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THE IMPACT OF THE COVID-19 PANDEMIC ON HOSPITALIZATIONS

AND ADMISSION PROFILE OF PATIENTS WITH HEART FAILURE

DECOMPENSATION AT THE ALBERT EINSTEIN ISRAELITA HOSPITAL

Elisa Rampazo Prado1

Abstract: Introduction: The coronavirus disease 2019 (COVID-19) pandemic was ofcially declared

by the WHO on March 11, 2020, and the rst Brazilian case was registered on February 26, 2020.

Since then, health systems have been adapted to receive the emerging ow of patients requiring

sense, a reduction in the number of hospitalizations due to HF decompensation was observed at

Hospital Israelita Albert Einstein (HIAE) from March to August 2020. In this study, we will evaluate

the impact of the COVID-19 pandemic on hospitalizations due to HF decompensation at HIAE,

through data on the clinical prole at the time of admission and the evolution of these patients

during hospitalization, comparing them with the period before the pandemic by the new coronavirus.

Objective: The objectives of the present study aim to quantify the reduction in hospitalizations,

evaluate the clinical prole at the time of admission and evaluate the morbidity and mortality of

these patients, comparing the current pandemic data with previous data. We do not aim to analyze

the relationship between COVID-19 infection and cardiovascular disease. Methods: Retrospective

observational cohort study, carried out in a database of patients who were admitted to HIAE with

and standard deviation, minimum and maximum, median and quartiles, for quantitative variables,

and by absolute and relative frequencies, for qualitative variables. Comparisons between periods

were veried using Chi-square or Fisher’s exact tests, and Student’s t-tests or Mann-Whitney tests,

according to the distribution characteristic. Data normality was veried using the Shapiro-Wilk test,

bloxplot graphs, histograms and quantile comparison graphs. Results: During the pandemic period,

we saw an increase in the number of hospitalizations due to decompensated heart failure, with these

patients being more severe, with rising creatinine levels during hospitalization and higher mortality

due to HF during the pandemic. However, these patients admitted to the service had a higher ejection

fraction compared to the previous period. The use of vasoconstrictor and inotropic drugs remained the

same. We had more female hospitalizations when compared to the pre-pandemic period. Conclusion:

March 11, 2020 was marked by the decree made ofcial bythe World Health Organization

(WHO) that classied the outbreak of the coronavirus disease2019 (COVID-19) as a pandemic.

According to the WHO, in 80% of patients COVID-19 manifests itself with mild symptoms and no

complications, in 15% requires hospitalizationand in 5% needs care in the intensive care unit (ICU).

(WHO, 2020)

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recommendations from international bodies, such as the WHO and the federal government. The

measure was an attempt to slow the spread of COVID-19 and reduce contagion rates, as a way to gain

enough timeto reorganize the health systemand build eld hospitals, thus avoiding the overload of

health services and the lack of hospital beds.

Due to the recommendations and changes established in the context of the pandemic, the

medical and surgical treatment of hospitalized and outpatient patients was restricted to urgent cases,

and all emergency and Intensive Care Unit (ICU) departments were prepared to receive patients

infected by the new coronavirus. Telemedicine consultations were also recommended for patients

who did not have suspected disease and who were not symptomatic, as a way to reduce exposure and

the risk of contagion.

contamination by the disease. A June 2020 study analyzed the impact of the new coronaviruson

in England, comparing the results with hospital data from previous years. The conclusion obtained

was that there was a reduction of approximately 50% inthe number of hospitalizations due to HF

during the lockdown period, and the patients who were admitted to the English health service had a

worse and more severe clinical prole. (BROMAGE et al, 2020)

symptoms reported in acute HF are dyspnea, lower limb edema, fatigue, orthopnea, and paroxysmal

nocturnal dyspnea, which may be accompanied by signs of jugular vengeal stasis, hepatojugular

reux, andpulmonary congestion (PONIKOWSKI, 2016). The onset and severity of symptoms

experienced and reported by patients withacute heart failure varies according to the underlying cause

ofheart failure.

