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

Telemedicine and Remote Management of Patients with Heart Failure: From Theory to Daily Practice

Background: Heart failure (HF) is responsible for a high number of hospitalizations, caused by a progressive worsening quality of life. Telemedicine allows for better management of patients' complex conditions, improving the care released. However, the risk of remaining at a testing stage often limits the integration of remote care in daily pathways for HF patients. The aim of this study is to outline the steps needed to integrate telemedicine activities into ordinary HF clinic practices. This methodology is applied to observe activities and trend improvements over a 12-month routine phase. Method: Three steps have been defined for an efficient introduction of remote care services in ordinary activities, integrating them with traditional in-person care: (i) introduction of temporary telemedicine projects, (ii) systematization of telemedicine pathways, and (iii) evaluation of monitoring phase. Observational data have been collected from structured interviews to show the rate of telemedicine activities achieved in clinical practice over the last year. Results: The methodology has been proposed in the HF clinic of the Italian hospital ASST Bergamo Est. After an initial testing phase, in which usability and user experience have been tested, four different remote activities were added: (i) telemonitoring for patients with an implantable device, (ii) follow-up televisits, (iii) nursing telephone support, and (iv) high-intensity telesurveillance pathways for patients after an HF acute event. During the last year, 218 telemonitoring pathways, 75 televisits, 500 telephone calls, and nine telesurveillance pathways have been performed. Success rates were high, and patients gave positive feedback. Conclusion: By integrating multiple telemedicine activities, it has been possible to better manage complex patients, keep track of disease progression, and improve their participation in care.

Virtual care during COVID-19: The perspectives of older adults and their healthcare providers in a cardiac rehabilitation setting

The present study aimed to explore the perspectives of older adults and health providers on cardiac rehabilitation care provided virtually during COVID-19. A qualitative exploratory methodology was used. Semi-structured interviews were conducted with 15 older adults and 6 healthcare providers. Five themes emerged from the data: (1) Lack of emotional intimacy when receiving virtual care, (2) Inadequacy of virtual platforms, (3) Saving time with virtual care, (4) Virtual care facilitated accessibility, and (5) Loss of connections with patients and colleagues. Given that virtual care continues to be implemented, and in some instances touted as an optimal option for the delivery of cardiac rehabilitation, it is critical to address the needs of older adults living with cardiovascular disease and their healthcare providers. This is particularly crucial related to issues accessing and using technology, as well as older adults' need to build trust and emotional connection with their providers.

The Evolution and Future of Intensive Care Management in the Era of Telecritical Care and Artificial Intelligence

Critical care practice has been embodied in the healthcare system since the institutionalization of intensive care units (ICUs) in the late '50s. Over time, this sector has experienced many changes and improvements in providing immediate and dedicated healthcare as patients requiring intensive care are often frail and critically ill with high mortality and morbidity rates. These changes were aided by innovations in diagnostic, therapeutic, and monitoring technologies, as well as the implementation of evidence-based guidelines and organizational structures within the ICU. In this review, we examine these changes in intensive care management over the past 40 years and their impact on the quality of care available to patients. Moreover, the current state of intensive care management is characterized by a multidisciplinary approach and the use of innovative technologies and research databases. Advancements such as telecritical care and artificial intelligence are being increasingly explored, especially since the COVID-19 pandemic, to reduce the length of hospitalization and ICU mortality. With these advancements in intensive care and ever-changing patient needs, critical care experts, hospital managers, and policymakers must also explore appropriate organizational structures and future enhancements within the ICU.

Recent functional decline and outpatient follow-up after hospital discharge: a cohort study

BACKGROUND

Functional decline is common following acute hospitalization and is associated with hospital readmission, institutionalization, and mortality. People with functional decline may have difficulty accessing post-discharge medical care, even though early physician follow-up has the potential to prevent poor outcomes and is integral to high-quality transitional care. We sought to determine whether recent functional decline was associated with lower rates of post-discharge physician follow-up, and whether this association changed during the COVID-19 pandemic, given that both functional decline and COVID-19 may affect access to post-discharge care.

METHOD

We conducted a retrospective cohort study using health administrative data from Ontario, Canada. We included patients over 65 who were discharged from an acute care facility during March 1st, 2019 - January 31st, 2020 (pre-COVID-19 period), and March 1st, 2020 - January 31st, 2021 (COVID-19 period), and who were assessed for home care while in hospital. Patients with and without functional decline were compared. Our primary outcome was any physician follow-up visit within 7 days of discharge. We used propensity score weighting to compare outcomes between those with and without functional decline.

