularisation, non-fatal myocardial infarction, heart failure, arrythmia, unstable angina. Major adverse cardiovascular events (MACE) was defined as the composite outcome of each individual safety endpoint.

Results: Despite unfavorable in-hospital outcomes among patients admitted during the pandemic compared to pre-pandemic era, both groups had similar 1-year all-cause mortality (11.2 vs. 8.5%, respectively, p = 0.454) but higher cardiac-related (14.1 vs. 5.1%, p < 0.001) and heart failure readmissions in the pandemic vs. pre-pandemic groups (7.1 vs. 1.7%, p = 0.037). Follow-up was more frequently conducted via teleconsultations (1.2 vs. 0.2 per patient/year, p = 0.001), with reduction in physical consultations (2.1 vs. 2.6 per patient/year, p = 0.043), during the pandemic vs. pre-pandemic era. Majority achieved guideline-directed medical therapy (GDMT) during pandemic vs. pre-pandemic era (75.9 vs. 61.6%, p = 0.010). Multivariable Cox regression demonstrated achieving medication target doses (HR 0.387, 95% CI 0.164–0.915, p = 0.031) and GDMT (HR 0.271, 95% CI 0.134–0.548, p < 0.001) were independent predictors of lower 1-year MACE after adjustment.

Conclusion: The pandemic has led to the wider application of teleconsultation, with increased adherence to GDMT, enhanced medication target dosing. Achieving GDMT was associated with favorable long-term prognosis.

Depression pandemic and cardiovascular risk in the COVID-19 era and long COVID syndrome: Gender makes a difference

The ongoing COVID-19 pandemic highlighted a significant interplay between cardiovascular disease (CVD), COVID-19 related inflammatory status, and depression. Cardiovascular (CV) injury is responsible for a substantial percentage of COVID-19 deaths while COVID-19 social restrictions emerged as a non-negligible risk factor for CVD as well as a variety of mental health issues, and in particular, depression. Inflammation seems to be a shared condition between these two disorders.

Gender represents a potential modifying factor both in CVD and depression, as well as in COVID-19 short- and long-term outcomes, particularly in cases involving long-term COVID complications.

Results from emerging studies indicate that COVID-19 pandemic affected male and female populations in different ways. Women seem to experience less severe short-term complications but suffer worse long-term COVID complications, including depression, reduced physical activity, and deteriorating lifestyle habits, all of which may impact CV risk. Here, we summarize the current state of knowledge about the interplay between COVID-19, depression, and CV risk in women.

Cardiovascular implications of the COVID-19 pandemic

The COVID-19 pandemic has rapidly emerged as one of the biggest public health concerns of the 21st century. Although it was initially reported as a cluster of pneumonia cases, it quickly became apparent that COVID-19 is not merely a respiratory tract infection. Its clinical course is often complicated by cardiovascular manifestations including venous and arterial thrombosis, electrical disturbances, and myocardial damage. In addition, the cardiovascular system is involved not only during infection but also preceding the contraction of the virus; having cardiovascular comorbidities indicates significant vulnerability to the pathogen. As longer-term data continue to accumulate, we now have concerns over its lasting cardiovascular effects after recovery. Moreover, there have been substantial collateral effects on the epidemiology of cardiovascular diseases. Reports of adverse cardiovascular events from vaccination have emerged as new hurdles to our efforts to bring an end to the pandemic. As such, the association between COVID-19 and the cardiovascular system and cardiovascular practice in general is expansive. In this review, we provide an overview of the knowledge and considerations in this field, based on the evidence available at the time of this writing.

Cardiac sequelae after coronavirus disease 2019 recovery: a systematic review

BACKGROUND

Coronavirus disease 2019 (COVID-19) has been implicated in a wide spectrum of cardiac manifestations following the acute phase of the disease.

OBJECTIVES

To assess the range of cardiac sequelae after COVID-19 recovery.

DATA SOURCES

PubMed, Embase, Scopus (inception through 17 February 2021) and Google scholar (2019 through 17 February 2021).

STUDY ELIGIBILITY CRITERIA

Prospective and retrospective studies, case reports and case series.

PARTICIPANTS

Adult patients assessed for cardiac manifestations after COVID-19 recovery.

EXPOSURE

Severe acute respiratory syndrome coronavirus 2 infection diagnosed by PCR.

METHODS

Systematic review.

