Heart India

ORIGINAL ARTICLE
Year
: 2020  |  Volume : 8  |  Issue : 3  |  Page : 133--137

Impact of coronavirus disease 2019 lockdown on catheterization laboratory: An Indian perspective


Ajay Pratap Singh1, Ranjit Kumar Nath1, Ajay Raj1, Neeraj Pandit1, Puneet Aggarwal1, Ashok Kumar Thakur1, Rajeev Bharadwaj1, Vinod Kumar1, Kriti Singh2,  
1 Department of Cardiology, Atal Bihari Vajpayee Institute of Medical Sciences, Dr. Ram Manohar Lohia Hospital, New Delhi, India
2 Department of Obstetrics and Gynaecology, Institute of Medical Sciences Banaras Hindu University, Varanasi, Uttar Pradesh, India

Correspondence Address:
Ajay Raj
Department of Cardiology, Atal Bihari Vajpayee Institute of Medical Sciences, Dr. Ram Manohar Lohia Hospital, New Delhi - 110 001
India

Abstract

Aims: This study aims to study the impact of coronavirus disease 2019 (COVID-19) lockdown on catheterization laboratory (Cath Lab) utilization for cardiac patients. Subjects and Methods: In this retrospective observational study, a total number of procedures in Cath Lab during COVID-19 lockdown were compared with pre-COVID-19 lockdown time to see the impact of the pandemic on cardiac patients undergoing interventions. Results: A total of 1982 procedures (1788 in prelockdown vs. 194 in lockdown; P < 0.001) were performed in the catheterization laboratory during the 6 months' time frame of this study. There was an alarming drop in procedures by 89.1% in the lockdown period with the maximum reduction seen in diagnostic coronary angiography (96.6%), elective angioplasty decreased by 96.4%, and primary angioplasty by 82.08%. There was an increase in rescue angioplasty by 80% (P < 0.001) during the lockdown phase. There was a fall of 83.9% in admissions of acute coronary syndrome and 62.76% reduction in heart failure admissions during the lockdown period. During the study period, there were a total of 2111 admissions in the cardiac care unit (1882 in pre vs. 229 in lockdown; P < 0.001), which showed an 87.14% reduction when compared to the prelockdown group. Conclusions: We report an alarming reduction in total admissions and catheterization laboratory procedures as an impact of COVID-19-related lockdown. This represents a serious problem regarding the handling of this pandemic by the health-care system and can be used to devise proper strategies for the recovery phase of the COVID-19 pandemic.



How to cite this article:
Singh AP, Nath RK, Raj A, Pandit N, Aggarwal P, Thakur AK, Bharadwaj R, Kumar V, Singh K. Impact of coronavirus disease 2019 lockdown on catheterization laboratory: An Indian perspective.Heart India 2020;8:133-137


How to cite this URL:
Singh AP, Nath RK, Raj A, Pandit N, Aggarwal P, Thakur AK, Bharadwaj R, Kumar V, Singh K. Impact of coronavirus disease 2019 lockdown on catheterization laboratory: An Indian perspective. Heart India [serial online] 2020 [cited 2021 Jan 25 ];8:133-137
Available from: https://www.heartindia.net/text.asp?2020/8/3/133/301595


Full Text



 Introduction



Coronavirus disease 2019 (COVID-19) is capable of human-to-human transmission and was first reported from China at the end of 2019.[1] The disease was named as severe acute respiratory syndrome coronavirus 2.[2] COVID-19 has a broad spectrum of severity of disease ranging from asymptomatic carriers to severe pneumonia and acute respiratory distress syndrome requiring mechanical ventilation.[3]

After the declaration of the COVID-19 pandemic on March 11, 2020 by the World Health Organization,[4] many countries imposed a social and international lockdown to limit the spread of infection. On the same line of action, the Government of India imposed a lockdown of 22 States and Union Territories where confirmed cases were reported from March 24, 2020 onward. Currently, the lockdown has been extended till June 30, 2020 for red zone areas.[5] This pandemic has burdened the health-care system affecting the public health-care delivery system. Utilization of the available resources and reallocation of manpower has led to significant changes in the working of the health system, and the cardiac catheterization laboratory is among the worst hit in this situation.

