Abstract
Introduction:
Global surge of COVID-19 forced most countries to impose variable measures to curb the disease. Jordan imposed one of the strictest lockdowns from mid-March through April 2020. Hospitals deferred elective cardiac catheterization procedures and most of those performed during that period were limited to urgent presentations. Our purpose is to evaluate the impact of strict lockdown on cardiac catheterization procedural volume.
Methods and Results:
We collected data about the numbers of all coronary angiography (CA) and percutaneous coronary intervention (PCI) procedures performed in 5 tertiary care hospitals in Amman, Jordan, from January through June 2020. We compared the volume of procedures performed in April 2020 (the strict lockdown month) to the corresponding period of prior year (April 2019) and to volumes performed prior to the lockdown in January–February 2020.
There was a 64% decline in CA and PCI volumes in April 2020 compared to April 2019. Comparing number of procedures performed in April 2020 to those in January–February 2020, there was 59% decline in CA and a 60% decline in PCI volumes. Following partial lifting of lockdown in May–June 2020, procedural volumes increased gradually.
Conclusion:
Strict COVID-19-related lockdown in Jordan was associated with drastic declines in cardiac catheterization procedural volumes.
Keywords: Cardiac catheterization, coronary angiography, COVID-19, percutaneous coronary intervention
INTRODUCTION
The COVID-19 pandemic has swept across the globe and different countries took variable measures to control the spread of the disease. Many countries implemented partial lockdown and restricted gatherings to small number of individuals while others imposed complete lockdown. Subsequently, elective medical procedures were deferred in most hospitals to minimize the use of resources and reduce the risk of COVID-19 transmission to patients and providers.[1]
In anticipation of the COVID-19 spread, Jordan took one of the most drastic measures by implementing a strict country-wide lockdown between March 17 and the end of April 2020 followed by gradual lifting. We sought to evaluate the impact of COVID-19-related complete lockdown on cardiac catheterization procedural volumes in Jordan.
METHODS
We collected data on the volume of coronary angiography (CA) and percutaneous coronary intervention (PCI) procedures performed in 5 private tertiary care hospitals in Amman, Jordan, in the period from January through June 2020. Strict lockdown was implemented from mid-March through April 2020. We compared procedural volumes of April 2020 (the strict lockdown month) to the same period of 2019. We also compared that to the procedural volumes of the period preceding the lockdown (i.e., average volumes of January and February 2020).
Data was obtained from the corresponding catheterization laboratories logbooks without accessing patient data. We calculated the total number of procedures performed in all participating hospitals for each month and compared the numbers of April 2020 to the corresponding month 2019 and to January–February 2020.
RESULTS
Figure 1 shows the monthly volume of CA and PCI for all participating institutions from January - June 2020. It demonstrates a moderate volume decline in March and a sharp decline during the strict lockdown month of April. Volume gradually increased following easing of lockdown during May and June 2020. Compared to the average January–February 2020, there was a 59% decline in CA procedures and 60% decline in PCI procedures performed during the month of April 2020.
Figure 1.
Monthly volume of cardiac catheterization procedures for all participating hospitals from January through June 2020. CA: coronary angiography, PCI: percutaneous coronary intervention
Figure 2 compares the CA and PCI volumes between April 2020 and the same period in 2019. There was a sharp 64% decline in both CA and PCI volumes in April 2020 compared to April 2019.
Figure 2.
Cardiac catheterization procedural volume of April 2020 compared to April 2019. CA: coronary angiography, PCI: percutaneous coronary intervention
DISCUSSION
Our report confirms sharp declines in cardiac catheterization procedures including CA and PCI during the COVID-19-related lockdown in Jordan. It is not surprising to see such sharp declines since Jordan had adopted one of the strictest lockdowns in the world.
Measures of lockdown, fear of contracting the disease, and limited health care resources have all impacted the health care delivery and led to deferral of elective procedures. Other factors contributing to the decline in procedures' volumes during the lockdown includes refrain of cardiac patients from coming to hospitals and a possibility of true reduction in acute coronary syndrome (ACS)presentations during the pandemic.[2,3,4,5]
Our findings align with observations reported by investigators from other countries including Spain which showed 48% decline in cardiac catheterization procedure volume.[6] Larger decline in our study could be related to the stricter lockdown measures and a significant decline in medical tourism during the lockdown. Jordan is a known hub of medical tourism, the severe travel restrictions during the lockdown and the ban on patients from neighboring countries from entering Jordan contributed to the marked decline in cardiac procedures.
