Impact of COVID-19 pandemic on cardiometabolic patients without SARS-CoV-2 infection in Latin America

Abstract

Background and Objectives: A cross-sectional survey including 38 questions about demography, clinical condition, changes in health habits, and medical treatments for cardiometabolic patients in outpatient follow-up was conducted. From June 15 to July 15, 2020, a total of 13 Latin-American countries participated in enrolling patients.

Methods: These countries were divided into 3 geographic regions: Region 1 including North, Central, and Caribbean Regions (NCCR), Region 2 including the Andean Region (AR), and Region 3 including the Southern Cone Region (SCR). 4.216 patients were analyzed, resulting in a coefficient of 33.82%, 32.23%, and 33.94% for NCCR, AR, and SCR, respectively.

Results: Significant differences were found between the AR, SCR, and NCCR regions. The analysis of habitual medication usage showed that discontinued use of medication was more present in AR, reaching almost 30% (p < 0.001). The main finding of this study was the negative impact that restrictive measures have on adherence to medications and physical activity: Rs = 0.84 (p = 0.0003) and Rs = 0.61 (p = 0.0032), respectively. AR was the most vulnerable region.

Conclusion: Restrictive quarantine measures imposed by the different countries showed a positive correlation with medication discontinuation and a negative correlation with physical activity levels in patients analyzed. These findings characterize the impact of the consequences left by this pandemic. Undoubtedly, restrictive measures have been and will continue to have reverberating negative effects in most Latin-American countries.

Keywords: COVID-19; Pandemic; Lockdown; Cardiometabolic patients; Latin America

Resumen

Antecedentes y Objetivos: Se realizó una encuesta transversal que incluyó 38 preguntas sobre demografía, estado clínico, cambio de hábitos de salud, tratamientos médicos a pacientes cardiometabólicos en seguimiento ambulatorio. Un total de 13 países latinoamericanos inscribieron pacientes del 15 de junio al 15 de julio de 2020.

Método: Los países se dividieron en 3 regiones geográficas Región 1 (NCCR): Región Norte, Centro y Caribe; Región 2 (AR): Región Andina; Región 3 (SCR): Región Cono Sur. Las medidas de aislamiento se estimaron a partir de informes nacionales y se correlacionaron utilizando el coeficiente R de Spearman. Se analizaron 4.216 pacientes, NCCR (33.82%); AR (32.23%) SCR (33.94%).

Resultados: Se encontraron diferencias significativas entre regiones. Este análisis de la medicación habitual mostró que la discontinuación de la medicación fue mayor en RA, llegando a casi el 30% (p < 0.001). El principal hallazgo de este estudio fue el impacto negativo que tienen las medidas restrictivas sobre la adherencia a la medicación y la actividad física, Rs = 0.84 (p = 0.0003) y Rs = 0.61 (p = 0.0032), respectivamente. Se encontraron diferencias significativas entre regiones. AR es la región más vulnerable.

Conclusiones: Las medidas restrictivas impuestas por los diferentes países (cuarentena) mostraron una correlación positiva con la interrupción de la medicación y una correlación negativa con la cantidad de actividad física. El impacto de las consecuencias que deja esta pandemia será muy profundo en la mayoría de los países latinoamericanos.

Palabras clave: COVID-19; Pandemia; Aislamiento; Pacientes cardiometabólicos; Latinoamérica

Background

One of the leading causes of death around the world is cardiovascular diseases (CVD). It is estimated that CVDs are responsible for approximately 1.8 million deaths annually in the Americas. According to recent data, 75% of these deaths in the region are attributable to chronic diseases, a percentage that represents an increase of almost 20% with respect to 1990. The main cause of mortality and morbidity among older adults in Latin America (LA) are CVD, which represent 25% of the total burden of diseases among population aged 60 years. Furthermore, the prevalence of CVDs increases linearly with age¹.

