Excess deaths in people with cardiovascular diseases during the COVID-19 pandemic

Banerjee, Amitava; Chen, Suliang; Pasea, Laura; Lai, Alvina G; Katsoulis, Michail; Denaxas, Spiros; Nafilyan, Vahe; Williams, Bryan; Wong, Wai Keong; Bakhai, Ameet; Khunti, Kamlesh; Pillay, Deenan; Noursadeghi, Mahdad; Wu, Honghan; Pareek, Nilesh; Bromage, Daniel; McDonagh, Theresa A; Byrne, Jonathan; Teo, James T H; Shah, Ajay M; Humberstone, Ben; Tang, Liang V; Shah, Anoop S V; Rubboli, Andrea; Guo, Yutao; Hu, Yu; Sudlow, Cathie L M; Lip, Gregory Y H; Hemingway, Harry

AIMS: Cardiovascular diseases (CVDs) increase mortality risk from coronavirus infection (COVID-19). There are also concerns that the pandemic has affected supply and demand of acute cardiovascular care. We estimated excess mortality in specific CVDs, both ‘direct’, through infection, and ‘indirect’, through changes in healthcare. METHODS AND RESULTS: We used (i) national mortality data for England and Wales to investigate trends in non-COVID-19 and CVD excess deaths; (ii) routine data from hospitals in England (n = 2), Italy (n = 1), and China (n = 5) to assess indirect pandemic effects on referral, diagnosis, and treatment services for CVD; and (iii) population-based electronic health records from 3 862 012 individuals in England to investigate pre- and post-COVID-19 mortality for people with incident and prevalent CVD. We incorporated pre-COVID-19 risk (by age, sex, and comorbidities), estimated population COVID-19 prevalence, and estimated relative risk (RR) of mortality in those with CVD and COVID-19 compared with CVD and non-infected (RR: 1.2, 1.5, 2.0, and 3.0). Mortality data suggest indirect effects on CVD will be delayed rather than contemporaneous (peak RR 1.14). CVD service activity decreased by 60–100% compared with pre-pandemic levels in eight hospitals across China, Italy, and England. In China, activity remained below pre-COVID-19 levels for 2–3 months even after easing lockdown and is still reduced in Italy and England. For total CVD (incident and prevalent), at 10% COVID-19 prevalence, we estimated direct impact of 31 205 and 62 410 excess deaths in England (RR 1.5 and 2.0, respectively), and indirect effect of 49 932 to 99 865 deaths. CONCLUSION: Supply and demand for CVD services have dramatically reduced across countries with potential for substantial, but avoidable, excess mortality during and after the pandemic.