Secondary Impact of the COVID-19 Pandemic on Patients With Heart Failure

Comparison of Short-Term Health Care Utilization Between Telemedicine-Delivered vs In-Person Care Visits for Heart Failure

Background

Patients with heart failure (HF) are a medically complex population with frequent hospitalizations. Downstream health care utilization following primary care delivered by telemedicine compared to in-person is unknown.

Objectives

The purpose of this study was to understand differences in return in-person visits, emergency department (ED) encounters, and hospitalizations following a telemedicine vs an in-person primary care visit for patients with HF seen for a HF-related complaint.

Methods

This was an observational study of all primary care visits for HF from January 1, 2022, to December 31, 2022, in an integrated health care delivery system. We compared 7-day in-person follow-up visits, ED visits, and hospitalizations (all-cause and HF-specific) by index visit type.

Results

We included 3,902 primary care visits with a primary diagnosis of HF. Most visits utilized telephone or video visits (58.4% total; 44.9% telephone, 13.5% video). After adjustment, telephone visits were associated with more in-person follow-up visits (6.14% vs 4.20%; adjusted OR: 1.08-2.21; P < 0.05) but fewer ED visits (6.12% vs 8.07%; adjusted OR: 0.55-0.97; P < 0.05) compared to in-person visits. Most hospitalized patients (74%) had an admitting diagnosis of HF. There was no difference between 7-day all-cause hospitalization following telephone or video visits compared to in-person visits.

Conclusions

Most patients used telemedicine to address HF-specific primary care concerns. Telephone visits were associated with slightly higher short-term in-person primary care follow-up but lower ED utilization. Overall, downstream ED visits and hospitalizations were low. Telephone and video visits appear to offer safe alternatives to in-person care for HF-related primary care and are a promising health care delivery strategy.

Assessing a Virtual Education Intervention for Patients With Atrial Fibrillation: A Qualitative Study of Patient Perceptions

BACKGROUND

Authors of studies of patients with atrial fibrillation (AF) have identified several knowledge gaps and misconceptions regarding the condition and its management. The COVID-19 pandemic heightened isolation of patients and underscored the need for education and knowledge building in order for patients to effectively manage AF during times of increased health risk.

OBJECTIVE

The aim of this study was to assess, using a qualitative approach, the experiences and perceived benefits of patients with AF regarding an 8-session virtual education intervention (AF-at-Home) during the early months of the COVID-19 pandemic.

METHODS

A qualitative study with 3 focus groups using a semistructured focus group guide was conducted and recorded online with the same trained moderator.

RESULTS

We identified 7 primary themes emerging from patients' experiences: (1) building knowledge beyond information available in clinic visits, (2) managing anxiety, (3) generating self-efficacy, (4) providing social comparison, (5) perceived benefits of both experiential and informational content, (6) facilitating self-management behaviors, and (7) facilitating communication with providers.

CONCLUSIONS

The analysis of the focus groups shows the benefits of a virtual education program in building knowledge, skills, and self-efficacy as well as reducing anxiety and normalizing one's experience by attending a program alongside other patients with AF.

Health Care Utilization and Death in Patients With Heart Failure During the COVID-19 Pandemic

Objective

To compare the 1-year health care utilization and mortality in persons living with heart failure (HF) before and during the coronavirus disease 2019 (COVID-19) pandemic.

Patients and Methods

Residents of a 9-county area in southeastern Minnesota aged 18 years or older with a HF diagnosis on January 1, 2019; January 1, 2020; and January 1, 2021, were identified and followed up for 1-year for vital status, emergency department (ED) visits, and hospitalizations.

Results

We identified 5631 patients with HF (mean age, 76 years; 53% men) on January 1, 2019, 5996 patients (mean age, 76 years; 52% men) on January 1, 2020, and 6162 patients (mean age, 75 years; 54% men) on January 1, 2021. After adjustment for comorbidities and risk factors, patients with HF in 2020 and patients with HF in 2021 experienced similar risks of mortality compared with those in 2019. After adjustment, patients with HF in 2020 and 2021 were less likely to experience all-cause hospitalizations (2020: rate ratio [RR], 0.88; 95% CI, 0.81-0.95; 2021: RR, 0.90; 95% CI, 0.83-0.97) compared with patients in 2019. Patients with HF in 2020 were also less likely to experience ED visits (RR, 0.85; 95% CI, 0.80-0.92).

Conclusion

In this large population-based study in southeastern Minnesota, we observed an approximately 10% decrease in hospitalizations among patients with HF in 2020 and 2021 and a 15% decrease in ED visits in 2020 compared with those in 2019. Despite the change in health care utilization, we found no difference in the 1-year mortality between patients with HF in 2020 and those in 2021 compared with those in 2019. It is unknown whether any longer-term consequences will be observed.

Virtual Cardiology: Past, Present, Future Directions, and Considerations

Purpose of Review

Through this review, we attempt to explore the role of telemedicine and virtual visits in the field of cardiology pre-COVID-19 and during COVID-19 pandemic, their limitations and their future scope for delivery of care.

Recent Findings

Telemedicine, which rose to prominence during COVID-19 pandemic, helped not only in reducing the burden on the healthcare system during a time of crisis but also in improving patient outcomes. Patients and physicians also favored virtual visits when feasible. Virtual visits were found to have the potential to be continued beyond the pandemic and play a significant role in patient care alongside conventional face-to-face visits.

Summary

Although tele-cardiology has proven beneficial in terms of patient care, convenience, and access, it comes with its fair share of limitations-both logistical and medical. Whilst there remains a great scope for improvement in the quality of patient care provided through telemedicine, it has shown the potential to become an integral part of medical practice in the future.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12170-023-00719-0.

The Evolving Phenotypes of Cardiovascular Disease during COVID-19 Pandemic

COVID-19 pandemic has negatively impacted the management of patients with acute and chronic cardiovascular disease: acute coronary syndrome patients were often not timely reperfused, heart failure patients not adequately followed up and titrated, atrial arrhythmias not efficaciously treated and became chronic. New phenotypes of cardiovascular patients were more and more frequent during COVID-19 pandemic and are expected to be even more frequent in the next future in the new world shaped by the pandemic. We therefore aimed to briefly summarize the main changes in the phenotype of cardiovascular patients in the COVID-19 era, focusing on new clinical challenges and possible therapeutic options.

Impact of lockdown on cardiovascular disease hospitalizations in a Zero-COVID-19 country

OBJECTIVES

There are concerns about the potential effect of social distancing used to control COVID-19 on the incidence of cardiovascular diseases (CVD).

STUDY DESIGN

Retrospective cohort study.

METHODS

We examined the association between lockdown and CVD incidence in a Zero-COVID country, New Caledonia. Inclusion criteria were defined by a positive troponin sample during hospitalization. The study period lasted for 2 months, starting March 20, 2020 (strict lockdown: first month; loose lockdown: second month) compared with the same period of the three previous years to calculate incidence ratio (IR). Demographic characteristics and main CVD diagnoses were collected. The primary endpoint was the change in incidence of hospital admission with CVD during lockdown compared with the historical counterpart. The secondary endpoint included influence of strict lockdown, change in incidence of the primary endpoint by disease, and outcome incidences (intubation or death) analyzed with inverse probability weighting method.

RESULTS

A total of 1215 patients were included: 264 in 2020 vs 317 (average of the historical period). CVD hospitalizations were reduced during strict lockdown (IR 0.71 [0.58-0.88]), but not during loose lockdown (IR 0.94 [0.78-1.12]). The incidence of acute coronary syndromes was similar in both periods. The incidence of acute decompensated heart failure was reduced during strict lockdown (IR 0.42 [0.24-0.73]), followed by a rebound (IR 1.42 [1-1.98]). There was no association between lockdown and short-term outcomes.