RESULTS

Our study included 21,771 (pre-COVID) and 17,248 (COVID) hospitalized patients, of whom 15,637 (71.8%) and 12,965 (75.2%) had recent functional decline. Pre-COVID, there was no difference in physician follow-up within 7 days of discharge (Functional decline 45.0% vs. No functional decline 44.0%; RR = 1.02, 95% CI 0.98-1.06). These results did not change in the COVID-19 period (Functional decline 51.1% vs. No functional decline 49.4%; RR = 1.03, 95% CI 0.99-1.08, Z-test for interaction p = 0.72). In the COVID-19 cohort, functional decline was associated with having a 7-day physician virtual visit (RR 1.15; 95% CI 1.08-1.24) and a 7-day physician home visit (RR 1.64; 95% CI 1.10-2.43).

CONCLUSIONS

Functional decline was not associated with reduced 7-day post-discharge physician follow-up in either the pre-COVID-19 or COVID-19 periods. In the COVID-19 period, functional decline was positively associated with 7-day virtual and home-visit follow-up.

Telemonitoring for heart failure: a meta-analysis

AIMS

Telemonitoring modalities in heart failure (HF) have been proposed as being essential for future organization and transition of HF care, however, efficacy has not been proven. A comprehensive meta-analysis of studies on home telemonitoring systems (hTMS) in HF and the effect on clinical outcomes are provided.

METHODS AND RESULTS

A systematic literature search was performed in four bibliographic databases, including randomized trials and observational studies that were published during January 1996-July 2022. A random-effects meta-analysis was carried out comparing hTMS with standard of care. All-cause mortality, first HF hospitalization, and total HF hospitalizations were evaluated as study endpoints. Sixty-five non-invasive hTMS studies and 27 invasive hTMS studies enrolled 36 549 HF patients, with a mean follow-up of 11.5 months. In patients using hTMS compared with standard of care, a significant 16% reduction in all-cause mortality was observed [pooled odds ratio (OR): 0.84, 95% confidence interval (CI): 0.77-0.93, I2: 24%], as well as a significant 19% reduction in first HF hospitalization (OR: 0.81, 95% CI 0.74-0.88, I2: 22%) and a 15% reduction in total HF hospitalizations (pooled incidence rate ratio: 0.85, 95% CI 0.76-0.96, I2: 70%).

CONCLUSION

These results are an advocacy for the use of hTMS in HF patients to reduce all-cause mortality and HF-related hospitalizations. Still, the methods of hTMS remain diverse, so future research should strive to standardize modes of effective hTMS.

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 Italian Society of Cardiology and Working Group on Telecardiology and Informatics 2023 updated position paper on telemedicine and artificial intelligence in cardiovascular disease

In 2015, the Italian Society of Cardiology and its Working Group on Telemedicine and Informatics issued a position paper on Telecardiology, resuming the most eminent evidence supporting the use of information and communication technology in principal areas of cardiovascular care, ranked by level of evidence. More than 5 years later and after the global shock inflicted by the SARS-CoV-2 pandemic, an update on the topic is warranted. Recent evidence and studies on principal areas of cardiovascular disease will be therefore reported and discussed, with particular focus on telemedicine for cardiovascular care in the COVID-19 context. Novel perspectives and opportunities disclosed by artificial intelligence and its applications in cardiovascular disease will also be discussed. Finally, modalities by which machine learning have realized remote patient monitoring and long-term care in recent years, mainly filtering critical clinical data requiring selective hospital admission, will be provided.

Digital Health Technologies for Post-Discharge Care after Heart Failure Hospitalisation to Relieve Symptoms and Improve Clinical Outcomes

The prevention of recurrent heart failure (HF) hospitalisations is of particular importance, as each such successive event may increase the risk of death. Effective care planning during the vulnerable phase after discharge is crucial for symptom control and improving patient prognosis. Many clinical trials have focused on telemedicine interventions in HF, with varying effects on the primary endpoints. However, the evidence of the effectiveness of telemedicine solutions in cardiology is growing. The scope of this review is to present complementary telemedicine modalities that can support outpatient care of patients recently hospitalised due to worsening HF. Remote disease management models, such as video (tele) consultations, structured telephone support, and remote monitoring of vital signs, were presented as core components of telecare. Invasive and non-invasive monitoring of volume status was described as an important step forward to prevent congestion-the main cause of clinical decompensation. The idea of virtual wards, combining these facilities with in-person visits, strengthens the opportunity for education and enhancement to promote more intensive self-care. Electronic platforms provide coordination of tasks within multidisciplinary teams and structured data that can be effectively used to develop predictive algorithms based on advanced digital science, such as artificial intelligence. The rapid progress in informatics, telematics, and device technologies provides a wide range of possibilities for further development in this area. However, there are still existing gaps regarding the use of telemedicine solutions in HF patients, and future randomised telemedicine trials and real-life registries are still definitely needed.

Towards A Framework for Implementing Remote Patient Monitoring From an Integrated Care Perspective: A Scoping Review

BACKGROUND

Remote patient monitoring (RPM) has been increasingly adopted over the last decade, with the COVID-19 pandemic fostering its rapid development. As RPM implementation is recognised as complex and highly demanding in terms of resources and processes, there are multiple challenges in providing RPM in an integrated logic.