In LA, a broad association of social, demographic, and political factors exists. This region is vulnerable to health inequities due to the socio-economic reality in which residents of the region find themselves in². Currently, LA is facing an exponential increase in health inequities, due to consequences generated by the coronavirus disease (COVID-19) pandemic^3-5. This scenario has transformed LA into a health region with immense vulnerability to pandemic and post-pandemic events. Thus, it is imperative to diagnose the situation in order to prepare us for the vast changes the pandemic has brought on us.

In recent months, governments and health science experts have promoted different strategies to alleviate the COVID-19 crisis, most of them being isolation or social distancing policies. However, the effectiveness of these measures is largely conditioned by underlying social structure. Thus, it is evident that there is a major gap in the consequences of the crisis between the highest and lowest income sectors of the region^6,7.

LA is facing a pressing challenge: maintaining an epidemiological strategy to promote social distancing without generating social and political crises. Furthermore, the economic damage from social distancing policies (accounting for the fact that a large percentage of the population depends on their daily work outside the home to survive) must be considered. The simultaneous balance of these components must be considered when developing a comprehensive solution, to ensure basic levels of well-being, and political stability are maintained^8,9.

The objective of our study was to analyze the impact of the different strategies used to control the pandemic on the health status of patients with cardiometabolic diseases, who did not have a COVID-19 infection, in the different regions of LA.

Methods

Results

Medication and adherence

Another aspect of the study that was analyzed is access to prescribed medication. The surveys looked at the number of medications prescribed and whether the patient discontinued their medication usage for any reason. This analysis showed that discontinued usage of medication was greater in AR, reaching almost 30%. This finding was demonstrated to a lesser extent in NCCR and ultimately the least in SCR, showing a significant difference between zones (p < 0.001) (Fig. 1).

Figure 1. Medication and Adherence. Medication and Adherence analysis showed that discontinued of medication was greater in AR, reaching almost 30% (1 in 3 patients), to a lesser extent in NCCR and ultimately less in SCR, showing a significant difference between zones (p < 0.001).

 

Effects of the pandemic

The presence of smoking as a dichotomous variable showed significant interregional differences. The prevalence of smoking was higher in AR, compared to SCR. NCCR had the lowest prevalence of the three. These differences are statistically significant (p < 0.001). When studying the intake of alcoholic beverages, a similar finding was observed. This variable is also dichotomous and showed the highest prevalence in SCR, then AR, and to a lesser extent in NCCR (p < 0.001) (Fig. 2).

Figure 2. Pathological habits. The presence of smoking variable showed significant interregional differences, its prevalence being is higher in AR, compared to SCR and NCCR (p < 0.001). The variables alcoholic beverage intake showing the highest prevalence in SCR, then in AR, and to a lesser extent in NCCR (p < 0.001).

 

Table 2 depicts variables affected by the COVID-19 pandemic. The analysis of physical activity during the last surveyed month showed the frequency of a sedentary lifestyle. As seen in figure 2, SCR showed a significant reduction in physical activity compared to the other zones. This area, therefore, is the one with the highest sedentary lifestyle. Regarding the diet consumed by the respondents, we can see that NCCR presents a lower rate of consumption of fruits and vegetables, by the number of daily snacks portions, with significant differences compared to AR and SCR (Fig. 2).

Table 2. Effects of the pandemic studied in the survey (food intake, body weight, influenza and pneumococcal vaccine) are shown divided by zones