CONCLUSIONS

Our study showed that lockdown was associated with a striking reduction in CVD hospitalizations, independently from viral spread, and a rebound of acute decompensated heart failure hospitalizations during looser lockdown.

The Impact of COVID-19 on Family Caregivers of Individuals With End-Stage Heart Failure

Before the COVID-19 pandemic, family caregivers were providing a tremendous amount of care for family members with heart failure with the prevalence of caregiver reliance in heart failure expected to increase in the United States. Social distancing and other restrictions during the COVID-19 pandemic may have added further challenges to caregiving routines. The purpose of this study was to examine the family caregiver perception of the effect of COVID-19 on caregiving routines. To determine caregiver perception of COVID-19's impact, 1 Likert question and 1 open-ended response were asked. Braun and Clark's method guided open-ended response thematic analysis. The 113 replies to the open-response question yielded themes such as social isolation, added fear, anxiety, or worry, changed appointments, wearing masks, and living status change. Social isolation (41.6%) was the most common theme; the most significant theme was living status change ( P = .003), and family caregivers reported that the pandemic affected their routines either negatively or somewhat negatively (62.1%). Family caregivers are affected during times of crisis. Research and policies that recognize the residual effects of COVID-19 on caregiving practices and support care transitions for family caregivers in the heart failure population are needed.

LEAP Virtual Visit Assessment (VIVA): a structured protocol for virtual visits for patients with heart failure

AIMS

Telemedicine may be of benefit in patients with heart failure (HF), although virtual visits are often carried out on an ad hoc basis. Herein, we discuss a structured protocol that defines all the steps needed for virtual visits, LEAP Virtual Visit, which includes guides and support kits for clinicians and patients.

METHODS

A working group of clinicians was established to develop a protocol for virtual visits. The virtual model for monitoring HF patients was based on measurement and sizing of patient flows, type of services, and critical organizational points. The process of virtual visits was broken down to identify the specific activities, players, roles, and support tools needed for implementation in daily practice.

RESULTS

In the protocol developed, sections were included on patient eligibility, exams, supportive tools, and practical organizational aspects. IT requirements were also considered and the most widely used teleconference platforms were compared according to features that were considered to be priority for virtual visits. Protocols and support kits were developed, including guides for clinicians and patients, two questionnaires to assess the level of satisfaction, patient diary, disease awareness brochure, and template to monitor key performance indicators. The phases include an enrolment phase, document sharing phase, pre-evaluation phase, the virtual visit itself, and the post-visit phase. The protocol for the virtual visit was divided into 8 sequential steps to be carried out between the clinic and patient/caregiver.

CONCLUSION

The protocol described can be expected to have a number of benefits for the patient, clinic, and healthcare structure.

The Potential of Cardiac Telerehabilitation as Delivery Rehabilitation Care Model in Heart Failure during COVID-19 and Transmissible Disease Outbreak: A Systematic Scoping Review of the Latest RCTs

Background and objective: Patients with heart failure are a high-risk group who may have a higher mortality rate if infected during the COVID-19 pandemic. The problem of a patient’s non-adherence to cardiac rehabilitation programs is still a challenge, resulting in disappointing long-term benefits of cardiac rehabilitation. Telehealth, including telerehabilitation, has grown in popularity to improve access to quality healthcare. It is more valuable and safer compared to usual rehabilitation care, especially during the current COVID-19 pandemic, to cut down unnecessary hospital visits and reduce the risk of cluster infections. This study aims to identify the efficacy of relevant randomized control trials (RCTs) using telerehabilitation in managing heart failure. The model, delivery care, safety, and efficacy were assessed. Material andMethods: This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis for Scoping Reviews (PRISMA-ScR). The authors included relevant records published in the last ten years from three databases: PubMed/MEDLINE, ProQuest, and EBSCO. Each included study was further assessed using Cochrane’s Risk of Bias (Rob 2) tool. Results: The telerehabilitation models consisted of cellphones, instant messaging, or online videoconferencing software. Some also included tool sets to monitor patients’ vital signs regularly or during exercise. Most patients adhered to and completed all provided programs. Cardiac telerehabilitation successfully improved patients’ physical fitness, quality of life, and mental health. No major adverse outcomes or significant complications were associated with the program. Conclusion: Cardiac telerehabilitation has the potential to deliver rehabilitation for heart failure patients, evidenced by its feasibility, efficacy, and safety. As a future perspective, this delivery care type can be applied throughout transmissible disease outbreaks or even globally.

Heart failure during the COVID-19 pandemic: clinical, diagnostic, management, and organizational dilemmas

The coronavirus 2019 (COVID-19) infection pandemic has affected the care of patients with heart failure (HF). Several consensus documents describe the appropriate diagnostic algorithm and treatment approach for patients with HF and associated COVID-19 infection. However, few questions about the mechanisms by which COVID can exacerbate HF in patients with high-risk (Stage B) or symptomatic HF (Stage C) remain unanswered. Therefore, the type of HF occurring during infection is poorly investigated. The diagnostic differentiation and management should be focused on the identification of the HF phenotype, underlying causes, and subsequent tailored therapy. In this framework, the relationship existing between COVID and onset of acute decompensated HF, isolated right HF, and cardiogenic shock is questioned, and the specific management is mainly based on local hospital organization rather than a standardized model. Similarly, some specific populations such as advanced HF, heart transplant, patients with left ventricular assist device (LVAD), or valve disease remain under investigated. In this systematic review, we examine recent advances regarding the relationships between HF and COVID-19 pandemic with respect to epidemiology, pathogenetic mechanisms, and differential diagnosis. Also, according to the recent HF guidelines definition, we highlight different clinical profile identification, pointing out the main concerns in understudied HF populations.

Gelatin Stabilizes Nebulized Proteins in Pulmonary Drug Delivery against COVID-19

Delivering medication to the lungs via nebulization of pharmaceuticals is a noninvasive and efficient therapy route, particularly for respiratory diseases. The recent worldwide severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) pandemic urges the development of such therapies as an effective alternative to vaccines. The main difficulties in using inhalation therapy are the development of effective medicine and methods to stabilize the biological molecules and transfer them to the lungs efficiently following nebulization. We have developed a high-affinity angiotensin-converting enzyme 2 (ACE2) receptor-binding domain (RBD-62) that can be used as a medication to inhibit infection with SARS-CoV-2 and its variants. In this study, we established a nebulization protocol for drug delivery by inhalation using two commercial vibrating mesh (VM) nebulizers (Aerogen Solo and PARI eFlow) that generate similar mist size distribution in a size range that allows efficient deposition in the small respiratory airway. In a series of experiments, we show the high activity of RBD-62, interferon-α2 (IFN-α2), and other proteins following nebulization. The addition of gelatin significantly stabilizes the proteins and enhances the fractions of active proteins after nebulization, minimizing the medication dosage. Furthermore, hamster inhalation experiments verified the feasibility of the protocol in pulmonary drug delivery. In short, the gelatin-modified RBD-62 formulation in coordination with VM nebulizer can be used as a therapy to cure SARS-CoV-2.