METHODS

To examine the structural elements that are relevant for implementing RPM integrated care, a scoping review was conducted in PubMed, Scopus, and Web of Science, leveraging a search strategy that combines terms relative to (1) conceptual models and reallife initiatives; (2) RPM; and (3) care integration.

RESULTS

28 articles were included, covering nine conceptual models and 19 real-life initiatives. Eighteen structural elements of RPM integrated care implementation were identified among conceptual models, defining a structure for assessing real-life initiatives. 78.9% of those initiatives referred to at least ten structural elements, with patient education and self-monitoring promotion, multidisciplinary core workforce, ICTs (information and communications technologies) and telemonitoring devices, and health indicators measurement being present in all studies, and therefore being core elements to the design of RPM initiatives.

CONCLUSION

RPM goes far beyond technology, with underlying processes and involved actors playing a central role in care provision. The structural elements identified can guide RPM implementation and promote maturity in adoption. Future research may focus on assessing design completeness, evaluating impacts, and analysing related financial arrangements.

A Sparse Sampling Sensor Front-End IC for Low Power Continuous SpO 2 & HR Monitoring

Photoplethysmography (PPG) is an attractive method to acquire vital signs such as heart rate and blood oxygenation and is frequently used in clinical and at-home settings. Continuous operation of health monitoring devices demands a low power sensor that does not restrict the device battery life. Silicon photodiodes (PD) and LEDs are commonly used as interface devices in PPG sensors; however, using of flexible organic devices can enhance the sensor conformality and reduce the cost of fabrication. In most PPG sensors, most of system power consumption is concentrated in powering LEDs, traditionally consuming mWs. Using organic devices further increases this power demand since these devices exhibit larger parasitic capacitances and typically need higher drive voltages.This work presents a sensor IC for continuous SpO ₂ and HR monitoring that features an on-chip reconstruction-free sparse sampling algorithm to reduce the overall system power consumption by  ∼ 70% while maintaining the accuracy of the output information. The designed frontend is compatible with a wide range of devices from silicon PDs to organic PDs with parasitic capacitances up to 10 nF. Implemented in a 40 nm HV CMOS process, the chip occupies 2.43 mm ² and consumes 49.7 μW and 15.2 μW of power in continuous and sparse sampling modes respectively. The performance of the sensor IC has been verified in vivo with both types of devices and the results are compared against a clinical grade reference. Less than 1 bpm and 1% mean absolute errors were achieved in both continuous and sparse modes of operation.

Well-Being, Physical Activity, and Social Support in Octogenarians with Heart Failure during COVID-19 Confinement: A Mixed-Methods Study

BACKGROUND

This study aimed to compare well-being and physical activity (PA) before and during COVID-19 confinement in older adults with heart failure (HF), to compare well-being and PA during COVID-19 confinement in octogenarians and non-octogenarians, and to explore well-being, social support, attention to symptoms, and assistance needs during confinement in this population.

METHODS

A mixed-methods design was performed. Well-being (Cantril Ladder of Life) and PA (International Physical Activity Questionnaire) were assessed. Semi-structured interviews were performed to assess the rest of the variables.

RESULTS

120 participants were evaluated (74.16 ± 12.90 years; octogenarians = 44.16%, non-octogenarians = 55.83%). Both groups showed lower well-being and performed less PA during confinement than before (p < 0.001). Octogenarians reported lower well-being (p = 0.02), higher sedentary time (p = 0.03), and lower levels of moderate PA (p = 0.04) during confinement. Most individuals in the sample considered their well-being to have decreased during confinement, 30% reported decreased social support, 50% increased their attention to symptoms, and 60% were not satisfied with the assistance received. Octogenarians were more severely impacted during confinement than non-octogenarians in terms of well-being, attention to symptoms, and assistance needs.

CONCLUSIONS

Well-being and PA decreased during confinement, although octogenarians were more affected than non-octogenarians. Remote monitoring strategies are needed in elders with HF to control health outcomes in critical periods, especially in octogenarians.

Smartphone-based cardiac implantable electronic device remote monitoring: improved compliance and connectivity

Aims

Remote monitoring (RM) is the standard of care for follow up of patients with cardiac implantable electronic devices. The aim of this study was to compare smartphone-based RM (SM-RM) using patient applications (myMerlinPulse™ app) with traditional bedside monitor RM (BM-RM).

