How Do Hospitalizations for Heart Failure Differ Before vs During the COVID-19 Era?

Patients hospitalized for acute heart failure during the coronavirus disease 2019 (COVID-19) pandemic presented with more advanced disease and were significantly more symptomatic at that time, according to study results out of Australia published in JACC: Heart Failure.

“We sought to compare the number of HF hospitalizations, patients characteristics on presentation, and key HF quality metrics across the COVID-19 and non–COVID-19 eras,” the study authors explained, knowing that COVID-19–related public health restrictions could adversely affect overall care of patients with heart failure, but lacking concrete data on just how or to what degree.

During their analysis, they investigated inpatient mortality, length of stay (LOS), and use of guideline-directed medical therapy through a comprehensive review of records for patients admitted to hospital cardiology and medical teams.

Countrywide lockdown began in Australia on March 16, so for the study, heart failure in the COVID-19 era was restricted to March 16 through April 14, 2020. For comparison, data on patients hospitalized for heart failure between 2014 and 2017 were gleaned from Austin Health’s Victorian Cardiac Outcomes Registry-HF, which collected such data over 30-day periods each of those years.

Compared with before COVID-19, hospitalizations for heart failure dropped a significant 41% (95% CI, 44%-74%; P < .001) during the pandemic: 54 vs 32, respectively. This was seen among patients with heart failure with reduced ejection fraction (HFrEF; ≤ 35%, 35%-44%) and preserved ejection fraction (HFpEF; 45%-49%, ≥50%) did:

• HFrEF:
  • ≤ 35%: 45 vs 9
  • 35%-44%: 48 vs 5
• HFpEF:
  • 45%-49%: 28 vs 2
  • ≥ 50%: 96 vs 16

There were 217 patients in the non–COVID-19 cohort and 32 in the COVID-19 cohort. Mean (SD) ages were similar, at 79.8 (11) and 80.2 (14) years.

Admissions for patient with heart failure and related conditions also dropped across the board for those with diabetes, hypertension, stroke, cardiac implantable-electronic devices, chronic kidney disease, dementia, active malignancy, and chronic obstructive pulmonary disease.

Mean (SD) measures for blood pressure, meanwhile, were consistent:

• Non–COVID-19 era:
  • Systolic: 136 (26) mmHg
  • Diastolic: 74 (16) mmHg
• COVID-19 era:
  • Systolic: 144 (29) mmHg
  • Diastolic: 77 (12) mmHg

However, more patients did present with New York Heart Association class III, IV, and III/IV symptoms during the COVID-19 era:

• Class III: 66% vs 46%
• Class IV: 31% vs 22%
• Class III/IV: 97%% vs 68%

Upon discharge, these patients were prescribed fewer angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs) compared with before the pandemic: 35% vs 57%. Prescriptions for beta-blockers rose, for 79% vs 67%, and those for mineralocorticoid agonists remained consistent, at 36% and 34%.

The authors hypothesize that a reduction in ACE inhibitor/ARB prescriptions could be out of an overabundance of caution due to knowledge of “upregulation of the ACE2 receptor by these drug classes, given that this receptor is known to mediate SARS-CoV-2 cellular entry,” but that this is not “medically justifiable.” Severe acute respiratory syndrome coronavirus 2, or SARS-CoV-2, is the virus that causes COVID-19.

“Underuse of ACE inhibitors and ARBs is of concern and may translate to adverse clinical outcomes,” the authors conclude. “Examining reasons for the reduced hospital presentations and enhancing integrated multidisciplinary outpatient models of care in this pandemic may mitigate the collateral impact of COVID-19 in patients with HF.”

The study limitation they cautioned about was the inconsistent timing of yearly data sampling, which could change by as much as 20% regarding heart failure admissions.

Reference

Toner L, Koshy AN, Ko J, Driscoll A, Farouque O. Clinical characteristics and trends in heart failure hospitalizations: an Australian experience during the COVID-19 Lockdown. JACC Heart Fail. 2020;8(10):872-875. doi:10.1016/j.jchf.2020.05.014