New strategies and therapies for the prevention of heart failure in high-risk patients

Despite declines in total cardiovascular mortality rates in the United States, heart failure (HF) mortality rates as well as hospitalizations and readmissions have increased in the past decade. Increases have been relatively higher among young and middle-aged adults (<65 years). Therefore, identification of individuals HF at-risk (Stage A) or with pre-HF (Stage B) before the onset of overt clinical signs and symptoms (Stage C) is urgently needed. Multivariate risk models (e.g., Pooled Cohort Equations to Prevent Heart Failure [PCP-HF]) have been externally validated in diverse populations and endorsed by the 2022 HF Guidelines to apply a risk-based framework for the prevention of HF. However, traditional risk factors included in the PCP-HF model only account for half of an individual's lifetime risk of HF; novel risk factors (e.g., adverse pregnancy outcomes, impaired lung health, COVID-19) are emerging as important risk-enhancing factors that need to be accounted for in personalized approaches to prevention. In addition to determining the role of novel risk-enhancing factors, integration of social determinants of health (SDoH) in identifying and addressing HF risk is needed to transform the current clinical paradigm for the prevention of HF. Comprehensive strategies to prevent the progression of HF must incorporate pharmacotherapies (e.g., sodium glucose co-transporter-2 inhibitors that have also been termed the "statins" of HF prevention), intensive blood pressure lowering, and heart-healthy behaviors. Future directions include investigation of novel prediction models leveraging machine learning, integration of risk-enhancing factors and SDoH, and equitable approaches to interventions for risk-based prevention of HF.

Clinical Support through Telemedicine in Heart Failure Outpatients during the COVID-19 Pandemic Period: Results of a 12-Months Follow Up

Background: Heart failure (HF) patients are predisposed to recurrences and disease destabilizations, especially during the COVID-19 outbreak period. In this scenario, telemedicine could be a proper way to ensure continuous care. The purpose of the study was to compare two modalities of HF outpatients’ follow up, the traditional in-person visits and telephone consultations, during the COVID-19 pandemic period in Italy. Methods: We conducted an observational study on consecutive HF outpatients. The follow up period was 12 months, starting from the beginning of the COVID-19 Italy lockdown. According to the follow up modality, and after the propensity matching score, patients were divided into two groups: those in G1 (n = 92) were managed with traditional in-person visits and those in G2 (n = 92) were managed with telephone consultation. Major adverse cardiovascular events (MACE) were the primary endpoints. Secondary endpoints were overall mortality, cardiovascular death, cardiovascular hospitalization, and hospitalization due to HF. Results: No significant differences between G1 and G2 have been observed regarding MACE (p = 0.65), cardiovascular death (p = 0.39), overall mortality (p = 0.85), hospitalization due to acute HF (p = 0.07), and cardiovascular hospitalization (p = 0.4). Survival analysis performed by the Kaplan–Meier method also did not show significant differences between G1 and G2. Conclusions: Telephone consultations represented a valid option to manage HF outpatients during COVID-19 pandemic, comparable to traditional in-person visits.

Remote invasive monitoring of pulmonary artery pressures in heart failure patients: Initial experience in Portugal in the context of the Covid-19 pandemic

Background

Decompensated heart failure (HF) is associated with poor short- and long-term prognosis. Remote invasive monitoring of pulmonary artery pressures (PAP) enables early detection of HF decompensation before symptoms occur and may improve clinical outcomes. We aimed to describe our initial experience with the use of the CardioMEMS™ remote monitoring system in patients with HF, including its safety and effectiveness.

Methods and results

Five patients with HF in New York Heart Association class III and at least one hospitalization due to decompensated HF in last 12 months, who underwent invasive remote monitoring of PAP, were included in this prospective registry. The median age was 66.0 years (interquartile range [IQR] 50.5-77.5 years), 80.0% were men and all had HF with reduced ejection fraction. The pulmonary artery (PA) sensor was placed in a left PA branch in all patients and no major procedural complications occurred. In median follow-up of 40 days (IQR 40-61 days), a total of 271 pressure readings were transmitted, patient compliance was 100% and freedom from sensor failure 98.1%. In three patients, PAP remained within the goal during follow-up. Two patients presented an increase in PAP to values above the targets, despite the absence of symptom worsening. These required dietary and diuretic dose adjustment, without the need for outpatient clinic visits, which reduced PAP. No hospitalizations for HF or deaths occurred during follow-up.

Conclusion

Hemodynamic-guided HF monitoring was safe and effective and may be a useful adjunctive tool to the standard-of-care management in selected HF patients, particularly in the context of the COVID-19 pandemic, where a reduction in the number of health care visits may be desirable.

Dynamics of Emergency Cardiovascular Hospital Admissions and In-Hospital Mortality During the COVID-19 Pandemic: Time Series Analysis and Impact of Socioeconomic Factors

Aims

This study aimed to evaluate the decline in urgent cardiovascular hospital admissions and in-hospital mortality during the COVID pandemic in two successive waves, and to evaluate differences by sex, age, and deprivation index subgroups.

Methods and Results

We obtained acute cardiovascular hospital episodes during the years 2019–2020 from region-wide data on public healthcare usage for the population of Catalonia (North-East Spain). We fitted time models to estimate the incidence rate ratios (IRRs) of the acute coronary syndrome (ACS) and acute heart failure (HF) admissions during the first pandemic wave, the between-waves period, and the second wave compared with the corresponding pre-COVID-19 periods and to test for the interaction with sex, age, and area-based socioeconomic level. We evaluated the effect of COVID-19 period on in-hospital mortality. ACS (n = 8,636) and HF (n = 27,566) episodes were defined using primary diagnostic ICD-10 codes. ACS and HF admissions decreased during the first wave (IRR = 0.66, 95%CI: 0.58–0.76 and IRR = 0.61, 95% CI: 0.55–0.68, respectively) and during the second wave (IRR = 0.80, 95%CI: 0.72–0.88 and IRR = 0.76, 95%CI: 0.69–0.84, respectively); acute HF admissions also decreased in the period between waves (IRR: 0.81, 95%CI: 0.74–0.89). The impact was similar in all sex and socioeconomic subgroups and was higher in older patients with ACS. In-hospital mortality was higher than expected only during the first wave.

Conclusion

During the first wave of the COVID-19 pandemic, there was a marked decline in urgent cardiovascular hospital admissions that were attenuated during the second wave. Both the decline and the attenuation of the effect have been similar in all subgroups regardless of age, sex, or socioeconomic status. In-hospital mortality for ACS and HF episodes increased during the first wave, but not during the second wave.

The Association of COVID-19 on Organizational Attitudes in Primary Care Among Interprofessional Practice Clinics

This article describes the association of COVID-19 on organizational attributes in primary care among 2 academic-practice partnership interprofessional collaborative practice (IPCP) clinics. Our team used a concurrent, triangulation repeated-measures study design to examine responses to the Survey of Organizational Attitudes of Primary Care (SOAP-C) instrument between January and December 2020. Analysis revealed statistically nonsignificant change over 12 months across all 4 subscales. Study results suggest that IPCP teams can function effectively through adversity. The IPCP model seemed to bolster resilience making it a viable model for ambulatory practices caring for vulnerable populations.

The Potential Impact of COVID-19 Virus on the Heart and the Circulatory System

Heart attacks, arrhythmias, and cardiomyopathy are all linked to the 2019 coronavirus disease (COVID-19), which has been identified as a risk factor for cardiovascular disease. Nothing can be held accountable in the current state of affairs. Undiagnosed chronic systolic heart failure (CSHF) develops when the heart’s second half of the cardiac cycle does not function properly. As a result, the heart’s blood pumping function is interrupted. Stress-induced cardiomyopathy may be caused by a variety of factors inside the body (SICM). Cytokine storm and microvascular dysfunction are among the issues. There is inflammation in the heart muscle, which may lead to stress-induced cardiomyopathy. A major part of our study is going to be devoted to understanding the effects of coronavirus on the cardiovascular system and blood vessels. A lot of time and effort has been put into figuring out the health effects of radiation exposure. The heart and circulatory system are shown to be affected by the coronavirus in this research. COVID-19 is shown to influence persons with heart disease, heart failure, arrhythmias, microvascular angiopathy, and cardiac damage in this study.

