Nationwide Initiation of Cardiovascular Risk Treatments During the COVID-19 Pandemic in France: Women on a Slippery Slope?

Objectives: This study examines the initiation of prescribed medication treatments for cardiovascular risk (antihypertensives, lipid-lowering drugs, oral anticoagulants in atrial fibrillation, and smoking cessation medications) during the COVID-19 pandemic in the French population. Methods: For each year between 2017 and 2021, we used the French National Insurance Database to identify the number of people with at least one reimbursement for these medications but no reimbursement in the previous 12 months. We computed incidence rate ratios (IRRs) between 2017-2019 and, respectively 2020 and 2021 using Poisson regression adjusted for age and 2017-2019 time trends. We recorded the number of lipid profile blood tests, Holter electrocardiograms, and consultations with family physicians or cardiologists. Results: In 2020, IRR significantly decreased for initiations of antihypertensives (-11.1%[CI95%, -11.4%;-10.8%]), lipid-lowering drugs (-5.2%[CI95%, -5.5%;-4.8%]), oral anticoagulants in atrial fibrillation (-8.6%[CI95%, -9.1%;-8.0%]), and smoking cessation medications (-50.9%[CI95%, -51.1%;-50.7%]) compared to 2017-2019. Larger decreases were found in women compared to men except for smoking cessation medications, with the sex difference increasing with age. Similar analyses comparing 2021 to 2017-2019 showed an increase in the initiation of lipid-lowering drugs (+ 11.6%[CI95%, 10.7%;12.5%]) but even lower rates for the other medications, particularly in women. In addition, the 2020 number of people visiting a family physician or cardiologist decreased by 8.4 and 7.4%. A higher decrease in these visits was observed in those over 65 years of age compared to those under 65 years of age. A greater use of teleconsultation was found in women. Conclusion: The COVID-19 pandemic heavily impacted the initiation of medication treatments for cardiovascular risk in France, particularly in women and people over 65 years.

One Year Prevalence of Venous Thromboembolism in Hospitalized COVID-19 Patients in France: Patients' Characteristics, Time Trends, and Outcomes.

BACKGROUND: Patients hospitalized with coronavirus disease-2019 (COVID-19) are at high risk of deep venous thrombosis (DVT) and pulmonary embolism (PE). OBJECTIVES: The aims were to provide time trends in the 2020 nation-wide prevalence of venous thromboembolism (VTE) in patients hospitalized with a COVID-19 diagnosis in France, and to describe in-hospital and up to 30-day postdischarge death. METHODS: All patients hospitalized in France with a COVID-19 diagnosis in 2020 were selected. Crude and age-adjusted prevalence of VTE and PE was computed by 4-week intervals and for the overall study period using Poisson regression. Time trends in in-hospital and 30-day postdischarge case-fatality rates were evaluated by comparing each 4-week intervals to weeks 10 to 14 corresponding to the first part of the first lockdown using logistic regression models. RESULTS: Among the 287,638 patients hospitalized with a COVID-19 diagnosis in 2020 in France, 14,985 (5.2%) had a concomitant VTE, with 10,453 (3.6%) having PE and 4,532 (1.6%) having DVT. In patients admitted to intensive care units, the crude prevalence of VTE and PE reached 16.1 and 11.0% respectively during the first lockdown. After adjustment, the prevalence of VTE and PE decreased during the year 2020 but a rebound was observed during the second lockdown. In-hospital case-fatality rates among hospitalized COVID-19 patients with PE globally decreased between the first and the second epidemic waves. CONCLUSION: Our study showed a decrease in the incidence of symptomatic VTE and PE in hospitalized COVID-19 patients, and a decreased time trend of outcomes during the second wave compared with the first one.

Impact of the COVID-19 pandemic and a national lockdown on hospitalizations for stroke and related 30-day mortality in France: A nationwide observational study.

