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Table of Contents
Year : 2022  |  Volume : 19  |  Issue : 1  |  Page : 21-25

Effect of coronavirus disease 2019 (COVID-19) pandemic on catheterization laboratory activity in Azadi Heart Center, Duhok, Iraq

1 Department of Cardiology, Azadi Heart Centre, Duhok, Iraq
2 College of Medicine, University of Duhok, Duhok, Iraq

Date of Submission14-Jul-2021
Date of Acceptance01-Sep-2021
Date of Web Publication20-Apr-2022

Correspondence Address:
Kamal A M Maerozy
Department of Cardiology, Azadi Heart Centre, Duhok
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/MJBL.MJBL_52_21

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Background: Coronavirus disease 2019 (COVID-19) has a remarkable impact on healthcare systems globally, and it has challenged patients, healthcare personnel, healthcare systems, and the general population under serious threats. Aim: The aim was to determine the effect of the COVID-19 pandemic on catheterization laboratory activity in Azadi Heart Center, Duhok, Iraq. Materials and Methods: All data of consecutive patients visiting Azadi Heart Center for Cardiac Intervention (coronary angiography, congenital intervention, and cardiac device implantation) in two calendar years period (2019 and 2020) were collected, compared, and studied to explore the effect of the pandemic on catheterization laboratories activity during the peak of the pandemic in our region. Results: A significant decrease in all cardiac procedures and interventions was detected except for emergency percutaneous coronary intervention, and the total number of procedures performed between January 1 and December 31, 2020 reduced by one-third as compared with the same period in 2019. Conclusion: During the peak of disease, the COVID-19 pandemic had reduced all catheterization laboratories activity by one-third except for emergency percutaneous coronary intervention.

Keywords: Catheterization laboratories activity, COVID-19 pandemic, interventional cardiology

How to cite this article:
Albarwari N, Ahmed MH, Maerozy KA, Mohammad JB. Effect of coronavirus disease 2019 (COVID-19) pandemic on catheterization laboratory activity in Azadi Heart Center, Duhok, Iraq. Med J Babylon 2022;19:21-5

How to cite this URL:
Albarwari N, Ahmed MH, Maerozy KA, Mohammad JB. Effect of coronavirus disease 2019 (COVID-19) pandemic on catheterization laboratory activity in Azadi Heart Center, Duhok, Iraq. Med J Babylon [serial online] 2022 [cited 2022 May 20];19:21-5. Available from: https://www.medjbabylon.org/text.asp?2022/19/1/21/343517

  Introduction Top

A cluster of viral pneumonia cases was reported to the media by Wuhan Municipal authorities, Hubei province, People’s Republic of China, on December 31, 2019, which were identified to be caused by severe acute respiratory syndrome coronavirus 2 by the World Health Organization (WHO) on January 11, 2020, and the disease eventually named coronavirus disease 2019 (COVID-19).[1],[2] Alarmed by the rapidity and severity of the global spread of the disease, WHO characterized the outbreak as pandemic on March 11, 2020.[3]

Linked to foreign visits, the disease reached the Kurdistan autonomous region of Iraq (KRI) on March 1, 2020, and the first case reported in Duhok province, one of three provinces of KRI, on March 19, 2020.[3] Given the high mortality and morbidity associated with the pandemic, WHO called for public health containment measures and lockdowns to preserve the lives and safety of their citizens. Duly, a multitude of measures implemented by majority of affected areas worldwide in an endeavor to contain the virus and reduce its transmission, and KRI followed a suit.[1],[4]

At the outset of the pandemic, the preventative measures in the region were so stringent, including a total curfew imposed on March 13 until April 23, 2020 and movement restrictions, that earned the region’s government praise from WHO.[5] However, a grave fall in global oil prices coupled with aforementioned measures has severely affected livelihood and income opportunities, prohibiting authorities from restoring to such measures in subsequent pandemic waves.[6] Logistically, KRI allocated separate facilities for suspected and confirmed cases since reported cases were relatively low at the first wave of the outbreak. In Duhok province, The Burns Hospital, a 50-bed hospital equipped with ventilators, was allocated for COVID-19 in early March 2020 and renamed Corona hospital.[7] A new 45-bed hospital was opened on March 29, 2020 to cater for suspected cases. Additionally, a new 100-bed hospital was inaugurated in mid-June 2021 to cater for more COVID patients.[8] Because of surging cases during the second wave of the virus, the authorities were forced to allocated Azadi General Hospital, the main and largest hospital in Duhok governorate, which also host Azadi Heart Centre, for COVID patients on August 17, 2020 until February 2021.[9] This is in line with measures taken elsewhere as many cardiac units have been reassigned as intensive care units (ICUs) for the care of COVID-19 patients.[10]

