An audit comparing management of patients with HFrEF at a DGH before and during the COVID-19 pandemic

This audit compared the management of patients with heart failure with reduced ejection fraction (HFrEF) admitted to a district general hospital (DGH) during comparative eight month periods before and during the COVID-19 pandemic. The periods studied were from 1 February 2019 to 30 September 2019 and between the same dates in 2020. We investigated differences in mortality and patient characteristics (age, gender and new or prior diagnosis). For patients who survived to discharge and who were not referred to palliative care, we also investigated whether there were differences in rates of echocardiography and prescription of angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor antagonists and beta blockers.

We found that the number of cases was lower during the pandemic and there was a lower mortality rate that was not statistically significant. There was a higher proportion of new cases (odds ratio [OR] 2.21, 95% confidence interval [CI] 1.24 to 3.94, p=0.008) and of female patients (OR 2.03, 95%CI 1.14 to 3.61, p=0.019). For survivors, there was a non-significant decrease in prescription rates for ACE inhibitors and angiotensin II receptor antagonists (81.6% vs. 71.4%, p=0.137) that was not seen for beta blockers. The length of stay was increased and there was also an increase in the interval between admission and echocardiography in patients who were newly diagnosed. Regardless of time period, the time before echocardiography was significantly associated with length of stay.

Background

Heart failure is a common cause of hospital admission in the UK, and the leading cause of admission in people aged 65 years or older.¹ Treatment with angiotensin-converting enzyme (ACE) inhibitors (ACEi), angiotensin-receptor blockers (ARB) and beta blockers are associated with reduced morbidity and mortality, while prompt imaging with a transthoracic echocardiogram (TTE) enables earlier diagnosis and appropriate management.² It has been recommended that a TTE should be done within 48 hours of admission.

Coronavirus disease 2019 (COVID-19) was declared as a global pandemic on 11 March 2020,³ and the UK had 491,805 cases by 30 September 2020.⁴ The pandemic had a huge impact on NHS services. The British Cardiovascular Society (BCS) and British Society for Heart Failure (BSH) released a statement with regards to prioritisation of heart failure service provision during the pandemic.⁵ In brief, there was a focus on avoiding face-to-face consultations and increased use of community-based teams. The aim was to reduce pressure on likely stretched hospital services and to keep vulnerable patients away from potential sources of infection. TTE guidelines during the pandemic likely led to inpatient delays because of factors such as the requirement to wear personal protective equipment and to decontaminate equipment between cases.⁶ For all admitted patients, there was a requirement for COVID-19 testing, and the wait for such results often meant a delay for other investigations. We did a comparative audit of heart failure with reduced ejection fraction (HFrEF) patients admitted to hospital before and during the pandemic period. The aim of the audit was to assess the overall effect of the pandemic on inpatient diagnosis and treatment.

Method

We selected patients from the National Heart Failure Audit (NHFA)⁷ who had heart failure with reduced ejection fraction ≤40% and were admitted to St. Richard’s Hospital, Chichester with one of the following ICD-10 (International classification of diseases version 10) codes in the first diagnostic position – I11.0, I25.5, I42.0, I42.9, I50.0, I50.1 and I50.9. The pre-pandemic cohort consisted of all patients admitted between 1 February 2019 and 30 September 2019, while the pandemic cohort was admitted between 1 February 2020 and 30 September 2020.

We compared age, gender, mortality and diagnosis (new case or prior diagnosis). For patients who survived and who were not referred to palliative care, we compared the use of ACEi/ARB and beta blockers. We considered that drugs had been prescribed even if they were subsequently withdrawn. We compared hospital length of stay and the interval between admission and inpatient TTE. We assessed a multiple linear regression model where length of stay was the dependent variable and interval before TTE, pandemic period, age and diagnosis were independent variables.

All statistics were performed using JMP^®, version 16.2.0, SAS Institute Inc. The Anderson-Darling test was used to assess whether data had a normal distribution. Data that were not normally distributed were summarised as median and interquartile range (IQR) and compared with the Wilcoxon rank-sum test. Results were presented as mean and standard deviation (SD) for continuous variables and as number (%) for categorical variables. Categorical variables were compared with Fisher’s exact test.

Results

There was a 36.8% reduction in cases during the pandemic (table 1) with an increase in the proportion of patients with a diagnosis of new HFrEF and who were female. The mortality rate was lower, but this was not statistically significant. Mortality was associated with age, and for all patients, the odds ratio (OR) for those aged over 80 years was 4.07 (95% confidence interval [CI] 1.64 to 10.10, p=0.003). There was also a non-significant reduction in patients on ACEi/ARB that was not seen for those on beta blockers. The length of stay was increased.

Patients with a new diagnosis were more likely to have inpatient TTE, while a significant proportion with known HFrEF had had a TTE within the preceding 12 months. The time before inpatient TTE was shorter for new cases and this increased during the pandemic.

In our multiple-regression model, only the time interval between admission and TTE was significantly associated with the length of stay (parameter estimate 0.93, SD 0.24, p=0.0002, R²=0.16).

Discussion

Our main findings were that the pandemic was associated with a lower number of cases and a higher proportion of patients who had a new diagnosis of HFrEF and who were female. There was reduced prescribing of ACEi and ARB that was not seen for beta blockers. The length of stay was increased, and for new cases, the interval before inpatient TTE was increased. Length of stay was strongly associated with interval before inpatient TTE, regardless of period.

The 36.8% drop in cases is consistent with reports that hospital admissions fell significantly during the first wave of the pandemic,⁸ and patients may have been less likely to seek help from medical services. It is possible that some known HFrEF cases were managed by the community heart failure nurses to avoid admission. An increase in new cases may partly be due to COVID-19 infection. However, myocarditis related to vaccination is rare, affecting mainly young males,⁹ and one study with case validation reported an incidence of COVID associated myocarditis of only 2.4 per 1,000 hospitalisations, with male preponderance.¹⁰ We are uncertain why the proportion of female patients was increased.

At the beginning of the pandemic, there were concerns that the use of ACEi and ARB may be associated with higher rates for COVID-19 infection and adverse outcomes. This may explain the non-significant reduction in their use. Current data suggest that use of these drugs is actually associated with reduced risk.¹¹

Locally, a likely important contributory factor for the longer wait for TTE for new cases was a requirement that all patients had to be tested for COVID-19, with samples being sent off-site, and COVID-19 negative patients were scanned first.

Conclusion

A lower prescription rate for ACEi/ARB is most likely a historical problem, whereas longer waits for TTE could be an exacerbation of a pre-existing problem. It seems that shortening waits is important as it contributes to length of stay. There continues to be an emphasis on investigating and managing patients in the community, and collecting data on these patients will give a more comprehensive understanding of the management of heart failure.

Conflicts of Interest

None declared.

Funding

None.

Study approval

Permission for this audit was given by the hospital audit committee with no requirement to seek ethical approval.

Key messages

• The proportion of new cases of heart failure with reduced ejection fraction (HFrEF) was increased during the COVID-19 pandemic. The proportion of female patients was also increased
• The proportion of patients on angiotensin-converting enzyme inhibitors (ACEi) and angiotensin-receptor blockers (ARB) was lower during the pandemic, with no change for those on beta blockers
• During the pandemic, the length of stay was prolonged and, for patients with a new diagnosis of HFrEF, the interval between admission and echocardiography was increased. Regardless of time period, the waiting time for an echo was strongly associated with length of stay

References

1. National Institute for Health and Care Excellence. Acute heart failure: diagnosis and management. CG187. London: NICE, 2021. Available from: https://www.nice.org.uk/guidance/cg187

2. National Institute for Health and Care Excellence. Acute heart failure. Quality statement 2: transthoracic doppler 2D echocardiography. London: NICE, 2015. Available from: https://www.nice.org.uk/guidance/qs103/chapter/Quality-statement-2-Transthoracic-doppler-2D-echocardiography

3. World Health Organization. WHO Director-General’s opening remarks at the media briefing on COVID-19 – 11 March 2020. Available at: https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19—11-march-2020

4. Gov.uk. Coronavirus (COVID-19) in the UK. Cases in United Kingdom. Available at: https://coronavirus.data.gov.uk/details/cases?areaType=overview&areaName=United Kingdom

5. British Cardiovascular Society. Prioritisation of heart failure service provision during COVID-19. London: BCS, 2020. Available from: https://www.britishcardiovascularsociety.org/news/prioritisaton-of-hf-services-covid-19

6. British Society of Echocardiography. COVID-19 guidance. London: BSE, 2020. Available from: https://www.bsecho.org/Public/News/Articles/2020/2020-03/202003-COVID-guidance-1.aspx

7. The National Institute for Cardiovascular Outcomes Research (NICOR). National heart failure audit (NHFA): 2021 summary report (2019/2020 data). London: Healthcare Quality Improvement Partnership, 2021. Available from: https://www.nicor.org.uk/wp-content/uploads/2021/10/NHFA-Domain-Report_2021_FINAL.pdf

8. Reschen ME, Bowen J, Novak A et al. Impact of the COVID-19 pandemic on emergency department attendances and acute medical admissions. BMC Emerg Med 2021;21:143. https://doi.org/10.1186/s12873-021-00529-w

9. Bozkurt B, Kamat I, Hotez PJ. Myocarditis with COVID-19 mRNA vaccines. Circulation 2021;144:471–84. https://doi.org/10.1161/CIRCULATIONAHA.121.056135

10. Ammirati E, Lupi L, Palazzini M et al. Prevalence, characteristics, and outcomes of COVID-19 associated acute myocarditis. Circulation 2022;145:1123–39. https://doi.org/10.1161/CIRCULATIONAHA.121.056817

11. Hippisley-Cox J, Young D, Coupland C et al. Risk of severe COVID-19 disease with ACE inhibitors and angiotensin receptor blockers: cohort study including 8.3 million people. Heart 2020;106:1503–11. https://doi.org/10.1136/heartjnl-2020-317393