In this study, we aim to study the effect of COVID-19 lockdown on the cardiac catheterization laboratory pre- and during the lockdown, hampering routine cardiac care.

 Subjects and Methods



This was a retrospective observational study done in the department of cardiology, where we recorded all the cases done in the Cath Lab of the department from the start of the nationwide lockdown on March 23, 2020 to the end of June 2020 (Group B). The control for Group B was the 3-month data of the prelockdown period extending from December 1, 2019 to March 1, 2020 (Group A). The period of the control group was defined by the fact that there was no social lockdown before March 23, 2020, and the disease was declared pandemic on March 11, 2020. We reviewed the data from the departmental records for comparison of the characteristics of the indication of the procedure in the groups and the procedure they underwent. We also collected data from the cardiac care unit (CCU) for the etiology of patients being admitted during the study time frame. The study protocol was cleared by the Institutional Ethical Committee.

 Results



A total of 2111 admissions were done in the CCU in the predefined time frame of this study in the department of cardiology. Total 1882 admissions were done in the prelockdown period (Group A) and 229 during the lockdown (Group B) period. A total of 1982 procedures were done in the Cath Lab with 1788 in Group A and 194 in Group B (P < 0001). During the prelockdown phase, the most common procedure was coronary angiography (CAG) (n = 961), whereas in Group B, it was permanent pacemaker implantation (PPI) (n = 41). There was a statistically significant decrease in all the procedures in the lockdown group when compared to prelockdown as shown in [Figure 1] except for the one procedure of rescue angioplasty (percutaneous transluminal coronary angioplasty [rPTCA]) (Group A [10] vs. Group B [18]; P < 0.001).{Figure 1}

Reduction in all emergency procedures such as CAG, elective angioplasty (PTCA + S)], primary angioplasty (1° PTCA), PPI, pulse generator replacement (PGR), temporary pacemaker implantation (TPI), and pulmonary valve balloon dilatation (PVBD) was seen in the period. In other procedures also, there was a significant fall in the lockdown group, percutaneous transvenous mitral commissurotomy (PTMC), Cath study, peripheral angiography, peripheral angioplasty (PTA), digital subtraction angiography (DSA), percutaneous device closure, coiling, and electrophysiology study as shown in [Table 1].{Table 1}

Comparing the percentage fall in lockdown period procedure with the prelockdown period, there was 96.6% fall in CAG, 82.08% in 1°PTCA, 96.44% in PTCA + S, 40.57% in PPI, 66.6% in TPI, and 42.30% fall in PGR.

Comparing the indication of admission between the two groups, the most common cause of admission was acute coronary syndrome (ACS) (Group A [456] vs. Group B [73]; P < 0.001) with ST-segment elevation myocardial infarction (STEMI) being the most common diagnosis (Group A [236] vs. Group B [56]; P < 0.001), followed by Non-ST segment elevation myocardial infarction (NSTEMI) (Group A [183] vs. Group B [15]; P < 0.001) and unstable angina (USA) (Group A [37] vs. Group B [2]; P < 0.001). A comparison of other indications for admission was done including stable angina (Group A [56] vs. Group B [8]; p0.001), heart blocks (Group A [76] vs. Group B [44]; P < 0.001), mitral stenosis (Group A [18] vs. Group B [0]; P = 0.016), pulmonary stenosis (Group A [4] vs. Group B [1]; P = 0.009) and PPI end of life for PGR (Group A [26] vs. Group B [15]; p0.002), which showed that the difference was statistically significant between all these indications for decrement in admissions during the lockdown period. The percentage drop was statistically significant for admissions of STEMI, NSTEMI, USA, stable angina, and heart block during the lockdown period as shown in [Figure 2]. There was 42.30% fall in PGR and 75% fall in pulmonary stenosis during the lockdown period when compared to the prelockdown period.{Figure 2}