Methods and results

The retrospective study included de-identified US patients who received either SM-RM or BM-RM capable of implantable cardioverter defibrillators or cardiac resynchronization therapy defibrillators (Abbott, USA). Patients in SM-RM and BM-RM groups were propensity-score matched on age and gender, device type, implant year, and month. Compliance with RM was quantified as the proportion of patients enrolling in the RM system (Merlin.net™) and transmitting data at least once. Connectivity was measured by the median number of days between consecutive transmissions per patient. Of the initial 9714 patients with SM-RM and 26 679 patients with BM-RM, 9397 patients from each group were matched. Remote monitoring compliance was higher in SM-RM; significantly more patients with SM-RM were enrolled in RM compared with BM-RM (94.4 vs. 85.0%, P < 0.001), similar number of patients in the SM-RM group paired their device (95.1 vs. 95.0%, P = 0.77), but more SM-RM patients transmitted at least once (98.1 vs. 94.3%, P < 0.001). Connectivity was significantly higher in the SM-RM, with patients transmitting data every 1.2 (1.1, 1.7) vs. every 1.7 (1.5, 2.0) days with BM-RM (P < 0.001) and remained better over time. Significantly more SM-RM patients utilized patient-initiated transmissions compared with BM-RM (55.6 vs. 28.1%, P < 0.001).

Conclusion

In this large real-world study, patients with SM-RM demonstrated improved compliance and connectivity compared with BM-RM.

A Contact-Free Optical Device for the Detection of Pulmonary Congestion-A Pilot Study

BACKGROUND

The cost of heart failure hospitalizations in the US alone is over USD 10 billion per year. Over 4 million Americans are hospitalized every year due to heart failure (HF), with a median length of stay of 4 days and an in-hospital mortality rate that exceeds 5%. Hospitalizations of patients with HF can be prevented by early detection of lung congestion. Our study assessed a new contact-free optical medical device used for the early detection of lung congestion.

METHODS

The Gili system is an FDA-cleared device used for measuring chest motion vibration data. Lung congestion in the study was assessed clinically and verified via two cardiologists. An algorithm was developed using machine learning techniques, and cross-validation of the findings was performed to estimate the accuracy of the algorithm.

RESULTS

A total of 227 patients were recruited (101 cases vs. 126 controls). The sensitivity and specificity for the device in our study were 0.91 (95% CI: 0.86-0.93) and 0.91 (95% CI: 0.87-0.94), respectively. In all instances, the observed estimates of PPVs and NPVs were at least 0.82 and 0.90, respectively. The accuracy of the algorithm was not affected by different covariates (including respiratory or valvular conditions).

CONCLUSIONS

This study demonstrates the efficacy of a contact-free optical device for detecting lung congestion. Further validation of the study results across a larger and precise scale is warranted.

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.

Impact of the COVID-19 Pandemic on the Effectiveness of a Metabolic Health Telemedicine Intervention for Weight Loss: A Propensity Score Matching Analysis

Background

Coronavirus disease 2019 (COVID-19) pandemic public health measures such as stay-at-home and mandatory work-from-home orders have been associated with obesogenic lifestyle changes, increased risk of weight gain, and their metabolic sequelae. We sought to assess the impact of this pandemic on weight loss from a telemedicine-delivered very-low-carbohydrate intervention targeting nutritional ketosis (NKI).

Methods

A total of 746 patients with a BMI ≥25kg/m2, enrolled between January and March 2020 and treated for at least 1 year with the NKI, were classified as pandemic cohort (PC). A separate cohort of 699 patients who received 1 year of the NKI in the preceding years, enrolled between January and March 2018, were identified as pre-pandemic cohort (Pre-PC). Demographic and clinical data were obtained from medical records to compare the cohorts and assess the outcomes. Using propensity score matching (PSM), balanced and matched groups of 407 patients in the Pre-PC and 407 patients in the PC were generated. Longitudinal change in absolute weight and percentage weight change from baseline to 1 year were assessed.

Results

Weight significantly decreased in both PC and Pre-PC at 3, 6, 9, and 12 months. The weight loss trajectory was similar in both PC and Pre-PC with no significant weight differences between the two cohorts at 3, 6, 9, and 12 months. On an average, the PC lost 7.5% body weight while the Pre-PC lost 7.9% over 1 year, and the percent weight loss did not differ between the two cohorts (p = 0.50).

Conclusion

A very-low-carbohydrate telemedicine intervention delivered comparable and medically significant weight loss independent of pandemic stress and lifestyle limitations.

Repostioning of Telemedicine in Cardiovascular World Post-COVID-19 Pandemic

Background

During the COVID-19 pandemic, telemedicine is a quickest expanding service solution to provide improved access to sophisticated healthcare that is efficient, cost-effective, and time-consuming.

Methods

This analysis is evaluated on the basis of several studies that look at the history, benefits, various techniques, challenges, uses, and impact of telemedicine in the treatment of heart failure and cardiac rehabilitation as during COVID-19 outbreak.

