Impact of COVID-19 on cardiovascular testing in the United States versus the rest of the world

Objectives: This study sought to quantify and compare the decline in volumes of cardiovascular procedures between the United States and non-US institutions during the early phase of the coronavirus disease-2019 (COVID-19) pandemic. Background: The COVID-19 pandemic has disrupted the care of many non-COVID-19 illnesses. Reductions in diagnostic cardiovascular testing around the world have led to concerns over the implications of reduced testing for cardiovascular disease (CVD) morbidity and mortality. Methods: Data were submitted to the INCAPS-COVID (International Atomic Energy Agency Non-Invasive Cardiology Protocols Study of COVID-19), a multinational registry comprising 909 institutions in 108 countries (including 155 facilities in 40 U.S. states), assessing the impact of the COVID-19 pandemic on volumes of diagnostic cardiovascular procedures. Data were obtained for April 2020 and compared with volumes of baseline procedures from March 2019. We compared laboratory characteristics, practices, and procedure volumes between U.S. and non-U.S. facilities and between U.S. geographic regions and identified factors associated with volume reduction in the United States. Results: Reductions in the volumes of procedures in the United States were similar to those in non-U.S. facilities (68% vs. 63%, respectively; p = 0.237), although U.S. facilities reported greater reductions in invasive coronary angiography (69% vs. 53%, respectively; p < 0.001). Significantly more U.S. facilities reported increased use of telehealth and patient screening measures than non-U.S. facilities, such as temperature checks, symptom screenings, and COVID-19 testing. Reductions in volumes of procedures differed between U.S. regions, with larger declines observed in the Northeast (76%) and Midwest (74%) than in the South (62%) and West (44%). Prevalence of COVID-19, staff redeployments, outpatient centers, and urban centers were associated with greater reductions in volume in U.S. facilities in a multivariable analysis. Conclusions: We observed marked reductions in U.S. cardiovascular testing in the early phase of the pandemic and significant variability between U.S. regions. The association between reductions of volumes and COVID-19 prevalence in the United States highlighted the need for proactive efforts to maintain access to cardiovascular testing in areas most affected by outbreaks of COVID-19 infection

Omecamtiv mecarbil in chronic heart failure with reduced ejection fraction, GALACTIC‐HF: baseline characteristics and comparison with contemporary clinical trials

Aims: The safety and efficacy of the novel selective cardiac myosin activator, omecamtiv mecarbil, in patients with heart failure with reduced ejection fraction (HFrEF) is tested in the Global Approach to Lowering Adverse Cardiac outcomes Through Improving Contractility in Heart Failure (GALACTIC‐HF) trial. Here we describe the baseline characteristics of participants in GALACTIC‐HF and how these compare with other contemporary trials. Methods and Results: Adults with established HFrEF, New York Heart Association functional class (NYHA) ≥ II, EF ≤35%, elevated natriuretic peptides and either current hospitalization for HF or history of hospitalization/ emergency department visit for HF within a year were randomized to either placebo or omecamtiv mecarbil (pharmacokinetic‐guided dosing: 25, 37.5 or 50 mg bid). 8256 patients [male (79%), non‐white (22%), mean age 65 years] were enrolled with a mean EF 27%, ischemic etiology in 54%, NYHA II 53% and III/IV 47%, and median NT‐proBNP 1971 pg/mL. HF therapies at baseline were among the most effectively employed in contemporary HF trials. GALACTIC‐HF randomized patients representative of recent HF registries and trials with substantial numbers of patients also having characteristics understudied in previous trials including more from North America (n = 1386), enrolled as inpatients (n = 2084), systolic blood pressure &lt; 100 mmHg (n = 1127), estimated glomerular filtration rate &lt; 30 mL/min/1.73 m2 (n = 528), and treated with sacubitril‐valsartan at baseline (n = 1594). Conclusions: GALACTIC‐HF enrolled a well‐treated, high‐risk population from both inpatient and outpatient settings, which will provide a definitive evaluation of the efficacy and safety of this novel therapy, as well as informing its potential future implementation

