COVID-19: An Argentinian perspective.

At the time of this writing (July 6, 2020), the mortality rate reported for COVID-19 in Argentina was <2%. Also, the country's critical care beds are ≤63% occupied. This achievement results from the excellent coordination and action by the Argentine Ministry of Health together with the 23 provinces and the Autonomous City of Buenos Aires of the nation for now.
MATERIALS AND METHODS: Regarding cardiovascular care for patients over 65 years of age, a more accurate analysis could be performed when two comparative half-yearly periods corresponding to the years 2019 and 2020 (pandemic time) were compared. The data collected regarding this age range revealed issues that had not previously been evaluated in our country. That undoubtedly proposes a different solution for the future based on a strict scientific analysis.
RESULTS: The ratio of patients who received stents to those that underwent coronary surgery was 6 to 1, while the ratio of patients who had off-pump surgery to those that underwent minimally invasive surgery was 69 to 1.
CONCLUSION: An Argentinian perspective regarding cardiovascular care is good because the country has an excellent level of qualified medical training in its cardiac surgery and interventional cardiology services, as well as healthcare infrastructure distributed throughout the country, which will undoubtedly be able to respond to the new challenges posed by the post-pandemic period.

INTRODUCTION

The healthcare system in Argentina is comprised of three subsectors. The public sector, financed with resources from general income for a consolidated amount that is equivalent to 2.7% of GDP, caters to the entire population, especially for citizens from low‐income backgrounds. The second sector is concerned with social security and is under contributory financing that amounts to 3.9% of GDP. This sector is made up of 291 administrators (National Social Works) who are dependent on the following unions grouped according to their activities; the National Institute of Social Services for Retirees and Pensioners (INSSJP), the 24 directed Social Works of each of the provinces that make up the territory and a heterogeneous group of Social Works for singular treatment. Lastly, the private health sector offers voluntary insurance and represents 2.8% of GDP. The social and health impact of the COVID‐19 pandemic in Argentina is characterized by a health system where its subsectors coexist in disjointed forms. The resulting system provides broad healthcare coverage and access, but given its heterogeneity, fragmentation, and segmentation, the gaps in quality, opportunity, and therefore equity, are variable. At the time of the emergence of the COVID‐19 pandemic, Argentina was showing signs of weakening in its social fabric and a macroeconomic panorama showing a tendency toward slowing down of economic activities. After a decade of stagnation, translated into a frank recession since 2018 (GDP fell 2.5% in 2018 and 2.2% in 2019), the country reported poverty levels measured by the income of the order of 38% of its inhabitants, high level of informality of 45% of population activities, annual inflation of 54% (2019), fiscal deficit (total) of 3.8% GDP, an unemployment rate of 9.8%, and 33.4% of urban households receiving some type of social assistance in a context of external credit restriction and imminent risk of default on their international financial obligations.

The country has adapted its healthcare system to the pandemic by increasing its focus on critical care services, optimizing and increasing low complexity beds for mild/moderate cases (hotel beds and construction of modular emergency hospitals), the deferral of nonurgent hospitalizations, the procurement of supplies, personal protective equipment, and the reduction of the use of hospital beds of high complexity (complexity Intensive Care Units/Coronary care Units [UTI/UCO]).

The first case of COVID‐19 in Argentina was reported on March 3, 2020. The country declared the coronavirus health emergency on March 12, 2020 (Decree of Necessity and Urgency No. 260/20). As a result, on March 15, 2020, teaching activities in face‐to‐face classes were interrupted, and on March 16, 2020, the closure of borders and the interruption of domestic flights until September 01, 2020, were established. As of March 19, 2020 (Decree 297/20), the Argentine government ordered a Preventive and Mandatory Social Isolation (ASPO) to protect its citizens. This was understood as a strict quarantine initially arranged for 2 weeks, and was carried out in different phases according to the emergency of cases in the different provinces and some specific localities of the country. The original isolation remains in force 120 days after it began in the Buenos Aires Metropolitan Area (AMBA), so it is social confinement to the extent that is unusual. ,