Within the current pandemic scenariodue to the new coronavirus, it was observed that the

patients most affected in seeking care in hospital services were those who suffered an exacerbation of

the chronic formof the disease. (BROMAGE et al, 2020)

Acute HF is one of the main causes of hospitalizations in Brazil and in the world and, as

it is apotentially fatal condition, there is a need forrapid and effective therapeutic intervention. In

HEALTH, 2023).

of chronic HF decompensationare, in descending order of incidence: medication adherence to drug

treatment, infectionand inadequate controlof sodium and water intake. Other causes of decompensation

involve arrhythmias, pulmonary embolism, andacute valvular disease. (ALBUQUERQUE et al, 2015)

Also according to the BREATHE study, the main etiologies of HF in patients who were

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of pulmonary congestion (wetor dry, if present or absent, respectively) and periphery hypoperfusion

(cold or hot, if present or absent, respectively). The combinationof these proles identies 4 groups,

which include acute HF presentations:

Prole A: patients without signs of hypoperfusionand without pulmonary congestion (hot

and dry);

Prole C: patient with signs of hypoperfusionand no pulmonary congestion (cold and dry);

Prole D: patient with signs of hypoperfusionand pulmonary congestion(cold and wet).

order to establish the correct therapy and initiate management in a timely manner, aiming to reduce

that the diagnosis be made based on clinical ndings, personal cardiovascular history and potential

cardiac and non-cardiac precipitants, in addition to performing a complete physical examination

looking for signs of congestion and peripheral hypoperfusion. Additional tests should be requested

upon admission to complement the clinical evaluation of the patient, in order to establish the triggering

After the diagnosis of HF decompensation, the patient’s risk of in-hospital mortality at

admission should be determined by the patient’s clinical presentation (COLLINS et al, 2015) and

by risk scores, the best validated being the ADHERE registry risk scale, which takes into account

the variables creatinine, systolic blood pressure and blood urea nitrogen (BUN). According to the

BREATHE study, in Brazil, 12.6% of hospital admissions due to HF decompensation result in death.

(YANCY et al, 2005)

The recommended treatment for acute chronic HF involves an approach that encompasses

the etiological management and its trigger and has a specic conduct for each admission prole,

taking into account systemic blood pressure (SBP) and the clinical-hemodynamic prole based on

Stevenson’s classication (1989). According to the Brazilian Guideline for Chronic and Acute Heart

suspensionof diuric use;

SBP > 110 mmHg and hot and humid hemodinic prole: vasodilator + diuretic+ BB + ACE/

SBP between 85 and 110 mmHg and hot and humid hemodinic prole: vasodilator + diuretic+

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BB + suspend use of ACE/ARB.

According to the BREATHE study, the main medications used in the intra-hospital

environment in Brazil were: loop diuretics (89.8%), beta blockers (57.1%), vasodilators (6.6%) and

inotropes (13.6%).

Brazilian records indicate an intra-hospital mortality rate between 4 and 12% (YANCY et

al, 2005) for patients with acute decompensated HF. The ADHERE registry indicates that patients

remain hospitalized for an average of 4.4 days. After hospital discharge, patients with HF still have

a risk of being readmitted within 90 days and a 30% chance of death within 1 year. (PONIKOWSKI

et al, 2016) In addition, increases in serum creatinine levels associated with long hospitalization in

Einstein (HIAE) during the novel coronavirus pandemic (March-August/2020).

heart failure during the months of the pandemic and to evaluate the hemodynamic prole at the

time of hospital admission of these patients, comparing the results with data from HIAE prior to the

pandemic. In addition, we will also evaluate in-hospital morbidity and compare the creatinine value

at admission and the highest value reached during hospitalization.

To analyze thediagnoses at hospital admissionand the use of vasoactive and inotropic

drugsbetween periods;

To compare in-hospital morbidity and mortality;

To evaluate the evolutionof creatinine with values at admissionand signicant changesduring

Relevance of the Study

The new coronavirus disease and the side effects caused by the lockdown have not yet been

fully explained in the medical literature regarding their harmful effects on population health.

