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Vol. 74. Issue 5.
Pages 469-472 (May 2021)
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Vol. 74. Issue 5.
Pages 469-472 (May 2021)
Scientific letter
DOI: 10.1016/j.rec.2020.10.015
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Impact of the first wave of the SARS-CoV-2 pandemic on preferential/emergent pacemaker implantation rate. Spanish study
Impacto de la primera ola de la pandemia de SARS-CoV-2 en la tasa de implante de marcapasos con indicación preferente/urgente. Estudio español
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Ricardo Salgado Arandaa,
Corresponding author
ricardosalgadodoc@gmail.com

Corresponding author:
, Nicasio Pérez Castellanoa,b, Óscar Cano Pérezc, Andrés Ignacio Bodegas Cañasd, Manuel Frutos Lópeze, Julián Pérez-Villacastín Domíngueza,b
a Unidad de Arritmias, Instituto Cardiovascular, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
b Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
c Unidad de Electrofisiología, Servicio de Cardiología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
d Unidad de Electrofisiología, Servicio de Cardiología, Hospital Universitario de Cruces, Baracaldo, Vizcaya, Spain
e Unidad de Arritmias, Servicio de Cardiología, Hospital Virgen del Rocío, Sevilla, Spain
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Tables (2)
Table 1. Characteristics of the total population, 2019 and 2020
Table 2. Relationship between the number of implant procedures during the 2019 and 2020 study periods and impact of the COVID-19 pandemic, by autonomous community
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To the Editor,

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).

Table 1.

Characteristics of the total population, 2019 and 2020

  Total  2019  2020  P 
Description of the population
Age, years  80±12.4  81±11.8  80±13  .700 
Women  611 (42.3)  376 (42.9)  235 (41.4)  .610 
HT  1068 (73.9)  640 (73)  428 (75.4)  .403 
DM  485 (33.6)  277 (31.6)  208 (36.6)  .087 
Heart disease  762 (52.7)  468 (53.4)  294 (51.8)  .551 
Dilated  31 (2.1)  17 (1.9)  14 (2.5)  .500 
Hypertensive  200 (13.8)  129 (14.7)  71 (12.5)  .235 
Hypertrophic  18 (1.2)  14 (1.6)  4 (0.7)  .135 
Ischemic  211 (14.6)  121 (13.8)  90 (15.8)  .282 
Valve disease  249 (17.2)  159 (18.1)  90 (15.8)  .261 