Changes in the risk of river flooding due to urban development along plain rivers. Case study: the city of Gualeguaychú

Fil: Sato, Rodolfo Alejandro. Universidad Nacional del Litoral. Facultad de Ingeniería y Ciencias Hídricas; Argentina.Muchas ciudades del Litoral argentino asentadas en la ribera de los ríos se encuentran con una parte de su territorio sujeto a inundaciones periódicas, debido a un proceso de urbanización creciente que en muchas ocasiones no reconoce reglas ni límites. En esta Tesis se estudio la ciudad de Gualeguaychú, en la provincia de Entre Ríos. Para el estudio del comportamiento del río se analizó la información de caudales y alturas registrados, se realizó la modelación hidrológica de la cuenca con el modelo HEC-HMS y la modelación hidráulica del tramo inferior del río con el modelo HEC-RAS. Se analizó el crecimiento urbano de los últimos 20 años y se evaluó la modificación en el riesgo de inundaciones producido por el crecimiento urbano. El incremento del riesgo de inundación puede producirse tanto por incremento de la amenaza como de la vulnerabilidad. Como resultado del estudio se obtuvo que el incremento de la amenaza se debe principalmente al incremento de niveles por las obstrucciones al flujo de las obras de infraestructuras realizadas y la urbanización de áreas inundables, pero este es mínimo si se compara con el incremento del riesgo que se produce por aumento de la vulnerabilidad debido a la edificación en zonas inundables, la cual tiene una tendencia que va en un aumento muy pronunciado. Como recomendación se propone que las áreas urbanas costeras se deberían dividir en distintos sectores regulando el uso del suelo de acuerdo a las curvas de riesgo hídrico determinadas como resultados del modelo hidráulico.Many cities in the Argentine Litoral settled on the banks of the rivers are a part of its territory subject to periodic flooding, due to increasing urbanization process that often does not recognize rules or limits. In this thesis the city of Gualeguaychú in the province of Entre Rios was studied. To study the behavior of river flow information and recorded heights we analyzed, hydrological basin modeling was performed using HEC-HMS model and hydraulic modeling of the lower section of the river with the HEC-RAS model. the urban growth of the last 20 years was analyzed and evaluated the change in the risk of flooding caused by urban growth. The increased risk of flooding may be produced by increasing the threat or the vulnerability. As a result of the study it was found that increasing the threat is primarily due to levels increased by the obstructions to the flow of infrastructure works carried out and the urbanization of flooded areas, but this is minimal when it´s compared with increased risk caused by increased vulnerability due to the construction in flood zones, which have a tendency to go on a very pronounced increase. As a recommendation is proposed that coastal urban areas should be divided into different sectors regulating land use according to hydric risk curves determined as results of the hydraulic model

