Reduction in Hospitalization and Increase in Mortality Due to Cardiovascular Diseases during the COVID-19 Pandemic in Brazil

Paulo Garcia Normando José de Arimatéia Araujo-Filho Gabriela de Alcântara Fonseca Rodrigo Elton Ferreira Rodrigues Victor Agripino Oliveira Ludhmila Abrahão Hajjar André Luiz Cerqueira Almeida Edimar Alcides Bocchi Vera Maria Cury Salemi Marcelo Melo About the authors

Resumo

Fundamento

Na pandemia pela COVID-19, o aumento da ocorrência e da mortalidade por doenças cardiovasculares (DCV) vem sendo reconhecido no mundo. No Brasil, é essencial que o impacto da COVID-19 na DCV seja analisado.

Objetivos

Avaliar o impacto desta pandemia nos números de internações hospitalares (IH), óbitos hospitalares (OH) e letalidade intra-hospitalar (LH) por DCV a partir de dados epidemiológicos do Sistema Único de Saúde (SUS).

Métodos

Estudo observacional de séries temporais por meio da análise comparativa das taxas de IH, OH e LH por DCV registrados entre janeiro e maio de 2020, usando como referência os valores obtidos no mesmo período entre 2016 e 2019 e os valores projetados por métodos de regressão linear para o ano de 2020. O nível significância estatística utilizado foi de 0,05.

Resultados

Em comparação com o mesmo período de 2019, houve um decréscimo de 15% na taxa de IH e de 9% no total de OH por DCV entre março e maio de 2020, acompanhado de um aumento de 9% na taxa de LH por esse grupo de doenças, sobretudo entre pacientes com idade de 20-59 anos. As taxas de IH e LH registradas em 2020 diferiram significativamente da tendência projetada para o corrente ano (p=0,0005 e 0,0318, respectivamente).

Conclusões

Durante os primeiros meses da pandemia, observou-se um declínio na IH associado a um aumento da LH por DCV no Brasil. Esses dados possivelmente são consequência do planejamento inadequado no manejo das DCV durante a pandemia, sendo necessária a implementação de ações imediatas para modificar esse cenário. (Arq Bras Cardiol. 2021; [online].ahead print, PP.0-0)

COVID-19; Betacoronavírus; Pandemia; Doenças Cardiovasculares/complicações; Epidemiologia; Hospitalização; Mortalidade; Comorbidades; Sistema Único de Saúde (SUS)

Abstract

Background

In the COVID-19 pandemic, the increase in the incidence of cardiovascular diseases (CVD) and mortality from them has been recognized worldwide. In Brazil, the impact of COVID-19 on CVD must be evaluated.

Objectives

To assess the impact of the current pandemic on the numbers of hospital admissions (HA), in-hospital deaths (ID), and in-hospital fatality (IF) from CVD by use of national epidemiological data from the Brazilian Unified Public Health System.

Methods

Time-series observational study using comparative analysis of the HA, ID, and IF due to CVD recorded from January to May 2020, having as reference the values registered in the same period from 2016 to 2019 and the values projected by linear regression methods for 2020. The statistical significance level applied was 0.05.

Results

Compared to the same period in 2019, there was a 15% decrease in the HA rate and a 9% decrease in the total ID due to CVD between March and May 2020, followed by a 9% increase in the IF rate due to CVD, especially among patients aged 20-59 years. The HA and IF rates registered in 2020 differed significantly from the projected trend for 2020 (p = 0.0005 and 0.0318, respectively).

Conclusions

During the first months of the pandemic, there were a decline in HA and an increase in IF due to CVD in Brazil. These data might have resulted from the inadequate planning of the CVD management during the pandemic. Thus, immediate actions are required to change this scenario. (Arq Bras Cardiol. 2021; [online].ahead print, PP.0-0)

COVID-19; Betacoronavirus; Pandemics; Cardiovascular Diseases/complications; Epidemiology; Hospitalization; Mortality; Comorbidities; Unified Health System

Introduction

The outbreak of the coronavirus disease 2019 (COVID-19) was declared a pandemic by the World Health Organization on March 11, 2020. In July 2020, Brazil ranked second in the number of cases and deaths from COVID-19. By July 24, 2020, Brazil had recorded 2 276 860 confirmed cases of COVID-19 and 84 551 deaths from the disease.11. Ahn D-G, Shin H-J, Kim M-H, Lee S, Kim HS, Myoung J, et al. Current status of epidemiology, diagnosis, therapeutics, and vaccines for novel coronavirus disease 2019 (COVID-19). J Microbiol Biotechnol. 2020 Mar 28;30(3):313–24.