Passive longitudinal weight and cardiopulmonary monitoring in the home bed

Home health monitoring has the potential to improve outpatient management of chronic cardiopulmonary diseases such as heart failure. However, it is often limited by the need for adherence to self-measurement, charging and self-application of wearables, or usage of apps. Here, we describe a non-contact, adherence-independent sensor, that when placed beneath the legs of a patient's home bed, longitudinally monitors total body weight, detailed respiratory signals, and ballistocardiograms for months, without requiring any active patient participation. Accompanying algorithms separate weight and respiratory signals when the bed is shared by a partner or a pet. Validation studies demonstrate quantitative equivalence to commercial sensors during overnight sleep studies. The feasibility of detecting obstructive and central apneas, cardiopulmonary coupling, and the hemodynamic consequences of non-sustained ventricular tachycardia is also established. Real-world durability is demonstrated by 3 months of in-home monitoring in an example patient with heart failure and ischemic cardiomyopathy as he recovers from coronary artery bypass grafting surgery. BedScales is the first sensor to measure adherence-independent total body weight as well as longitudinal cardiopulmonary physiology. As such, it has the potential to create a multidimensional picture of chronic disease, learn signatures of impending hospitalization, and enable optimization of care in the home.

Effects of the COVID-19 pandemic on heart failure hospitalizations in Japan: interrupted time series analysis

Aims

The Coronavirus Disease 2019 (COVID‐19) pandemic has had unprecedented effects on health care utilization for acute cardiovascular diseases. Although hospitalizations for acute coronary syndrome decreased during the COVID‐19 pandemic, there is a paucity of data on the trends and management of heart failure (HF) cases. Furthermore, concerns have been raised that angiotensin‐converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) may increase susceptibility to COVID‐19. This study aimed to elucidate changes in HF hospitalizations from the COVID‐19 state of emergency in Japan and investigated changes in the prescription of ACEIs and ARBs, and in‐hospital mortality.

Methods and results

We performed an interrupted time series analysis of HF hospitalizations in Japan to verify the impacts of the COVID‐19 state of emergency. Changes in the weekly volume of HF hospitalizations were taken as the primary outcome measure. Between 1 April 2018 and 4 July 2020, 109 429 HF cases required admission. After the state of emergency, an immediate decrease was observed in HF cases per week [−3.6%; 95% confidence interval (CI): −0.3% to −6.7%, P = 0.03]. There was no significant change in the prescription of ACEIs or ARBs after the state of emergency (4.2%; 95% CI: −0.3% to 8.9%, P = 0.07). The COVID‐19 pandemic had no effect on in‐hospital mortality among HF patients (5.3%; 95% CI: −4.9% to 16.6%, P = 0.32).

Conclusions

We demonstrated a decline in HF hospitalizations during the COVID‐19 pandemic in Japan, with no clear evidence of a negative effect on the prescription of ACEIs and ARBs or in‐hospital mortality.

Impact of COVID-19 on Heart Failure Self-Care: A Qualitative Study

BACKGROUND

Difficulties in coping with and self-managing heart failure (HF) are well known. The COVID-19 pandemic may further complicate self-care practices associated with HF.

OBJECTIVE

The aim of this study was to understand COVID-19's impact on HF self-care, as well as related coping adaptations that may blunt the impact of COVID-19 on HF health outcomes.

METHODS

A qualitative study using phone interviews, guided by the framework of vulnerability analysis for sustainability, was used to explore HF self-care among older adults in central Texas during the late spring of 2020. Qualitative data were analyzed using directed content analysis.

RESULTS

Seventeen older adults with HF participated (mean [SD] age, 68 [9.1] years; 62% female, 68% White, 40% below poverty line, 35% from rural areas). Overall, the COVID-19 pandemic had an adverse impact on the HF self-care behavior of physical activity. Themes of social isolation, financial concerns, and disruptions in access to medications and food indicated exposure, and rural residence and source of income increased sensitivity, whereas adaptations by healthcare system, health-promoting activities, socializing via technology, and spiritual connections increased resilience to the COVID-19 pandemic.

CONCLUSIONS

The study's findings have implications for identifying vulnerabilities in sustaining HF self-care by older adults and empowering older adults with coping strategies to improve overall satisfaction with care and quality of life.

COVID-19 pandemic and its impact on service provision: A cardiology prospect

Coronavirus disease 2019 (COVID-19) pandemic has significantly impacted the availability of cardiology services and management of cardiac conditions. Elective surgeries, outpatient appointments and cardiac imaging have been largely cancelled across the world due to the risk of infection transmission and the need for reallocation of resources to deal with the increasing number of COVID-19 patients. The impact on patients with cardiac co-morbidities during these times may be drastic. However, cardiologists and hospitals across the world have implemented measures to ensure on-going monitoring and care of patients remotely. In this review, we discuss the impact of COVID-19 on cardiac services including interventional cardiology services, cardiac imaging and outpatient appointments. In addition, implications for future research and clinical practice are also discussed.

Covid-19 and development of heart failure: mystery and truth

Coronavirus disease 2019 (Covid-19) is a novel worldwide pandemic caused by a novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). During Covid-19 pandemic, socioeconomic deprivation, social isolation, and reduced physical activities may induce heart failure (HF), destabilization, and cause more complications. HF appears as a potential hazard due to SARS-CoV-2 infection, chiefly in elderly patients with underlying comorbidities. In reality, the expression of cardiac ACE2 is implicated as a target point for SARS-CoV-2-induced acute cardiac injury. In SARS-CoV-2 infection, like other febrile illnesses, high blood viscosity, exaggerated pro-inflammatory response, multisystem inflammatory syndrome, and endothelial dysfunction-induced coagulation disorders may increase risk of HF development. Hypoxic respiratory failure, as in pulmonary edema, severe acute lung injury (ALI), and acute respiratory distress syndrome (ARDS) may affect heart hemodynamic stability due to the development of pulmonary hypertension. Indeed, Covid-19-induced HF could be through the development of cytokine storm, characterized by high proliferation pro-inflammatory cytokines. In cytokine storm-mediated cardiac dysfunction, there is a positive correlation between levels of pro-inflammatory cytokine and myocarditis-induced acute cardiac injury biomarkers. Therefore, Covid-19-induced HF is more complex and related from a molecular background in releasing pro-inflammatory cytokines to the neuro-metabolic derangements that together affect cardiomyocyte functions and development of HF. Anti-heart failure medications, mainly digoxin and carvedilol, have potent anti-SARS-CoV-2 and anti-inflammatory properties that may mitigate Covid-19 severity and development of HF. In conclusion, SARS-CoV-2 infection may lead to the development of HF due to direct acute cardiac injury or through the development of cytokine storms, which depress cardiomyocyte function and cardiac contractility. Anti-heart failure drugs, mainly digoxin and carvedilol, may attenuate severity of HF by reducing the infectivity of SARS-CoV-2 and prevent the development of cytokine storms in severely affected Covid-19 patients.

Remote monitoring of patients with heart failure during the first national lockdown for COVID-19 in France

Background

Multiparametric remote monitoring of patients with heart failure (HF) has the potential to mitigate the health risks of lockdowns for COVID-19.