There has been documented delay of patients seeking hospital treatment for many reasons. Uncertainty about the disease and its effect and lack of effective treatment or vaccine caused anxiety and distress in a majority of Kurdistan people because of fear of contracting the virus and fear of death.[11] These fears were augmented by misinformation rapidly spreading across both mainstream and social media.[12] Additionally, preventive measures and lockdown prohibited normal movement. And lastly, disruption to normal routine work in hospitals and deployment of staff to corona wards added insult to an injury. For instance, a deferral of elective cardiac procedures is recommended by the Center for Disease Control and Prevention to limit resource utilization.[13]

The pandemic has an unprecedented impact on the cardiac care delivery system globally. There were several studies concerning the effect of the COVID-19 pandemic on cardiac catheterization laboratory activity focusing on systems, physicians, supporting staff, and patients.[14],[15]

Our study is conducted to determine the effect of the COVID-19 pandemic on cardiac catheterization laboratory workload in Azadi Heart Center, Duhok, Iraq. We sought to understand if there was a change in procedural volumes and workload during the COVID-19 pandemic.

  Materials and Methods Top

We collected retrospectively data of consecutive patients attended Azadi Heart Center for cardiac procedures including coronary angiography, percutaneous coronary and endovascular intervention, congenital heart disease intervention, and cardiac device implantation during the COVID-19 pandemic between January 1 and December 31, 2020, and compared them with the corresponding timeline in the year 2019. Analysis was performed by Microsoft Excel and statistical package for social sciences version 25 (IBM SPSS Statistics for Windows, Version 25.0, Armonk, NY: IBM Corp).

Ethical approval

The study was conducted in accordance with the ethical principles that have their origin in the Declaration of Helsinki. It was carried out with patients verbal and analytical approval before sample was taken. The study protocol and the subject information and consent form were reviewed and approved by a local ethics committee according to the document number 48 (including the number and the date in 105/12/2019) to get this approval.

Statistical analysis

The trend of monthly catheterization laboratory activities for years 2019 and 2020 is presented as a line graph created by Microsoft Excel 2013. The comparison of catheterization laboratory between years 2019 and 2020 was examined in an independent t-test. The statistical analyses were performed by statistical package for social sciences version 25 (IBM SPSS Statistics for Windows, Version 25.0, Armonk, NY: IBM Corp).

  Results Top

As shown in [Figure 1] and [Figure 2], there was a significant decrease in all cardiac procedures and interventions except emergency percutaneous coronary intervention (PCI), which increased by 26.9%. The total number of procedures performed between January 1 and December 31, 2020 reduced by a third as compared to the same period in 2019: 2210 versus 3171 procedures, respectively. [Figure 3] demonstrates a 39.35% reduction in diagnostic coronary angiogram and 37.2% reduction in elective PCI procedures in 2020 as compared to those in 2019. The number of pacemaker implantation reduced by one-third and both congenital and peripheral procedures dwindled by approximately a half.
Figure 1: Total number of activities in 2019 and 2020

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Figure 2: Emergency PCIs in 2019 and 2020

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Figure 3: Comparison of various catheterization procedures between years 2019 and 2020