Considering that COVID-19 is spread primarily via droplets expelled during talking, coughing, and sneezing, or via contaminated surfaces,44. Wiersinga WJ, Rhodes A, Cheng AC, Peacock SJ, Prescott HC. Pathophysiology, transmission, diagnosis, and treatment of coronavirus disease 2019 (COVID-19): A Review. JAMA. 2020 Aug 25;324(8):782-93.restrictions to people traffic and contact have been proposed by government and public health authorities in most western countries. In Brazil, the logistic challenges to meet the patients’ demands have included not only the increase in the number of beds in intensive care units and wards, but also the suspension of elective healthcare provision and of elective complementary tests and procedures, in addition to targeting public resources at the COVID-19 management.55. Castro MC, Carvalho LR de, Chin T, et al. Demand for hospitalization services for COVID-19 patients in Brazil. medRxiv. 2020 Apr 1;2020.03.30.20047662.

Population studies in other countries have reported a relative reduction in hospital admissions for cardiovascular diseases (CVD) during the COVID-19 pandemic,88. Brasil, Ministério da Saúde. DATASUS. Morbidade Hospitalar do SUS (SIH/SUS) [Internet]. 2020. [Citado em 20 jul 2020] Disponível em: https://datasus.saude.gov.br/acesso-a-informacao/morbidade-hospitalar-do-sus-sih-sus/
https://datasus.saude.gov.br/acesso-a-in...
, 99. Toniolo M, Negri F, Antonutti M, Masé M, Facchin D. Unpredictable fall of severe emergent cardiovascular diseases hospital admissions during the COVID-19 pandemic: Experience of a single large center in northern Italy. J Am Heart Assoc. 2020 Jul 7;9(13):e017122. in association with an increase in the fatality rates related to that group of diseases,1010. Alsaied T, Aboulhosn JA, Cotts TB, Daniels CJ, Etheridge SP, Feltes TF, et al. Coronavirus disease 2019 (COVID-19) pandemic implications in pediatric and adult congenital heart disease. J Am Heart Assoc. 2020 Jun 16;9(12):e017224. , 1111. Shi S, Qin M, Shen B, Cai Y, Liu T, Yang F, et al. Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China. JAMA Cardiol. 2020 Jul 1;5(7):802-10 a reason for great concern in the international medical and scientific community.

Thus, we tested the hypothesis that, during the COVID-19 pandemic, there was a reduction in cardiovascular care provision and in the number of cardiovascular interventions performed, which might have led to higher in-hospital mortality from CVD in the general population. Using public databases from the Brazilian Unified Public Health System (SUS), this study aimed at assessing the impact of the pandemic on the number of hospital admissions and on in-hospital fatality due to CVD in Brazil from January to May 2020, as compared to those in the same months of the previous 4 years. In addition, pre-hospital clinical elements, such as elective procedures, were assessed.

Methods

This is a time-series observational study to assess the hospital admissions, in-hospital deaths, and in-hospital fatality rates (percentage of deaths among the admissions) related to CVD at SUS own units or at healthcare units with which SUS maintains an agreement, from January to May of the years 2016 to 2020. In addition, CVD-related in-hospital and outpatient procedures performed at those units during the same periods were assessed. The first two variables were classified according to age group as follows: child/adolescent (0-19 years), adult (20-59 years), and elderly (60 years and older). Data were collected on July 9, 2020, from the Brazilian Hospital Information System and Brazilian Outpatient Information System of the SUS (SIH and SIA/SUS, respectively), available at the DATASUS platform. Those systems are public and anonymous, in accordance with the first article of the Resolution 510/2016 of the Brazilian Committee on Ethics and Research. It is worth noting that updates on past admissions can occur in the platform at any time, thus, it is not guaranteed that all data are consolidated, regardless of the year.