Results

Patients avoided or refused medical treatment during COVID-19 pandemic despite the risk of illness and the threat of infections spreading. Telemedicine has become a non-traditional form of care delivery due to better access and high-end technologies such as virtual consultations, face-to-face video, smartphone visits, two-way text communication, distant patient history, and distal characteristic assessment. Remote monitoring can help manage cardiovascular disease risk factors and increase patient participation in blood pressure, heart failure data, and workout or other activity progress.

Conclusion

Based on the findings of past studies, we can infer that telemedicine is still an emerging subject in the treatment and management of cardiovascular disease. Telemedicine and similar technologies will also revolutionize healthcare services by expanding their reach and providing a big pool of database for better research and analysis.

Telecommunication for Advance Care Planning in Heart Failure

Heart failure is a chronic illness that carries a significant burden for patients, caregivers and health systems alike. The integration of palliative care and telehealth is a growing area of interest in heart failure management to help alleviate these burdens. This review focuses on the incorporation of advance care planning for complex decision-making in heart failure in the setting of increasing virtual care and telehealth. The review will also consider the role of virtual education for advance care planning and serious illness communication. Telecommunication for clinical care and clinical education are both described as non-inferior to in-person methods. Nevertheless, more research is needed to discern best practices and the optimal integration of methods.

Home Blood Pressure and Telemedicine: A Modern Approach for Managing Hypertension During and After COVID-19 Pandemic

Hypertension is the most common cardiovascular risk factor for acute cardiovascular outcomes, including acute coronary disease, stroke, chronic kidney disease and congestive heart failure. Despite the fact that it represents the most prevalent risk factor in the general population, mostly in elderly individuals, its awareness is still relatively low, being about one third of patients living with undiagnosed hypertension and high risk of experiencing acute cardiovascular events. In addition, though recent improvement in pharmacological and non-pharmacological therapeutic options, hypertension is largely uncontrolled, with about 35-40% of treated hypertensive patients achieving the recommended therapeutic targets. Among different modern interventions proposed for improving blood pressure control in treated hypertensive patients, a systematic adoption of home BP monitoring has demonstrated to be one of the most effective. Indeed, it improves patients' awareness of the disease and adherence to prescribed medications and allows tailoring and personalizing BP lowering therapies. Home BP monitoring is particularly suitable for telemedicine and mobile-health solutions. Indeed, in specific conditions, when face-to-face interactions between patients and physicians are not allowed or even suspended, as in case of COVID-19 pandemic, telemedicine may ensure effective management of hypertension, as well as other cardiovascular and non-cardiovascular comorbidities. This review will summarize strengths and limitations of telemedicine in the clinical management of hypertension with a particular focus on the lessons learned during the COVID-19 pandemic.

Kidney Care during COVID-19 in the UK: Perspectives of Healthcare Professionals on Impacts on Care Quality and Staff Well-Being

In light of the rapid changes in healthcare delivery due to COVID-19, this study explored kidney healthcare professionals' (HCPs) perspectives on the impact of these changes on care quality and staff well-being. Fifty-nine HCPs from eight NHS Trusts across England completed an online survey and eight took part in complementary semi-structured interviews between August 2020 and January 2021. Free-text survey responses and interviews were analysed using inductive thematic analysis. Themes described the rapid adaptations, concerns about care quality, benefits from innovations, high work pressure, anxiety and mental exhaustion in staff and the team as a well-being resource. Long-term retention and integration of changes and innovations can improve healthcare access and efficiency, but specification of conditions for its use is warranted. The impact of prolonged stress on renal HCPs also needs to be accounted for in quality planning. Results are further interpreted into a theoretical socio-technical framework.

Post-ST-Segment Elevation Myocardial Infarction Follow-Up Care During the COVID-19 Pandemic and the Possible Benefit of Telemedicine: An Observational Study

Background: Infectious control measures during the COVID-19 pandemic have led to the propensity toward telemedicine. This study examined the impact of telemedicine during the pandemic on the long-term outcomes of ST-segment elevation myocardial infarction (STEMI) patients.

Methods: This study included 288 patients admitted 1 year before the pandemic (October 2018–December 2018) and during the pandemic (January 2020–March 2020) eras, and survived their index STEMI admission. The follow-up period was 1 year. One-year primary safety endpoint was all-cause mortality. Secondary safety endpoints were cardiac readmissions for unplanned revascularisation, non-fatal myocardial infarction, heart failure, arrythmia, unstable angina. Major adverse cardiovascular events (MACE) was defined as the composite outcome of each individual safety endpoint.

