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 Table of Contents  
Year : 2021  |  Volume : 10  |  Issue : 2  |  Page : 15-18

Heart failure admissions during COVID-19 pandemic

1 Senior Consultant and Interventional Cardiologist, Little Flower Hospital and Research Institute,  , India
2 Senior Consultant and Interventional Cardiologist, Lisie Heart Institute,  , India
3 Consultant Cardiologist, Little Flower Hospital, Angamaly, India
4 Senior Consultant and Interventional Cardiologist, Aster Mims, Cheranelloor, India
5 Senior Consultant and Interventional Cardiologist, Renai Medicity, Palarivattom P.O, India
6 Senior Consultant and Interventional Cardiologist, St. Joseph’s Hospital, Kothamangalam, India
7 Senior Consultant and Interventional Cardiologist, MBMM Hospital, Kothamangalam, Ernakulam, Kerala, India
8 Senior Consultant and Interventional Cardiologist, Lakshmi Hospital, Pallimmukku, Kochi, India

Date of Web Publication14-Feb-2022

Correspondence Address:
Dr. Sajan Narayanan
Department of Cardiology, Little Flower Hospital & Research Institute, Angamaly, Kochi 683572, Kerala.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/khj.khj_3_21

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Background and Objectives: Severe acute respiratory syndrome due to coronavirus (SARS-COVID-19) was declared as pandemic on March 12, 2020. Government of India declared a total lockdown from March 25, 2020. We report the trends in heart failure (HF) admissions to cardiac care units (CCU) of Ernakulam district of Kerala during lockdown period in comparison with the equivalent period of 2019. Materials and Methods: We conducted a retrospective multicenter observational survey to collect data on admissions for HF at CCUs of Ernakulam district in Kerala from January to May 15, 2020. Records were analyzed for admissions during the equivalent period of 2019. Trends in admissions during lockdown phases were analyzed separately. Results: We observed a reducing trend in the number of admissions with a diagnosis of HF from February 2020. During lockdown phase, a 25.4% reduction in the number of HF admissions was recorded as compared to the equivalent period of 2019. The decrease was evident during all three phases of lockdown. Hospitals located within Kochi Corporation Limits recorded 36.2%, 22%, and 22.9% decrease, respectively, during phases 1, 2, and 3 of lockdown period. There was no decrease in the number of HF admissions to centers located at the periphery during this period. Conclusion: This study confirms a reduction in the number of HF admissions during lockdown period. The decrease was more evident in centers located within metropolitan city limits.

Keywords: Acute decompensation, cardiac care units, heart failure, lockdown, SARS COVID-19

How to cite this article:
Narayanan S, Jabir A, Rajesh, Varma R, Thomas V, Thomas M, Gopakumar K S, Balachandran A. Heart failure admissions during COVID-19 pandemic. KERALA HEART J 2021;10:15-8

How to cite this URL:
Narayanan S, Jabir A, Rajesh, Varma R, Thomas V, Thomas M, Gopakumar K S, Balachandran A. Heart failure admissions during COVID-19 pandemic. KERALA HEART J [serial online] 2021 [cited 2023 Sep 24];10:15-8. Available from:

  Introduction Top

World Health Organization (WHO) declared coronavirus disease-2019 (COVID-19) as a global pandemic on March 12, 2020. Government of India imposed lockdown (LD) from March 25, which was extended in three phases. Several facilities including schools, department stores, malls, and restaurants were closed. Public and private transport vehicle movements were restricted and people were encouraged to stay at home. Consequently, patients with chronic illnesses such as coronary artery disease (CAD) and heart failure (HF) could have changed their behavior if symptoms occurred to avoid hospital visits. Whether collateral damage of restriction to public transport and movement has affected a serious illness like HF is unknown. The Trivandrum Heart Failure Registry reported higher in-hospital and 90-day mortality among patients admitted with acute decompensated HF when compared to international registries.[1] In-hospital mortality in acute HF was reported to be as high as 6.4% in large registry data from Kerala.[2] Press reports in early April noted that at least at tertiary care centers there was a reduction in the number of admissions to cardiac care units (CCUs).[3] On the contrary, there were social media reports that peripheral centers were witnessing a spike in the number of admissions for HF during LD phase.


The objective of this study was to look into trends in HF admissions to hospitals within Ernakulam district during LD period and to compare with equivalent period of 2019.

  Materials and methods Top

We conducted a multicenter retrospective observational survey involving cardiology intensive care units (CCUs) of Ernakulam district. Cochin Cardiology forum (registered forum of cardiologists practicing within Ernakulam district of Kerala) invited all affiliated consultants and hospitals to participate in the survey. Data were collected from January 1 to May 15, 2020. Same data were also collected for equivalent period of 2019. All consecutive HF admissions (new-onset HF and acute decompensation of chronic HF) were assessed. Diagnosis of HF was done by institution protocols and included HF with preserved ejection fraction (HFpEF), HF with mid-range ejection fraction (HFmrEF), and HF with reduced ejection fraction (HFrEF). Data were analyzed separately for LD period (phase 1 from March 25 to April 15, phase 2 from April 16 to 30, and phase 3 from May 1 to 15). To examine whether there is any heterogenicity in admission patterns with respect to location of centers, hospitals were divided into central (located within Kochi Corporation Limits) and peripheral centers (located outside Kochi Corporation Limits).