For the analysis of the procedures, we used the codes of the SUS System for the Management of the Table of Procedures, Medications, Orthoses, Prostheses and Materials (SIGTAP). For each procedure selected, the in-hospital and outpatient productions were added, considering all correlated procedure codes. The procedures were as follows:

Diagnostic procedures: cardiac catheterization, echocardiography (stress, transesophageal, and transthoracic), electrocardiography, cardiac pacemaker implantation, 24-hour Holter monitoring, ambulatory blood pressure monitoring (ABPM), exercise test.

Surgical procedures: cardiovascular, endovascular, and vascular surgeries.

To assess the number of admissions, in-hospital deaths, and in-hospital fatality, we selected, for each age group, the records of the secondary diagnoses related to the corresponding cardiovascular pathologies in the List of Morbidity of the 10th Revision of the International Statistical Classification of Diseases and Related Health Problems (CID-10). The following disease categories were considered: stroke, hypertensive diseases (essential arterial hypertension and other hypertensive diseases), rheumatic diseases (acute rheumatic fever and chronic rheumatic heart disease), acute myocardial infarction (AMI), heart failure, congenital malformations of the circulatory system, and conduction disorders and arrhythmias.

Statistical Analysis

Considering that the procedures and surgeries are discriminated in the system regarding only their nature (outpatient or in-hospital), a descriptive analysis of how such procedures were distributed in those categories was performed. Regarding data from admission and in-hospital deaths, the variables sex, age group, skin color/race, and type of healthcare (urgency or emergency) were considered.

Aiming at understanding the possible impact of the pandemic on the dynamics of the procedures, admissions, and in-hospital deaths related to CVD, the numbers regarding the months of March, April, and May – the most affected months of 2020 by the pandemic in Brazil – were compared for the years 2016 to 2020. The values recorded from 2019 and 2020 and their corresponding percent variation were compared. It is worth noting that a variation in the number of admissions and in-hospital deaths from one year to the other or a change in the mean of the previous years as compared to 2020 is not necessarily caused by the pandemic. We considered this hypothetical variation a possible consequence of an already established trend in the previous years. Finally, the value expected for the year 2020 was estimated by use of linear regression. Such analysis allows assuming whether the number of procedures, surgeries, admissions, and in-hospital deaths or the in-hospital fatality rate observed in the previous years showed a trend towards increase or decrease. Thus, that analysis captured both the trend of the years and the statistical variations occurring in the previous years.

Although normality tests were not performed, the normal distribution of data over time was assumed, considering the central limit theorem, because the data of each year are a totalization of several random variables. Homocedasticity could not be completely verified, because DATASUS does not provide completely individualized data.

Statistical analyses were performed for both the number of surgeries and procedures, and for each individual procedure/surgery as well. Similarly, those analyses were performed for admissions, in-hospital deaths, and in-hospital fatality, considering each morbidity studied individually as well as the sum of all of them, which is an analysis of the cardiovascular causes in general.

Because linear regression has a gaussian error, Student t test was performed for the mean of a sample to compare the values projected with those recorded in 2020, and the null hypothesis was rejected with p<0.05 (95% confidence interval). The Microsoft® Excel® and Scilab® 6.1.0 software were used to perform the statistical analyses described and to build the tables and graphs.

Results

Descriptive Analysis

Based on the data collected regarding the months from January to May of the years 2016 to 2020, we identified 35 744 058 procedures, 1 336 472 hospital admissions, and 142 157 in-hospital deaths, and the last two were divided according to region, sex, age group, race/skin color, and healthcare type as shown in Table 1 . Complete data illustrating the variation in the numbers initiating in March 2020 are shown in the figures of the supplementary material.

Table 1
– Descriptive analysis of the number of procedures, surgeries, admissions, and in-hospital deaths from January to May of the years 2016 to 2020

Graph Analysis

1A shows the data regarding the diagnostic and surgical procedures performed from March to May of 2016 to 2020. In addition, the estimates for 2020 (dotted lines), calculated by using data from 2016 to 2019, are also shown. A trend towards an increase in the number of diagnostic and surgical procedures (dotted lines) for the year 2020 is observed. However, the real data show a significant decrease when compared to data from the previous year.