BACKGROUND AND PURPOSE: The aim of this nationwide study was to assess the impact of the COVID-19 pandemic on stroke hospitalization rates, patient characteristics and 30-day case fatality rates. METHODS: All hospitalizations for stroke from January to June of each year from 2017 to 2020 were selected using International Classification of Diseases, 10th revision, codes I60 to I64 in the national hospital discharge database. Patient characteristics and management were described according to three time periods: pre-lockdown, lockdown, and post-lockdown. Weekly incidence rate ratios (IRRs) were computed to compare time trends in the rates of patients hospitalized for stroke as well as in-hospital and 30-day case fatality rates between the years 2017-2019 and 2020. RESULTS: In 2020, between weeks 1 and 24, 55,308 patients were hospitalized for stroke in France. IRRs decreased by up to 30% for all age groups, sex, and stroke types during the lockdown compared to the period 2017-2019. Patients hospitalized during the second and third weeks of the lockdown had higher in-hospital case fatality rates compared to 2017-2019. In-hospital case fatality rates increased by almost 60% in patients aged under 65 years. Out-of-hospital 30-day case fatality rates increased between weeks 11 and 15 among patients who returned home after their hospitalization. Important changes in care management were found, including fewer stroke patients admitted to resuscitation units, more admitted to stroke care units, and a shorter mean length of hospitalization. CONCLUSIONS: During the first weeks of the lockdown, rates of patients hospitalized for stroke fell by 30% and there were substantial increases of both in-hospital and out-of-hospital 30-day case fatality rates.

Care management and 90-day post discharge mortality in patients hospitalized for myocardial infarction and COVID-19: A French nationwide observational study.

BACKGROUND: Concomitant or cured coronavirus disease 2019 (COVID-19) in patients with myocardial infarction (MI) may lead to difficulties in acute care management and impair prognosis. AIMS: To describe and compare the characteristics, care management and 90-day post discharge outcomes of patients hospitalized for MI who did not have COVID-19 with those of patients with concomitant or previous hospital-diagnosed COVID-19. METHODS: This population-based French study included all patients hospitalized for MI in France (30 December 2019 to 04 October 2020) from the French National Health Data System. Outcomes were described for each COVID-19 group and compared using adjusted logistic regression analysis. RESULTS: Among 55,524 patients hospitalized for MI, 135 had previous hospital-diagnosed COVID-19 and 329 had concomitant COVID-19. Patients with previous hospital-diagnosed COVID-19 had more personal history of cardiovascular diseases than those without concomitant/previous confirmed COVID-19. In-hospital and 90-day post discharge mortality rates of patients with previous COVID-19 were 8.1% and 4.0%, respectively, compared with 3.5% and 3.0% in patients without concomitant/previous confirmed COVID-19 (odds ratio [OR]adjin-hospital 1.83, 95% confidence interval [CI] 0.97-3.46; ORadjpostdischarge 0.77, 95% CI 0.28-2.13). Patients with concomitant COVID-19 had more personal history of cardiovascular diseases, but also a poorer prognosis than their no concomitant/no previous confirmed COVID-19 counterparts; they presented excess cardiac complications during hospitalization (ORadj 1.62, 95% CI 1.29-2.04), in-hospital mortality (ORadj 3.31, 95% CI 2.32-4.72) and 90-day post discharge mortality (ORadj 2.09, 95% CI 1.24-3.51). CONCLUSIONS: In-hospital and 90-day post discharge mortality of patients hospitalized for MI who had previous hospital-diagnosed COVID-19 did not seem to differ from those hospitalized for MI alone. Conversely, concomitant COVID-19 and MI carried a poorer prognosis extending beyond the hospital stay. Special attention should be given to patients with simultaneous COVID-19 and MI, in terms of acute care and secondary prevention.

Myocardial infarction throughout 1 year of the COVID-19 pandemic: French nationwide study of hospitalization rates, prognosis and 90-day mortality rates.

