procedures, 2 as recommended by the Centers for Disease Control and Prevention as well as the guidelines from the Electrophysiology section of the American College of Cardiology and the Arrhythmia Committee of the American Heart Association, 3 were implemented in Peru.
Electrophysiology units are not exempt from these changes; therefore, the impact of the COVID-19 pandemic on the implantation of cardiac pacing devices such as pacemakers was investigated.
Cross-sectional descriptive study used the pacemaker implant database of the Department of Cardiology of the Edgardo Rebagliati Martins National Hospital (HNERM), the national reference hospital, the largest in the country, where an average of 600 procedures are performed per year including de-novo pacemaker implants and pacemaker replacements. The hospital has two emergencies, one of which was dedicated to receiving COVID patients and the other to non-COVID patients. The admission of any patient has not been restricted.
In the present study, we only considered de-novo pacemaker implants (DNPI) performed from January 2017 to April 30, 2020, generator replacements were excluded from the analysis as they are generally elective procedures; The data of the de-novo pacemakers implanted between January 1st to April 30th from 2017 to 2020 were used and compared with each other. Likewise, the average number of DNPI in the last 12 months prior to the start of the COVID-19 pandemic in Peru was calculated and compared with the average number of DNPI in the COVID-19 pandemic in Peru.
Until the time of the present study, the HNERM was not desig- For the purposes of this study, time has been divided into two periods: "before COVID" (BC) and "COVID". The BC period is comprised of the 14 months prior to the pandemic in Peru (from January 1st, 2019 to February 29th, 2020); March 6th, 2020, was identified as the beginning of the COVID period, the date on which the first COVID-19 case was reported in Peru and substantial changes began in the health system, until April 30, 2020 (date the study ended).
In addition, the COVID period was subdivided into: "presocial isolation" period (COVID-preSI, from March 6th to March 15th) and "social isolation" period (COVID-SI, from March 16th to 30th April). We compared the total number of DNPI and the number of pacemaker implants according to etiology in the last 4 years, considering the same time interval.
We compare the monthly total of DNPIs from January 2019 to April 2020. We also compare the average DNPI per month between BC and COVID periods. The "t-student" test was used to estimate the change in the average DNPI between both periods.
The total number of pacemaker implants per month in Rebagliati hospital was lower in March and April 2020 compared to the months prior to the start of the COVID-19 pandemic ( Figure 1 ). 
The present study was carried out at HNERM, which is the hospital center that performs the largest number of pacemaker implants per year (de novo pacemaker implant and replacement).
In the present investigation we observe a great reduction in the And if we consider the number of pacemaker implants for complete or high-grade atrial ventricular block, which are usually the most symptomatic patients, it has also decreased.
We hypothesized that the decrease in the number of DNPI is because of multiple factors, such as the fear of getting COVID because of going to the hospital, a hypothesis suggested by us and other authors previously, both in cardiovascular pathologies 5-7 and other disciplines. [8] [9] [10] [11] The fear of infection has already been reported in a study of psychological responses to emerging outbreaks of infectious diseases. 12 We consider as possible causes of this decrease, the difficulty in getting around that limits timely access to the hospital. Another question asked is whether, in addition, patients underestimate their symptoms and prefer to stay home. 5,6,10 All of the above can have a deleterious impact on the health of the population, with an increase in morbidity and mortality, not only today, but also in the coming months.
The findings found are an early sign of an impending problem, which we must be prepared for. We must start educating patients with a cardiac pathology to go to cardiology services in the event of the onset or worsening of the disease or use digital means for remote orientation, remote monitoring, among other tools, and thus avoid fatal outcomes.
On the other hand, strategies must be developed on the management of patients with cardiac pathology during admission to medical units or emergencies. In this context, these units must be implemented with full biosafety protection for health professionals, patients, family members and companions, as well as considering the isolation of patients who require DNPI and are diagnosed with COVID-19 infection, previous reports have explained how to implement these strategies as well. 3 In general terms, the cause of the reduction in the number of DNPI is considered to be multifactorial; the Figure 3 showed a marked decreased in peacemaker implants in the isolation period, and as the emergency room was open to any patients 24/7, the attendance of patients to the emergency probably was affected by the decision of the patients, so it is believed that what determines the patient not to go to the emergency would be the fear of getting COVID. Even so, this fear can be controlled to avoid fatal cardiovascular outcomes.
Our results indicate a very significant reduction (73%) in de-novo pacemaker implantation during the months of the COVID-19 pandemic. The reduction in the number of de-novo pacemaker occurred independently of the etiology.
A single hospital center in Peru was considered; although it is true that a single center experience may not represent the entire national situation, this hospital has the peculiarity of receiving patients from all over the country and being the one that implants the largest number of pacemakers per year. 