Results: Despite unfavorable in-hospital outcomes among patients admitted during the pandemic compared to pre-pandemic era, both groups had similar 1-year all-cause mortality (11.2 vs. 8.5%, respectively, p = 0.454) but higher cardiac-related (14.1 vs. 5.1%, p < 0.001) and heart failure readmissions in the pandemic vs. pre-pandemic groups (7.1 vs. 1.7%, p = 0.037). Follow-up was more frequently conducted via teleconsultations (1.2 vs. 0.2 per patient/year, p = 0.001), with reduction in physical consultations (2.1 vs. 2.6 per patient/year, p = 0.043), during the pandemic vs. pre-pandemic era. Majority achieved guideline-directed medical therapy (GDMT) during pandemic vs. pre-pandemic era (75.9 vs. 61.6%, p = 0.010). Multivariable Cox regression demonstrated achieving medication target doses (HR 0.387, 95% CI 0.164–0.915, p = 0.031) and GDMT (HR 0.271, 95% CI 0.134–0.548, p < 0.001) were independent predictors of lower 1-year MACE after adjustment.

Conclusion: The pandemic has led to the wider application of teleconsultation, with increased adherence to GDMT, enhanced medication target dosing. Achieving GDMT was associated with favorable long-term prognosis.

Telehealth at scale can improve chronic disease management in the community during a pandemic: An experience at the time of COVID-19

Background

During the COVID-19 pandemic, telehealth became a vital resource to contain the virus’s spread and ensure continuity of care of patients with a chronic condition, notably arterial hypertension and heart disease. This paper reports the experience based on a telehealth platform used at scale to manage chronic disease patients in the Italian community.

Methods and findings

Patients’ health status was remotely monitored through ambulatory blood pressure monitoring (ABPM), resting or ambulatory electrocardiogram (ECG), spirometry, sleep oximetry, and cardiorespiratory polysomnography performed in community pharmacies or general practitioners’ offices. Patients also monitored their blood pressure (BP), heart rate (HR), blood oxygen saturation (SpO₂), body temperature, body weight, waist circumference, blood glucose, and lipids at home through a dedicated smartphone app. All data conveyed to the web-based telehealth platform were used to manage critical patients by doctors promptly. Data were analyzed and compared across three consecutive periods of 2 months each: i) before the national lockdown, ii) during the lockdown (from March 9 to May 17, 2020), and iii) after the end of the containment measures. Overall, 13,613 patients visited community pharmacies or doctors’ offices. The number of overall tests dropped during and rose after the lockdown. The overall proportion of abnormal tests was larger during the outbreak. A significant increase in the prevalence of abnormal ECGs due to myocardial ischemia, contrasted by a significantly improved BP control, was observed. The number of home users and readings exchanged increased during the pandemic. In 226 patients, a significant increase in the proportion of SpO₂ readings and a significant reduction in the entries for all other parameters, except BP, was observed. The proportion of abnormal SpO₂ and BP values was significantly lower during the lockdown. Following the lockdown, the proportion of abnormal body weight or waist circumference values increased.

Conclusions

Our study results support the usefulness of a telehealth solution to detect deterioration of the health status during the COVID-19 pandemic.

Trial registration

The study is registered with ClinicalTrials.gov at number NCT03781401.

The effect of the COVID-19 pandemic on emergency department visits for serious cardiovascular conditions

OBJECTIVE

We examine how emergency department (ED) visits for serious cardiovascular conditions evolved in the coronavirus (COVID-19) pandemic over January-October 2020, compared to 2019, in a large sample of U.S. EDs.

METHODS

We compared 2020 ED visits before and during the COVID-19 pandemic, relative to 2019 visits in 108 EDs in 18 states in 115,716 adult ED visits with diagnoses for five serious cardiovascular conditions: ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), ischemic stroke (IS), hemorrhagic stroke (HS), and heart failure (HF). We calculated weekly ratios of ED visits in 2020 to visits in 2019 in the pre-pandemic (Jan 1-March 10), early-pandemic (March 11-April 21), and later-pandemic (April 22-October 31) periods.

RESULTS

ED visit ratios show that NSTEMI, IS, and HF visits dropped to lows of 56%, 64%, and 61% of 2019 levels, respectively, in the early-pandemic and gradually returned to 2019 levels over the next several months. HS visits also dropped early pandemic period to 60% of 2019 levels, but quickly rebounded. We find mixed evidence on whether STEMI visits fell, relative to pre-pandemic rates. Total adult ED visits nadired at 57% of 2019 volume during the early-pandemic period and have only party recovered since, to approximately 84% of 2019 by the end of October 2020.

CONCLUSION

We confirm prior studies that ED visits for serious cardiovascular conditions declined early in the COVID-19 pandemic for NSTEMI, IS, HS, and HF, but not for STEMI. Delays or non-receipt in ED care may have led to worse outcomes.