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[Figure 4] and [Figure 5] reveal that the most noticeable difference in the monthly breakdown of the data showed two troughs. The first one coincided with total regional lockdown between March and April 2020 at the beginning of the outbreak, and the second dip was during the peak of the second wave where major hospitals in the city, including Azadi Heart Centre, were dedicated to COVID-19 patients with suspensions of all routine works from August 2019. One hundred and seventeen diagnostic coronary angiogram was performed in March 2019, which dropped to 84 in March 2020, a reduction of 28%. Likewise, there was a 37% reduction in coronary stent implantation with 54 cases in March 2019 versus 34 cases in March 2020. In April 2019, there were 88 diagnostic coronary angiograms and only 24 cases in April 2020, a staggering reduction of 83%. During these corresponding two months, there was a 88% reduction in elective PCI procedures with 88 and 24 cases, respectively. Similarly, there was a significant reduction in diagnostic angiogram and elective PCI in July, August, and September 2019 as compared to 2020 with 34.9%, 98.6%, and 76.7% for diagnostic studies and 61.6%, 97.3%, and 47.5% for stent implantation, respectively.
Figure 4: Monthly trends of catheterization laboratory activities from January to December 2019

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Figure 5: Monthly trends of catheterization laboratory activities from January to December 2020

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Conversely, there was a huge increase in emergency PCI in March and April 2020 as compared to 2019 with a rise of 310% and 150%, respectively. In August and September 2020, there was a decrease of emergency PCI of 51% and 29.2%, respectively.

  Discussion Top

Our center is a territory referral cardiac intervention and cardiac surgery center in Duhok governorate serving a population in excess of 1.5 million. The catchment area of our center also hosting hundreds of thousands of internally displaced people (IDP) who sought refuge in the area in the aftermath of ISIS control of neighboring Nineveh province. Additionally, Syrian refugees who fled the civil war are also distributed in the region. The destitute IDPs and refugees are housed in 22 refugees camps under the auspice of the region’s government.[16] We inaugurated round-the-clock primary PCI program for ST-elevation myocardial infarction in July 2019.

In our study, we identified a significant decline in catheterization laboratories workload particularly in curfews months March–April 2020 and when all routine services were suspended and dedicated to COVID-19 patients in August 2020–January 2021. There are many reasons that can explain these findings. Quarantine measures limited people movement, limitations of availability of hospital beds, and staff shortage due to deployment to other departments such as emergency and ICUs, the balance of patient best interest and staff exposure, and people general fears of exposure to healthcare services dealing directly with contagion COVID-19 patients. Our results are congruous with published multiple studies in the literature. Roffi et al. reported a massive procedural decline in a survey of 363 members of the European Association of PCI.[17] In a study conducted by Ullah et al., 48.5% reduction in coronary catheterization, 40% drop in NSTEMI, and 83% in urgent elective work in a single hospital in England, over a 10-week COVID peak period, were reported.[18] Kwong et al. detected a significant decline in PCI procedures. Fewer patients underwent PCI for stable angina.[19] Elliot and Grozier found report a >50% decrease in in-patient coronary procedures during the level 4 lockdown.[20]

The other major finding is that there was a rise of emergency PCI by a quarter. This is to be expected as our primary PCI program was established in July 2019.

  Conclusion Top

During the peak COVID-19 pandemic, all catheterization laboratories activity declined by one-third except for emergency PCI. The results highlight the great impact of the pandemic on cardiology daily clinical practice in our locality, which has limited resources.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

