Heart failure management during the COVID-19 outbreak in Italy: a telemedicine experience from a heart failure university tertiary referral centre

Insights into heart failure hospitalizations, management, and services during and beyond COVID-19

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus-2. The clinical presentation of this virus mainly manifests in the respiratory system but may also lead to severe complications in the cardiovascular system. The global burden of COVID-19 has led to an unprecedented need to gain further insight into patient outcomes, management, and clinical practice. This review aims to provide an overview of the current literature on heart failure (HF) hospitalizations, management, and care pathways for supporting patients during and beyond this pandemic. A literature review of five areas of interest was conducted and included: (i) HF hospitalization; (ii) recognizing the needs and supporting HF patients during COVID-19; (iii) supporting rehabilitation services; (iv) transitioning to a telehealth framework; and (v) the need for evidence. Patients with new-onset or existing HF are particularly vulnerable, but a significant reduction in HF hospital admissions has been reported. During these periods of uncertainty, the current care pathways for acute and elective cardiac patients have had to change with the relocation of HF services to protect the vulnerable and reduce transmission of COVID-19. Optimizing community HF services has the potential to reduce the pressures on secondary care during the recovery from this pandemic. Telemedicine and virtual health care are emerging technologies and overcome the risk of in-person exposure. Successful remote delivery of cardiac rehabilitation services has been reported during the pandemic. Delivery of a robust telehealth framework for HF patients will improve communication between clinician and patient. The reduction in HF admissions is a concern for the future and may result in unintended mortality. New-onset and current HF patients must understand their diagnosis and future prognosis and seek help and support using the appropriate platform when needed. Realigning HF services and the use of telemedicine and virtual health care has great potential but needs to be carefully understood to ensure engagement and approval in this population to overcome barriers and challenges.

The impact of COVID-19 on the management of heart failure: a United Kingdom patient questionnaire study

Aims

The coronavirus disease 2019 (COVID‐19) pandemic has created significant challenges to healthcare globally, necessitating rapid restructuring of service provision. This questionnaire survey was conducted amongst adult heart failure (HF) patients in the United Kingdom (UK), to understand the impact of COVID‐19 upon HF services.

Methods and results

The survey was conducted by the Pumping Marvellous Foundation, a UK HF patient charity. ‘Survey Monkey’ was used to disseminate the questionnaire in the Pumping Marvellous Foundation 's online patient group and in 10 UK hospitals (outpatient hospital and community HF clinics). There were 1050 responses collected (693/1050—66% women); 55% (579/1050) were aged over 60 years. Anxiety level was significantly higher regarding COVID‐19 (mean 7 ± 2.5 on anxiety scale of 0 to 10) compared with anxiety regarding HF (6.1 ± 2.4; P < 0.001). Anxiety was higher amongst patients aged ≤60 years about HF (6.3 ± 2.2 vs. 5.9 ± 2.5 in those aged >60 years; P = 0.005) and COVID‐19 (7.3 ± 2.3 vs. 6.7 ± 2.6 those aged >60 years; P < 0.001). Sixty‐five per cent of respondents (686/1050) reported disruption to HF appointments (cancellation or postponement) during the lockdown period. Thirty‐seven per cent reported disruption to medication prescription services, and Thirty‐four per cent reported inability to access their HF teams promptly. Thirty‐two per cent expressed reluctance to attend hospital (25% stated they would only attend hospital if there was no alternative, and 7% stated that they would not attend hospital at all).

Conclusions

The COVID‐19 pandemic has caused significant anxiety amongst HF patients regarding COVID‐19 and HF. Cancellation or postponement of scheduled clinic appointments, investigations, procedures, prescription, and monitoring services were implicated as sources of anxiety.

