Heart disease mortality during the early pandemic period in the United States

  1. Jeremy Samuel Faust
  2. Zhenqiu Lin
  3. Kalen N. Wright
  4. Michael A. Di Iorio
  5. Carrie D. Walsh
  6. Harlan M. Krumholz

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Abstract

Importance

The coronavirus disease 2019 (COVID-19) outbreak has been associated with decreases in acute myocardial infarction diagnoses (AMI) and admissions in the United States. Whether this affected heart disease deaths is unknown.

Objective

To determine whether changes in heart disease deaths occurred during the early pandemic period in the US, we analyzed areas without large COVID-19 outbreaks. This isolated the effect of decreased healthcare-seeking behavior during the early outbreak.

Design, Setting, and Participants

We performed an observational study of heart disease-specific mortality using National Center for Health Statistics data (NCHS). Weekly provisional counts were disaggregated by jurisdiction of occurrence during 2019 and 2020 for all-cause deaths, COVID-19 deaths, and heart disease deaths. For the primary analysis, jurisdictions were included if; 1) There was no all-cause excess mortality during the early pandemic period (weeks 14–17, 2020); 2) The completeness of that data was estimated by NCHS to be >97% as of July 22, 2020, and; 3) Decreases in emergency department (ED) visits occurred during the study period. We compared heart disease death rates during the early pandemic period with corresponding weeks in 2019 and a pre-pandemic control period of 2020 as a sensitivity analysis. Incident rate and rate ratios were calculated.

Exposure

The US COVID-19 outbreak.

Main Outcomes and Measures

Incidence of heart disease deaths.

Results

Twelve states met the primary inclusion criteria, capturing 747,375,188 person-weeks for the early pandemic period and 740,987,984 person-weeks for the 2019 control period. The mean incidence rate (per 100,000 person-weeks) for heart disease in states without excess deaths during the early pandemic period was 3.95 (95% CI 3.83 to 4.06) versus 4.19 (95% CI 4.14 to 4.23) during the corresponding period in 2019. The incident rate ratio (2020/2019) was 0.91 (95% CI 0.87 to 0.97). No state recorded an increase from either the corresponding period in 2019 or the 2020 prepandemic control period. Two states recorded fewer heart disease deaths.

Conclusions and Relevance

This observational study found a decrease in heart disease deaths during the early US outbreak in regions without significant COVID-19 burdens, despite decreases in ED utilization. Long term follow-up data are needed.

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  1. ScreenIT

    SciScore for 10.1101/2020.08.16.20175406: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board Statementnot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    No key resources detected.

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    There are limitations to this study. While death certificates have limitations, we compared death certificate information in different time periods but within the same jurisdictions. Therefore, any biases should be generally consistent. The design cannot determine what caused the change in heart disease-specific mortality in the regions which experienced significant COVID-19 burdens. We also cannot determine long-term outcomes at this stage, and some of the harm of avoidance in care may only be manifest over time. The study provides important new information suggesting that changes in behaviors and exposures in non-COVID-19 areas may have, in part, reduced triggers for acute cardiovascular events. There may have also been some harm with avoidance of care. In some areas with large COVID-19 burdens, cardiovascular deaths increased; future research needs to untangle whether there is misclassification during a period of excess deaths or whether COVID-19 itself increases cardiovascular deaths.

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    About SciScore

    SciScore is an automated tool that is designed to assist expert reviewers by finding and presenting formulaic information scattered throughout a paper in a standard, easy to digest format. SciScore checks for the presence and correctness of RRIDs (research resource identifiers), and for rigor criteria such as sex and investigator blinding. For details on the theoretical underpinning of rigor criteria and the tools shown here, including references cited, please follow this link.

  2. Version published to 10.1101/2020.08.16.20175406v1 on medRxiv