Short-term Outcomes in Ambulatory Heart Failure during the COVID-19 Pandemic: Insights from Pulmonary Artery Pressure Monitoring.

Coronavirus disease-2019 (COVID-19) has surpassed 1.5 million confirmed cases in the United States and more than 92,000 deaths have been recorded. COVID-19 has impacted health care systems worldwide, affecting care and outcomes of non-COVID cardiovascular illnesses. , However, the impact on the outcomes of patients with heart failure (HF) remains largely unexplored. Preliminary data suggest a decline in emergency department (ED) visits for HF during the pandemic, but with worse outcomes in hospitalized patients, possibly due to patients’ concerns about COVID-19 exposure prompting late presentation.4, 5, 6 We examined the impact of the COVID-19 pandemic on HF disease management through the lens of ambulatory hemodynamic monitoring of high-risk patients.

Methods

We retrospectively reviewed all patients actively managed at our institution if they had pulmonary artery pressure (PAP) sensors 57 days before and after March 11, 2020 (declaration of state of emergency in Massachusetts). Patients with left ventricular assist devices or heart transplantations were excluded.

Patients recorded daily PAPs in the recumbent position using a wireless sensor. Routine review of PAP trends by clinicians was performed 1–6 times per month, and concerning trends triggered clinician-patient contact. PAP volatility was defined as the difference between the measured PAP and a preset target PAP. Frequency of clinical activities, diuretic adjustments, follow-up visits, and worsening events due to heart failure (HF) (combining ED visits and HF hospitalizations [HFHs]) were examined. Paired sample t tests or Wilcoxon signed-rank tests were used for continuous variables, depending on their distribution. Pearson ꭕ2 or Fisher exact tests were used for categorical variables. This project was undertaken as a quality-improvement initiative and was exempt from ethics committee review per institutional policy.

Results

Our inclusion criteria were met by 21 patients (mean age 60 ± 15 years, 14 (67%) women; 12 (57%) had preserved ejection fraction ≥ 50%), and 17 (81%) had hypertension). A total of 1162 hemodynamic transmissions were recorded, including 577 in the period prior to COVID-19 and 585 during the pandemic (median 49 [23-86] measurements per patient).

During the post-COVID period, PAP volatility increased, with more frequent deviations above the preset PAP threshold (from a median of 4 per patient (2–24) to 10 (4–26), P= 0.170), but time-averaged PAP continuous measurements remained stable (35 ± 8 vs 37 ± 10, 18 ± 5 vs 18 ± 5, and 24 ± 6 vs 25 ± 7 for systolic, diastolic and mean PAPs before and after March 11, respectively; P> 0.05 for all) (Fig. 1 ). Clinician-initiated patient contacts increased during the pandemic from a median of 3 per-patient (1–6) to 6 (3–9) (P= 0.003), with a total of 52 additional contacts for the aggregate cohort. The number of scheduled clinical visits (face-to-face or telemedicine) decreased in the post-COVID period from 18 to 9 for the aggregate cohort (P= 0.029). Finally, fewer worsening HF events were noted (1 vs 11, P= 0.024) for the aggregate cohort in the post-COVID period.

Fig. 1

Area chart showing trend in deviation from threshold pulmonary artery pressure over time. PAP = pulmonary artery pressure.

Discussion

In this small cohort of high-risk patients managed by implantable PAP monitors, PAP volatility increased during the COVID-19 pandemic, which may be due to reduced access to healthful food and exercise venues in the context of social-distancing regulations. The increase in PAP volatility was effectively managed by a parallel increase in clinician-patient interactions. The result was that rather than an increase in hospital admissions, as might have been anticipated from the increase in PAP threshold crossings, fewer HFHs were observed during the pandemic. These data suggest that the lower rates of HFH in our cohort are not entirely related to patients’ hesitance to seek medical care but are at least partially due to effective remote management.

The pandemic has strained health care systems worldwide, highlighting the need for effective strategies for remote management of patients with HF. A single-center Italian study reported a 49% reduction in ED visits for HF in the post-COVID period but with a nearly 3-fold increase in mortality in hospitalized patients, reflecting reluctance to seek medical care. In comparison, our study revealed stable clinical courses and fewer HFHs, albeit in a small sample size, reflecting the potential role of PAP monitoring in managing patients, particularly amid a pandemic, when they have limited access to direct medical care.

As we emerge from the pandemic, these lessons underscore the potential value of PAP monitoring and enhanced patient engagement in limiting the frequency of HF exacerbations. , This analysis, however, should be viewed in the context of important limitations, including small sample size, retrospective study design, a highly selected patient cohort, and short follow-up duration, which cannot rule out the possibility of a rebound increase in HFH as the COVID-19 pandemic subsides. Larger studies are needed to validate the above findings.