Note: The information on the coronavirus outbreak is continually evolving. The content within this activity serves as a historical reference to the information that was available at the time of this publication. We continue to add to the collection of activities on this subject as new information becomes available. It is the policy of Medscape Education to avoid the mention of brand names or specific manufacturers in accredited educational activities. However, manufacturer names related to the approved COVID-19 vaccines are provided in this activity in an effort to promote clarity. The use of manufacturer names should not be viewed as an endorsement by Medscape of any specific product or manufacturer.

Clinical Context

Despite the devastating direct toll of COVID-19, indirect effects of the pandemic on health care and outcomes may be of similar importance. Although hospitalizations for acute cardiovascular (CV) conditions fell during the pandemic, cardiovascular disease (CVD) mortality has risen substantially.

It is still unknown whether avoidance of medical care, overwhelmed medical personnel, and/or other factors directly or indirectly related to COVID-19 explain increased CVD deaths during the pandemic. Underlying disparities including structural racism and the US healthcare system may be exacerbated by the pandemic.

Study Synopsis and Perspective

Cardiovascular disease mortality rose significantly during the COVID-19 pandemic and persists more than 2 years on and, once again, Black persons have been disproportionately affected, an analysis of death certificates shows.

The findings "suggest that the pandemic may reverse years or decades of work aimed at reducing gaps in [CV] outcomes," Sadeer G. Al-Kindi, MD, Case Western Reserve University, Cleveland, Ohio, told theheart.org | Medscape Cardiology.

Although the disparities are in line with previous research, he said, "[w]hat was surprising is the persistence of excess [CV] mortality approximately 2 years after the pandemic started, even during a period of low COVID-19 mortality."

"This suggests that the pandemic resulted in a disruption of healthcare access and, along with disparities in COVID-19 infection and its complications, he said, "may have a long-lasting effect on healthcare disparities, especially among vulnerable populations."

The study was published online July 20 in Mayo Clinic Proceedings^[1] with lead author Scott E. Janus, MD, also of Case Western Reserve University.

Al-Kindi and colleagues used 3,598,352 US death files to investigate trends in deaths due specifically to CVD as well as its subtypes: myocardial infarction (MI), stroke, and heart failure (HF) in 2018 and 2019 (prepandemic) and the pandemic years 2020 and 2021. Baseline demographics showed a higher percentage of older, female, and Black individuals among the CVD subtypes of interest.

Overall, there was an excess CVD mortality of 6.7% during the pandemic compared with prepandemic years, including a 2.5% rise in MI deaths and an 8.5% rise in stroke deaths. Heart failure mortality remained relatively steady, decreasing only 0.1%.

Subgroup analyses revealed "striking differences" in excess mortality between Black and White persons, the authors noted. Black persons had an overall excess mortality of 13.8% vs 5.1% for White persons compared with the prepandemic years. The differences were consistent across subtypes: MI (9.6% vs 1%); stroke (14.5% vs 6.9%); and HF (5.1% vs −1.2%; P < .001 for all).

When the investigators looked at deaths on a yearly basis with 2018 as the baseline, they found CVD deaths increased by 1.5% in 2019, 15.8% in 2020, and 13.5% in 2021 among Black persons compared with 0.5%, 5.1%, and 5.7%, respectively, among white persons.

Excess deaths from MI rose by 9.5% in 2020 and by 6.7% in 2021 among Black persons but fell by 1.2% in 2020 and by 1% in 2021 among White persons.

Disparities in excess HF mortality were similar, rising 9.1% and 4.1% in 2020 and 2021 among Black persons yet dipping 0.1% and 0.8% in 2020 and 2021 among White persons.

The "most striking difference" was in excess stroke mortality, which doubled among Black persons compared with White persons in 2020 (14.9% vs 6.7%) and in 2021 (17.5% vs 8.1%), according to the authors.

Although the disparities were expected, "there is clear value in documenting and quantifying the magnitude of these disparities," Amil M. Shah, MD, MPH, Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts, told theheart.org | Medscape Cardiology.

In addition to being observational, the main limitation of the study, he noted, is the quality and resolution of the death certificate data, which may limit the accuracy of the cause of death ascertainment and classification of race or ethnicity; "[h]owever," he added, "I think these potential inaccuracies are unlikely to materially impact the overall study findings."

Shah, who was not involved in the study, said he would like to see additional research into the diversity and heterogeneity in risk among Black communities.

"Understanding the environmental, social, and healthcare factors -- both harmful and protective -- that influence risk for CVD morbidity and mortality among Black individuals and communities offers the promise to provide actionable insights to mitigate these disparities."

"Intervention studies testing approaches to mitigate disparities based on race/ethnicity" are also needed, he added. These may be at the policy, community, health system, or individual level, and community involvement in phases will be essential."

Meanwhile, both Al-Kindi and Shah urged physicians to be aware of the disparities and the need to improve access to care and address social determinants of health in vulnerable populations.

These disparities "are driven by structural factors, and are reinforced by individual behaviors. In this context, implicit bias training is important to help clinicians recognize and mitigate bias in their own practice," Shah said. "Supporting diversity, equity, and inclusion efforts, and advocating for anti-racist policies and practices in their health systems" can also help.

Al-Kindi and Shah have disclosed no relevant financial relationships.

Mayo Clin Proc. Forthcoming 2022.^[1]

Clinical Implications

• Excess CVD mortality has disproportionately affected Black persons vs White persons during the COVID-19 pandemic.
• Further studies should target and eliminate healthcare disparities.
• Implications for the Healthcare Team: The healthcare team should be aware of disparities and the need to improve care access and address social determinants of health in vulnerable populations.

Earn Credit