BACKGROUND: Studies reported a decrease in hospital admissions for myocardial infarction (MI) in early 2020 as a result of the coronavirus disease 2019 (COVID-19) crisis, mainly restricted to the beginning of the pandemic. AIMS: To describe national trends in hospital admissions for MI in 2020, and to compare patient characteristics, in-hospital prognosis and 90-day mortality between patients who had an MI in 2020 and those admitted in 2017-2019. METHODS: All patients hospitalized for MI in France from 2017 to 2020 were selected from the national hospital discharge database. Analyses compared temporal trends in MI admissions, in-hospital cardiac complications and mortality rates in 2020 versus 2017-2019. RESULTS: In 2020, 94,747 patients were hospitalized for MI, corresponding to a 6% decrease in MI admissions compared with 2017-19. This decrease was larger during the first lockdown (-24%; P<0.0001) than during the second lockdown (-8%; P<0.0001). Reductions in MI admissions were more pronounced and longer among patients with non-ST-segment elevation MI, older people and women. An increase in ST-segment elevation MI admissions was observed between lockdowns (+4%; P=0.0005). Globally, and after adjustment for age, sex and calendar year, in-hospital and 90-day post-discharge mortality rates did not differ in 2020 versus 2017-19: incidence rate ratio (IRR)adjin-hospital 1.03, 95% confidence interval (CI) (0.98-1.08); IRRadj90-daypost-discharge 1.06, 95% CI (0.98-1.13). CONCLUSIONS: In 2020, a significant decrease in MI admissions was observed, and was marked at the beginning of the year. This highlights the need to disseminate public information on the importance of maintaining care and regular medical follow-up. The effect of the COVID-19 crisis on acute and 3-month outcomes of patients hospitalized for MI appears limited. Nevertheless, monitoring of chronic MI complications and the impact on non-hospitalized patients should continue.

Changes in the epidemiology of patients hospitalized in France with deep venous thrombosis and pulmonary embolism during the COVID-19 pandemic.

INTRODUCTION: The onset of the COVID-19 pandemic and the first national lockdown implemented might have disrupted the epidemiology of deep venous thrombosis (DVT) and pulmonary embolism (PE). This study aimed to analyze time trends in patients hospitalized for DVT and PE in France and related in-patient and 90-day post-admission mortality rates. MATERIALS AND METHODS: All patients hospitalized in France for DVT or PE between January and September (weeks 1-40) for each year from 2017 to 2020, were selected. Weekly incidence rate ratios (IRR) were computed to compare the rates of patients hospitalized in 2020 with those hospitalized in 2017-2019. RESULTS: Compared with the 2017-2019 study period, the rates of patients hospitalized with a primary diagnosis (PD) of DVT or PE in 2020 were significantly (50 and 40%, respectively) lower during weeks 12-13. The rate of patients hospitalized with an associated diagnosis (AD) of PE during weeks 12-19 of 2020 was twice as high as in the same period in 2017-2019. The prevalence of COVID-19 in patients hospitalized with a PD of DVT and PE, and in those hospitalized with an AD of DVT and PE reached respectively 4.0, 9.6, 17.2 and 44.6 during the country's first lockdown. Inpatients case-fatality rates in patients hospitalized with an AD of PE increased significantly during weeks 12-13. CONCLUSIONS: Epidemiology of VT and PE was seriously impacted by the COVID-19 pandemic in 2020 in France, with a significant decrease in the rate of patients hospitalized for PE and a threefold increase in the related in-patient mortality rate. This highlight the need to inform the general population about the symptoms of PE and about the need to immediately seek medical care, particularly those infected with SARS-CoV-2.

A modelling study investigating short and medium-term challenges for COVID-19 vaccination: From prioritisation to the relaxation of measures.

