International Impact of COVID-19 on the Diagnosis of Heart Disease

Abstract

Background: The coronavirus disease 2019 (COVID-19) pandemic has adversely affected diagnosis and treatment of noncommunicable diseases. Its effects on delivery of diagnostic care for cardiovascular disease, which remains the leading cause of death worldwide, have not been quantified.

Objectives: The study sought to assess COVID-19's impact on global cardiovascular diagnostic procedural volumes and safety practices.

Methods: The International Atomic Energy Agency conducted a worldwide survey assessing alterations in cardiovascular procedure volumes and safety practices resulting from COVID-19. Noninvasive and invasive cardiac testing volumes were obtained from participating sites for March and April 2020 and compared with those from March 2019. Availability of personal protective equipment and pandemic-related testing practice changes were ascertained.

Results: Surveys were submitted from 909 inpatient and outpatient centers performing cardiac diagnostic procedures, in 108 countries. Procedure volumes decreased 42% from March 2019 to March 2020, and 64% from March 2019 to April 2020. Transthoracic echocardiography decreased by 59%, transesophageal echocardiography 76%, and stress tests 78%, which varied between stress modalities. Coronary angiography (invasive or computed tomography) decreased 55% (p < 0.001 for each procedure). In multivariable regression, significantly greater reduction in procedures occurred for centers in countries with lower gross domestic product. Location in a low-income and lower-middle-income country was associated with an additional 22% reduction in cardiac procedures and less availability of personal protective equipment and telehealth.

Conclusions: COVID-19 was associated with a significant and abrupt reduction in cardiovascular diagnostic testing across the globe, especially affecting the world's economically challenged. Further study of cardiovascular outcomes and COVID-19-related changes in care delivery is warranted.

Keywords: COVID-19; cardiac testing; cardiovascular disease; coronavirus; global health.

Graphical abstract

Figure 1

Flow Diagram Detailing Survey Completion The 8-page online survey, including changes in practice performance and procedure numbers, was emailed to participants via various organizations and completed by June 10, 2020. A total of 909 participants from 108 countries were included in the final analysis.

Central Illustration

Reduction in Worldwide Cardiovascular Disease Diagnostic Testing Volume in the Beginning of the Coronavirus Disease 2019 Pandemic (March and April 2020) (Top panel) Bar chart of cardiovascular disease test volumes by International Atomic Energy Agency world regions for 2019 and for 2 months in 2020. Note the different y-axis for world regions and worldwide. The percent reductions from 2019 are reported at the tops of the columns. (Bottom panel) World map demonstrating reductions in total cardiovascular procedural volume from March 2019 to April 2020 across the 108 participating countries. Countries or territories of a country shaded gray did not have data available. The procedures recorded included morphologic and other types of rest imaging (transthoracic echocardiography and transesophageal echocardiography, cardiac magnetic resonance, positron emission tomography for infective endocarditis), coronary imaging (coronary computed tomography angiography, coronary artery calcium, and invasive coronary angiography) and stress imaging (exercise electrocardiography, stress echocardiography, nuclear stress imaging [single-photon emission computed tomography and positron emission tomography], and stress cardiac magnetic resonance). S.E. = Southeast.

Figure 2

Worldwide Reduction in Individual Cardiac Procedure Types During the Beginning of the COVID-19 Pandemic The bar graph demonstrates the reduction in the number of each procedure type for the entire world between March 2019, March 2020, and April 2020. All types of stress test modalities (exercise electrocardiography, stress echocardiography, nuclear stress imaging [single-photon emission computed tomography and positron emission tomography], and stress cardiac magnetic resonance) are grouped together. All modalities demonstrate a reduction in March 2020 and a further reduction in April 2020. CMR = cardiac magnetic resonance; COVID-19 = coronavirus disease 2019; CT = computed tomography; TEE = transesophageal echocardiography; TTE = transthoracic echocardiography.

Figure 3

Reduction in Procedures Around the World for Nonstress Imaging World maps are displayed to show reduction in nonstress imaging numbers (morphological and other indications on the left, coronary evaluation on the right) from March 2019 to April 2020. All modalities demonstrate significant reduction over this time period. Countries and territories of a country shaded gray did not have data available. CAC = coronary artery calcium score; CCTA = coronary computed tomography angiography; ICA = Invasive coronary angiography; other abbreviations as in Figure 2.

Figure 4

Worldwide Reduction in Stress Imaging Procedures (Top panel) Bar graph demonstrating reduction in procedure numbers for all stress studies in 758 facilities in 99 countries, who performed at least 1 modality of stress imaging. Individual modalities are also displayed showing reduction in each in March 2020, compared with March 2019, and a further reduction to April 2020. (Bottom panel) The world maps further illustrate these reductions for individual countries for stress electrocardiography (ECG), echocardiography (Echo), nuclear (combined single-photon emission computed tomography [SPECT] and positron emission tomography [PET]) imaging, and cardiac magnetic resonance (CMR) imaging between March 2019 and April 2020. Gray shading indicates data not available from the country or territory.

Figure 5

Reduction in Cardiac Diagnostic Procedures by Income Level The bar graph demonstrates the reduction between March 2019 and April 2020 in the number of cardiac diagnostic procedures, in low-income, lower–middle-income, upper–middle-income, and high-income countries. Abbreviations as in Figures 2 and 3.