In the social field, the implementation of the mandatory confinement generated a significant worsening of the preceding economic conditions, leading to a drop‐in activity of 11.5% as early as March. Various estimates consider that the economic downturn in Argentina is the highest in the region. The national government established a series of nonsanitary initiatives to alleviate the effects of the closure of many small‐ and medium‐sized companies, through the following: Emergency Family Income (IFE)—a monthly bonus of approximately US $140 to be received by 8,300,000 highly vulnerable people, subsidies for the payment of wages up to a maximum of US $480, allocation of credits at zero rates to low‐paid independent workers, distribution of food stamps, and other subsidies to pensioners and recipients of social assistance. At present, these initiatives amount to 2.14% of GDP. , , From a public health point of view, the impact of the pandemic was more noticeable in large urban conglomerates and the aforementioned AMBA region, especially on the population with lower socioeconomic status. As of July 06, 2020, 406,200 tests, 77,815 infections, and 1523 deaths were recorded. However, given that 90% of the cases are concentrated in the AMBA with 14.8 million inhabitants, about 37% of the population of Argentina, a more precise estimate of the impact of COVID‐19 should consider this population as the closest denominator to the reality of the pandemic in the country for now.

The particularly compromised data of the Argentine strategy results are due to the coincidence between the early implementation of strict confinement and success achieved in slowing down the appearance of cases as well as the late appearance of the peak of the epidemic curve coinciding with clear signs of social exhaustion and deterioration of the living conditions of most of the population. This means that at present, the country can show efficient management in terms of emergency management, but with the persistence of an important space of uncertainty regarding the final result, expressed both in the final number of fatal cases and in the economic and social consequences of its implementation. The critical point lies in the feasibility of containing viral transmission, particularly but not exclusively in overcrowded communities, such as the neighborhoods of the city of Buenos Aires. Closed and highly transmissible establishments (prisons and nursing homes) that require extreme care are not omitted. What prevails at the current peak of the pandemic is the strengthening of a dynamic health strategy that interrupts the chain of contagion. Through systematic testing of probable cases, close monitoring of contacts and their traceability, the presence of the pandemic in the country can be redefined. Also, by putting community, integrality, and interdisciplinarity at the center, primary health care with a territorial focus that is effective, rational, directed to the community, conveyed through investigating agents/tracers that support an active search and identification strategy, and enables the isolation of confirmed cases and possible infections, should be emphasized. This alternative is the one that can minimize transmission in the immediate future and demands on‐site health personnel to be agents of prevention—containment—mitigation against future outbreaks. In recent weeks, the strategy in the AMBA, particularly in the city of Buenos Aires, has turned more actively toward this alternative.

MATERIALS AND METHODS

The Argentine Government decided to face the COVID‐19 health problem in stages, extending social confinement. During this time, the real impact of the COVID‐19 pandemic on cardiovascular medicine in Argentina with respect to variations in diagnoses and treatments carried out is a complex issue to measure. The current pandemic in the nation is still in the ascending stage of case growth, and the development of any further escalation is difficult to predict and evaluate. Besides, most of the works published to date focus on mental health problems, and there is very little information regarding what happens with chronic cardiovascular diseases, their neglect due to loss of effective monitoring capacity, underdiagnosis, and undertreatment or unwarranted delay in the resolution of eventual complications. The prolonged quarantine introduced on March 20, takes more than 100 days, and it has generated an underutilization of the number of consultations, which have suffered a very considerable drop. An estimated drop of about 75% regarding cardiac pathologies or other issues, such as hypertension or diabetes, was reported. So far, the downward curve has not reversed what is necessary. Patients have postponed the frequency of their usual check‐ups and, in turn, for fear of hospital transmission, often delay emergency care in the face of symptoms, which can worsen their prognosis. Among the 62% of reported cases of reduction in care or late access are those with angor symptoms or acute ischemic coronary syndromes, with 28% less acute myocardial infarction (AMI) admission compared with the same period in 2019. This data has been reported by 30 centers that perform interventional cardiology procedures. The emergency services, in general, suffered a of 30% in March and 50%in April less hospitalizations. Also, a contraction of 46% of the number of patients admitted early to critical care units for strokes and 70% with respect to transient ischemic attacks was observed. These statistical considerations, which have been observed throughout the period both at the level of public and private providers, speak of a probability of an increase of 3500–10,000 deaths between April and October that could be preventable, of which between 400 and 800 would be due to AMI.

