On 14 March 2020, a state of alarm was declared in Spain because of the SARS-CoV-2 coronavirus (COVID-19) pandemic, and home confinement was made mandatory to control the high number of cases of this infection. In the health sector, all nonpriority medical activity was limited, but urgent activity was maintained. Nonetheless, during the first weeks of confinement, a decrease of up to 40% was observed across the country in the number of alerts for ST-segment elevation acute myocardial infarction.1 According to reports from other countries, there may have been a similar reduction in the treatment of bradyarrhythmia.2,3 The present study analyzes the impact of the first COVID-19 wave on the treatment of severe bradyarrhythmia in Spain.

Through the Cardiac Pacing Section of the Spanish Society of Cardiology, centers with activity in this field were requested to collaborate in the study. An online database was provided to record the number and characteristics of pacemaker implantation procedures with a preferential/urgent indication carried out between 15 March and 15 May, 2019, and the same dates in 2020, in order to perform a comparison. Scheduled elective procedures, battery replacements, lead repositioning, and pacing system extensions were not included. The deadline for submitting the data was 15 June, 2020.

Data were sent by 31 centers in 13 autonomous communities of Spain. The general characteristics are shown in table 1. Although the populations were similar during the 2 periods, there was a significant reduction in the number of procedures performed in asymptomatic patients (10% vs 6.3%; P=.014) and those with presyncope (21.9% vs 15.8%; P=.005) relative to the 2019 activity. Complete atrioventricular block (cAVB) was the most common cause in the 2 periods, but it was significantly more frequent in 2020 (41.6% vs 47.7%; P=.023).

Patients in the 2020 period had slightly worse creatinine clearance values (median, 65.2 vs 61.1mL/min; P=.019) and higher levels of the amino-terminal fraction of brain pro-natriuretic peptide (median, 1012 vs 1429; P=.010). Although these factors could indicate greater severity, there were no differences in the percentage of patients treated in intensive care units (ICUs) or in transvenous pacemaker use. The only difference found was more frequent vasoactive drug prescription in 2020 (22.8% vs 32.2%; P=.001), which could be related to the higher percentage of patients with cABV.

As in other reported series, there was a 35.2% total decrease in the number of preferential/urgent pacemaker implantations compared with 2019 (568 vs 877; P < .001).

All autonomous communities analyzed except the Balearic Islands experienced a reduction in activity, although to a varying degree (table 2). Through the use of data from official reports of the Ministry of Health and the National Institute of Statistics, an attempt was made to explain this variability by relating it to the impact of the pandemic in each region. No correlations were found with the number of infected individuals in each autonomous community (Spearman ρ=0.162; P=.596), the number persons hospitalized with a diagnosis of COVID-19 (ρ=–0.028; P=.929), the number of persons admitted to the ICU (ρ=–0.217; P=.476), or the number of deaths due to this disease (ρ=0.105; P=.734) per 100 000 population. Nor was there an association between the decrease in pacemaker procedures and saturation of the health system in each region, measured by the following ratios: number of COVID-19 hospitalizations/beds available at baseline (ρ=0.080; P=.796), or the number of COVID-19 ICU hospitalizations/ICU beds available at baseline (ρ=0.061; P=.844). As mentioned, the aim of this study was to obtain a general view of what happened during the first wave of the pandemic in Spain. However, to properly interpret these results it is important to note that the information collected covered only 40% of the provinces, and the population at risk included in the analysis represented an average of 33.3% of the total in each autonomous community (table 2). This was an important limitation for establishing a relationship between the impact of the pandemic and the reduction in activity.

To summarize, the first wave of the COVID-19 pandemic significantly affected treatment of acute heart disease, even though urgent care was guaranteed. The impact on bradyarrhythmia treatment was similar to the reported findings in ischemic heart disease and data from other countries. This difference does not seem to be related only to “competing risk”.4 It is likely that patients reduced their physical activity during the state of alarm and, therefore, their probability of experiencing symptoms. In addition, those with mild symptoms were less likely to seek medical assessment. This could explain the lower pacemaker implantation rate in asymptomatic and presyncope patients. The disruption of ambulatory activity may also have limited the possibility to attain a prompt diagnosis in patients with mild conduction disorders, which could explain the relative increase in implants for cAVB. These findings should be taken into account in future COVID-19 waves to improve organization during crises by maintaining essential outpatient activity and fostering public confidence that all areas of the health system are safe against contagion.