Acute heart failure in elderly patients: a review of invasive and non-invasive management

Acute heart failure (AHF) is a major cause of unplanned hospitalisations in the elderly and is associated with high mortality. Its prevalence has grown in the last years due to population aging and longer life expectancy of chronic heart failure patients. Although international societies have provided guidelines for the management of AHF in the general population, scientific evidence for geriatric patients is often lacking, as these are underrepresented in clinical trials. Elderly have a different risk profile with more comorbidities, disability, and frailty, leading to increased morbidity, longer recovery time, higher readmission rates, and higher mortality. Furthermore, therapeutic options are often limited, due to unfeasibility of invasive strategies, mechanical circulatory support and cardiac transplantation. Thus, the in-hospital management of AHF should be tailored to each patient's clinical situation, cardiopulmonary condition and geriatric assessment. Palliative care should be considered in some cases, in order to avoid unnecessary diagnostics and/or treatments. After discharge, a strict follow-up through outpatient clinic or telemedicine is can improve quality of life and reduce rehospitalisation rates. The aim of this review is to offer an insight on current literature and provide a clinically oriented, patient-tailored approach regarding assessment, treatment and follow-up of elderly patients admitted for AHF.

COVID-19 and cardiovascular comorbidity: novel approaches to reduce mortality

Cardiovascular diseases (CVDs) remain the leading cause of death worldwide and significantly affect patient quality of life and socioeconomic status. Numerous reports consistently demonstrate that CVDs are a major risk factor for severe course of coronavirus disease 2019 (COVID-19), including higher risks of hospitalizations and inpatient mortality. In the context of the current pandemic, managing patients with CVDs requires special attention from doctors. There are now more and more reports of the long-term effects of COVID-19. The long-term effects on cardiovascular system of millions of COVID-19 survivors are currently unknown. The aim of the review was to systematize the accumulated knowledge about the mutual influence of COVID-19 and CVDs. The features of CVD impact on the course and outcomes of COVID-19, as well as the reasons for the worsening of CVD course in patients with COVID-19 are considered. The impact of redistribution of health care resources and large-scale isolation measures on the management of patients with CVDs is discussed. The review also presents the most relevant data on long COVID. Predictors of a long-term disease course were identified for risk stratification in order to timely implement preventive measures and develop an individualized treatment. The authors focused on finding novel approaches to reduce CVD mortality during a pandemic.

The Benefits of Telemedicine in Personalized Prevention of Cardiovascular Diseases (CVD): A Systematic Review

INTRODUCTION

Adverse effects on personalized care and outcomes of cardiovascular diseases (CVD) could occur if health systems do not work in an efficient manner. The pandemic caused by COVID-19 has opened new perspectives for the execution and advancement of cardiovascular tests through telemedicine platforms.

OBJECTIVE

This study aimed to analyze the usefulness of telemedical systems for providing personal care in the prevention of CVD.

METHODS

A systematic review analysis was conducted on the literature available from libraries such as PubMed (Medline), Scopus (Embase), and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Data available in the last 10 years (2011-2020) were also examined by PRISMA guidelines. The selected studies were divided into two categories: (1) benefits of telemedicine in CVD prevention, and (2) recent progress in telemedical services for personalized care of CVD.

RESULTS

The literature search produced 587 documents, and 19 articles were considered in this review. Results highlighted that the timely delivery of preventive care for CVD which can be implemented virtually can benefit and modify morbidity and mortality. This could also reduce the pressure on hospitals by decreasing acute CVD occurrence among the general population. The use of these technologies can also help to reduce access to hospitals and other medical devices when not necessary.

CONCLUSIONS

Telemedicine platforms can be used for regular checkups for CVD and contribute to preventing the occurrence of acute events and more in general the progression of CVD.

Telemonitoring and Care Program for Left Ventricular Assist Device Patients During COVID-19 Outbreak: A European Experience

Coronavirus disease 2019 (COVID-19) radically modified the organization of healthcare systems with shutdown of routine activities and outpatient clinics. Herein, we report our institutional experience with a Telemonitoring and Care Program (TC-Program) to monitor and support left ventricular assist device (LVAD) patients during COVID-19 outbreak. This single-arm cohort study analyzed 156 patients who entered the TC-Program at our institution between April and August 2020. The TC-Program was based on routine phone calls to patients and a 24/7 emergency line. In November 2020, patients were asked for feedback on the TC-Program and checked for survival, transplant, or explant. The primary endpoint was the rate of TC-Program-driven interventions. Patients (males: 82.8%) were 61 years old (interquartile range [IQR]: 53.0-67.5) and on LVAD support for 1,266 days (IQR: 475-2,211). Patients were included in the TC-Program for a median time of 99 days (min:15, max:120) and received a median number of six phone calls (min:1, max:14). Twenty-three patients (14.7%) were referred for clinical evaluation after phone contact. Two patients (1.27%) were diagnosed with COVID-19: one of them died after intensive care, and one remained paucisymptomatic and recovered. Three patients asked to exit the program considering it not useful while the others gave high rates in terms of usefulness (median: 9, IQR: 8-10), information (median: 9, IQR: 8-10), good medical care (median: 9, IQR: 8-10), and psychologic support (median: 8, IQR: 7-10). A TC-Program based on the four ICSA principles (Inform, Care, Support, and Adapt) is feasible in LVAD patients and can be rapidly implemented during the COVID-19 pandemic.