Previous studies have already suggested a decrease in hospitalizations and a decrease in the

care of chronic patients, which may worsen long-term care. Therefore, it is intriguing to assess the

anonymously, making the data protected and, consequently, safe for patients.

Given the above, we propose as a hypothesis that during the rst wave of the pandemic

(March 2020 to August 2020) we had a decrease in hospital admissions for HF, but those admitted

were in greater severity, causing greater mortality and morbidity due to Acute Heart Failure.

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This retrospective observational study included 327 patients diagnosed with Acute Heart

Failure upon admission to Hospital Israelita Albert Einstein between October 2019 and August 2020.

None of these patients were tested for COVID-19.

All patients were over 18 years of age and were also included based on documentation of

A patients admitted between October 2019 and February 2020, with a total of 89 patients; and, group

B, patients admitted between March 2020 and August 2020, totaling n = 119.

The objective of the groups was an an comparative analysis contemplating the achievement

of the study objectives Throughyou are from the HIAE database.

We used a database from the Hospital Israelita Albert Einstein, in the city of São Paulo, for

analysis.

In the database, the main quantitative variables that will be analyzed are:

• Number of patients admitted to the service;

• Creatinine at the time of hospital admission and after 24 hours, 48 hours, 72 hours and at

the time of hospital discharge;

value = 0.207), with ischemic diseases being the most frequent (pre-pandemic = 78.5% and post-

period had Ischemic + Idiopathic etiology; four patients in each period had Valvular + Idiopathic

etiology (Table 2A).

Regarding the use of inotropic drugs during hospitalization, the prevalence was higher in

the pre-pandemic period (43.8% vs. 31.9%), but this difference was not signicant (p value = 0.079)

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Milrinone (Table 2D).

Regarding the use of vasoconstrictor drugs during hospitalization, the prevalence was similar

1E). Patients could use more than one drug at the same time, with norepinephrine being the most

commonly used drug in both periods (Table 2F).

In-hospital morbidity and mortality prole

The type of hospital discharge did not show a signicant difference between the periods

vs. 4.5%) (Table 3A).

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The length of stay also did not show a signicant difference, with a median of eight days in

the pre-pandemic period and seven days in the post-pandemic period (p-value = 0.578) (Table 3B).

The left ventricular ejection fraction showed a signicant difference between the periods,

= 0.250) (Table 3C); diastolic blood pressure (pre-mean = 75 vs. post-mean = 74; p-value = 0.870)

creatinine on admission (pre-median = 1.48 vs. post-median = 1.49; p-value = 0.996) (Table 3F).

We compared creatinine values on admission with the highest value observed during

hospitalization. Although we found no evidence of differences in creatinine values between the

periods, as seen in Tables 3F and 3G, in both periods we observed an increase in creatinine values

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Exacerbations of Heart Failure

The benets of physical exercise and diet to compensate for HF and health are already well

documented in the literature (ROGERS et al, 2017). However, the change in life dynamics imposed

by quarantine created barriers to the practice of physical activities and the maintenance of a balanced

diet.

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of analysis.

Furthermore, during the analysis period during the pandemic, we found that patients had

higher left ventricular ejection fraction (LVEF) (30 vs. 35). Although the values are different, they

are still considered as HF with reduced ejection fraction (HFrEF) according to the current literature

(JESUS et al, 2024). According to GOMEZ-SOTO et al (2024), physical exercise is an important

predictor for the prognosis of patients with HFrEF, preventing decompensation and reducing mortality.

As mentioned above, data indicate that during the lockdown there was a decrease in the practice of

physical activities (ROBINSON et al, 2021).

However, there were no active questions in our study about eating habits, physical activity

and weight change during the period. Furthermore, as we started our analysis at an early stage of the

overweight, although the comparison between groups did not show statistical relevance.

inconsistent with the literature already recorded. This fact can be explained by regional differences in

the penetrance and temporal severity of the pandemic (BOOTH et al, 2020).

In addition, we also recorded data on more hospitalizations of female patients. Previous data

indicate that women with HF are more likely to present psychological changes such as anxiety and

in females may be correlated with the difference in treatment (CAMPBELL et al, 2024) provided in