At the same time, the need to have a high complexity hospital bed for the treatment of severe cases of COVID‐19 with respiratory compromise significantly reduced the number of scheduled surgical interventions, leaving room for emergency care only. This has resulted in hospitals operating at an average of 50% bed capacity. It is estimated that at the national level, the number of general surgeries contracted by 73% compared with the same period in the previous year. And a similar phenomenon occurs with practices of high cardiovascular complexity, be it cardiac surgeries or percutaneous intervention, with an average reduction of 59% for the former, 62% for percutaneous intervention, and 58% for angioplasties of the neck vessels, abdomen, and lower limbs. It is known that in terms of acute coronary ischemia, a drop from 40% to 60% in the opportunity for timely reperfusion treatment implies an increase in mortality of the order of 3%–5%. It is enough to consider that a marginal increase in the relative risk of death from cardiovascular causes between 10% and 15% could lead to an average excess of 8000 preventable deaths.

RESULTS

On the basis of information from the main solidary health financer in Argentina, the INSSJP, which provides coverage to 5 million beneficiaries, most of whom are over 65 years of age, it has been possible to cross data from the same semesters of 2019 and 2020 as well. To break down what happened with cardiac surgical practices with and without extracorporeal circulation and interventional hemodynamics that have been carried out during the specific period of social confinement. These correspond to a total offer of 313 hemodynamic services and 170 cardiac surgery services throughout the country.

Figure 1 shows the impact of the extended quarantine on the total volume of cardiovascular practices of high complexity (cardiac surgery, peripheral vascular surgery, diagnostic and interventional hemodynamics, placement of pacemakers, and electrophysiology) between January and June 2020. The benefits/losses for the period 2020 begins in March (Day 20 of confinement) and becomes especially significant in April with a 69.8% reduction in activities. Subsequently, a very slight recovery of some specific activities is observed from May (Source: own elaboration according to INSSJP data, Argentina 2019–2020). Concerning benefits of cardiac surgery, during the period of social confinement, there is also a sharp 73.5% drop in April compared with January in the same year with more frequent cardiac surgeries, and a recovery of only 57% is achieved compared with the same month in 2019. The total number of cardiac surgeries in this group of patients for the period January/June 2020 was 1578, against 2105 for the same period in 2019, resulting in an interperiod contraction of 39.5% (Figures 2 and 3).

Figure 1

Cardiovascular practices of high complexity. Comparison of the first semester 2019–2020 (COVID‐19 pandemic)

Figure 2

Cardiac surgery in the National Institute of Social Services for Retirees and Pensioners population 2019 first semester. AMR, antibody‐mediated rejection; AVR, aortic valve replacement; CABG, coronary artery bypass grafting; CIA, ASD atrial septal defect; ECC, extracorporeal circulation; RV, redo valve o reoperation valve; VR, valve replacement

Figure 3

Cardiac surgery in the National Institute of Social Services for Retirees and Pensioners population 2020 first semester. AMR, antibody‐mediated rejection; AVR, aortic valve replacement; CABG, coronary artery bypass grafting; ECC, extracorporeal circulation; IAC, interarterial course

Regarding the benefits of interventional cardiology, such as coronary angiography plus coronary and peripheral angioplasty and transcatheter aortic valve replacement (TAVR) together with aortic/pulmonary valvuloplasty, an abrupt drop was also registered. Based on the frequency of percutaneous coronary interventions, it was more evident in the case of simple coronary angioplasty (single lesion in one or two vessels) and less marked in the rest (combined and complex). Comparing the total angioplasties of the first semester of 2020—corresponding to 8543 benefits—against the same period of 2019 with 9973, the decrease in activity is slightly less, of the order of 18%.

In the case of TAVR, in March, April, and May, the implants fall to zero until June when they are placed. This arises from the type of scheduling practice. As a result, the need not to occupy beds, especially intensive care beds, has been significantly reduced. The case is different for transapical TAVR, which from March drops definitively to zero. An interesting fact is a relative increase in the number of basically aortic valvuloplasty, which is supposed to have been used as an emergency mechanism against eventual decompensations of severe aortic stenosis in elderly patients. Comparing both semesters of 2019 and 2020, the difference between valvuloplasty and transcatheter aortic valve implantation (TAVI) is 103 practices (311 against 208), although specifically in the case of TAVI, it is 197 against 79, a 59.5% difference (Figures 4 and 5).