Aims

To compare health care use, physiological variables, and HF decompensations during one month before and during the first month of the first French national lockdown for COVID-19 among patients undergoing remote monitoring.

Methods

Transmitted vital parameters and data from cardiac implantable electronic devices were analyzed in 51 patients. Medical contact was defined as the sum of visits and days of hospitalization.

Results

The lockdown was associated with a marked decrease in cardiology medical contact (118 days before vs 26 days during, -77%, p = 0.003) and overall medical contact (180 days before vs 79 days during, -58%, p = 0.005). Patient adherence with remote monitoring was 84±21% before and 87±19% during lockdown. The lockdown was not associated with significant changes in various parameters, including physical activity (2±1 to 2±1 h/day), weight (83±16 to 83±16 kg), systolic blood pressure (121±19 to 121±18 mmHg), heart rate (68±10 to 67±10 bpm), heart rate variability (89±44 to 78±46 ms, p = 0.05), atrial fibrillation burden (84±146 vs 86±146 h/month), or thoracic impedance (66±8 to 66±9 Ω). Seven cases of HF decompensations were observed before lockdown, all but one of which required hospitalization, versus six during lockdown, all but one of which were managed remotely.

Conclusions

The lockdown restrictions caused a marked decrease in health care use but no significant change in the clinical status of HF patients under multiparametric remote monitoring.

lay summary

The first French COVID-19 lockdown had a huge detrimental impact on conventional health care use (-78% in cardiology medical contact). However the lockdown had little impact over the short-term, if any, on vital parameters and the clinical status of patients with heart failure who were adherent to multiparametric remote monitoring. This remote monitoring strategy allowed early identification and home management of most of the heart failure decompensations during the lockdown.

Ambulatory monitoring promises equitable personalized healthcare delivery in underrepresented patients

The pandemic has brought to everybody's attention the apparent need of remote monitoring, highlighting hitherto unseen challenges in healthcare. Today, mobile monitoring and real-time data collection, processing and decision-making, can drastically improve the cardiorespiratory-haemodynamic health diagnosis and care, not only in the rural communities, but urban ones with limited healthcare access as well. Disparities in socioeconomic status and geographic variances resulting in regional inequity in access to healthcare delivery, and significant differences in mortality rates between rural and urban communities have been a growing concern. Evolution of wireless devices and smartphones has initiated a new era in medicine. Mobile health technologies have a promising role in equitable delivery of personalized medicine and are becoming essential components in the delivery of healthcare to patients with limited access to in-hospital services. Yet, the utility of portable health monitoring devices has been suboptimal due to the lack of user-friendly and computationally efficient physiological data collection and analysis platforms. We present a comprehensive review of the current cardiac, pulmonary, and haemodynamic telemonitoring technologies. We also propose a novel low-cost smartphone-based system capable of providing complete cardiorespiratory assessment using a single platform for arrhythmia prediction along with detection of underlying ischaemia and sleep apnoea; we believe this system holds significant potential in aiding the diagnosis and treatment of cardiorespiratory diseases, particularly in underserved populations.

Ambulatory Management of Worsening Heart Failure: Current Strategies and Future Directions

Heart failure (HF) is a highly prevalent and morbid disease in the USA. The chronic, progressive course of HF is defined by periodic exacerbations of symptoms, described as 'worsening heart failure' (WHF). Previously, episodes of WHF have required hospitalization for intravenous diuretics; however, recent innovations in care delivery models for patients with HF have allowed a transition from the acute care setting to the ambulatory setting. The development of remote monitoring strategies, including device-based algorithms and implantable haemodynamic monitoring systems, has facilitated more advanced surveillance of patients, aiming to prevent the clinical deterioration that leads to hospitalization. Additionally, the establishment of multidisciplinary HF clinics has provided the setting and resources for the outpatient treatment of WHF, specifically the administration of intravenous diuretics. Here we review the current state of ambulatory HF management, including mechanisms for patient monitoring and treatment, and outline future opportunities for outpatient management of this patient population.

Recent trends in cardiovascular disease deaths: a state specific perspective

BACKGROUND

The rate of decline in cardiovascular disease (CVD) mortality has lessened nationally. How these findings apply to specific states or causes of CVD deaths is not known. Examining these trends at the state level is important to plan local interventions.

METHODS

We analyzed CVD mortality trends in Minnesota (MN) using the U.S. Centers for Disease Control and Prevention (CDC) Wide-ranging ONline Data for Epidemiologic Research (WONDER). Trends were analyzed by age, sex, type of CVD and location of death.

RESULTS

CVD mortality rates in MN declined in 2000-2009 and then leveled off in 2010-2018, paralleling national rates. Age- and sex-adjusted CVD mortality decreased by 3.7% per year in 2000-2009 (average annual percent changes [AAPC]: -3.7; 95% CI: - 4.8, - 2.6) with no change observed in 2010-2018. Those aged 65-84 years had the most rapid early decline in CVD mortality (AAPC: -5.9, 95% CI: - 6.2, - 5.7) and had less improvement in 2010-2018 (AAPC: -1.8, 95% CI: - 2.2, - 1.5), and the younger age group (25-64 years) now experiences the most adverse trends (AAPC: 1.2, 95% CI: 0.7-1.8). Coronary heart disease (CHD) and cerebrovascular disease had the largest relative decreases in mortality in 2000-2009 (CHD AAPC: -5.2; 95% CI: - 6.5,-3.9; cerebrovascular disease AAPC: -4.4, 95% CI: - 5.2, - 3.6) with no change 2010-2018. Heart failure (HF)/cardiomyopathy followed similar trends with a 2.5% decrease (AAPC 95% CI: - 3.5, - 1.5) per year in 2000-2009 and no change in 2010-2018. Deaths from other CVD also decreased in the early time period (AAPC: -1.6, 95% CI: - 2.7, - 0.5) but increased in 2010-2018 (AAPC: 1.9, 95% CI: 0.5, 3.3). In- and out-of-hospital death rates improved in 2000-2009 with a slowing in improvement for in-hospital death and no further improvement for out-of-hospital death in 2010-2018.

CONCLUSION

Concerning CVD mortality trends occurred in MN. In the most recent decade (2010-2018) mortality from all CVD subtypes plateaued or even increased. CVD mortality among the younger age groups increased as well. These data are congruent with adverse national trends supporting their generalizability. These adverse trends underscore the urgent need for CVD prevention and treatment, as well as continued surveillance to assess progress at the state and national level.

Implantable Cardioverter-Defibrillator Shocks During COVID-19 Outbreak

Background

COVID‐19 was temporally associated with an increase in out‐of‐hospital cardiac arrests, but the underlying mechanisms are unclear. We sought to determine if patients with implantable defibrillators residing in areas with high COVID‐19 activity experienced an increase in defibrillator shocks during the COVID‐19 outbreak.

Methods and Results

Using the Medtronic (Mounds View, MN) Carelink database from 2019 and 2020, we retrospectively determined the incidence of implantable defibrillator shock episodes among patients residing in New York City, New Orleans, LA, and Boston, MA. A total of 14 665 patients with a Medtronic implantable defibrillator (age, 66±13 years; and 72% men) were included in the analysis. Comparing analysis time periods coinciding with the COVID‐19 outbreak in 2020 with the same periods in 2019, we observed a larger mean rate of defibrillator shock episodes per 1000 patients in New York City (17.8 versus 11.7, respectively), New Orleans (26.4 versus 13.5, respectively), and Boston (30.9 versus 20.6, respectively) during the COVID‐19 surge. Age‐ and sex‐adjusted hurdle model showed that the Poisson distribution rate of defibrillator shocks for patients with ≥1 shock was 3.11 times larger (95% CI, 1.08–8.99; P=0.036) in New York City, 3.74 times larger (95% CI, 0.88–15.89; P=0.074) in New Orleans, and 1.97 times larger (95% CI, 0.69–5.61; P=0.202) in Boston in 2020 versus 2019. However, the binomial odds of any given patient having a shock episode was not different in 2020 versus 2019.