World Health Organization. Coronavirus disease 2019 (COVID-19): Situation report. vol. 43; 2020. Available from: https://www.unidosus.org/issues/health/covid19/?gclid=Cj0KCQjwl7qSBhD-ARIsACvV1X13_QqNC4jDykF4mZlDaBIg1TiSOJi AUzrhj6GyJjowPj0RjJP4bPMaAkJwEALw_wcB. [Last accessed on 22 June 2021].  Back to cited text no. 1
WHO. Naming the coronavirus disease (COVID-19) and the virus that causes it; 2020. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/naming-the-coronavirus-disease-(covid-2019)-and-the-virus-that-causes-it. [Last accessed on 12 September 2021].  Back to cited text no. 2
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Shilani H The World Health Organization (WHO) in Iraq on Thursday praised the measures and leadership role played by the Kurdistan Regional Government (KRG) in facing the ongoing outbreak of coronavirus. Available from: https://www.kurdistan24.net/public/index.php/en/story/22061-WHO praises-Kurdistan-Region%E2%80%99s-anti-coronavirus-efforts. [Retrieved on 17 June 2021].  Back to cited text no. 5
UNCHR. The impact of COVID-19 on daily-wage work and the 575 refugee households that rely on it in the Kurdistan Region of Iraq (KR-I). Available from: https://reliefweb.int/sites/reliefweb.int/files/resources/IMPACT_UNHCR_Report_Impact%20of%20COVID-19%20on%20Daily-wage%20Work_v2.pdf. [Retrieved on 17 June 2021].  Back to cited text no. 6
Merza MA, Haleem Al Mezori AA, Mohammed HM, Abdulah DM COVID-19 outbreak in Iraqi Kurdistan: The first report characterizing epidemiological, clinical, laboratory, and radiological findings of the disease. Diabetes Metab Syndr 2020;14:547-54.  Back to cited text no. 7
Sherwani H Kurdistan’s Duhok inaugurates 100-bed hospital for COVID-19 patients. Available from: https://www.kurdistan24.net/en/news/72a29307-bb7f-407b-8fab-7e2ee4870e68. [Retrieved on 17 June 2021].  Back to cited text no. 8
Shafaq News. Duhok allocates its largest hospital to treat COVID patients. Available from: https://shafaq.com/en/Economy/Duhok-allocates-its-largest-hospital-to-treat-Covid-19-patients. [Retrieved on 17 June 2021].  Back to cited text no. 9
Blbas HTA, Aziz KF, Nejad SH, Barzinjy AA. Phenomenon of depression and anxiety related to precautions for prevention among population during the outbreak of COVID-19 in Kurdistan Region of Iraq: Based on questionnaire survey. J Public Health2022;30:567-71.  Back to cited text no. 10
Driggin E, Maddox TM, Ferdinand KC, Kirkpatrick JN, Ky B, Morris AA, et al. ACC health policy statement on cardiovascular disease considerations for COVID-19 vaccine prioritization: A report of the American College of Cardiology solution set oversight committee. J Am Coll Cardiol 2021;77:1938-48.  Back to cited text no. 11
Larson HJ The biggest pandemic risk? Viral misinformation. Nature 2018;562:309.  Back to cited text no. 12
Nasca TJ; CDC. Coronavirus disease 2019 (COVID-19). Centers for Disease Control and Prevention; 2020. Available from: https://www.cdc.gov/coronavirus/2019-ncov/. [Last accessed on 17 January 2021].  Back to cited text no. 13
Rodríguez-Leor O, Cid-Álvarez B, Ojeda S, Martín-Moreiras J, Ramón Rumoroso J, López-Palop R, et al. Impact of the COVID-19 pandemic on interventional cardiology activity in Spain. REC Interv Cardiol 2020;2:82-9.  Back to cited text no. 14
Banning AP, Sabate M, Valgimigli M The impact of the COVID-19 pandemic upon patients, staff, and on the future practices of percutaneous coronary intervention. Eur Heart J Suppl 2020;22:P13-8.  Back to cited text no. 15
Duhok Governorate. Board of Relief and Humanitarian Affairs—Executive Directorate. IDPs and Refugees in Duhok Governorate. Profile and General Information; 2018. Available from: https://www.kurdipedia.org/files/books/2018/162886.PDF? ver=131870161089783010. [Last accessed on 3 July 2021].  Back to cited text no. 16
Roffi M, Capodanno D, Windecker S, Baumbach A, Dudek D Impact of the COVID-19 pandemic on interventional cardiology practice: Results of the EAPCI survey. Eurointervention 2020;16:247-50.  Back to cited text no. 17
Ullah A, Fraser DGW, Fath-Ordoubadi F, Holt CM, Malik N Decrease in cardiac catheterization and MI during COVID pandemic. Am Heart J Plus 2021;1:100001.  Back to cited text no. 18
Kwong JC, Schwartz KL, Campitelli MA, Chung H, Crowcroft NS, Karnauchow T, et al. Acute myocardial infarction after laboratory-confirmed influenza infection. N Engl J Med 2018;378:345-53.  Back to cited text no. 19
Elliott JM, Crozier IG Decreases in cardiac catheter laboratory workload during the COVID-19 level 4 lockdown in New Zealand. Intern Med J 2020;50:1000-3.  Back to cited text no. 20


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


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