The adverse impact of COVID-19 pandemic on cardiovascular disease prevention and management in England, Scotland and Wales: A population-scale analysis of trends in medication data

Objectives To estimate the impact of the COVID-19 pandemic on cardiovascular disease (CVD) and CVD management using routinely collected medication data as a proxy. Design Descriptive and interrupted time series analysis using anonymised individual-level population-scale data for 1.32 billion records of dispensed CVD medications across 15.8 million individuals in England, Scotland and Wales. Setting Community dispensed CVD medications with 100% coverage from England, Scotland and Wales, plus primary care prescribed CVD medications from England (including 98% English general practices). Participants 15.8 million individuals aged 18+ years alive on 1st April 2018 dispensed at least one CVD medicine in a year from England, Scotland and Wales. Main outcome measures Monthly counts, percent annual change (1st April 2018 to 31st July 2021) and annual rates (1st March 2018 to 28th February 2021) of medicines dispensed by CVD/ CVD risk factor; prevalent and incident use. Results Year-on-year change in dispensed CVD medicines by month were observed, with notable uplifts ahead of the first (11.8% higher in March 2020) but not subsequent national lockdowns. Using hypertension as one example of the indirect impact of the pandemic, we observed 491,203 fewer individuals initiated antihypertensive treatment across England, Scotland and Wales during the period March 2020 to end May 2021 than would have been expected compared to 2019. We estimated that this missed antihypertension treatment could result in 13,659 additional CVD events should individuals remain untreated, including 2,281 additional myocardial infarctions (MIs) and 3,474 additional strokes. Incident use of lipid-lowering medicines decreased by an average 14,793 per month in early 2021 compared with the equivalent months prior to the pandemic in 2019. In contrast, the use of incident medicines to treat type-2 diabetes (T2DM) increased by approximately 1,642 patients per month. Conclusions Management of key CVD risk factors as proxied by incident use of CVD medicines has not returned to pre-pandemic levels in the UK. Novel methods to identify and treat individuals who have missed treatment are urgently required to avoid large numbers of additional future CVD events, further adding indirect cost of the COVID-19 pandemic. ### Competing Interest Statement AB has received grant funding from AstraZeneca, NIHR, UKRI, European Union, and the British Medical Association. The other authors have not declared any competing interests. ### Clinical Protocols ### Funding Statement The British Heart Foundation Data Science Centre (grant No SP/19/3/34678, awarded to Health Data Research (HDR) UK) funded co-development (with NHS Digital) of the trusted research environment, provision of linked datasets, data access, user software licences, computational usage, and data management and wrangling support, with additional contributions from the HDR UK data and connectivity component of the UK governments chief scientific advisers national core studies programme to coordinate national covid-19 priority research. Consortium partner organisations funded the time of contributing data analysts, biostatisticians, epidemiologists, and clinicians. This work was supported by the Con-COV team funded by the Medical Research Council (grant number: MR/V028367/1). This work was supported by Health Data Research UK, which receives its funding from HDR UK Ltd (HDR-9006) funded by the UK Medical Research Council, Engineering and Physical Sciences Research Council, Economic and Social Research Council, Department of Health and Social Care (England), Chief Scientist Office of the Scottish Government Health and Social Care Directorates, Health and Social Care Research and Development Division (Welsh Government), Public Health Agency (Northern Ireland), British Heart Foundation (BHF) and the Wellcome Trust. This work was supported by the ADR Wales programme of work. The ADR Wales programme of work is aligned to the priority themes 410 as identified in the Welsh Governments national strategy: Prosperity for All. ADR Wales brings together data science experts at Swansea University Medical School, staff from the Wales Institute of Social and Economic Research, Data and Methods (WISERD) at Cardiff University and specialist teams within the Welsh Government to develop new evidence which supports Prosperity for All by using the SAIL Databank at Swansea University, to link and analyse anonymised data. ADR Wales is part of the Economic and Social Research Council (part of UK Research and Innovation) funded ADR UK (grant ES/S007393/1). This work was supported by the Wales COVID-19 Evidence Centre, funded by Health and Care Research Wales. All three national TREs receive support from the Data and Connectivity National Core Study, led by HDR UK in partnership with the Office of National Statistics and funded by United Kingdom Research and Innovation (grant MC\_PC\_20029). RS & RT are funded by UCLH NIHR BRC and CD is funded by HDR UK. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The North East-Newcastle and North Tyneside 2 research ethics committee provided ethical approval for the CVD-COVID-UK research programme (REC No 20/NE/0161). The BHF Data Science Centre approvals and oversight board deemed that this project (proposal CCU014 Assessing the Impact of Cardiovascular Disease through Medicines) fell within the scope of the consortium's ethical and regulatory approvals. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes Data used in this study are available in NHS Digitals Trusted Research Environment (TRE) for England, but as restrictions apply they are not publicly available (https://digital.nhs.uk/coronavirus/coronavirus-data-services-updates/trusted-research-environment-service-for-england). The CVD-COVID-UK/COVID-IMPACT programme led by the BHF Data Science Centre (https://www.hdruk.ac.uk/helping-with-health-data/bhf-data-science-centre/) in partnership with HDR UK received approval to access data in NHS Digitals TRE for England from the Independent Group Advising on the Release of Data (IGARD) (https://digital.nhs.uk/about-nhs-digital/corporate-information-and-documents/independent-group-advising-on-the-release-of-data) via an application made in the Data Access Request Service (DARS) Online system (ref. DARS-NIC-381078-Y9C5K) (https://digital.nhs.uk/services/data-access-request-service-dars/dars-products-and-services). The CVD-COVID-UK/COVID-IMPACT Approvals & Oversight Board (https://www.hdruk.ac.uk/projects/cvd-covid-uk-project/)) subsequently granted approval to this project to access the data within the TRE for England, the Scottish National Safe Haven and the Secure Anonymised Information Linkage (SAIL) Databank. The de-identified data used in this study was made available to accredited researchers only. Data used in this study are available in the Scottish National Safe Haven (Project Number: 2021-0102), but as restrictions apply they are not publicly available. Access to data may be granted on application to the Public Benefit and Privacy Panel for Health and Social Care (PBPP (https://www.informationgovernance.scot.nhs.uk/pbpphsc/)). Applications are co-ordinated by eDRIS (electronic Data Research and Innovation Service (https://www.isdscotland.org/Products-and-services/Edris/)). The anonymised data used in this study was made available to accredited researchers only through the Public Health Scotland (PHS) eDRIS User Agreement (https://www.isdscotland.org/Products-and-services/Edris/_docs/eDRIS-User-Agreement-v16.pdf). Data used in this study are available in the SAIL Databank at Swansea University, Swansea, UK, but as restrictions apply they are not publicly available. All proposals to use SAIL data are subject to review by an independent Information Governance Review Panel (IGRP). Before any data can be accessed, approval must be given by the IGRP. The IGRP gives careful consideration to each project to ensure proper and appropriate use of SAIL data. When access has been granted, it is gained through a privacy protecting data safe haven and remote access system referred to as the SAIL Gateway. SAIL has established an application process to be followed by anyone who would like to access data via SAIL at https://www.saildatabank.com/application-process.