Others  53 (3.7)  28 (3.2)  25 (4.4)  .233 
Symptoms
Asymptomatic  124 (8.6)  88 (10)  36 (6.3)  .014 
Asthenia  171 (11.8)  99 (11.3)  72 (12.7)  .425 
Dyspnea  276 (19.1)  154 (17.6)  122 (21.5)  .064 
Presyncope  282 (19.5)  192 (21.9)  90 (15.8)  .005 
Syncope  547 (37.9)  316 (36)  231 (40.7)  .076 
Cardiorespiratory arrest  22 (1.5)  13 (1.5)  9 (1.6)  .877 
ECG abnormality justifying the device
Sinus dysfunction  183 (12.7)  118 (13.5)  65 (11.4)  .261 
1st degree block,  3 (0.2)  2 (0.2)  1 (0.2)  .832 
Type 1 2nd degree block,  17 (1.2)  9 (1)  8 (1.4)  .510 
2:1 block  132 (9.1)  83 (9.5)  49 (8.6)  .589 
Type 2 2nd degree block  69 (4.8)  46 (5.2)  23 (4)  .298 
Complete block  636 (44)  365 (41.6)  271 (47.7)  .023 
Slow AF  124 (8.6)  78 (8.9)  46 (8.1)  .598 
Blocked AF  159 (11)  93 (10.6)  66 (11.6)  .547 
Bifascicular block  37 (2.6)  28 (3.2)  9 (1.6)  .059 
Trifascicular block  34 (2.4)  21 (2.4)  13 (2.3)  .897 
Alternating block  11 (0.8)  6 (0.7)  5 (0.9)  .675 
Bradycardia-tachycardia syndrome  23 (1.6)  17 (1.9)  6 (1.1)  .191 
AVN ablation  8 (0.6)  6 (0.7)  2 (0.1)  .406 
Carotid sinus hypersensitivity  3 (0.2)  2 (0.2)  1 (0.2)  .832 
Clinical situation/severity
Heart rate, bpm  40±21  41±24  40±20  .023 
Creatinine clearance, mL/min/1.73 m2  63.3±36.7  65.2±37.1  61.1±37.3  .050 
NT-proBNP, pg/mL  1.230±3.330  1.012±2.885  1.429±4.846  .010 
LVEF, %  60±60±6.5  60±.039 
ICU requirement  445 (32.4)  276 (33.2)  169 (31.3)  .468 
Age in ICU, y  79.2±12.6  79.7±13.6  79±12  .900 
Vasoactive drug requirement  383 (26.5)  200 (22.8)  183 (32.2)  .001 
Temporary PM requirement  228 (15.8)  137 (15.6)  91 (16)  .734 
Implantation and hospital stay
Total days of hospitalization  4±4±3±< .001 
Days to implantation  2±2±1±< .001 
Days hospitalized following implantation  1±1±1±< .001 
Pacing mode        .524 
AAI  3 (0.2)  3 (0.2)  .284 
VVI  532 (36.8)  321 (36.6)  211 (37.1)  .834 
VDD  53 (3.7)  35 (4)  18 (3.2)  .417 
DDD  827 (57.2)  504 (57.5)  323 (56.9)  .821 
CRT  26 (1.8)  13 (1.5)  13 (2.3)  .226 
Complications  64 (4.4)  43 (4.9)  21 (3.7)  .276 
Pericardial effusion  4 (0.3)  3 (0.3)  1 (0.2)  .487 
Perforation  1 (0.1)  1 (0.1)  .607 
Displacement  24 (1.7)  17 (1.9)  7 (1.2)  .305 
Hematoma  18 (1.2)  11 (1.3)  7 (1.2)  .971 
Pneumothorax  11 (0.8)  7 (0.8)  4 (0.7)  .552 
Death  6 (0.4)  4 (0.5)  2 (0.4)  .559 