Comparing the heart failure (HF) admissions in both the groups (Group A [94] vs. Group B [35]; P < 0.001), it was significantly more in the prelockdown group; a 62.76% fall was seen in HF hospitalizations during the lockdown period. The total admission during the study period in the CCU was also significantly more in the prelockdown period (Group A [1882] vs. Group B [229]; P < 0.001), and comparing the fall in percentage, we found a 87.7% fall in total admission in the lockdown period as shown in [Figure 3].{Figure 3}

 Discussion



In this single-center observational study, there was a dramatic fall in the total number of procedures postimplementation of the COVID-19 lockdown since March 2020. A similar finding of drastic reduction was also seen with the total number of admissions along the entire spectrum of cardiovascular diseases affecting mainly ACS. The probable cause of such a significant drop can be attributed to the number of causes and the government implemented COVID-19 lockdown being the most decisive one. Other factors such as avoidance of medical care due to implementation of social distancing, grave concerns among the patients of contracting COVID-19 infection from the hospital itself, overburdened medial transport facilities increasing the burden of late presentations, after being told extensively by the local and national government to stay at home and avoid hospital until absolutely necessary, it has inculcated a sense of reluctance and avoidance in the patients; many people has lost jobs during this COVID-19 lockdown period bring a financial constrain and limiting them to visit hospitals. Another reason that led to such an alarming reduction can be the reallocation of health-care providers in such a difficult time of pandemic to fill in the overburdened emergency medical services due to the exponential increase in cases of COVID-19, which has led to the development of attitude of deferral of less urgent cases at both the patient and medical system.

In this study, we found a significant reduction in CCU admissions for STEMI (76.2%), NSTEMI (91.8%), and USA (94.5%) in the COVID-19 lockdown period.

A similar finding was also seen in Italy where they found a 48.4% reduction in (acute myocardial infarction [AMI]), 65.1% reduction in NSTEMI, and a 26.5% reduction in STEMI cases when compared to previous year data for the same time frame.[6] Such alarming reduction has already been reported from Germany, where they found that at peak of COVID-19, the admission rate fell significantly (41.1 as compared to 55.9 [previous year reference] and 53.7 (same year reference) P < 0.001). They also showed a reduction in admission in STEMI (8.9 post vs. 11.1 pre; P < 0.001), NSTEMI (31.3 post vs. 42.4 pre; P < 0.001), and USA (13.3 post vs. 18.1 pre; P < 0.001).[7] A significant reduction was also seen in a study done in Monaco where they found an 18% reduction compared to the previous year during this time of COVID-19 pandemic.[8]

A Spanish study was also in concordance to these figures where they reported a 56% reduction in interventional diagnostic procedures and 48% reduction in coronary intervention procedures during this pandemic time.[9] A similar alarming result was also seen in the United States of America having the maximum number of COVID-19 patients currently; in there, they found a 38% reduction in activation of catheterization laboratory to AMI.[10]

In another study done in Hong Kong, China, they observed a significant decrease in 1° PTCA during the COVID-19 period when compared to the same time in the previous year (7 in COVID-19 time vs. 48 same time frame in 2019; P < 0.001); they also showed that the delay from the onset of the symptoms to first medical contact was significantly increased during this pandemic time (318 min vs. 82.5 min in 2019; P < 0.001).[11]

In this study, we also report an increase in rescue PTCA during the lockdown period (Group A [10] vs. Group B [18]; P < 0.001); this can be explained with the delay of the patient reaching to a PCI capable center as shown in Chinese study.[11] Moreover, in many centers, due to lack of proper resources, COVID-19 testing and prevailing logistics problem thrombolysis is considered before 1°PTCA, especially in hemodynamically stable patients with moderate-to-severe COVID symptoms.[12] Another hypothesis for such fall in AMI is shown by the study done by Baldi et al. from Italy where they showed that there was 52% increase in out hospital cardiac arrest during this COVID-19 pandemic when compared to the previous year data.[13]