Telemedicine in Heart Failure During COVID-19: A Step Into the Future

During the Coronavirus Disease 2019 worldwide pandemic, patients with heart failure are a high-risk group with potential higher mortality if infected. Although lockdown represents a solution to prevent viral spreading, it endangers regular follow-up visits and precludes direct medical assessment in order to detect heart failure progression and optimize treatment. Furthermore, lifestyle changes during quarantine may trigger heart failure decompensations. During the pandemic, a paradoxical reduction of heart failure hospitalization rates was observed, supposedly caused by patient reluctance to visit emergency departments and hospitals. This may result in an increased patient mortality and/or in more complicated heart failure admissions in the future. In this scenario, different telemedicine strategies can be implemented to ensure continuity of care to patients with heart failure. Patients at home can be monitored through dedicated apps, telephone calls, or devices. Virtual visits and forward triage screen the patients with signs or symptoms of decompensated heart failure. In-hospital care may benefit from remote communication platforms. After discharge, patients may undergo remote follow-up or telerehabilitation to prevent early readmissions. This review provides a comprehensive appraisal of the many possible applications of telemedicine for patients with heart failure during Coronavirus disease 2019 and elucidates practical limitations and challenges regarding specific telemedicine modalities.

Adult cardiovascular surgery and the coronavirus disease 2019 (COVID-19) pandemic: the Italian experience

The coronavirus disease 2019 (COVID-19) pandemic has profoundly affected all health care professionals. The outbreak required a thorough reorganization of the Italian regional local health care system to preserve resources such as ventilators, beds in intensive care units and surgical and anaesthesiological staff. Levels of priority were created, together with a rigorous triage procedure for patients with COVID-19, which led to postponement of all elective procedures. Urgent cases were discussed with the local heart team and percutaneous approaches were selected as the first treatment option to reduce hospital stay. COVID-19 and COVID-19-free pathways were created, including adequate preparation of the operating room, management of anaesthesiological procedures, transportation of patients and disinfection. It was determined that patients with chronic diseases were at increased risk of adverse outcomes. Systemic inflammation, cytokine storm and hypercoagulability associated with COVID-19 increased the risk of heart failure and cardiac death. In this regard, the early use of extracorporeal membrane oxygenation could be life-saving in patients with severe forms of acute respiratory distress syndrome or refractory heart failure. The goal of this paper was to report the Italian experience during the COVID-19 pandemic in the setting of cardiovascular surgery.

In-hospital care in acute heart failure during the COVID-19 pandemic: insights from the German-wide Helios hospital network

AIMS

The coronavirus disease 2019 (COVID-19) pandemic has led to changes in health care utilization for different acute cardiovascular diseases. Whether hospitalization rates and in-hospital mortality were affected by the pandemic in patients with acute symptomatic heart failure (HF) was investigated in this study.

METHODS AND RESULTS

Administrative data provided by 67 German Helios hospitals were examined for patients with a main discharge diagnosis of HF using ICD codes. Urgent hospital admissions per day were compared for a study period (13 March-21 May 2020) with control intervals in 2020 (1 January-12 March) and 2019 (13 March-21 May), resulting in a total of 13 484 patients excluding all patients with laboratory-proven COVID-19 infection. Incidence rate ratios (IRR) were calculated using Poisson regression. Generalized linear mixed models were used for univariable and multivariable analysis to identify predictors of in-hospital mortality. The number of admissions per day was lower in the study period compared to the same year [IRR 0.69, 95% confidence interval (CI) 0.67-0.73, P < 0.01] and the previous year control group (IRR 0.73, 95% CI 0.70-0.76, P < 0.01). Age was similar throughout the intervals, but case severity increased in terms of distribution within New York Heart Association (NYHA) classes and comorbidities. Within the study period, 30-day rates for urgent hospital readmissions were higher compared to the same year but not the previous year control group. In-hospital mortality was 7.3% in the study period, 6.1% in the same year (P = 0.03) and 6.0% in the previous year control group (P = 0.02). In multivariable analysis, age, NYHA class and other predictors of fatal outcome were identified but hospitalization during the study period was not independently associated with mortality.

CONCLUSION

Our data showed a significant reduction of urgent hospital admissions for HF with increased case severity and concomitant in-hospital mortality during the COVID-19 pandemic in Germany. Identifying causes of reduced inpatient treatment rates is essential for the understanding and valuation with regard to future optimal management of patients with HF.

Temporal trends in decompensated heart failure and outcomes during COVID-19: a multisite report from heart failure referral centres in London

AIMS

Admission rates for acute decompensated heart failure (HF) declined during the COVID-19 pandemic. However, the impact of this reduction on hospital mortality is unknown. We describe temporal trends in the presentation of patients with acute HF and their in-hospital outcomes at two referral centres in London during the COVID-19 pandemic.