RESULTS

Thirty-five studies (fifteen prospective cohort, seven case reports, five cross-sectional, four case series, three retrospective cohort and one ambidirectional cohort) evaluating cardiac sequelae in 52 609 patients were included. Twenty-nine studies used objective cardiac assessments, mostly cardiac magnetic resonance imaging (CMR) in 16 studies, echocardiography in 15, electrocardiography (ECG) in 16 and cardiac biomarkers in 18. Most studies had a fair risk of bias. The median time from diagnosis/recovery to cardiac assessment was 48 days (1-180 days). Common short-term cardiac abnormalities (<3 months) included increased T1 (proportion: 30%), T2 (16%), pericardial effusion (15%) and late gadolinium enhancement (11%) on CMR, with symptoms such as chest pain (25%) and dyspnoea (36%). In the medium term (3-6 months), common changes included reduced left ventricular global longitudinal strain (30%) and late gadolinium enhancement (10%) on CMR, diastolic dysfunction (40%) on echocardiography and elevated N-terminal proB-type natriuretic peptide (18%). In addition, COVID-19 survivors had higher risk (risk ratio 3; 95% CI 2.7-3.2) of developing heart failure, arrythmias and myocardial infarction.

CONCLUSIONS

COVID-19 appears to be associated with persistent/de novo cardiac injury after recovery, particularly subclinical myocardial injury in the earlier phase and diastolic dysfunction later. Larger well-designed and controlled studies with baseline assessments are needed to better measure the extent of cardiac injury and its clinical impact.

Impact of the COVID-19 pandemic on coronary artery bypass graft surgery in Brazil: A nationwide perspective

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic has been a worldwide challenge, and efforts to "flatten the curve," including restrictions imposed by policymakers and medical societies, have forced a reduction in the number of procedures performed in the Brazilian Health Care System. The aim of this study is to evaluate the outcomes of coronary artery bypass graft (CABG) from 2008 to 2020 in the SUS and to assess the impacts of the COVID-19 pandemic in the number of procedures and death rate of CABG performed in 2020 through the database DATASUS.

METHODS

This study is based on publicly available material obtained from DATASUS, the Brazilian Ministry of Health's data processing system, on numbers of surgical procedures and death rates. Only isolated CABG procedures were included in our study. We used the TabNet software from the DATASUS website to generate reports.

RESULTS

We identified 281,760 CABG procedures performed from January 2008 to December 2020. The average number of procedures until the end of 2019 was of 22,104. During 2020 there was a 25% reduction CABG procedures, to 16,501. There was an increase in the national death rate caused by a statistical significant increase in death rates in Brazil's Southeast and Central-west regions.

CONCLUSION

The COVID-19 pandemic remains a global challenge for Brazil's health care system. During the year of 2020 there was a reduction in access to CABG related to an increase in the number of COVID-19 cases. There was also an increase in the national CABG death rate.

Older phase 2 cardiac rehabilitation patients engaged in gardening maintained physical function during the COVID-19 pandemic

This study aimed to clarify the effects of gardening on hemodynamic response, rating of perceived exertion (RPE) during exercise, and body weight in patients in whom phase 2 cardiac rehabilitation (CR) was interrupted due to the Coronavirus disease 2019 (COVID-19) pandemic. Among 76 outpatients participating in consecutive phase 2 CR in both periods from March to April and June to July 2020, which were before and after CR interruption, respectively, at Sanda City Hospital were enrolled. The inclusion criterion was outpatients whose CR was interrupted due to COVID-19. Patients under the age of 65 were excluded. We compared the data of hemodynamic response and RPE during exercise on the last day before interruption and the first day after interruption when aerobic exercise was performed at the same exercise intensity in the gardener group and the non-gardener group. Forty-one patients were enrolled in the final analysis. After CR interruption, the gardener group did not show any significant difference in all items, whereas the non-gardener group experienced significant increase in HR (Peak) (p = 0.004) and worsening of the Borg scale scores for both dyspnea and lower extremity fatigue (p = 0.039 and p = 0.009, respectively). Older phase 2 CR patients engaged in gardening did not show any deterioration in hemodynamic response or RPE during exercise, despite CR interruption and refraining from going outside. Gardening may be recommended as one of the activities that can maintain or improve physical function in older phase 2 CR patients during the COVID-19 pandemic.