Figure 1B depicts the numbers of admissions and in-hospital deaths recorded, considering all morbidities studied. In addition, the estimates for 2020 (dotted lines), calculated by using data from 2016 to 2019, are also shown. The graph shows the same trend towards an increase observed in the previous graph but not confirmed in the year 2020, when a steep decline is observed. Regarding the number of deaths, the projected trend would be that of maintenance, contrasting with the intense reduction in the number of in-hospital deaths recorded in the months of March to May 2020.

Figure 1C illustrates the in-hospital fatality rate due to CVD in general, showing a drastic increase in the in-hospital fatality rate in 2020 as compared to those recorded in previous years. In this case, the variation is in the opposite direction to that observed for the admissions and in-hospital deaths, which decreased in 2020.

Figure 1
– Analysis of the trend in: (a) the number of procedures and surgeries; (b) the number of admissions and deaths; and (c) in-hospital fatality rate in March to May of 2016 to 2020. p-value calculated from the difference between the value projected and the value recorded in 2020 using Student t distribution.

That analysis was replicated for each type of procedure and surgery, as well as for the number of admissions, in-hospital deaths and in-hospital fatality rate for each pathology studied. Those results are summarized in Tables 2 and 3 , which show data from 2019 and 2020, the percent difference between these years, the value projected for 2020 (which indicates the trend from 2016 to 2019), the confidence interval, and the p-value of that projection. The results according to age group are shown in the supplementary material.

Table 2
– Statistical analysis of the reduction in the number of procedures and surgeries in March to May of 2019 and 2020 and their comparison
Table 3
– Statistical analysis of the number of admissions, in-hospital deaths, and in-hospital fatality rate in March to May of 2019 and 2020 and their comparison

Diagnostic and Surgical Procedures

Table 2 shows the comparison of the number of diagnostic and surgical procedures performed in March, April, and May of 2019 and 2020, with a total drop of 45% in all procedures studied in 2020. The procedures with the most significant reductions were as follows: ABPM (74% reduction), exercise test (59%), and 24-hour Holter (51%). Electrocardiography and echocardiography had a decrease of 41% and 42%, respectively. Cardiac catheterization and pacemaker implantation had the smallest decline, 27% and 11%, respectively.

The total number of surgeries performed in March, April, and May 2020 decreased by 20% as compared to the previous year, which was not statistically significant (p=0.0854). However, when considering only cardiovascular and endovascular surgeries, declines of 13% and 32%, respectively, were observed, both with statistical significance (p<0.05).

Admissions

Regarding the admissions due to cardiovascular diseases in March, April, and May 2020, a 15% reduction was observed as compared to the same period of the previous year ( Table 3 ). Data from all diseases analyzed individually also showed a statistically significant reduction. The greatest differences were in admissions due to hypertensive diseases, followed by those due to rheumatic diseases, with 33% and 29% reductions, respectively. It is worth noting that admissions due to AMI had the smallest reduction (4%).

In general, all diseases showed a decrease in admissions from 2019 to 2020 for all age groups. The following are worthy of note: AMI, whose difference in admissions had statistical significance only for the elderly group; heart failure, in which the extreme age groups (child/adolescent and elderly) had the greatest impacts; and conduction disorders and other arrhythmias, which showed statistically significant reduction only for the elderly. When considering admissions from stroke, the adults and the elderly had significant reductions (11% and 12%, respectively). Regarding admissions from hypertensive diseases, all age groups had statistically significant reductions.

In-hospital Deaths and In-hospital Fatality Rate

The absolute number of deaths due to CVD decreased by 8% from March to May 2020 as compared to the same period in 2019 ( Table 3 ). The deaths related to hypertensive diseases in the age group 20-59 years had a 21% increase in 2020 (p<0.05; supplementary material).

Regarding the general fatality rates, there was an overall 9% increase when comparing the same months of 2019 and 2020. Except for AMI, whose fatality rate decreased by 5%, all other pathologies had an increase in fatality rates. Regarding the pathologies individually, hypertensive diseases and heart failure stood out, with 29% and 8% increases in their in-hospital fatality rates, respectively, from 2019 to 2020 (p<0.05).