When HF admission was compared between the two groups, there was a significant less admission during the COVID-19 lockdown (Group A [94] vs. Group B [35]; P < 0.001), which averaged to 7.84 admissions/week in Group A compared to 2.92/week in Group B (P < 0.001). This finding of our study was similar with the study done in the United Kingdom where the HF hospitalization was decreased to 4/week, which was significantly low when compared to the previous 3 years of rates during the same time.[14]

Similarly, when individual procedures were considered in the lockdown period, we found a significant decrease in diagnostic angiography (96.6%), PGR (42.30%), PPI (40.57%), and TPI (66.67%), whereas other procedures decreased up to 100% like EP study, PTMC, peripheral angiogram, PTA, device closure, and coiling compared to prelockdown time frame. This decrease was more than the previous Spanish study [9] where the fall was 56% in diagnostic procedures, 48% in coronary therapeutics, and 81% in structural therapeutics. The reason for such sudden fall can be due to the cancellation of elective procedures as per the Government of India mandate,[15] and all of the cardiac health-care systems were prioritizing toward non-COVID-19 emergency cases only, and deferral of nonemergency cases was taken up as a measure to conserve the manpower, resources like N95 masks, and personal protective equipment for the pandemic.

A similar reduction in admissions and procedures has been reported from almost all the fields of medicine and surgery due to the COVID-19 pandemic.[16],[17],[18],[19],[20]

This study brings out the frightening picture of reduction in the hospitalization and catheterization procedures during this COVID-19 pandemic. This fall is due to an actual decrease in the incidence of the disease or due to lockdown requires larger studies. This should ring an alarm as the number of pending procedures will flood once the pandemic is in the recovery phase and a proper plan is to be devised for fluid rebooting of the Cath Lab during that phase. Another aspect of this fall can be seen as an increase in late presentation, postmyocardial infarction complication, and patient with advanced HF yet to come in the recovery phase of the pandemic which may overburden the health-care delivery system.

 Conclusions



This study shows that due to the COVID-19 lockdown, there was a significant reduction in the functioning of the cardiac catheterization laboratory when compared to the previous functioning laboratory, hampering the management of cardiac patients requiring indicated interventions. This can be used to devise proper strategies for better health-care delivery system in the recovery phase of the COVID-19 pandemic.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Authors Contribution:

Conceptualization: Ajay Raj and Ajay Pratap Singh Writing - original draft: Ajay Pratap Singh Writing - review & editing: Ranjit Kumar Nath and Puneet Aggarwal Formal analysis: Neeraj Pandit and Rajeev Bharadwaj Investigation: Vinod Kumar Supervision: Kriti Singh and Ashok Kumar Thakur Statistical analysis: Kriti Singh

Ethical Approval

All procedures done were following the ethical standards of the institutional ethics committee and with the Helsinki Declaration of 1964 and later versions. Written Informed consent was obtained from all patients participating in the study.

