Heart failure admissions and device therapy provision during the COVID-19 pandemic

Hall, R.; Chattopadhyay, R.; Pugh, P. J.

Introduction The 2020 Covid-19 pandemic saw a marked nationwide reduction in hospital admissions due to cardiovascular disease. In many institutions, including ours, it also saw redistribution of patient care from a specialty-based approach to a ward-based system, meaning patients being admitted and remaining under the care of non-specialist teams. We wished to examine the impact of these changes on heart failure patients presenting during the pandemic and on appropriate delivery of complex device therapies. Methods The study was undertaken in a large UK teaching hospital, where the annual audit programme includes NICE guidance (Technology Appraisal 314: Implantable Cardioverter Defibrillators and Cardiac Resynchronisation Therapy for Arrhythmias and Heart Failure). As per the NICE guideline, patients admitted to hospital were identified, using discharge codes, with: serious ventricular arrhythmia;familial cardiac condition with high risk of sudden cardiac death (SCD);surgical repair of congenital heart disease;and patients with heart failure and LVEF <36%. Findings during the pandemic (March to August 2020) were compared with non-pandemic (the same period in 2019). Fisher's exact test was used to compare proportions. Results Table 1 shows how many patients were eligible for device therapy and how many were offered it. Among nonheart failure patients, device therapy prescription was consistent in the 2 periods observed. Table 2 shows details of heart failure admissions during the study periods. Among heart failure patients, an 8% reduction in hospital admissions due to heart failure was observed during the pandemic. Among these patients, the proportion eligible for device therapy did not alter significantly. However, there was a significant reduction in the proportion of eligible patients who were offered device therapy (79% vs 94%, p=0.03). In addition, there was a trend towards a greater chance of patients being considered too frail for device therapy during the pandemic (p=0.08). Among 12 patients overlooked for device therapy, 10 were not under the care of Cardiology. Among 31 patients considered too frail for device therapy, 26 were not under the care of Cardiology. Conclusion During the Covid-19 pandemic, a modest reduction in hospital admission for heart failure was observed with a marked fall in identification of those eligible for device therapy. There are a number of possible explanations, including the lack of recognition of indications for device therapy when patients are under the care of non-specialists, an increased perception of patient frailty during a crisis and intense pressure to discharge patients quickly. These findings suggest that cardiac services should actively look for heart failure patients who may have missed out on life-saving device therapies during the pandemic.