Regionalização das Vazões Máximas nas Sub-bacias do Arroyo Feliciano

The paper consists of the study of the Feliciano Stream basin, which has a single gauging. On the basis of a calibrated model, it was sought to use a storm distribution compatible with the observed flow information, so that its error would be considered acceptable. The sub-basins were modeled for storms of different recurrences distributed in time according to the adopted pattern and different physical parameters were determined for each one of them. With the information generated, a multivariate statistical analysis was carried out that will define hydrologically homogeneous regions and select the parameters and variables with the highest incidence in the maximum flow values With the results of maximum flows obtained in the hydrological model for the different sub-basins and preset recurrences, a list of their most important variables and parameters was carried out. Afterwards, a multivariate statistical analysis was performed in order to define hydrologically homogeneous regions and establish which variables had a greater incidence in the flow values. As a result, practical formulas were obtained that allow a preliminary estimate of flows to be obtained based on the physiographic characteristics of the sub-basins and the maximum mean areal precipitation for a recurrence of 2 years. In addition, regional frequency equations were defined, enabling the calculation of a flood index, which translates the estimated flow for any adopted recurrence between 2 and 100 years. El trabajo consiste en el estudio y regionalización de caudales máximos de las subcuencas del Arroyo Feliciano, considerando que este curso de agua posee una sola estación de aforo. A partir de un modelo hidrológico calibrado, se analizaron distintas distribuciones temporales de tormenta para determinar aquella para la cual los caudales simulados se aproximan a los observados, asumiendo un margen de error considerado como aceptable. Se modelaron las subcuencas para tormentas de distintas recurrencias, distribuidas temporalmente según un patrón adoptado, y se determinaron distintos parámetros físicos para cada una de ellas. Con esta información, se realizó un análisis estadístico multivariado que permitió definir regiones hidrológicamente homogéneas y seleccionar los parámetros y variables de mayor incidencia en los valores de caudales máximos. Como resultados se obtuvieron fórmulas prácticas que permiten alcanzar una estimación preliminar de caudales, en base a las características fisiográficas de las subcuencas, y la precipitación máxima media areal, para una recurrencia de 2 años. Además, se definieron ecuaciones regionales de frecuencia para calcular un índice de creciente, el cual permite estimar el caudal para cualquier recurrencia de interés, entre 2 y 100 años, a partir de los caudales de 2 años determinados por la ecuación de regionalización.O trabalho consiste no estudo e regionalização das vazões máximas das sub-bacias do Arroyo Feliciano, considerando que este curso d'água possui apenas uma estação medidora.A partir de um modelo hidrológico calibrado, foram analisadas diferentes distribuições temporais de tempestades para determinar aquela para a qual as vazões simuladas se aproximam das observadas, assumindo uma margem de erro considerada aceitável.As sub-bacias foram modeladas para tempestades de diferentes recorrências, distribuídas temporalmente de acordo com um padrão adotado, e diferentes parâmetros físicos foram determinados para cada uma delas.Com essas informações, foi realizada uma análise estatística multivariada que permitiu definir regiões hidrologicamente homogêneas e selecionar os parâmetros e variáveis ​​com maior incidência nos valores de vazão máxima.Como resultado, foram obtidas fórmulas práticas que permitem estimar preliminarmente as vazões, com base nas características fisiográficas das sub-bacias, e a pluviosidade máxima média da área, para uma recorrência de 2 anos. Além disso, foram definidas equações de frequência regional para calcular um índice de inundação, que permite estimar a vazão para qualquer recorrência de interesse, entre 2 e 100 anos, a partir das vazões de 2 anos determinadas pela equação de regionalização

Reduction of cardiac imaging tests during the COVID-19 pandemic: The case of Italy. Findings from the IAEA Non-invasive Cardiology Protocol Survey on COVID-19 (INCAPS COVID)

Background: In early 2020, COVID-19 massively hit Italy, earlier and harder than any other European country. This caused a series of strict containment measures, aimed at blocking the spread of the pandemic. Healthcare delivery was also affected when resources were diverted towards care of COVID-19 patients, including intensive care wards. Aim of the study: The aim is assessing the impact of COVID-19 on cardiac imaging in Italy, compare to the Rest of Europe (RoE) and the World (RoW). Methods: A global survey was conducted in May–June 2020 worldwide, through a questionnaire distributed online. The survey covered three periods: March and April 2020, and March 2019. Data from 52 Italian centres, a subset of the 909 participating centres from 108 countries, were analyzed. Results: In Italy, volumes decreased by 67% in March 2020, compared to March 2019, as opposed to a significantly lower decrease (p &lt; 0.001) in RoE and RoW (41% and 40%, respectively). A further decrease from March 2020 to April 2020 summed up to 76% for the North, 77% for the Centre and 86% for the South. When compared to the RoE and RoW, this further decrease from March 2020 to April 2020 in Italy was significantly less (p = 0.005), most likely reflecting the earlier effects of the containment measures in Italy, taken earlier than anywhere else in the West. Conclusions: The COVID-19 pandemic massively hit Italy and caused a disruption of healthcare services, including cardiac imaging studies. This raises concern about the medium- and long-term consequences for the high number of patients who were denied timely diagnoses and the subsequent lifesaving therapies and procedures