Conclusions

Defibrillator shock episodes increased during the higher COVID‐19 activity in New York City, New Orleans, and Boston. These observations may provide insights into COVID‐19–related increase in cardiac arrests.

Characterizing Health Care Delays and Interruptions in the United States During the COVID-19 Pandemic: Internet-Based, Cross-sectional Survey Study

Background

The COVID-19 pandemic has broader geographic spread and potentially longer lasting effects than those of previous disasters. Necessary preventive precautions for the transmission of COVID-19 has resulted in delays for in-person health care services, especially at the outset of the pandemic.

Objective

Among a US sample, we examined the rates of delays (defined as cancellations and postponements) in health care at the outset of the pandemic and characterized the reasons for such delays.

Methods

As part of an internet-based survey that was distributed on social media in April 2020, we asked a US–based convenience sample of 2570 participants about delays in their health care resulting from the COVID-19 pandemic. Participant demographics and self-reported worries about general health and the COVID-19 pandemic were explored as potent determinants of health care delays. In addition to all delays, we focused on the following three main types of delays, which were the primary outcomes in this study: dental, preventive, and diagnostic care delays. For each outcome, we used bivariate statistical tests (t tests and chi-square tests) and multiple logistic regression models to determine which factors were associated with health care delays.

Results

The top reported barrier to receiving health care was the fear of SARS-CoV-2 infection (126/374, 33.6%). Almost half (1227/2570, 47.7%) of the participants reported experiencing health care delays. Among those who experienced health care delays and further clarified the type of delay they experienced (921/1227, 75.1%), the top three reported types of care that were affected by delays included dental (351/921, 38.1%), preventive (269/921, 29.2%), and diagnostic (151/921, 16.4%) care. The logistic regression models showed that age (P<.001), gender identity (P<.001), education (P=.007), and self-reported worry about general health (P<.001) were significantly associated with experiencing health care delays. Self-reported worry about general health was negatively related to experiencing delays in dental care. However, this predictor was positively associated with delays in diagnostic testing based on the logistic regression model. Additionally, age was positively associated with delays in diagnostic testing. No factors remained significant in the multiple logistic regression for delays in preventive care, and although there was trend between race and delays (people of color experienced fewer delays than White participants), it was not significant (P=.06).

Conclusions

The lessons learned from the initial surge of COVID-19 cases can inform systemic mitigation strategies for potential future disruptions. This study addresses the demand side of health care delays by exploring the determinants of such delays. More research on health care delays during the pandemic is needed, including research on their short- and long-term impacts on patient-level outcomes such as mortality, morbidity, mental health, people’s quality of life, and the experience of pain.

Cardiac Resynchronization Therapy Remote Monitoring - COVID-19 Pandemic Experiences and Future Perspectives

Cardiac resynchronization therapy (CRT) is a well-established form of the treatment for heart failure (HF) in patients with left ventricle contraction dyssynchrony. Apart from typical in-office management, remote monitoring enables constant surveillance on both the patient's and the device's condition. This way, in case of any problems, clinical decisions could be made earlier leading to better outcome of CRT patients. COVID-19 pandemic with following lockdowns in many countries resulted in getting more attention on remote monitoring systems. The aim of this paper was to gather and summarize worldwide experiences from CRT remote monitoring during COVID-19 pandemic and point out future possibilities for HF patients treated with CRT. Already published experiences from remote monitoring of CRT devices during COVID-19 restrictions confirmed previous advantages of telemedical approach, however, more publications in this area would be helpful.

Emergency Department Visits for Nonfatal Opioid Overdose During the COVID-19 Pandemic Across Six US Health Care Systems

Study objective

People with opioid use disorder are vulnerable to disruptions in access to addiction treatment and social support during the COVID-19 pandemic. Our study objective was to understand changes in emergency department (ED) utilization following a nonfatal opioid overdose during COVID-19 compared to historical controls in 6 healthcare systems across the United States.

Methods

Opioid overdoses were retrospectively identified among adult visits to 25 EDs in Alabama, Colorado, Connecticut, North Carolina, Massachusetts, and Rhode Island from January 2018 to December 2020. Overdose visit counts and rates per 100 all-cause ED visits during the COVID-19 pandemic were compared with the levels predicted based on 2018 and 2019 visits using graphical analysis and an epidemiologic outbreak detection cumulative sum algorithm.

Results

Overdose visit counts increased by 10.5% (n=3486; 95% confidence interval [CI] 4.18% to 17.0%) in 2020 compared with the counts in 2018 and 2019 (n=3020 and n=3285, respectively), despite a 14% decline in all-cause ED visits. Opioid overdose rates increased by 28.5% (95% CI 23.3% to 34.0%) from 0.25 per 100 ED visits in 2018 to 2019 to 0.32 per 100 ED visits in 2020. Although all 6 studied health care systems experienced overdose ED visit rates more than the 95th percentile prediction in 6 or more weeks of 2020 (compared with 2.6 weeks as expected by chance), 2 health care systems experienced sustained outbreaks during the COVID-19 pandemic.

Conclusion

Despite decreases in ED visits for other medical emergencies, the numbers and rates of opioid overdose-related ED visits in 6 health care systems increased during 2020, suggesting a widespread increase in opioid-related complications during the COVID-19 pandemic. Expanded community- and hospital-based interventions are needed to support people with opioid use disorder and save lives during the COVID-19 pandemic.

Effect of a virtual self-management intervention for atrial fibrillation during the outbreak of COVID-19

BACKGROUND

As the pandemic continues to unfold, effective, technology-based solutions are needed to help patients with atrial fibrillation (AF) maintain their health and well-being during the outbreak of COVID-19.

METHODS

This single-center, pilot study investigated the effects of a 4-week (eight sessions) virtual AF self-management program. Questionnaires were completed at baseline and 1 week after the intervention, and assessed AF knowledge, adherence to self-management behaviors, mental health, physical function, and disease-specific quality of life in patients with AF. Secondary outcomes included knowledge of COVID-19, intervention, acceptability, and satisfaction.

RESULTS

Of 68 patients who completed baseline questionnaires, 57 participated in the intervention and were included in the analysis (mean age of 73.4 ± 10.0 years, 60% male). Adherence to AF self-monitoring behaviors, including monitoring their heart rate (p < .001), heart rhythm (p = .003), and blood pressure (p = .013) were significantly improved at the end of the intervention compared with baseline. Symptom identification (p = .007) and management (p < .001) also improved. Reductions in sleep disturbance (p < .001), anxiety (p = .014), and depression (p = .046) were also observed. Misinformation and inaccurate beliefs about COVID-19 were significantly reduced at the end of the intervention compared with baseline.

CONCLUSIONS

This pilot study suggests that a virtual patient education program could have beneficial effects on adherence to guideline-recommend self-care of AF, emotional wellbeing, physical function, and knowledge of COVID-19 in patients with AF. Future randomized studies in larger samples are needed to determine the clinical benefits of the intervention.

Impact of the 2019 Novel Coronavirus Disease Pandemic on the Performance of a Cardiovascular Department in a Non-epidemic Center in Beijing, China

Background: Knowledge of the impact of the 2019 novel coronavirus disease (COVID-19) pandemic on the performance of a cardiovascular department in a medical referral hub center from a non-epidemic area of China is limited.

