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On Jan. 12, 2021, MedPage Today reported on early studies describing COVID-19's indirect effects on cardiovascular testing and deaths around the world. As a review of the year's top stories, we report on the ongoing challenges in closing the backlog of routine heart care.

While COVID-19 vaccines were authorized late last year, 2021 was the year that vaccination finally became available to most Americans, many of whom had had cardiovascular care disrupted the previous year -- whether for fear of contracting SARS-CoV-2 in healthcare facilities, because their elective procedures were cancelled, or other reasons.

With widespread COVID vaccination in place by the spring of 2021, there was hope that more patients would return to the medical care that they had gone without for months.

For example, the sharp reduction of U.S. adult cardiac surgery volumes starting in April 2020, along with high procedural mortality, were documented in a study of the Society of Thoracic Surgeons Adult Cardiac Surgery Database. By July 2020, heart surgery volumes reportedly bounced back to approximately pre-pandemic levels -- although still not enough to make up for the pile-up of missed operations accrued in the first year of the pandemic.

However, by May 2021, things appeared to be back to normal. Hospitals were no longer bursting at the seams and more than half of the U.S. adult population was at least partially vaccinated against COVID-19. Interventional cardiologists said their cath labs had been back to business as usual for months. In Israel, where more adults were vaccinated, operators were working longer hours to catch up on in a backlog of catheterizations.

Yet the recent wave of Omicron infections around the world has some concerned that systems of cardiovascular care are about to be tested again.

"Our services for patients with heart disease at the Royal Infirmary of Edinburgh are unchanged currently. The main challenge for cardiology services will be to maintain staffing levels over the winter period. We are already stretched and with more community transmission of coronavirus, colleagues will have to be flexible and cover staff absences to maintain these services," said cardiologist Nicholas Mills, MBChB, PhD, of his institution in Scotland.

The importance of staffing was highlighted when an interventional cardiologist was recorded as Israel's first Omicron COVID-19 patient in late November. He reported extreme fatigue for 72 hours and was , still weak, 10 days after his diagnosis.

"The most important message for our patients is that they should continue to seek help for acute cardiac care despite the pandemic and emergence of Omicron," Mills told MedPage Today in mid-December.

"At present we are taking care of patients the way we've been doing, but of course are concerned about patients and staff getting COVID in this wave. Contingency planning is the key and just making sure that everyone tries to stay as safe as possible and is fully boosted with vaccinations is key," said interventional cardiologist Ajay Kirtane, MD, SM, of Columbia University Irving Medical Center/NewYork-Presbyterian in New York City.

In the U.S., more than 72% of adults are -- the gaps in vaccination arising in part due to fears of side effects.

Fanning the flames were alarming reports of myocarditis after COVID vaccination throughout the year, which were countered by studies suggesting a favorable clinical course for those affected, even in a diverse population. There was general consensus that post-vaccination myocarditis is rare, even if some estimates are higher than others.

For clinicians, the larger worry was the suffering in store for heart patients in the long run in light of their weight gain, lifestyle changes, and deferred healthcare during the pandemic. Even the American Heart Association announced that it was from its Impact Goal for 2020-2023 to increase life expectancy around the world; its new focus toward 2024 would be on health equity projects instead.

"The United States is facing an oncoming wave of death and disability from CCDs [common chronic diseases], especially cardiometabolic diseases ... The fight against COVID-19 has given us a glimpse of what is possible. If we act now, we can significantly reduce the damage from the impending tsunami," wrote former FDA commissioner (and current nominee for a return tenure) Robert Califf, MD, of Verily Life Sciences, .

In a tailored to the pandemic, the European Society of Cardiology reminded people with cardiovascular disease to continue maintaining a healthy lifestyle, taking their prescribed heart medications, and staying on top of their cardiac follow-up appointments.

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