Impact of COVID-19 on Diagnostic Cardiac Procedural Volume in Oceania: The IAEA Non-Invasive Cardiology Protocol Survey on COVID-19 (INCAPS COVID)

Objectives: The INCAPS COVID Oceania study aimed to assess the impact caused by the COVID-19 pandemic on cardiac procedure volume provided in the Oceania region. Methods: A retrospective survey was performed comparing procedure volumes within March 2019 (pre-COVID-19) with April 2020 (during first wave of COVID-19 pandemic). Sixty-three (63) health care facilities within Oceania that perform cardiac diagnostic procedures were surveyed, including a mixture of metropolitan and regional, hospital and outpatient, public and private sites, and 846 facilities outside of Oceania. The percentage change in procedure volume was measured between March 2019 and April 2020, compared by test type and by facility. Results: In Oceania, the total cardiac diagnostic procedure volume was reduced by 52.2% from March 2019 to April 2020, compared to a reduction of 75.9% seen in the rest of the world (p&lt;0.001). Within Oceania sites, this reduction varied significantly between procedure types, but not between types of health care facility. All procedure types (other than stress cardiac magnetic resonance [CMR] and positron emission tomography [PET]) saw significant reductions in volume over this time period (p&lt;0.001). In Oceania, transthoracic echocardiography (TTE) decreased by 51.6%, transoesophageal echocardiography (TOE) by 74.0%, and stress tests by 65% overall, which was more pronounced for stress electrocardiograph (ECG) (81.8%) and stress echocardiography (76.7%) compared to stress single-photon emission computerised tomography (SPECT) (44.3%). Invasive coronary angiography decreased by 36.7% in Oceania. Conclusion: A significant reduction in cardiac diagnostic procedure volume was seen across all facility types in Oceania and was likely a function of recommendations from cardiac societies and directives from government to minimise spread of COVID-19 amongst patients and staff. Longer term evaluation is important to assess for negative patient outcomes which may relate to deferral of usual models of care within cardiology

International Impact of COVID-19 on the Diagnosis of Heart Disease

Background: The coronavirus disease 2019 (COVID-19) pandemic has adversely affected diagnosis and treatment of noncommunicable diseases. Its effects on delivery of diagnostic care for cardiovascular disease, which remains the leading cause of death worldwide, have not been quantified. Objectives: The study sought to assess COVID-19's impact on global cardiovascular diagnostic procedural volumes and safety practices. Methods: The International Atomic Energy Agency conducted a worldwide survey assessing alterations in cardiovascular procedure volumes and safety practices resulting from COVID-19. Noninvasive and invasive cardiac testing volumes were obtained from participating sites for March and April 2020 and compared with those from March 2019. Availability of personal protective equipment and pandemic-related testing practice changes were ascertained. Results: Surveys were submitted from 909 inpatient and outpatient centers performing cardiac diagnostic procedures, in 108 countries. Procedure volumes decreased 42% from March 2019 to March 2020, and 64% from March 2019 to April 2020. Transthoracic echocardiography decreased by 59%, transesophageal echocardiography 76%, and stress tests 78%, which varied between stress modalities. Coronary angiography (invasive or computed tomography) decreased 55% (p &lt; 0.001 for each procedure). In multivariable regression, significantly greater reduction in procedures occurred for centers in countries with lower gross domestic product. Location in a low-income and lower–middle-income country was associated with an additional 22% reduction in cardiac procedures and less availability of personal protective equipment and telehealth. Conclusions: COVID-19 was associated with a significant and abrupt reduction in cardiovascular diagnostic testing across the globe, especially affecting the world's economically challenged. Further study of cardiovascular outcomes and COVID-19–related changes in care delivery is warranted