Variables	NCCR	AR	SCR	p value
n	1.426	1.359	1.431
Food intake (fruit and vegetables)				< 0.001
Rarely	8.98% (128)	6.40% (87)	7.76% (111)
1-3 times/week	39.62% (565)	34.22% (465)	30.68% (439)
4-6 times/week	22.86% (326)	21.04% (286)	24.18% (346)
Everyday	28.54% (407)	38.34% (521)	37.39% (535)
Body weight perception				< 0.001
Lost	20.27% (289)	23.77% (323)	12.86% (184)
Same	45.37% (647)	52.47% (713)	40.67% (582)
Increased	34.36% (490)	23.77% (323)	46.47% (665)
Influenza vaccine	35.20% (502) 95% CI = 32.72-37.74	34.44% (468) 95% CI = 31.90-37.03	69.39% (993) 95% CI = 66.93-71.77	< 0.001
Pneumococcal vaccine	11.08% (158) 95% CI = 9.49-12.82	19.94% (271) 95% CI = 17.84-22.16	42.63% (610) 95% CI = 40.04-45.23	< 0.001
Discontinuation medication	13.53% (193) 95% CI = 11.80-15.42	28.70% (390) 95% CI = 26.30-31.18	9.57% (137) 95% CI = 8.09-11.21	< 0.001
Discontinuation medication if secundary prevention (n: 1141)	17.28% (70/405) 95% CI = 13.72-21.32	26.92% (91/338) 95% CI = 22.26-31.98	12.56% (50/398) 95% CI = 9.46-16.22	< 0.001
Tabacco	14.87% (212) 95% CI = 13.05-16.82	18.62% (253) 95% CI = 16.57-20.78	9.85% (141) 95% CI = 8.35-11.51	< 0.001
Alcohol consumption	41.44% (591) 95% CI = 38.87-44.05	36.35% (494) 95% CI = 33.78-38.97	49.76% (712) 95% CI = 47.13-52.37	0.000
Physical activity	17.67% (252) 95% CI = 15.72-19.75	16.34% (222) 95% CI = 14.40-18.41	9.64% (138) 95% CI = 8.16-11.29	< 0.001

 

Impact of isolation measures due to the COVID-19 pandemic

The impact of restrictive isolation measures was analyzed, as they had an influence on some relevant indicators in these patients. It was observed that there was an increase in sedentary lifestyle in the most restrictive countries (r = −0.60; CI = −0.5 - −0.87; p = 0.003) (Fig. 3).

Figure 3. Impact of isolation measures due to the COVID-19 pandemic. It observed that there is an increase in sedentary lifestyle in the most restrictive countries (r = –0. 60; CI = –0.5 to –0.87; p = 0.003). Access to medications was analysed, a high negative correlation could be observed between the level of adherence and the degree of severity of the restrictions (r = –0.868; CI = –0.96 - –0.57; p < 0.001).

 

On the other hand, access to medications was analyzed based on the evaluation of the degree of adherence during the last month in a pandemic. A high negative correlation was observed between the level of adherence and the degree of severity of the restrictions (r = −0.868; CI = −0.96 - −0.57; p < 0.001) (Fig. 3).

In the rest of the variables studied, there was no identified significant correlation with the restrictive measures.

Discussion

The main finding of study is the relationship between the degree of confinement in each country and variables such as decreased adherence to medication and lowered levels of physical activity in patients with cardiovascular risk. Overall, AR was the most vulnerable region with a lower income and education level, and higher medication discontinuation.

The analysis of the population characteristics from the surveys showed a difference in the average age when comparing to similar epidemiological studies in the region. This older age may be due to higher life expectancy in the Southern Cone. Furthermore, the low percentages of unemployment and overcrowding may be associated with the specific characteristics of surveyed population. Many of the patients who participated in the study came from the private sector or had union medical coverage. This shows that at the time of the consultation, they were still employed through formal positions.

The higher presence of valvular heart disease and lower number of implanted devices is attributable to a lower income level in SCR and AR¹³.

Regarding variables, in the past 30 days (during the pandemic), there was a lower consumption of fruits and vegetables. This finding coincides with several epidemiological reports from the surveyed countries. However, it is difficult to establish whether this was caused by the pandemic or is a persistent characteristic of this population. Some reports show that this index is not as low as in this study^14-16.