AF, atrial fibrillation; AVN, atrioventricular node; CRT, cardiac resynchronization therapy; DM, diabetes mellitus; ECG, electrocardiogram; HT, hypertension; ICU, intensive care unit; LVEF, left ventricular ejection fraction; NT-proBNP, amino-terminal fraction of brain pro-natriuretic peptide; PM, pacemaker.

Values are expressed as No. (%) or mean±standard deviation.

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.

Table 2.

Relationship between the number of implant procedures during the 2019 and 2020 study periods and impact of the COVID-19 pandemic, by autonomous community

Autonomous community  Autonomous communitypopulation  Implants in 2019  Implants in 2020  Reduction in 2020 activity  Infected*  Hospitalized*  ICU hospitalized*  Deaths*  Hospitalizations/beds  Hospitalizations/ICU beds 
Andalusia  29.1%  149  93  37.6%  147.61  73.22  9.01  16.39  0.29  1.43 
Hospital 1  5.5%  23  73.9%             
Hospital 2  5.3%  26  13  50.0%             
Hospital 3  6.6%  42  40  4.8%             
Hospital 4  6%  23  11  52.2%             
Hospital 5  5.7%  35  23  34.3%             
Aragon  30.3%  53  25  52.8%  413.56  200.71  17.13  66.10  0.50  1.38 
Hospital 6  30.3%  53  25  52.8%             
Community of Madrid  35.9%  188  120  36.2%  993.64  632.67  53.68  120.96  2.05  5.95 
Hospital 7  5.6%  44  27  38.6%             
Hospital 8  2.9%  19  52.6%             
Hospital 9  6.6%  29  20  31.0%             
Hospital 10  3.4%  42.9%             
Hospital 11  6.7%  33  31  6.1%             
Hospital 12  5.9%  12  83.3%             
Hospital 13  4.8%  44  27  38.6%             
ValencianCommunity  22%  116  72  37.9%  216.84  108.62  14.43  27.78  0.39  1.46 
Hospital 14  2.8%  14  64.3%             
Hospital 15  5%  33  23  30.3%             
Hospital 16  6%  44  30  31.8%             
Hospital 17  4.3%  15  40.0%             
Hospital 18  3.9%  10  50.0%             
Castile-La Mancha  22.1%  20  16  20.0%  815.94  444.05  31.29  137.93  1.62  4.84 
Hospital 19  22.1%  20  16  20.0%             
Castile and León  25.6%  69  44  36.2%  765.52  360.44  22.68  108.85  0.92  3.74 
Hospital 20  11%  28  25  10.7%             
Hospital 21  14.6%  41  19  53.7%             
Catalonia  2%  11  18.2%  725.52  382.26  39.73  71.45  0.85  4.49 
Hospital 22  2%  11  18.2%             
Galicia  36.9%  68  46  32.4%  334.91  95.94  10.93  22.45  0.26  1.31 
Hospital 23  22.2%  21  18  14.3%             
Hospital 24  14.7%  47  28  40.4%             
Balearic Islands  36.4%  37  38  2.7%  172.43  98.66  14.70  19.05  0.29  1.19 
Hospital 25  28.7%  22  23  4.5%             
Hospital 26  7.7%  15  15  0.0%             
Canary Islands  44.3%  52  33  36.5%  106.07  43.61  8.27  7.06  0.12  0.76 
Hospital 27  24.3%  33  13  60.6%             
Hospital 28  20%  19  20  5.3%             
La Rioja  100%  17  58.8%  1.268.95  470.33  28.72  110.48  1.42  6.42 
Hospital 29  100%  17  58.8%             
Chartered Community of Navarre  30.8%  39  18  53.8%  785.22  312.59  20.79  80.25  0.89  2.15 
Hospital 30  30.8%  39  18  53.8%             
Basque Country  17.3%  58  47  19%  602.01  317.56  26.18  65.59  0.88  4.25 
Hospital 31  17.3%  58  47  19.0%             

ICU, intensive care unit.

Hospitalizations/beds: number of COVID-19 hospitalizations in the community/available hospital beds in the community at baseline.

ICU hospitalizations/beds: number of COVID-19 ICU hospitalizations in the community/available ICU beds in the community.

Autonomous community population: percentage of the total population of the autonomous community attending each center.

The information used in this table was obtained from the official reports of the Ministry of Health on the course of the pandemic (report No.o 107) and the National Institute of Statistics (2019 Registry).

*

Per 100 000 population.

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.

Acknowledgements

The coordinators of this study express their sincere gratitude to the researchers who collaborated by collecting and sending data from their respective centers: Francisco de Asís Díaz Cortegana, Javier García Seara, Julia Martínez Solé, Pablo Ávila Alonso, Luis Borrego Bernanbé, José María González Rebollo, Ernesto Díaz Infante, Óscar Alcalde Rodríguez, Josep Navarro Manchón, Francisco Javier García Fernández, José Manuel Rubio Campal, Luis Álvarez Acosta, María del Carmen Expósito Pineda, Rosa Macías-Ruíz, Pilar Cabanas Grandío, Rubén Juárez Prera, Miguel Ángel Arias, Pablo Moriña Vázquez, Tomás Ripoll-Vera, Marta Pombo Jiménez, Fernando Cabestrero de Diego, Diego Lorente Carreño, Vicente Bertomeu González, Rafael Raso Raso, Pau Alonso Fernández and Jorge Toquero Ramos.

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Unpredictable fall of severe emergent cardiovascular diseases hospital admissions during the COVID-19 pandemic: experience of a single large center in Northern Italy.
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Rev Esp Cardiol., 73 (2020), pp. 1084-1085
Copyright © 2020. Sociedad Española de Cardiología
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