Statistical analysis

Descriptive statistics were used for the baseline characteristics of the data. The significance of month-wise admissions of LD periods in year-wise and hospital-wise analysis were done using chi-square test for trend. A value of P < 0.05 was considered statistically significant. All data were analyzed using the SPSS software program, version 20.0.

  Results Top

Fourteen centers participated in the study. Seven centers were located within Kochi Corporation Limits (central hospitals) and seven centers were in peripheral location (peripheral hospitals). All centers had CCUs managed by cardiology specialists.

[Figure 1] shows HF admissions from January to May. HF admissions during 2020 recorded a reducing trend from the month of February till May as compared to equivalent period of 2019.
Figure 1: Heart failure admissions for months from January to May

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A 25.4% reduction in the number of HF patients was recorded during LD (421 vs. 314) when compared to 2019 [Figure 2]. During LD phase 1, there was 28% reduction in number of HF cases (180 vs. 130), 16% (119 vs. 100), and 16.7% (132 vs. 110) decrease, respectively, during phases 2 and 3 [Figure 3].
Figure 2: Heart failure admissions fell by 25.4% during lockdown phase in 2020

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Figure 3: Heart failure admissions during individual lockdown (LD) phases

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An interesting trend in hospital admissions was noted according to location. At central hospitals, there was a 36.2% decrease (108 vs. 69) during phase 1 of LD. There were 22% (82 vs. 64) and 22.9% (70 vs. 54) reductions during phases 2 and 3, respectively, when compared to equivalent period of 2019 [Figure 4].
Figure 4: Heart failure admissions to central hospitals during lockdown (LD) period

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Peripheral centers witnessed a small decrease in HF admissions during LD phases when compared to the previous year [Figure 5].
Figure 5: Heart failure admissions to peripheral centers during lockdown (LD) phases

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[Figure 6] shows the difference in HF admissions of years 2019 and 2020 among the central and peripheral hospitals. Among the central hospitals, difference in HF admissions between years shows that during LD phase 1, there were 39 more admissions in 2019, during phases 2 and 3; there were 18 and 16 more admissions, respectively, in 2019 as compared with the equivalent period of 2020. Among the peripheral hospitals, phases 1 and 2 had one more admission, respectively, and phase 3 had six more admissions in 2019 as compared with 2020. The difference observed in HF admission trends of central and peripheral hospitals was statistically significant (P < 0.05).
Figure 6: Difference in heart failure admissions during lockdown (LD) phases

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  Discussion Top

Our study examined the collateral consequences for HF admissions during LD period imposed due to COVID-19 pandemic. We observed an overall reduction of 25.5% in the number of HF admissions during the time frame concerned. Danish society reported a 30% decrease in HF admissions during the pandemic phase-related LD in Denmark.[4] A 46.8% decrease in hospitalization for HF during the pandemic week compared to equivalent week in 2019 was reported from Italy.[5] This study shows a heterogenicity in admission patterns according to hospital location. Centers located within metropolitan city limits recorded a marked reduction in the number of HF admissions. Peripheral centers also noted a decrease in the number of patients admitted with diagnosis of HF, although of lesser magnitude. There could be several explanations to the above finding. First, due to restrictions imposed on transport, patients could not attend cities for treatment. Second, primary care physicians would have treated minor worsening of HF symptoms with outpatient titration of drugs. Third, the patients could have changed their behavioral pattern by decreasing physical activity due to restrictions imposed on public mobility and consequently would not have noticed minor worsening of functional class.


This study is observational in its design and it has, therefore, inborn limitations. This study only examined the absolute numbers. No information on demographics were collected. Important clinical variables such as etiology of HF, left ventricular ejection fraction, renal function, and in-hospital outcomes were not determined. The study also does not differentiate between HF with reduced and preserved ejection fraction.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Sivadasanpillai H, Ganapathi S, Thajudeen A, Sunitha V, Govindan V, Charantharayil GB, et al. Clinical presentation, management, in-hospital and 90-day outcomes of heart failure patients in Trivandrum, Kerala, India: The Trivandrum Heart Failure Registry. Eur J Heart Fail 2015;17:794-800.  Back to cited text no. 1
Harikrishnan S, Jabir A, Sanjay G, Jeemon P, Joseph STIGI Clinical presentation, practice patterns and in-hospital mortality: Findings from the Kerala heart failure registry (KHFR) of 5789 patients.J Heart failure 2019;116-7.  Back to cited text no. 2
Kerala hospitals see a nearly 50% drop in heart attack cases. The Times of India2020.  Back to cited text no. 3
Charlotte A, Thomas G, Emil F, Matthew P, Julie A, Morten L et al. Incidence of new-onset and worsening heart failure before and after the COVID-19 epidemic lockdown in Denmark: A nationwide cohort study. Circ Heart Fail 2020;13:e007274.  Back to cited text no. 4
Salvatore DR, Carmen S, Cristina B, Maria Pia C, Antonio C, Pasquale Perrone F et al. Reduction in hospitalisations for myocardial infarction in Italy in the COVID -19 era. Eur Heart J 2020;0: 1-6.  Back to cited text no. 5


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]


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