It was suggested that the decline in cardiac procedures may be related to migration of patients from the private to the public sector, particularly at such times of financial hardships during the lockdown. However, this suggestion is unlikely to have played a major role since Jordan had designated many public hospitals as COVID-19 facilities with extreme restriction of cardiac procedures at these hospitals. Cardiac procedures at the participating private hospitals were less restricted since none of these hospitals treated COVID-19 patients during the lockdown.
CONCLUSIONS
Jordan imposed one of the strictest COVID-19-related lockdowns. The strict lockdown was associated with drastic declines in volumes of cardiac catheterization procedures with gradual increase in volumes after partial lifting of the lockdown.
Impact on daily practice
Deferral of cardiac procedures and delay of cardiac patients' presentation to hospitals for early diagnosis and management may increase adverse cardiac events including death and the development of heart failure.[7] Moreover, a decline in cardiac procedures may negatively impact training programs at teaching hospitals.[8]
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgment
We would like to thank the following hospitals and their representatives for participating in data collection: (1) Arab Medical Center (Albara' A. Al-Holy, MS), (2) Khalidi Medical Center (Khaled Salah Yacoub), (3) Istishari Hospital (Nimer Darawsheh), (4) Jordan Hospital, and (5) Specialty Hospital (Mazen Sudqi, MD).
REFERENCES
- 1.Mahmud E, Dauerman HL, Welt FG, Messenger JC, Rao SV, Grines C, et al. Management of acute myocardial infarction during the COVID-19 pandemic: A Consensus Statement from the Society for Cardiovascular Angiography and Interventions (SCAI), the American College of Cardiology (ACC), and the American College of Emergency Physicians (ACEP) Catheter Cardiovasc Interv. 2020;96:336–45. doi: 10.1002/ccd.28946. [DOI] [PubMed] [Google Scholar]
- 2.Garcia S, Albaghdadi MS, Meraj PM, Schmidt C, Garberich R, Jaffer FA, et al. Reduction in ST-Segment Elevation Cardiac Catheterization Laboratory Activations in the United States During COVID-19 Pandemic. J Am Coll Cardiol. 2020;75:2871–2. doi: 10.1016/j.jacc.2020.04.011. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.De Filippo O, D'Ascenzo F, Angelini F, Bocchino PP, Conrotto F, Saglietto A, et al. Reduced rate of hospital admissions for ACS during Covid-19 outbreak in Northern Italy. N Engl J Med. 2020;383:88–9. doi: 10.1056/NEJMc2009166. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.De Rosa S, Spaccarotella C, Basso C, Calabrò MP, Curcio A, Filardi PP, et al. Reduction of hospitalizations for myocardial infarction in Italy in the COVID-19 era. Eur Heart J. 2020;41:2083–8. doi: 10.1093/eurheartj/ehaa409. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Mafham MM, Spata E, Goldacre R, Gair D, Curnow P, Bray M, et al. COVID-19 pandemic and admission rates for and management of acute coronary syndromes in England. Lancet. 2020;396:381–9. doi: 10.1016/S0140-6736(20)31356-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Rodriguez-Leor Oriol, Cid-Alvarez B, Ojeda S, Martin-Moreiras J, Rumoroso JR, Lopez-Palop R, et al. Impact of the COVID-19 pandemic on interventional cardiology activity in Spain. Rec Interv Cardiol. 2020;2:82–89. [Google Scholar]
- 7.Banerjee A, Pasea L, Harris S, Gonzalez-Izquierdo A, Torralbo A, Shallcross L, et al. Estimating excess 1-year mortality associated with the COVID-19 pandemic according to underlying conditions and age: A population-based cohort study. Lancet. 2020;395:1715–25. doi: 10.1016/S0140-6736(20)30854-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Kadavath S, Mohan J, Ashraf S, Kassier A, Hawwass D, Madan N, et al. Cardiac catheterization laboratory volume changes during COVID-19-findings from a cardiovascular fellows consortium. Am J Cardiol. 2020;130:168–9. doi: 10.1016/j.amjcard.2020.06.009. [DOI] [PMC free article] [PubMed] [Google Scholar]