METHODS AND RESULTS

A total of 1372 patients hospitalized for HF in two referral centres in South London between 7 January and 14 June 2020 were included in the study and their outcomes compared with those of equivalent patients of the same time period in 2019. The primary outcome was all-cause in-hospital mortality. The number of HF hospitalizations was significantly reduced during the COVID-19 pandemic, compared with 2019 (P < 0.001). Specifically, we observed a temporary reduction in hospitalizations during the COVID-19 peak, followed by a return to 2019 levels. Patients admitted during the COVID-19 pandemic had demographic characteristics similar to those admitted during the equivalent period in 2019. However, in-hospital mortality was significantly higher in 2020 than in 2019 (P = 0.015). Hospitalization in 2020 was independently associated with worse in-hospital mortality (hazard ratio 2.23, 95% confidence interval 1.34-3.72; P = 0.002).

CONCLUSIONS

During the COVID-19 pandemic there was a reduction in HF hospitalization and a higher rate of in-hospital mortality. Hospitalization for HF in 2020 is independently associated with more adverse outcomes. Further studies are required to investigate the predictors of these adverse outcomes to help inform potential changes to the management of HF patients while some constraints to usual care remain.

Pattern of emergency department referral during the Covid-19 outbreak in Italy

BACKGROUND

The coronavirus disease (COVID-19) outbreak is putting the European National Health Systems under pressure. Interestingly, Emergency Department (ED) referrals for reasons other than Covid-19 seem to have declined steeply. In the present paper, we aimed to verify how the Covid-19 outbreak changed ED referral pattern.

METHODS

We retrospectively reviewed the clinical records of patients referred to the ED of a University Hospital in Northern Italy from 1st March to 13th April 2020. We compared the following data with those belonging to the same period in 2019: number of EDs accesses, rate of hospital admission, frequencies of the most common causes of ED referral, priority codes of access.

RESULTS

The number of ED referrals during the Covid-19 outbreak was markedly reduced when compared to the same period in 2019 (3059 vs. 5691;-46.3%). Conversely, the rate of hospital admission raised from 16.9% to 35.4% (p<0.0001), with a shift toward higher priority codes of ED admission. In 2020, we observed both a reduction of the number of patients referred for both traumatic (513, 16.8% vs. 1544, 27.1%; χ2=118.7, p<0.0001) and non-traumatic (4147 vs. 2546) conditions. Among the latter, suspected Covid-19 accounted for 1101 (43.2%) accesses.

CONCLUSIONS

The Covid-19 pandemic completely changed the pattern of ED referral in Italy, with a marked reduction of the accesses to the hospitals. This could be related to a limited exposure to traumas and to a common fear of being infected during EDs in-stay. This may limit the misuse of EDs for non- urgent conditions, but may also delay proper referrals for urgent conditions.

Implementation and Usefulness of Telemedicine During the COVID-19 Pandemic: A Scoping Review

OBJECTIVES

Identify and summarize the available literature on the acceleration in the use of telemedicine in the midst of the COVID-19 pandemic, with an aim to provide justification and guidance for its implementation to overcome the limitations associated with the pandemic worldwide.

METHODS

We conducted a scoping review through different search strategies in MEDLINE and Google Scholar to identify the available literature reporting data on implementation and usefulness of various modalities of telemedicine during the current pandemic. We summarized the included studies according to field and mode of implementation in a narrative way.

RESULTS

We included 45 studies that fulfilled selection criteria. About 38% of the studies were conducted in the United States of America (USA), followed by 15.5% in India and 15.5% in China. Most studies (73%) were cross-sectional studies based on historical records. All publications were written in English with the exception of 1 studied published in Spanish. The majority of reports focused on use of telemedicine for outpatient care, followed by in-hospital care.

CONCLUSION

The COVID-19 pandemic has promoted the use of telemedicine, a tool that has transformed the provision of medical services. Several modes of implementation are useful to overcome difficulties for patient care during the pandemic. Its benefits are specific to different fields of medical practice. Such benefits, along with the guidance and reported experiences should invite health systems to work for an effective and comprehensive implementation of telemedicine in various fields.