key: cord-0828341-kj7c3l7r
authors: Toner, Liam; Koshy, Anoop N.; Ko, Jefferson; Driscoll, Andrea; Farouque, Omar
title: Clinical Characteristics and Trends in Heart Failure Hospitalizations: An Australian Experience during the COVID-19 Lockdown
date: 2020-08-11
journal: JACC Heart Fail
DOI: 10.1016/j.jchf.2020.05.014
sha: 8cf0a72730388a0f43a83c796bc766befd319ea6
doc_id: 828341
cord_uid: kj7c3l7r

nan

Heart failure is a leading cause of morbidity, mortality and healthcare resource utilization.

The coronavirus disease 2019 (COVID-19) pandemic presents novel challenges at the patient level as dyspnoea is a cardinal symptom of both conditions. The unprecedented challenges to healthcare systems have led to implementation of rapid ambulatory telehealth services. The consequences of COVID-19 and associated public health regulatory changes may adversely impact patients with heart failure due to patient avoidance of medical care (1) . The secondary impact of the COVID-19 lockdown on the incidence and acuity of heart failure hospitalizations has not been studied.

We sought to compare the number of heart failure hospitalizations, patient characteristics on presentation and key heart failure quality metrics across the COVID-19 and non-COVID-19 eras. Key metrics assessed included inpatient mortality, length-of-stay and use of guidelinedirected medical therapy. Cases were identified after comprehensive record review of all patients hospitalized under the cardiology and internal medicine teams. HF The COVID-19 era was defined as the first thirty-day period from the beginning of lockdown in Australia (March 16-April 14, 2020). This period coincided with the peak of the COVID-19 epidemic curve in Australia. These data were compared to historical data at our hospital from the Victorian Cardiac Outcomes Registry (VCOR)-HF which was collected prospectively over 30-day period each year 2014-2017. The methodology and results of the VCOR-HF project have been previously described. (2) This registry is coordinated by the independent Center of Cardiovascular Research and Education in Therapeutics at Monash University with periodic quality control audits that demonstrate a data accuracy of 97%. (2) Data from 2018-19 had not been collated by the registry at the time of the study and was excluded. The data was collected at Austin Health, a major quaternary hospital with a catchment population of 1.14 million people.

Overall, 249 patients were included in the study analysis. There were 32 heart failure hospitalizations in the COVID-19 era, which represents a 41% reduction from our historical monthly mean of 54 hospitalizations (range 44-74, p<0.001; Figure 1 ). Baseline clinical characteristics and burden of chronic disease were similar across the COVID-19 and non-COVID era. The proportion of patients diagnosed with heart failure with reduced ejection fraction did not vary. Infection remained the most common precipitant for acute heart failure in both COVID and non-COVID eras ( Table 1) . Of note, 31% of heart failure hospitalizations in the COVID-era were managed initially in a COVID-19 medical unit due to a high index of suspicion for infection with SARS-CoV-2. Among these patients, there were no confirmed cases of SARS-CoV-2.

Patients admitted during the COVID-19 era were significantly more symptomatic on presentation with a higher proportion with New York Heart Association (NYHA) class III/IV symptoms (96.9%, 71%, p =0.001). No major differences in heart failure quality metrics including intensive care admission or in-hospital mortality were recorded ( Table 1) . Length of hospital stay was numerically lower in the COVID-19 era, although this was not statistically significant (median 4.0 vs 6.0 days, p=0.16). With regards to goal directed medical therapy, prescription rates of beta-blockers and mineralocorticoid receptor antagonist were similar across the eras. However, there was a significant reduction in use of angiotensin converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) in the COVID-19 era (35.7% vs 57.1%, p = 0.03).

In this study evaluating early data on acute heart failure hospitalizations during the COVID-19 era, three key findings merit attention. First, there was a 41% reduction in hospitalizations J o u r n a l P r e -p r o o f due to heart failure. Second, patients hospitalized during the COVID-19 era had significantly higher NYHA classification. Lastly, despite comparable clinical characteristics of the patients across the eras, there was a significant reduction in the prescription of ACEI/ARBs in the COVID-era.

While some anecdotal reports have indicated a reduction in acute heart failure presentations, no data to date has been presented to support this notion. The significant reduction in heart The Australian government commenced lockdown restrictions on March 16, 2020 to reduce the spread of COVID-19. Over the next 30 days the number of cases in Australia rose from 310 to 6,400 and the first deaths were recorded .(4) Fortunately, this was followed by a reduction in the number of new cases due to successful lockdown restrictions as there were only 588 new cases in the following 30 days. As such, the period of our data collection reflects the peak of the Australian COVID-19 epidemic curve. We speculate that as lockdown restrictions are eased these social impacts will lessen, and heart failure admissions will return to levels observed in the pre-COVID era. The long-term sequalae of this interruption remains to be seen.

It is notable that our cohort had a significant reduction in ACEI/ARB prescription in the COVID-era. Lower use may be due to the widely publicised concerns regarding upregulation of the ACE2 receptor by these drug classes, given that this receptor is known to mediate SARS-CoV-2 cellular entry. (5) However, in light of the strong evidence supporting use of these agents in patients with heart failure, underutilization of these therapies is not medically justifiable . (6) A limitation of our data reporting trends in hospitalizations is the variation in the timing of data sampling across the years. Seasonality may account for a variation of at most 20% in heart failure admissions . (7) In conclusion, we report a 41% reduction in heart failure hospitalizations and a significant increase in the proportion of patients presenting with NYHA class III/IV symptoms in the COVID-19 era. Despite restructuring of management pathways, in-hospital clinical outcomes in patients admitted with heart failure remained unchanged. Underutilization of ACEI & ARBs is of concern and may translate to adverse clinical outcomes. Examining reasons for the reduced hospital presentations and enhancing integrated multidisciplinary outpatient models of care in this pandemic may mitigate the collateral impact of COVID-19 in patients with heart failure. 

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