Impact of the COVID-19 pandemic on predictions of death from stroke in a poor region of Brazil: a retrospective cohort study

Stroke and cardiovascular disease are the leading causes of morbidity and mortality worldwide. However, epidemiological indicators show a decrease in the number of stroke deaths in recent decades, which can be attributed to advances in clinical interventions. The coronavirus disease 2019 (COVID-19) pandemic and the redirection of health services raised concerns about the diagnosis and treatment of other diseases and health problems, particularly in low-income areas.(1) Although the occurrence of stroke is relatively low among patients hospitalized with COVID-19, the risk of death is higher among those with these two conditions.(2) Thus, the aim of this study was to investigate the impact of the COVID-19 pandemic on the prediction of deaths from stroke in a low-income region of Brazil. This was a retrospective cohort of stroke patients admitted to a tertiary hospital in the state of Sergipe between February 2019 and February 2020 (prepandemic period) and between March 2020 and March 2021 (during the pandemic). Sergipe is located in Brazil’s Northeast region, which has the highest concentration of highly vulnerable people in the country. The following predictor variables were dichotomized: sex (female or male); age (< 60 years or ≥ 60 years); marital status (with a partner [married, stable union, or other forms of union] or without a partner [widowed, single, or divorced]); orotracheal intubation (yes or no); alternative feeding route (yes or no); dysphagia (yes or no); poststroke motor dysfunction (yes or no); poststroke communication difficulties (yes or no); dyspnea (yes or no); mental confusion (yes or no); length of stay (< 14 days or ≥ 14 days); stroke period (prepandemic or during the COVID-19 pandemic); and laboratory diagnosis of COVID-19 with reverse-transcriptase polymerase chain reaction (RT‒PCR; yes or no). A multiple logistic regression model was built with backward selection to assess the influence of predictor variables on the outcome of interest (in-hospital death). The odds ratio (OR) with a 95% confidence interval (95%CI) was used as a measure of association. Analyses were performed by using JASP software version 0.13 (JASP Team, Amsterdam, Netherlands). This study was approved by the Human Research Ethics Committee of the Federal University of Sergipe (approval number 4.219.456). Written informed consent was obtained from all participants. The current study included 253 stroke patients: 115 who had a stroke before the pandemic and 138 who had a stroke during the pandemic. Most patients were men (53.8%) and over 60 years of age (82.6%). COVID-19 was identified in 20 (14.5%) of stroke patients hospitalized during the pandemic. Fifty-three in-hospital deaths were recorded, with 26 (49.1%) occurring prior to the pandemic and 27 (50.9%) occurring during the pandemic. Ten (37%) deaths reported during the pandemic were among patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). João Ricardo Bispo de Jesus1 , Paulo Ricardo MartinsFilho2 , Aline Ferreira de Brito Mota3 , Crislaine Souza Santos1 , Joyce Menezes Santos3 , Franklim Oliveira Souza1 , Raphaela Barroso Guedes-Granzotti1 , Miburge Bolivar Gois-Junior1 , Kelly da Silva 1


LETTER TO THE EDITOR TO THE EDITOR,
Stroke and cardiovascular disease are the leading causes of morbidity and mortality worldwide. However, epidemiological indicators show a decrease in the number of stroke deaths in recent decades, which can be attributed to advances in clinical interventions. The coronavirus disease 2019 (COVID-19) pandemic and the redirection of health services raised concerns about the diagnosis and treatment of other diseases and health problems, particularly in low-income areas. (1) Although the occurrence of stroke is relatively low among patients hospitalized with COVID-19, the risk of death is higher among those with these two conditions. (2) Thus, the aim of this study was to investigate the impact of the COVID-19 pandemic on the prediction of deaths from stroke in a low-income region of Brazil. This was a retrospective cohort of stroke patients admitted to a tertiary hospital in the state of Sergipe between February 2019 and February 2020 (prepandemic period) and between March 2020 and March 2021 (during the pandemic). Sergipe is located in Brazil's Northeast region, which has the highest concentration of highly vulnerable people in the country.
The following predictor variables were dichotomized: sex (female or male); age (< 60 years or ≥ 60 years); marital status (with a partner [married, stable union, or other forms of union] or without a partner [widowed, single, or divorced]); orotracheal intubation (yes or no); alternative feeding route (yes or no); dysphagia (yes or no); poststroke motor dysfunction (yes or no); poststroke communication difficulties (yes or no); dyspnea (yes or no); mental confusion (yes or no); length of stay (< 14 days or ≥ 14 days); stroke period (prepandemic or during the COVID-19 pandemic); and laboratory diagnosis of COVID-19 with reverse-transcriptase polymerase chain reaction (RT-PCR; yes or no). A multiple logistic regression model was built with backward selection to assess the influence of predictor variables on the outcome of interest (in-hospital death). The odds ratio (OR) with a 95% confidence interval (95%CI) was used as a measure of association. Analyses were performed by using JASP software version 0.13 (JASP Team, Amsterdam, Netherlands).
This study was approved by the Human Research Ethics Committee of the Federal University of Sergipe (approval number 4.219.456). Written informed consent was obtained from all participants.
This study examined how the COVID-19 pandemic affected the prediction of stroke deaths in one of Brazil's states with the highest rates of socioeconomic vulnerability.
Although some conditions, such as orotracheal intubation and the use of alternative feeding, are known prognostic factors among stroke patients, our findings point to SARS-CoV-2 infection as a new factor associated with death in this population. However, we did not observe an impact of the period of hospitalization on the occurrence of in-hospital deaths from stroke, possibly due to the continued care of acute stroke crises despite the difficulties imposed by the pandemic in Brazil.