When considering the age groups, the in-hospital fatality increase in the admissions due to CVD was statistically significant only among adults. Considering the diseases individually, it is worth noting that the in-hospital fatality increase due to hypertensive diseases was statistically significant only for adults. Regarding heart failure, adults and elderly showed statistical difference in that rate (p<0.05; Tables 2 and 3 of the supplementary material).

Discussion

This study shows a reduction in the cardiovascular care provided to the Brazilian population by the SUS during the COVID-19 pandemic, which resulted in both a reduction in the number of hospital admissions for CVD and an increase in the in-hospital fatality rate from those diseases.

Our results are similar to those of a study carried out in Italy during 7 days in March 2020, which showed a 13.3% reduction in the proportion of patients with AMI as compared to that same week of 2019. In addition, that study reported a 39.2% increase in acute coronary syndromes and a 31.5% increase in the time elapsed from medical contact to coronary revascularization.1212. De Rosa S, Spaccarotella C, Basso C, Calabro MP, Curcio A, Filardi PP, et al. Reduction of hospitalizations for myocardial infarction in Italy in the COVID-19 era. Eur Heart J. 2020 07;41(22):2083–8.

In our study, regarding the number of admissions, there was a reduction for all morbidities and age groups analyzed, mainly in April and May, possibly because of the COVID-19 pandemic. Other studies carried out in different countries have reported similar findings.1313. Laccourreye O, Mirghani H, Evrard D, Bonnefont P, Brugel L, Tankere F, et al. Impact of the first month of Covid-19 lockdown on oncologic surgical activity in the Ile de France region university hospital otorhinolaryngology departments. Eur Ann Otorhinolaryngol Head Neck Dis. 2020 Sep;137(4):273-6.The population’s fear of contracting the virus and the systematization of the healthcare, prioritizing the pandemic, justify that initial impact.1616. . Changes in hospital admissions for urgent conditions during COVID-19 pandemic. Am J Manag Care.2020;26(8):327-8. , 1717. Mantica G, Riccardi N, Terrone C, Gratarola A. Non-COVID-19 visits to emergency departments during the pandemic: the impact of fear. Public Health. 2020 Jun 1;183:40–1. That reduction has also been reported for other diseases, as shown by the studies on stroke in Italy1818. Morelli N, Rota E, Terracciano C, Immovilli P, Spallazzi M, Colombi D, et al. The baffling case of ischemic stroke disappearance from the casualty Department in the COVID-19 Era. Eur Neurol. 2020;83(2):213–5.and China.1919. Tam C-CF, Cheung K-S, Lam S, Wong A, Yung A, Sze M, et al. Impact of coronavirus disease 2019 (COVID-19) outbreak on ST-segment–elevation myocardial infarction care in Hong Kong, China. Circ Cardiovasc Qual Outcomes. 2020 Apr;13(4):e006631

The reassignment of human resources in the fight against COVID-19 was similar in several countries, despite the heterogeneity of their health systems.1212. De Rosa S, Spaccarotella C, Basso C, Calabro MP, Curcio A, Filardi PP, et al. Reduction of hospitalizations for myocardial infarction in Italy in the COVID-19 era. Eur Heart J. 2020 07;41(22):2083–8.Some countries, such as Australia and New Zealand, to prepare hospitals to provide healthcare to a large number of patients with COVID-19, kept the delivery of surgical care limited to emergency or high-priority elective cases.2020. McBride KE, Brown KG, Fisher OM, Steffens D, Yeo DA, Koh CE. Impact of the COVID-19 pandemic on surgical services: early experiences at a nominated COVID-19 centre. ANZ J Surg. 2020;90(5):663–5.In a hospital in Northern Italy, one of the epicenters of the pandemic in that country, the planned surgical activities were interrupted to increase the number of intensive care physicians available to patients with COVID-19, and the outpatient activities were cut to half.2121. Maniscalco P, Poggiali E, Quattrini F, Ciatti C, Magnacavallo A, Caprioli S, et al. The deep impact of novel CoVID-19 infection in an Orthopedics and Traumatology Department: the experience of the Piacenza Hospital. Acta Bio-Medica Atenei Parm. 2020 May 11;91(2):97–105.This rearrangement in the healthcare model was expected to have an impact on the mortality from other diseases, whose usual healthcare delivery flow was reduced, favoring clinical decompensations, diagnostic delay, and disease progression.

Despite the reduction in absolute numbers of in-hospital deaths, there was an increase in the in-hospital fatality rate of admissions due to CVD. That reduction in the number of deaths might have resulted from the lack of proper reporting and the deficient structure of the health system to properly designate the COVID-19-related cause of death as cardiovascular. The interaction between COVID-19 and the cardiovascular system is currently well known, after 7 months of disease. COVID-19 is related to a high prevalence of cardiac injury, arrhythmias, myocarditis, acute coronary syndrome, heart failure, cardiogenic shock, and thromboembolic events.2222. Costa IB, Bittar CS, Rizk SI, Araujo Filho AE, Santos KA, Machado TI, et al. The heart and COVID-19: What cardiologists need to know.. Arq Bras Cardiol. 2020;114(5):805-16.The increased fatality in admissions due to CVD reflects the potential severity of COVID-19 in CVD and the possible patient’s delay in searching medical care, being then hospitalized in more severe conditions. The increased fatality of patients admitted due to CVD has reached the most economically-active part of the population (20-59 years), adding more concern to the ongoing economic crisis. Although some studies have observed a similar impact of the pandemic on hospital care,1313. Laccourreye O, Mirghani H, Evrard D, Bonnefont P, Brugel L, Tankere F, et al. Impact of the first month of Covid-19 lockdown on oncologic surgical activity in the Ile de France region university hospital otorhinolaryngology departments. Eur Ann Otorhinolaryngol Head Neck Dis. 2020 Sep;137(4):273-6. , 1515. Bromage DI, Cannata A, Rind IA, Gregorio C, Piper S, Shah AM, et al. The impact of COVID-19 on heart failure hospitalization and management: report from a Heart Failure Unit in London during the peak of the pandemic. Eur J Heart Fail. 2020 Jun;22(6):978-84. , 2020. McBride KE, Brown KG, Fisher OM, Steffens D, Yeo DA, Koh CE. Impact of the COVID-19 pandemic on surgical services: early experiences at a nominated COVID-19 centre. ANZ J Surg. 2020;90(5):663–5. ours might be one of the first to demonstrate an increase in the in-hospital fatality rate due to CVD.1212. De Rosa S, Spaccarotella C, Basso C, Calabro MP, Curcio A, Filardi PP, et al. Reduction of hospitalizations for myocardial infarction in Italy in the COVID-19 era. Eur Heart J. 2020 07;41(22):2083–8.

This study has the limitation of assessing only one part of the Brazilian population, the one with access to only the SUS-provided healthcare. Thus, our data cannot be extrapolated to the whole population of Brazil. It is worth noting that the impact demonstrated on the fatality of Brazilians might be overestimated, because the population cared for at the SUS, being socioeconomically disadvantaged, has a poorer control of cardiovascular risk factors, in addition to having access to medication of poorer quality and in an unsatisfactory manner.2424. Mandelzweig L, Goldbourt U, Boyko V, Tanne D. Perceptual, social, and behavioral factors associated with delays in seeking medical care in patients with symptoms of acute stroke. Stroke. 2006 May;37(5):1248–53.Such factors on their own make that population more vulnerable to clinical decompensation, with consequent higher in-hospital fatality. Moreover, the restriction of elective admissions might have influenced in-hospital fatality, although that type of healthcare represents only 7.80% of the total of admissions ( Table 1 ). It is worth noting the shortness of the period analyzed (3 months). Therefore, further studies should validate these findings and compare them to those of other periods.

Conclusions

Ours is the first study to assess the impact on cardiovascular health at the SUS across Brazil during the COVID-19 pandemic. These data support the concern that healthcare delivery might have been postponed or reduced during the COVID-19 pandemic.

References

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  • Study Association
    This study is not associated with any thesis or dissertation work.
  • Ethics Approval and Consent to Participate
    This article does not contain any studies with human participants or animals performed by any of the authors.
  • Sources of Funding .There were no external funding sources for this study.

Publication Dates

  • Publication in this collection
    08 Feb 2021

History

  • Received
    25 July 2020
  • Reviewed
    22 Sept 2020
  • Accepted
    14 Oct 2020
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