Diagnostic CV Procedures Rebounded After Dipping in 2020

Diagnostic cardiovascular procedure volumes in the U.S. have more than recovered following early pandemic declines, albeit with regional differences and changed preferences for testing modalities, a study showed.

Procedural volumes exceeded March 2019 levels by 4% in April 2021, whereas other countries around the world were still 6% below their prepandemic baseline (P=0.008), according to Andrew Einstein, MD, PhD, of Columbia University Irving Medical Center in New York City, and collaborators of the INCAPS COVID 2 study.

In the U.S., not all procedural volumes recovered to the same extent. Coronary CT angiography exceeded prepandemic volumes (+22% over baseline), as did cardiac MRI (+16%) and stress cardiac MRI (+14%). Also making small gains were transesophageal echocardiography (+10%) and transthoracic echocardiography (+8%).

In contrast, procedures losing ground since COVID were PET cardiac infection studies (-20%), stress ECG (-13%), stress echocardiography (-11%), and stress SPECT (-6%). Meanwhile, barely changing were volumes for stress PET (0% change), coronary artery calcium CT (0%), and invasive coronary angiography (-2%), Einstein’s group reported in Radiology: Cardiothoracic Imaging.

“Exercise stress testing is an aerosolizing procedure that can expose staff to respiratory droplets and was thus discouraged during the acute phase of the pandemic by some societal guidelines. On the other hand, CT offers shorter testing times and reduced contact between patients and staff, which may have been a factor in some facilities throughout the pandemic,” the authors explained.

Shifting clinical practice and evolving guidelines may also account for the observed changes in procedure volumes during the study period, they said.

Less clear was the reason behind the U.S. regional differences in the rebounding of cardiovascular diagnostic procedures. By April 2021, volumes were exceeding baseline in the Midwest (+11), Northeast (+9%), and the South (+1%). The West, in contrast, declined significantly (-7%, P=0.03).

Einstein and colleagues said they could not find any explanation for this after assessing factors such as COVID-19 prevalence, facility type, practice setting, baseline procedure volume, telehealth use, and demographics across regions.

Trends in testing after 2021 also remain to be elucidated, given the many people complaining of long COVID symptoms or activity limitations.

“Cardiovascular disease remains the leading cause of death for both men and women,” Einstein stressed in a press release. “Diagnostic procedures are imperative for the timely diagnosis and risk stratification of patients with suspected cardiovascular disease.”

INCAPS COVID 2 assessed 669 facilities in 107 countries, including 93 facilities in 34 U.S. states. Participating sites were asked to report volumes for each diagnostic imaging modality used at their facility for March 2019 (baseline), April 2020, and April 2021.

Baseline procedure volume per center was higher for U.S. facilities compared with all non-U.S. facilities (951 vs 222) and non-U.S. high-income country facilities (951 vs 300).

Similar to other countries, however, the U.S. had a 66% reduction in procedural volumes in April 2020 — when the pandemic was well underway — compared with March 2019.

The disproportionate rebound in procedure volumes by April 2021 was attributed to centers reporting lower recovery in lower-middle (-41%) and low-income countries (-50%). High-income countries (0%) did not significantly differ from the U.S. (+4%) in volume recovery.

“To address potential excess morbidity and mortality rates from CVD [cardiovascular disease] in economically disadvantaged regions, a multifaceted approach is necessary, which may include strategies such as increasing telehealth infrastructure, leveraging mobile clinics, and improving healthcare worker training to augment recovery of cardiovascular diagnostic procedures,” the authors wrote.

Outside the rebound in procedural volume, the U.S. stood alone in the magnitude of testing facilities adopting telehealth for patient care (61% vs 38%, P<0.001) and remote reading of studies (53% vs 34%, P<0.001) compared with other countries.

“The rapid transition from in-person to telehealth visits in the United States was largely facilitated by the Centers for Medicare & Medicaid Services, which amended regulations to increase telehealth reimbursements and removed geographic barriers to care,” Einstein’s team recalled.

“Though further studies are needed to gauge the long-term impact of increased telehealth use on patient outcomes, studies have already shown that telehealth is associated with increased patient satisfaction, improved patient retention, and improved access to care for a wide range of patient populations and communities,” they added.

The INCAPS COVID 2 group acknowledged that their survey study design left room for biases and inaccurate reporting by each center.

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