The Impact of COVID-19 Pandemic and Lockdown Restrictions on Cardiac Implantable Device Recipients with Remote Monitoring

Abstract

From 2020, many countries have adopted several restrictions to limit the COVID-19 pandemic. The forced containment impacted on healthcare organizations and the everyday life of patients with heart disease. We prospectively analyzed data recorded from implantable defibrillators and/or cardiac resynchronization devices of Italian patients during the lockdown (LDP), post-lockdown period (PLDP) and a control period (CP) of the previous year. We analyzed device data of the period 9 March 2019-31 May 2020 of remotely monitored patients from 34 Italian centers. Patients were also categorized according to areas with high/low infection prevalence. Among 696 patients, we observed a significant drop in median activity in LDP as compared to CP that significantly increased in the PLDP, but well below CP (all p < 0.0001). The median day heart rate and heart rate variability showed a similar trend. This behavior was associated during LDP with a significant increase in the burden of atrial arrhythmias (p = 0.0150 versus CP) and of ventricular arrhythmias [6.6 vs. 1.5 per 100 patient-weeks in CP; p = 0.0026]; the latter decreased in PLDP [0.3 per 100 patient-weeks; p = 0.0035 vs. LDP]. No modifications were recorded in thoracic fluid levels. The high/low prevalence of COVID-19 infection had no significant impact. We found an increase in the arrhythmic burden in LDP coupled with a decrease in physical activity and heart rate variability, without significant modifications of transthoracic impedance, independent from COVID-19 infection prevalence. These findings suggest a negative impact of the COVID-19 pandemic, probably related to lockdown restrictions.

Keywords: COVID-19; arrhythmias; heart failure; pandemia; physical activity; telemonitoring.

Figure 1

Median activity of the entire population during the study period. Legend: Period 1 = Lockdown control period (year 2019); Period 2 = Post-lockdown control period (year 2019); Period 3 = Lockdown period (year 2020); Period 4 = Post-lockdown period (year 2020). For the temporal definition of the three periods, please see the Methods section; p < 0.0001 for mean period 3 vs. mean period 1, mean period 3 vs. mean period 4, mean period 2 vs. mean period 4; p = 0.0162 mean period 1 vs. mean period 2.

Figure 2

Total time in AT/AF of the entire population during the study period. Legend: Period 1 = Lockdown control period (year 2019); Period 2 = Post-lockdown control period (year 2019); Period 3 = Lockdown period (year 2020); Period 4 = Post-lockdown period (year 2020). For the temporal definition of the three periods please see the Methods section; AT/AF = atrial tachycardia/atrial fibrillation; p = 0.0150 for mean period 3 vs. mean period 1; p = N.S. for all other comparisons.

Figure 3

Median heart rate variability of the entire population during the study period. Legend: Period 1 = Lockdown control period (year 2019); Period 2 = Post-lockdown control period (year 2019); Period 3 = Lockdown period (year 2020); Period 4 = Post-lockdown period (year 2020). For the temporal definition of the three periods please see the Methods section; HRV = heart rate variability; p < 0.0001 for mean period 3 vs. mean period 1, mean period 3 vs. mean period 4; p = 0.0018 for mean period 1 vs. mean period 2; p = N.S. for all other comparisons.

Figure 4

Burden of ventricular arrhythmias of the entire population during the study period. (A). Mean weekly number of ventricular arrhythmias (VT monitor, VT, FVT and VF); (B) Mean weekly number of ventricular tachycardias (VT). end: Period 1 = Lockdown control period (year 2019); Period 2 = Post-lockdown control period (year 2019); Period 3 = Lockdown period (year 2020); Period 4 = Post-lockdown period (year 2020). For the temporal definition of the three periods please see the Methods section; VA = ventricular arrhythmias; VT = ventricular tachycardias; (A): p = 0.026 for mean period 3 vs. mean period 1; p = 0.0338 for mean period 3 vs. mean period 4; p = N.S. for all other comparisons. (B): p = 0.024 for mean period 3 vs. mean period 1; p = 0.0035 for mean period 3 vs. mean period 4; p = N.S. for all other comparisons.

Figure 5

Evaluation of restricting policies in the U.S. and Italy during the observation periods analyzed by O’Shea et al. (blue shaded) and in our analysis (red-shaded area is the lockdown period, and the green-shaded area is the post-lockdown period). The y-axis reports a composite measure based on nine response indicators including school closures, workplace closures, and travel bans, rescaled to a value from 0 to 100 (100 = strictest) (for additional information, see https://ourworldindata.org/grapher/covid-stringency-index?tab=chart, accessed on 2 January 2021).