References

1Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med 2020;382:727-33.
2Fauci AS, Lane HC, Redfield RR. Covid-19-Navigating the uncharted. N Engl J Med 2020;382:1268-9.
3Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020;382:1708-20.
4World Health Organization. 2020. Coronavirus. Available from: https://www.who.int/healthtopics/coronavirus#tab=tab_1. [Last accessed on 2020 Jul 10].
5The Lancet. India under COVID-19 lockdown. Lancet 2020;395:1315.
6De Rosa S, Spaccarotella C, Basso C, Calabrò MP, Curcio A, Filardi PP, et al. Reduction of hospitalizations for myocardial infarction in Italy in the COVID-19 era. Eur Heart J 2020;41:2083-8.
7Kessler T, Graf T, Hilgendorf I, Rizas K, Martens E, von Zur Mühlen C, et al. Hospital admissions with acute coronary syndromes during the COVID-19 pandemic in German cardiac care units. Cardiovasc Res 2020;116:1800-1.
8Enache B, Claessens YE, Boulay F, Dor V, Eker A, Civaia F, Pathak A. Reduction in cardiovascular emergency admissions in Monaco during the COVID-19 pandemic. Clin Res Cardiol. 2020 Jun 12:1–2. doi: 10.1007/s00392-020-01687-w. Epub ahead of print. PMID: 32533248; PMCID: PMC7291940.
9Oriol Rodríguez-Leor, Belén Cid-Álvarez, Soledad Ojeda, Javier Martín-Moreiras, José Ramón Rumoroso, et al. Impacto de la pandemia de COVID-19 sobre la actividad asistencial en cardiología intervencionista en España. REC Interv Cardiol. 2020;2:82-89. doi: https://doi.org/10.24875/RECICE.M20000123
10Garcia S, Albaghdadi MS, Meraj PM, Schmidt C, Garberich R, Jaffer FA, et al. Reduction in ST-Segment Elevation Cardiac Catheterization Laboratory Activations in the United States During COVID-19 Pandemic. J Am Coll Cardiol 2020;75:2871-2.
11Tam CF, Cheung KS, Lam S, Wong A, Yung A, Sze M, et al. Impact of coronavirus disease 2019 (COVID-19) outbreak on ST-segment-elevation myocardial infarction care in Hong Kong, China. Circ Cardiovasc Qual Outcomes 2020;13:e006631.
12Kerkar PG, Naik N, Alexander T, Bahl VK, Chakraborty RN, Chatterjee SS, et al. Cardiological Society of India: Document on acute MI care during COVID-19. Indian Heart J 2020;72:70-4.
13Baldi E, Sechi GM, Mare C, Canevari F, Brancaglione A, Primi R, et al. Out-of-Hospital Cardiac Arrest during the Covid-19 Outbreak in Italy. N Engl J Med 2020;383:496-8.
14Bromage DI, Cannatà A, Rind IA, Gregorio C, Piper S, Shah AM, et al. The impact of COVID-19 on heart failure hospitalization and management: Report from a Heart Failure Unit in London during the peak of the pandemic. Eur J Heart Fail 2020;22:978-84.
15Mohfw. Gov. In, 2020. “Advisory for the Hospitals and Medical Education System”. Available from: https://www.mohfw.gov. in/pdf/AdvisoryforHospitalsandMedicalInstitutions.pdf. [Last accessed on 2020 Jul 13].
16Hampton M, Clark M, Baxter i, Stevens R, Flatt E, Murray J, et al. The effects of a UK lockdown on orthopaedic trauma admissions and surgical cases. Bone Joint Open 2020;5:137-43.
17Grandi G, Del Savio MC, Caroli M, Capobianco G, Dessole F, Tupponi G, et al. (2020), The impact of COVID-19 lockdown on admission to gynecological emergency departments: Results from a multicenter Italian study. Int J Gynecol Obstet, 151: 39-42. doi:10.1002/ijgo.13289.
18Motterle G, Morlacco A, Iafrate M, Bianco M, Federa G, Xhafka O, et al. The impact of COVID-19 pandemic on urological emergencies: a single-center experience. World J Urol. 2020 May 23:1–5. doi: 10.1007/s00345-020-03264-2. Epub ahead of print. PMID: 32447443; PMCID: PMC7245166.
19Kristoffersen ES, Jahr SH, Thommessen B, Rønning OM. Effect of COVID-19 pandemic on stroke admission rates in a Norwegian population. Acta Neurol Scand. 2020 Jul 3:10.1111/ane.13307. doi: 10.1111/ane.13307. Epub ahead of print. PMID: 32620027; PMCID: PMC7361547.
20Cozza V, Fransvea P, La Greca A, De Paolis P, Marini P, Zago M, et al. I-ACTSS-COVID-19-the Italian acute care and trauma surgery survey for COVID-19 pandemic outbreak. Updates Surg 2020;72:297-304.
21“India: WHO Coronavirus Disease (COVID-19) Dashboard”. COVID19. Who. Int, 2020. Available from: https://covid19.who.int/region/searo/country/in. [Last accessed on 2020 Jul 13].