The COVID-19 pandemic: challenges in providing supportive care to those with cardiovascular disease in a time of plague

PURPOSE OF REVIEW

COVID-19 has permeated the very essence of human existence and society and disrupted healthcare systems. The attrition stemming from this highly contagious disease particularly affects those rendered vulnerable by age and infirmity, including those with underlying cardiovascular disease. This article critically reviews how best to integrate supportive care into the management of those affected.

RECENT FINDINGS

Numerous studies have described the pathophysiology of COVID-19, including that specifically arising in those with cardiovascular disease. Potential treatment strategies have emerged but there is limited guidance on the provision of palliative care. A framework for implementation of this service needs to be developed, perhaps involving the training of non-specialists to deliver primary palliative care in the community, bolstered by the use of telemedicine. The appropriate use of limited clinical resources has engendered many challenging discussions and complex ethical decisions. Prospective implementation of future policies requires the incorporation of measures to assuage moral distress, burnout and compassion fatigue in healthcare staff who are psychologically and physically exhausted.

SUMMARY

Further research based on patient-centred decision making and advance care planning is required to ensure the supportive needs of COVID-19 patients with cardiovascular disease are adequately met. This research should focus on interventions applicable to daily healthcare practice and include strategies to safeguard staff well-being.

Heart Failure and Coronavirus Disease-19

Globally, 4.2% population suffer from heart failure. The condition has a mortality rate between 56% and 78%. Coronavirus disease-2019 (COVID-19) was first reported in December 2019 and became a pandemic since March 11, 2020. As COVID-19 emerges, cardiovascular disorders including, heart failure, become one of the most common comorbidity that increase the risk for contracting the disease. Heart failure and COVID-19 have reciprocal relationship. Patients with heart failure are at higher risk for COVID-19 with more unfavorable outcome. COVID-19 itself may deteriorate pre-existing heart failure in the subject. This situation is mediated by the presence of angiotensin converting enzyme-2 (ACE-2) in cardiac myocytes and pericytes, direct effect of viral invasion to myocytes and pericytes, downregulation of ACE-2 which hampers cardiovascular function, and uncontrolled inflammation known as cytokine storm. Prudent management, including implementation of telemedicine, continuation of ACE inhibitor and angiotensin receptor blocker, and medications’ side effects monitoring, is important in managing patients with coexisting heart failure and COVID-19.

Frailty in Acute and Chronic Coronary Syndrome Patients Entering Cardiac Rehabilitation

Worldwide population ageing is partly due to advanced standard of care, leading to increased incidence and prevalence of geriatric syndromes such as frailty and disability. Hence, the age at the onset of acute coronary syndromes (ACS) keeps growing as well. Moreover, ageing is a risk factor for both frailty and cardiovascular disease (CVD). Frailty and CVD in the elderly share pathophysiological mechanisms and associated conditions, such as malnutrition, sarcopenia, anemia, polypharmacy and both increased bleeding/thrombotic risk, leading to a negative impact on outcomes. In geriatric populations ACS is associated with an increased frailty degree that has a negative effect on re-hospitalization and mortality outcomes. Frail elderly patients are increasingly referred to cardiac rehabilitation (CR) programs after ACS; however, plans of care must be tailored on individual's clinical complexity in terms of functional capacity, nutritional status and comorbidities, cognitive status, socio-economic support. Completing rehabilitative intervention with a reduced frailty degree, disability prevention, improvement in functional state and quality of life and reduction of re-hospitalization are the goals of CR program. Tools for detecting frailty and guidelines for management of frail elderly patients post-ACS are still debated. This review focused on the need of an early identification of frail patients in elderly with ACS and at elaborating personalized plans of care and secondary prevention in CR setting.

Cardiac rehabilitation via telerehabilitation in COVID-19 pandemic situation

Background

Adherence to medication and lifestyle changes are very important in the secondary prevention of cardiovascular disease. One of the ways is by doing a cardiac rehabilitation program.

Main body of the abstract

Cardiac rehabilitation program is divided into three phases. The cardiac rehabilitation program’s implementation, especially the second phase, center-based cardiac rehabilitation (CBCR), has many barriers not to participate optimally. Therefore, the third phase, known as home-based cardiac rehabilitation (HBCR), can become a substitute or addition to CBCR. On the other hand, this phase is also an essential part of the patients’ functional capacity. During the coronavirus disease-2019 pandemic, HBCR has become the leading solution in the cardiac rehabilitation program’s sustainability. Innovation is needed in its implementation, such as telerehabilitation. So, the cardiac rehabilitation program can be implemented by patients and monitored by health care providers continuously.

Short conclusion

Physicians play an essential role in motivating patients and encouraging their family members to commit to a sustainable CR program with telerehabilitation to facilitate its implementation.