The SCR region was most affected by a higher increase in consumption of alcoholic beverages and increases in the rates of a sedentary lifestyle.

One of the most important differences we found was weight gain, with clear differences between regions. There was an evidently higher rate of obesity in the southern cone. National reports and the World Health Organization (WHO) show that both Argentina, Chile, and Paraguay have rates of excess weight that range between 50 and 65%^14-16.

Another finding is the high percentage of vaccinated citizens, especially in SCR. These results have been discussed extensively in a separate publication because a comprehensive detail of the findings is deserved. Some differences can be accounted by the fact that some of the centers that participated in the study, belonged to centers of reference in geographic areas with high population density¹⁷.

It was observed that AR was the most affected by unemployment, smoking, medication adherence, and a lower educational level. Regarding adherence to medication, worrying results were depicted through the findings. Although it is known that adherence to medications globally is low, this problem does not only affect CVD. Data from the National Institute of Health regarding antihypertensive drugs report an adherence rate below 60%. Data from other studies in different countries of LA show adherence rates ranging between 50 and 70%. The data obtained from this survey shows a significant worsening of adherence, at least from the 1^st months of the pandemic^18-22.

Isolation and social distancing imposed by governments were analyzed, coinciding with lower adherence rates and lower physical activity in the most restrictive countries^23-25. Due to the significant differences between nations and regions, a particular health analysis is necessary in each case to implement the appropriate strategies. In the CorCOVID study, similar results have been found in other studies such as INTERHEART²⁶ and PURE²⁷. SARS-Cov2 pandemic greatly deepened these differences. Likely, the long and strict quarantines prevented adequate controls and follow-up of patients with CVD. Thus, this generated a new short-term pandemic of heart disease, advanced kidney disease, and stroke disability. Fear of contracting COVID-19 and government messaging about self-isolation and avoiding hospital visits unless necessary likely resulted in patients not seeking and delaying medical care. This finding may have manifested itself as the increase in the number of out-of-hospital cardiac arrest that has been observed in Italy and France^28,29.

The impact of the consequences left by this pandemic will be very profound in most Latin American countries. These consequences will not only deepen the current deficiencies but also worsen the quality of life and overall life expectancy in different regions. Several international organizations were aware of these consequences and advocated for stricter measures in countries that already have additional risk factors, such as the absence of permanent drinking water or overcrowding, among others.

Limitations

One of the main limitations of this study is that the data was obtained from a registry of different social, economic, and political strata, not allowing for homogeneity within the studied population. The isolation or social distancing scenario was analyzed by country, but in each region, it was noted that countries had varying levels of stringency in their guidelines.

The data comes from different centers, public and private, which limits the ability of the authors to estimate whether the results can be extrapolated to the general population. Thus, information on the perception of the respondents, availability of doctors, medicines, and varied resources in different countries, may lead to an overestimation or underestimation of the data.

The survey was conducted at the same time in all participating countries. This is a potential limitation because the varying peaks of the pandemic in different regions of the world at different times were very notable. However, when analyzing the database of the University of Johns Hopkins, the peaks with the highest incidence of COVID19 in LA were almost equitemporal, so the authors consider the results valid despite this difference.

Conclusions

In our observational study, it was evident that AR is the most vulnerable region, with a lower income and educational coinciding with a higher rate of medication discontinuation. Confinement measures have caused a worsening of two fundamental indicators of CVD in patients. One is poor adherence to prescribed medications, either due to not being able to attend medical check-ups, loss of employment due to the closure of factories or companies or fear of leaving home, resulting in extremely low values. Another is low physical activity, a likely product of home confinement. Both likely demonstrate serious consequences in these regions with increases in deaths, heart attacks, strokes, or heart failure.

Because this study is an observational study, the methodology does not allow for drawing causal conclusions. However, it is important to note that urban areas have greater social risk.

Sanitary measures should be applied to improve the deficiencies found, as well as to develop clinical trials with more robust data.