Method: The data on the total number of non-emergency medical cares (including the number of out-patient clinic attendances, the number of patients who were hospitalized in non-intensive care wards, and patients who underwent elective cardiac intervention procedures) and emergency medical cares [including the number of emergency department (ED attendances) and chest pain center (CPC attendances), as well as the number of patients who were hospitalized in coronary care unit (CCU) and the number of patients who underwent emergency cardiac intervention procedures] before and during the pandemic (time before the pandemic: 20th January 2019 to 31st March 2019 and time during the pandemic: 20th January 2020 to 31st March 2020) in the Department of Cardiology and Macrovascular Disease, Beijing Tiantan Hospital, Capital Medical University were collected and compared.

Results: Both the non-emergency medical and emergency medical cares were affected by the pandemic. The total number of out-patient clinic attendance decreased by 44.8% and the total number of patients who were hospitalized in non-intensive care wards decreased by 56.4%. Pearson correlation analysis showed that the number of out-patient clinic attendance per day was not associated with the number of new confirmed COVID-19 cases and the cumulative number of confirmed COVID-19 patients in Beijing (r = −0.080, p = 0.506 and r = −0.071, p = 0.552, respectively). The total number of patients who underwent non-emergency cardiac intervention procedures decreased during the pandemic, although there were no statistically significant differences except for patent foramen ovale (PFO) occlusion (1.7 ± 2.9 vs. 8.3 ± 2.3, p = 0.035). As for the emergency medical cares, the ED attendances decreased by 22.4%, the total number of CPC attendances increased by 10.3%, and the number of patients who were hospitalized in CCU increased by 8.9%: these differences were not statistically significant. During the pandemic, the proportion of hospitalized patients with ST segment elevation myocardial infarction (STEMI) and non-ST segment elevation myocardial infarction (NSTEMI) significantly increased (19.0 vs. 8.7%, p < 0.001; 28.8 vs. 18.0%, p < 0.001, respectively); also, the number of primary percutaneous coronary intervention (PCI) increased by 10.3%. There was no significant difference between patients before and during the pandemic regarding the age, gender, baseline and discharge medication therapy, as well as length of stay and in-hospital mortality.

Conclusions: Our preliminary results demonstrate that both the non-emergency and emergency medical cares were affected by the COVID-19 pandemic even in a referral medical center with low cross-infection risk. The number of the out-patient clinic attendances not associated with the number of confirmed COVID-19 cases could be due to different factors, such as the local government contamination measures. The proportion of hospitalized patients with acute myocardial infarction increased in our center during the pandemic since other hospitals stopped performing primary angioplasty. A hub-and-spoke model could be effective in limiting the collateral damage for patients affected by cardiovascular diseases when the medical system is stressed by disasters, such as COVID-19 pandemic.

Interprofessional primary care during COVID-19: a survey of the provider perspective

BACKGROUND

Interprofessional primary care (IPC) teams provide comprehensive and coordinated care and are ideally equipped to support those populations most at risk of adverse health outcomes during the COVID-19 pandemic, including older adults, and patients with chronic physical and mental health conditions. There has been little focus on the experiences of healthcare teams and no studies have examined IPC practice during the early phase of the COVID-19 pandemic. The objective of the study was to describe the state of interprofessional health provider practice within IPC teams during the COVID-19 pandemic.

METHODS

Observational cross-sectional design. A web-based survey was deployed to IPC providers working in team-based primary care clinics in the province of Ontario, Canada. The survey included 26 close-ended and six open-ended questions. Close-ended questions were analyzed using descriptive statistics. Content analysis was used to analyze the open-ended questions.

RESULTS

445 surveys were included in the final analysis. Service delivery shifted from in-person care (77% pre-COVID-19) to telephone (76.5% during the COVID-19 pandemic). Less than half of the respondents (40%) reported receiving any training for virtual delivery. Wait times to access team members were reported to have decreased. There has also been a shift in what IPC providers report as the most commonly seen conditions, with increases in visits related to mental health concerns, acute infections (including COVID-19), social isolation, and resource navigation. Respondents also reported a reduction in healthcare provision for multiple chronic conditions including diabetes, cardiovascular disease, and chronic pain.

CONCLUSIONS

IPC teams are rapidly shifting their practice to supporting their patients during the pandemic. A surge in mental health issues has been seen and is expected to continue to increase in response to COVID-19. Understanding early experiences can help plan for future pandemic waves.

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.

Advanced remote care for heart failure in times of COVID-19 using an implantable pulmonary artery pressure sensor: the new normal

Heart failure (HF) is a major public health problem and a leading cause of hospitalization in western countries. Over the past decades, the goal has been to find the best method for monitoring congestive symptoms to prevent hospitalizations. Addressing this task through regular physician visits, blood tests, and imaging has proven insufficient for optimal control and has not decreased enough HF-related hospitalization rates. In recent years, new devices have been developed for this reason and CardioMEMS is one of the therapeutic monitoring options. CardioMEMS has shown to be effective in preventing and reducing HF hospitalizations in patients both with HF with reduced ejection fraction and HF with preserved ejection fraction. CardioMEMS’ versatility has made it a great option for pulmonary artery pressure monitoring, both during the coronavirus disease-19 (COVID-19) pandemic and when the clinic visits have (partially) resumed. CardioMEMS is the remote haemodynamic monitoring system with the most evidence-driven efficacy, and COVID-19 has put it in the spot as a centre-stage technology for HF monitoring. In a few months of the COVID-19 epidemic, CardioMEMS has grown to maturity, making it the new normal for high-quality, high-value remote HF care.

End-stage heart failure patients should be treated instantly despite a pandemic with all-time available technology to ensure best outcomes

Since the earliest cases of coronavirus disease 2019 (COVID-19) infection were reported, our care delivery systems have been reorganized and challenged in unprecedent ways, specifically the cardiovascular community. COVID-19 poses a challenge for heart transplantation, affecting donor selection, immunosuppression, and posttransplant management. Left Ventricular Assist Device (LVAD) therapy is currently a viable option for patients with end-stage heart failure as a bridge to heart transplantation or destination therapy. Here, we present a therapeutic strategy for the management of acute HF with Intermacs profiles from 1 to 4, with or without Covid-19 infection, exemplified by serie of patients presenting with severe HF and successfully treated by LVAD therapy during the spread of the Covid-19 pandemic and the French national lockdown. This experience has shown that we still have the capacity to provide the right therapy for the right disease to the right patient. LVAD implantation seems to be the treatment of choice for advanced HF due to the lack of healthy donor hearts for cardiac transplantation. Covid or non-Covid context, we have to take care of our patients with end-stage HF the best we can.

Health Care Delivery for Heart Failure Patients During The COVID-19 Pandemic; A Consensus of The Saudi Heart Failure Working Group (SAUDI-HF)

The Coronavirus disease 2019 (COVID-19) pandemic led to global and national rapid health system changes to treat the affected patients and prevent the spread of the virus. The social distancing, redirecting resources, and nationwide lockdown led to the cancellation of non-urgent hospital visits and interruption of continuity of care for patients with chronic cardiac conditions such as heart failure (HF). This consensus document addresses the domains of health care delivery that are affected by the pandemic. It explains the current situation of health care delivery to heart failure patients and further recommendation on how to overcome this. Thus, maintaining quality and continuity of care to the HF population.

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.