Figure 4

Interventional cardiology in the National Institute of Social Services for Retirees and Pensioners population 2019 first semester. CABG, coronary artery bypass grafting; PTCA, percutaneous transluminal coronary angioplasty

Figure 5

Interventional cardiology in the National Institute of Social Services for Retirees and Pensioners population 2020 first semester. CABG, coronary artery bypass grafting; PTCA, percutaneous transluminal coronary angioplasty

CONCLUSIONS

The Argentine health system provides broad healthcare coverage and access, but given its heterogeneity, fragmentation, and segmentation, the gaps in quality, opportunity, and therefore equity, are significant. At the time of the emergence of the COVID‐19 pandemic, Argentina was showing signs of a weakening social fabric. Also, the excellent coordination and action by the country's Ministry of Health, together with its 23 provinces and the Autonomous City of Buenos Aires, has resulted in the country's critical care beds being ≤63% occupied considering COVID‐positive patients and carriers of other non‐COVID pathologies. Likewise, an incipient recovery of the attention for other pathologies has been observed, even in the areas with the highest incidence of patients with COVID‐19. This was possible, among other actions, by the epidemiological surveillance system and the centralized control system for hospital beds that the Ministry of Health of the nation and those of each province put in place. Worthy of note is the excellent response capacity of health personnel working in the public and private sectors at all levels of the Argentine health system. Clearly, the analysis of the situation in Argentina concerning cardiovascular pathology during the period of the COVID‐19 pandemic shows a frank decrease in benefits in all cardiovascular diseases as in the rest of the world. Depending on the local epidemiological situation, coronary care unit beds should be available to manage patients with COVID‐19.

This has been deepened in direct relation with those areas of the country where the incidence of cases with COVID‐19 has been higher, characterized by a higher population density. For patients older than 65 years, a more accurate analysis could be carried out, comparing what happened when contrasting two comparative semi‐annual periods corresponding to the years 2019 and 2020 (pandemic time). The data collected regarding this age range revealed issues that had not previously been evaluated in our country. They undoubtedly propose a different solution for the future based on strict scientific analysis. One of the most important conclusions regarding the treatment of acute coronary syndrome is that the ratio between patients in this age group who received stents versus coronary surgery was 6 to 1, and regarding off‐pump surgery versus minimally invasive surgery, the ratio was 69 to 1. And that 83% of interventional hemodynamics turn out to be simple angioplasties (one lesion in up to two vessels) with a use rate of 11.7 × 10,000 beneficiaries versus 2.09 × 10,000 CABG beneficiaries and 0.17 × 1000 beneficiaries for off‐pump coronary artery bypass (OPCAB), an average of 1.5 stents placed per patient. These data show that more than 20% of those who receive stents do so in the left anterior descending coronary artery. Except for clinical situations where coronary surgery using arterial conduits and without the use of extracorporeal circulation (OPCAB) is indisputable as the most appropriate long‐term treatment, for the vast majority of the population with coronary heart disease, having a healthy anterior descending artery or a patent left internal mammary artery–left anterior descending coronary artery (LIMA–LAD) graft is the main determinant of the patient's prognosis and survival. Minimally invasive LIMA–LAD surgery provides excellent long‐term results, , with reports of its performance on an outpatient basis and with minimal hospitalization. LIMA–LAD can be performed with minimal resources in a completely isolated surgical area of COVID‐19, within the hospital.

Another option to consider for patients under these circumstances is the hybrid treatment of coronary heart disease. It combines minimally invasive surgery for LAD and stents in other vessels. Surgeons must take the initiative and play an active role in the therapeutic decision process regarding the application of this method that guarantees an early discharge with a more significant remote patency. It is clear that with this option, hospitalization can be reduced considerably as all procedures are performed in one place (hybrid room), with little requirement for intensive beds. The pandemics and their next waves will surely force the acceleration of this type of treatment, for which it is important to educate cardiac surgeons to train in this combined surgical and intervention technique together with the interventional cardiology. There is no doubt that the COVID‐19 pandemic has reduced surgical opportunities for coronary patients. But as the country begins a careful reopening and more myocardial revascularization procedures are scheduled, the time will have come to consider new procedures and clinical–surgical decisions that allow patients with acute coronary disease to receive the appropriate treatment on time. About half of coronary cases are either urgent or emergent, which means they must be treated immediately. The other half are electives that can be programmed. The advantage of using minimally invasive cardiac surgery is the presence of less postoperative discomfort, faster healing times, and less risk of infections. The procedure also makes cardiac surgery possible in patients who were considered high risk for traditional surgery with extracorporeal circulation due to their age or medical history, adding to the low risk of associated percutaneous intervention. An Argentinian perspective is good because the country has an excellent level of qualified medical training in its cardiac surgery and interventional cardiology services, as well as healthcare infrastructure distributed throughout the country, which will undoubtedly be able to respond to the new challenges posed by the post‐pandemic period.