BACKGROUND: The roll-out of COVID-19 vaccines is a multi-faceted challenge whose performance depends on pace of vaccination, vaccine characteristics and heterogeneities in individual risks. METHODS: We developed a mathematical model accounting for the risk of severe disease by age and comorbidity, and transmission dynamics. We compared vaccine prioritisation strategies in the early roll-out stage and quantified the extent to which measures could be relaxed as a function of the vaccine coverage achieved in France. FINDINGS: Prioritizing at-risk individuals reduces morbi-mortality the most if vaccines only reduce severity, but is of less importance if vaccines also substantially reduce infectivity or susceptibility. Age is the most important factor to consider for prioritization; additionally accounting for comorbidities increases the performance of the campaign in a context of scarce resources. Vaccinating 90% of ≥65 y.o. and 70% of 18-64 y.o. before autumn 2021 with a vaccine that reduces severity by 90% and susceptibility by 80%, we find that control measures reducing transmission rates by 15-27% should be maintained to remain below 1000 daily hospital admissions in France with a highly transmissible variant (basic reproduction number R0  = 4). Assuming 90% of ≥65 y.o. are vaccinated, full relaxation of control measures might be achieved with a vaccine coverage of 89-100% in 18-64 y.o or 60-69% of 0-64 y.o. INTERPRETATION: Age and comorbidity-based vaccine prioritization strategies could reduce the burden of the disease. Very high vaccination coverage may be required to completely relax control measures. Vaccination of children, if possible, could lower coverage targets necessary to achieve this objective.

Characteristics, Management, and Case-Fatality of Patients Hospitalized for Stroke with a Diagnosis of COVID-19 in France.

INTRODUCTION: COVID-19 was found to be associated with an increased risk of stroke. This study aimed to compare characteristics, management, and outcomes of hospitalized stroke patients with or without a hospital diagnosis of CO-VID-19 at a nationwide scale. METHODS: This is a cross-sectional study on all French hospitals covering the entire French population using the French national hospital discharge databases (Programme de Médicalisation des Systèmes d'Information, included in the Système National des Données de Santé). All patients hospitalized for stroke between 1 January and 14 June 2020 in France were selected. A diagnosis of COVID-19 was searched for during the index hospitalization for stroke or in a prior hospitalization that had occurred after 1 January 2020. RESULTS: Among the 56,195 patients hospitalized for stroke, 800 (1.4%) had a concomitant COVID-19 diagnosis. Inhospital case-fatality rates were higher in stroke patients with COVID-19, particularly for patients with a primary diagnosis of COVID-19 (33.2%), as compared to patients hospitalized for stroke without CO-VID-19 diagnosis (14.1%). Similar findings were observed for 3-month case-fatality rates adjusted for age and sex that reached 41.7% in patients hospitalized for stroke with a concomitant primary diagnosis of COVID-19 versus 20.0% in strokes without COVID-19. CONCLUSION: Patients hospitalized for stroke with a concomitant COVID-19 diagnosis had a higher inhospital and 3 months case-fatality rates compared to patients hospitalized for stroke without a COVID-19 diagnosis. Further research is needed to better understand the excess of mortality related to these cases.

Emergency department admissions for myocardial infarction and stroke in France during the first wave of the COVID-19 pandemic: National temporal trends and regional disparities.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic and the national lockdown have led to significant changes in the use of emergency care by the French population. AIMS: To describe the national and regional temporal trends in emergency department (ED) admissions for myocardial infarction (MI) and stroke, before, during and after the first national lockdown. METHODS: The weekly numbers of ED admissions for MI and stroke were collected from the OSCOUR® network, which covers 93.3% of all ED admissions in France. National and regional incidence rate ratios from 02 February until 31 May (2020 versus 2017-2019) were estimated using Poisson regression for MI and stroke, before, during and after lockdown. RESULTS: A decrease in ED admissions was observed for MI (-20% for ST-segment elevation MI and-25% for non-ST-segment elevation MI) and stroke (-18% for ischaemic and-22% for haemorrhagic) during the lockdown. The decrease became significant earlier for stroke than for MI. No compensatory increase in ED admissions was observed at the end of the lockdown for these diseases. Important regional disparities in ED admissions were observed, without correlation with the regional levels of COVID-19 cases. The impact of lockdown on ED admissions was particularly significant in six regions (Ile-de France, Occitanie, Provence-Alpes-Côte d'Azur, Nouvelle Aquitaine, Hauts-de-France and Bretagne). CONCLUSIONS: The decrease in ED admissions for MI and stroke observed during the lockdown was probably caused by fear of COVID-19 and augmented by the lockdown, and was heterogeneous across the French territory. ED admissions were slow to return to the usual levels from previous years, without a compensatory increase. These results underline the need to reinforce messages directed at the population to encourage them to seek care without delay in case of cardiovascular symptoms.