Reduction in heart failure hospitalization rate during coronavirus disease 19 pandemic outbreak

AIMS

The recent coronavirus disease 19 (COVID-19) pandemic outbreak forced the adoption of restraint measures, which modified the hospital admission patterns for several diseases. The aim of the study is to investigate the rate of hospital admissions for heart failure (HF) during the early days of the COVID-19 outbreak in Italy, compared with a corresponding period during the previous year and an earlier period during the same year.

METHODS AND RESULTS

We performed a retrospective analysis on HF admissions number at eight hospitals in Italy throughout the study period (21 February to 31 March 2020), compared with an inter-year period (21 February to 31 March 2019) and an intra-year period (1 January to 20 February 2020). The primary outcome was the overall rate of hospital admissions for HF. A total of 505 HF patients were included in this survey: 112 during the case period, 201 during intra-year period, and 192 during inter-year period. The mean admission rate during the case period was 2.80 admissions per day, significantly lower compared with intra-year period (3.94 admissions per day; incidence rate ratio, 0.71; 95% confidence interval [CI], 0.56-0.89; P = 0.0037), or with inter-year (4.92 admissions per day; incidence rate ratio, 0.57; 95% confidence interval, 0.45-0.72; P < 0.001). Patients admitted during study period were less frequently admitted in New York Heart Association (NYHA) Class II compared with inter-year period (P = 0.019). At covariance analysis NYHA class was significantly lower in patients admitted during inter-year control period, compared with patients admitted during case period (P = 0.014).

CONCLUSIONS

Admissions for HF were significantly reduced during the lockdown due to the COVID-19 pandemic in Italy.

COVID-19 and Heart Failure: The Big Challenge

Patients with chronic heart failure (HF) are among the most vulnerable populations in the COVID era. HF patients infected with COVID-19 are at a significant risk of severe illness and death. They usually present with shortness of breath and radiologic signs of an acute decompensation, which can mask the manifestations of COVID-19. Delay in the diagnosis increases the risk of individual poor outcomes and jeopardizes healthcare workers if protective and isolation measures are not established promptly. Furthermore, the COVID-19 pandemic is forcing health-care systems to modify the delivery of care to patients. Outpatient services are being done virtually, and elective procedures postponed. These may have an impact on the quality of life and survival of chronic HF patients. We present two cases of patients with the previous history of HF who developed an acute exacerbation secondary to COVID-19 infection. In this review, we focused on the main challenges physicians face when dealing with COVID-19 in chronic HF patients at the individual and system levels.

COVID-19: Implications for People with Chagas Disease

As the global COVID-19 pandemic advances, it increasingly impacts those vulnerable populations who already bear a heavy burden of neglected tropical disease. Chagas disease (CD), a neglected parasitic infection, is of particular concern because of its potential to cause cardiac, gastrointestinal, and other complications which could increase susceptibility to COVID-19. The over one million people worldwide with chronic Chagas cardiomyopathy require special consideration because of COVID-19’s potential impact on the heart, yet the pandemic also affects treatment provision to people with acute or chronic indeterminate CD. In this document, a follow-up to the WHF-IASC Roadmap on CD, we assess the implications of coinfection with SARS-CoV-2 and Trypanosoma cruzi, the etiological agent of CD. Based on the limited evidence available, we provide preliminary guidance for testing, treatment, and management of patients affected by both diseases, while highlighting emerging healthcare access challenges and future research needs.

The Heart Failure Readmission Intervention by Variable Early Follow-up (THRIVE) Study

Background:

In-person clinic follow-up within 7 days after discharge from a heart failure hospitalization is associated with lower 30-day readmission. However, health systems and patients may find it difficult to complete an early postdischarge clinic visit, especially during the current pandemic. We evaluated the effect on 30-day readmission and death of follow-up within 7 days postdischarge guided by an initial structured nonphysician telephone visit compared with follow-up guided by an initial clinic visit with a physician.

Methods and Results:

We conducted a pragmatic randomized trial in a large integrated healthcare delivery system. Adults being discharged home after hospitalization for heart failure were randomly assigned to either an initial telephone visit with a nurse or pharmacist to guide follow-up or an initial in-person clinic appointment with primary care physicians providing usual care within the first 7 days postdischarge. Telephone appointments included a structured protocol enabling medication titration, laboratory ordering, and booking urgent clinic visits as needed under physician supervision. Outcomes included 30-day readmissions and death and frequency and type of completed follow-up within 7 days of discharge. Among 2091 participants (mean age 78 years, 44% women), there were no significant differences in 30-day heart failure readmission (8.6% telephone, 10.6% clinic, P =0.11), all-cause readmission (18.8% telephone, 20.6% clinic, P =0.30), and all-cause death (4.0% telephone, 4.6% clinic, P =0.49). Completed 7-day follow-up was higher in 1027 patients randomized to telephone follow-up (92%) compared with 1064 patients assigned to physician clinic follow-up (79%, P <0.001). Overall frequency of clinic visits during the first 7 days postdischarge was lower in participants assigned to nonphysician telephone guided follow-up (48%) compared with physician clinic-guided follow-up (77%, P <0.001).

Conclusions:

Early, structured telephone follow-up after hospitalization for heart failure can increase 7-day follow-up and reduce in-person visits with comparable 30-day clinical outcomes within an integrated care delivery framework.

Registration:

URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03524534.

Impact of lockdown on patients with congestive heart failure during the coronavirus disease 2019 pandemic

AIMS

Cardiovascular co-morbidities like congestive heart failure (CHF) alter the course of coronavirus disease 2019. Factors associated with the outbreak and lockdown can exacerbate CHF.

METHODS AND RESULTS

We analysed the answers of 124 randomly selected CHF outpatients (mean age 71.0 ± 14.0 years, 60.5% male) interviewed by phone during the sixth and seventh weeks of the lockdown. Most patients were treated for New York Heart Association class II (38.7%) and reduced ejection fraction HF (70.2%). Psychological distress (Kessler 6 score ≥ 5) was common (18.5%), and 21.8% felt worse than before the lockdown. Few patients (n = 10) adjusted their intake of HF medications, always on medical prescription. Decreased physical activity was common (41.9%) and more frequent in women (P = 0.025) and urban dwellers (P = 0.009). Almost half of respondents (46.0%) declared increased screen time, but only few declared more alcohol intake (4.0%). Weight gain was common (27.4%), and 44.4% of current smokers increased tobacco consumption. Adherence to recommended salt or fluid intake restrictions was reduced in 14.5%. Increase in HF symptoms was commonly reported (21.8%) and tended to be higher in women than in men (P = 0.074). Of the 23 patients who had a phone teleconsultation during the pandemic, 16 had initially planned an in-person consultation that they switched for teleconsultation.

CONCLUSIONS

During the lockdown, psychological distress and decreased well-being were common in CHF outpatients, and there was an increase in unhealthy lifestyle behaviours. These changes may negatively impact short-term and long-term prognoses. Medication adherence was maintained, and limitations in access to care were partly counterbalanced by use of telehealth.

Considerations for Heart Failure Care During the COVID-19 Pandemic

The coronavirus-2019 (COVID-19) infection pandemic has affected the care of patients with heart failure (HF) who have contracted COVID-19 as well as those without COVID-19 who have been impacted by the restructuring of health care delivery. Patients with HF and other cardiovascular comorbidities are at risk for severe disease and complications of infection. Similarly, COVID-19 has been demonstrated to cause myocarditis and may be implicated in new-onset cardiomyopathy. During this pandemic, special considerations are needed for patients with advanced HF, including those supported by durable left ventricular assist devices (LVADs) and heart transplant recipients. The purpose of this review is to summarize emerging data regarding the development of HF secondary to COVID-19 infection in patients with advanced HF and the implications of the pandemic for care of uninfected patients with HF.