Cardiac myosin activation with omecamtiv mecarbil in systolic heart failure

BACKGROUND The selective cardiac myosin activator omecamtiv mecarbil has been shown to improve cardiac function in patients with heart failure with a reduced ejection fraction. Its effect on cardiovascular outcomes is unknown. METHODS We randomly assigned 8256 patients (inpatients and outpatients) with symptomatic chronic heart failure and an ejection fraction of 35% or less to receive omecamtiv mecarbil (using pharmacokinetic-guided doses of 25 mg, 37.5 mg, or 50 mg twice daily) or placebo, in addition to standard heart-failure therapy. The primary outcome was a composite of a first heart-failure event (hospitalization or urgent visit for heart failure) or death from cardiovascular causes. RESULTS During a median of 21.8 months, a primary-outcome event occurred in 1523 of 4120 patients (37.0%) in the omecamtiv mecarbil group and in 1607 of 4112 patients (39.1%) in the placebo group (hazard ratio, 0.92; 95% confidence interval [CI], 0.86 to 0.99; P = 0.03). A total of 808 patients (19.6%) and 798 patients (19.4%), respectively, died from cardiovascular causes (hazard ratio, 1.01; 95% CI, 0.92 to 1.11). There was no significant difference between groups in the change from baseline on the Kansas City Cardiomyopathy Questionnaire total symptom score. At week 24, the change from baseline for the median N-terminal pro-B-type natriuretic peptide level was 10% lower in the omecamtiv mecarbil group than in the placebo group; the median cardiac troponin I level was 4 ng per liter higher. The frequency of cardiac ischemic and ventricular arrhythmia events was similar in the two groups. CONCLUSIONS Among patients with heart failure and a reduced ejection, those who received omecamtiv mecarbil had a lower incidence of a composite of a heart-failure event or death from cardiovascular causes than those who received placebo. (Funded by Amgen and others; GALACTIC-HF ClinicalTrials.gov number, NCT02929329; EudraCT number, 2016 -002299-28.)

Worldwide Disparities in Recovery of Cardiac Testing 1 Year Into COVID-19

BACKGROUND The extent to which health care systems have adapted to the COVID-19 pandemic to provide necessary cardiac diagnostic services is unknown.OBJECTIVES The aim of this study was to determine the impact of the pandemic on cardiac testing practices, volumes and types of diagnostic services, and perceived psychological stress to health care providers worldwide.METHODS The International Atomic Energy Agency conducted a worldwide survey assessing alterations from baseline in cardiovascular diagnostic care at the pandemic's onset and 1 year later. Multivariable regression was used to determine factors associated with procedure volume recovery.RESULTS Surveys were submitted from 669 centers in 107 countries. Worldwide reduction in cardiac procedure volumes of 64% from March 2019 to April 2020 recovered by April 2021 in high- and upper middle-income countries (recovery rates of 108% and 99%) but remained depressed in lower middle- and low-income countries (46% and 30% recovery). Although stress testing was used 12% less frequently in 2021 than in 2019, coronary computed tomographic angiography was used 14% more, a trend also seen for other advanced cardiac imaging modalities (positron emission tomography and magnetic resonance; 22%-25% increases). Pandemic-related psychological stress was estimated to have affected nearly 40% of staff, impacting patient care at 78% of sites. In multivariable regression, only lower-income status and physicians' psychological stress were significant in predicting recovery of cardiac testing.CONCLUSIONS Cardiac diagnostic testing has yet to recover to prepandemic levels in lower-income countries. Worldwide, the decrease in standard stress testing is offset by greater use of advanced cardiac imaging modalities. Pandemic-related psychological stress among providers is widespread and associated with poor recovery of cardiac testing. (C) 2022 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation