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BackgroundPatients with underlying cardiovascular disease and Coronavirus disease 2019 (COVID-19) infection are at increased risk of morbidity and mortality. However, there is limited information on management and outcomes of patients presenting with acute coronary syndrome (ACS) and concomitant COVID19 infection. ObjectivesThis multisource national analysis of live data from England was designed to characterise the presenting profile and outcomes of patients hospitalized with ACS and COVID-19 infection. MethodsMultisource data from all acute NHS hospital in England was linked to study the characteristics and outcomes of patients hospitalized with COVID-19 ACS compared to non COVID-19 ACS patients. Hierarchical multilevel models were constructed to study the association between COVID19 ACS and in-hospital and 30-day mortality. ResultsBetween 1st March 2020 and 31st May 2020, 517 (4.0%) were admitted with COVID-19 ACS from a total of 12,958 ACS patients. COVID-19 ACS patients were generally older, BAME ethnicity, more comorbid and had unfavourable presenting characteristics compared to non-COVID-19 ACS patients. They were less likely to receive invasive coronary strategy in the form of coronary angiography (67.7% vs 81.0%), PCI (30.2% vs 53.9%), dual antiplatelet medication 76.3% vs 88.0%), and other important secondary medication. Patients with COVID-19 ACS had higher in-hospital (aOR 3.27 95%CI 2.41-4.42) and 30-day mortality (aOR 6.53 95%CI 5.1-8.36) compared to non COVID-19 ACS group. ConclusionCOVID-19 infection is prevalent but less frequent in the patients hospitalized with ACS in England. Presence of COVID-19 infection in patients with ACS is associated with significant mortality hazard.
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BackgroundThe COVID-19 pandemic has resulted in a high death toll. We aimed to describe the place and cause of death during the COVID-19 pandemic. MethodsThis national death registry included all adult (aged [≥]18 years) deaths in England and Wales between 1st January 2014 and 30th June 2020. Analyses were based upon ICD-10 codes corresponding to the underlying cause of death as stated on the Medical Certificate of Cause of Death. Daily deaths during COVID-19 pandemic were compared against the expected daily deaths estimated using Farrington surveillance algorithm for daily historical data between 2014 and 2020, by place and cause of death. FindingsBetween 2nd March and 30th June 2020, there was an excess mortality of 57,860 (a proportional increase of 35%) compared with the expected deaths, of which 50,603 (86.2%) were COVID-19 related. Almost half the excess deaths occurred in care homes (25,611 deaths) where deaths were 55% higher than expected. One fifth of the excess deaths occurred in hospital (15,938 deaths; a proportional increase of 21%) with the remainder occurring at home (16,190 deaths; a proportional increase of 39%). At home, only 14% of 16,190 excess deaths were related to COVID-19, with 5,963 deaths due to cancer and 2,485 deaths due to cardiac disease, very few of which involved COVID-19. In care homes or hospices, 61% of the 25,611 excess deaths were related to COVID-19, 5,539 of which were due to respiratory disease and most of these (4,315 deaths) involved COVID-19. In hospital, there were 16,174 fewer deaths than expected which did not involve COVID-19, and there were 4,088 fewer deaths due to cancer and 1,398 fewer deaths due to cardiac disease than expected. InterpretationThe COVID-19 pandemic has resulted in a substantial increase in the absolute numbers of deaths occurring at home and care homes. There was a huge burden of excess deaths occurring in care homes, which were poorly characterised, and were likely to be, at least in part, the result of undiagnosed COVID-19. There was a smaller but important and ongoing excess in deaths at home, particularly from cancer and cardiac disease, which suggests avoidance of hospital care for non-COVID-19 conditions. FundingThe study is unfunded.
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BackgroundAortic stenosis requires timely treatment with either surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR). This study aimed to investigate the indirect impact of COVID-19 on national SAVR and TAVR activity and outcomes. MethodsThe UK TAVR Registry and the National Adult Cardiac Surgery Audit were used to identify all TAVR and SAVR procedures in England, between January 2017 and June 2020. The number of isolated AVR, AVR+coronary artery bypass graft (CABG) surgery, AVR+other surgery and TAVR procedures per month was calculated. Separate negative binomial regression models were fit to monthly procedural counts, with functions of time as covariates, to estimate the expected change in activity during COVID-19. ResultsWe included 13376 TAVR cases, 12328 isolated AVR cases, 7829 AVR+CABG cases, and 6014 AVR+Other cases. Prior to March 2020 (UK lockdown), monthly TAVR activity was rising, with a slight decrease in SAVR activity during 2019. We observed a rapid and significant drop in TAVR and SAVR activity during the COVID-19 pandemic, especially for elective cases. Cumulatively, over the period March to June 2020, we estimated an expected 2294 (95% CI 1872, 2716) cases of severe aortic stenosis who have not received treatment. ConclusionThis study has demonstrated a significant decrease in TAVR and SAVR activity in England following the COVID-19 outbreak. This situation should be monitored closely, to ensure that monthly activity rapidly returns to expected levels. There is potential for significant backlog in the near-to-medium term, and potential for increased mortality in this population.
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ObjectivesTo examine short-term primary causes of death after percutaneous coronary intervention (PCI) in a national cohort before and during COVID-19. BackgroundPublic reporting of PCI outcomes is a performance metric and a requirement in many healthcare systems. There are inconsistent data on the causes of death after PCI, and what proportion of these are attributable to cardiac causes. MethodsAll patients undergoing PCI in England between 1st January 2017 and 10th May 2020 were retrospectively analysed (n=273,141), according to their outcome from the date of PCI; no death and in-hospital, post-discharge, and 30-day death. ResultsThe overall rates of in-hospital and 30-day death were 1.9% and 2.8%, respectively. The rate of 30-day death declined between 2017 (2.9%) and February 2020 (2.5%), mainly due to lower in-hospital death (2.1% vs. 1.5%), before rising again from 1st March 2020 (3.2%) due to higher rates of post-discharge mortality. Only 59.6% of 30-day deaths were due to cardiac causes, the most common being acute coronary syndrome, cardiogenic shock and heart failure, and this persisted throughout the study period. 10.4% of 30-day deaths after 1st March 2020 were due to confirmed COVID-19. ConclusionsIn this nationwide study, we show that 40% of 30-day deaths are due to non-cardiac causes. Non-cardiac deaths have increased even more from the start of the COVID-19 pandemic, with one in ten deaths from March 2020 being COVID-19 related. These findings raise a question of whether public reporting of PCI outcomes should be cause-specific.
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ImportanceThe COVID-19 pandemic has resulted in a decline in admissions with cardiovascular (CV) emergencies. The fatal consequences of this are unknown. ObjectivesTo describe the place and causes of acute CV death during the COVID-19 pandemic. DesignRetrospective nationwide cohort. SettingEngland and Wales. ParticipantsAll adult (age [≥]18 years) acute CV deaths (n=580,972) between 1st January 2014 and 2nd June 2020. ExposureThe COVID-19 pandemic (defined as from the onset of the first COVID-19 death in England on 2nd March 2020). Main outcomesPlace (hospital, care home, home) and acute CV events directly contributing to death as stated on the first part of the Medical Certificate of Cause of Death. ResultsAfter 2nd March 2020, there were 22,820 acute CV deaths of which 5.7% related to COVID-19, and an excess acute CV mortality of 1752 (+8%) compared with the expected daily deaths in the same period. Deaths in the community accounted for nearly half of all deaths during this period. Care homes had the greatest increase in excess acute CV deaths (1065, +40%), followed by deaths at home (1728, +34%) and in hospital (57, +0%). The most frequent cause of acute CV death during this period was stroke (8,290, 36.3%), followed by acute coronary syndrome (ACS) (5,532, 24.2%), heart failure (5,280, 23.1%), pulmonary embolism (2,067, 9.1%) and cardiac arrest (1,037, 4.5%). Deep vein thrombosis had the greatest increase in cause of excess acute CV death (18, +25%), followed pulmonary embolism (340, +19%) and stroke (782, +10%). The greatest cause of excess CV death in care homes was stroke (700, +48%), compared with cardiac arrest (80, +56%) at home, and pulmonary embolism (126, +14%) and cardiogenic shock (41, +14%) in hospital. Conclusions and relevanceThe COVID-19 pandemic has resulted in an inflation in acute CV deaths above that expected for the time of year, nearly half of which occurred in the community. The most common cause of acute CV death was stroke followed by acute coronary syndrome and heart failure. This is key information to optimise messaging to the public and enable health resource planning.
