Impact of COVID-19 on Cardiovascular Testing in the United States Versus the Rest of the World

Abstract

Objectives: This study sought to quantify and compare the decline in volumes of cardiovascular procedures between the United States and non-U.S. institutions during the early phase of the coronavirus disease-2019 (COVID-19) pandemic.

Background: The COVID-19 pandemic has disrupted the care of many non-COVID-19 illnesses. Reductions in diagnostic cardiovascular testing around the world have led to concerns over the implications of reduced testing for cardiovascular disease (CVD) morbidity and mortality.

Methods: Data were submitted to the INCAPS-COVID (International Atomic Energy Agency Non-Invasive Cardiology Protocols Study of COVID-19), a multinational registry comprising 909 institutions in 108 countries (including 155 facilities in 40 U.S. states), assessing the impact of the COVID-19 pandemic on volumes of diagnostic cardiovascular procedures. Data were obtained for April 2020 and compared with volumes of baseline procedures from March 2019. We compared laboratory characteristics, practices, and procedure volumes between U.S. and non-U.S. facilities and between U.S. geographic regions and identified factors associated with volume reduction in the United States.

Results: Reductions in the volumes of procedures in the United States were similar to those in non-U.S. facilities (68% vs. 63%, respectively; p = 0.237), although U.S. facilities reported greater reductions in invasive coronary angiography (69% vs. 53%, respectively; p < 0.001). Significantly more U.S. facilities reported increased use of telehealth and patient screening measures than non-U.S. facilities, such as temperature checks, symptom screenings, and COVID-19 testing. Reductions in volumes of procedures differed between U.S. regions, with larger declines observed in the Northeast (76%) and Midwest (74%) than in the South (62%) and West (44%). Prevalence of COVID-19, staff redeployments, outpatient centers, and urban centers were associated with greater reductions in volume in U.S. facilities in a multivariable analysis.

Conclusions: We observed marked reductions in U.S. cardiovascular testing in the early phase of the pandemic and significant variability between U.S. regions. The association between reductions of volumes and COVID-19 prevalence in the United States highlighted the need for proactive efforts to maintain access to cardiovascular testing in areas most affected by outbreaks of COVID-19 infection.

Keywords: COVID-19; cardiovascular disease; cardiovascular imaging; coronavirus; diagnostic cardiovascular procedure.

Graphical abstract

Figure 1

Percentage Reduction in Procedure Volumes from March 2019 to April 2020 for U.S. and Non-U.S. Imaging Centers Clustered bar graphs showing the percentage reduction in procedure volumes from March 2019 to April 2020 by diagnostic test type and by U.S. (red) and non-U.S. (green) centers. ICA (p < 0.001) and stress PET (p = 0.021) were the only tests in which the difference in percent reduction between U.S. and non-U.S. centers was statistically significant. CAC = coronary artery calcium scan; CCTA = coronary computed tomographic angiography; CMR = cardiac magnetic resonance imaging; ECG = electrocardiogram; echo = echocardiogram; ICA = invasive coronary angiography; IQR = interquartile range; PET = positron emission tomography; SPECT = single-photon emission computed tomography; TEE = transesophageal echocardiogram; TTE = transthoracic echocardiogram.

Central Illustration

Geographic Differences in Diagnostic Cardiovascular Procedure Volume Reductions in the United States U.S. maps demonstrate the percentage of reduction in diagnostic cardiovascular procedures from March 2019 to March 2020 (left map) and March 2019 to April 2020 (right map). States are grouped together by U.S. census regions: West (left), Midwest (top middle), Northeast (top right), and South (bottom right). Alaska and Hawaii are included in the West region. Differences in overall volume reductions were similar between U.S. regions in March 2020 (p = 0.069) but different in April 2020 (p < 0.001), with the greatest declines seen in the Northeast and Midwest.

Figure 2

Reduction in U.S. Cardiovascular Procedure Volumes by Diagnostic Test and Region Clustered bar graphs display the number of procedures for March 2019 (red), March 2020 (green), and April 2020 (blue) for each test and each U.S. region. TTE was the most represented diagnostic test in the study, followed by stress tests and ICA procedures. The greatest declines in the volume of procedures were seen in stress tests, CCTA, CMR, and CAC. Regional declines were greatest in the Northeast and Midwest, followed by the South and West. PET infection is not shown in the figure due to the small sample size. Abbreviations as in Figure 1.