Heart failure-related hospitalisation and management during the COVID-19 pandemic: a reflection. Reply.

‘COVID‐19 alert: stay at home if you feel unwell’. This wording represents the leading recommendation of a Google landing page displaying to anyone seeking hospitals addresses and contacts during the COVID‐19 outbreak. Such a message resumes the huge failure in communication that occurred during this unprecedented event. The perception of hospitals as unsafe places, carrying a higher risk to diffuse contagion, along with patients' honest desire not to overwhelm a massively stressed healthcare system lead to untoward and unfavourable consequences. Several reports showed indeed a remarkable decrease in hospital admissions even for life‐threatening conditions such as acute coronary syndromes (ACS) and heart failure (HF). , , Despite initially some people argued that many explanations could account for such circumstance (e.g. air quality improvement, reduction of exposition to stressful situations), the suddenness and the amplitude of the phenomenon strongly suggest a population‐based behavioural pattern. The recent work by Baldi et al., showing a clear correlation between the COVID‐19 epidemic trend and the increased incidence of out‐of‐hospital cardiac arrests in four Italian provinces highly burdened by the disease, confirms that many preventable non‐COVID deaths must be added to the toll of the pandemic. The interesting letter by Shah et al. correctly questions if the medical community could have been more pro‐active in reaching out to patients with cardiological issues during the pandemic, suggesting that remote control monitoring could have provided key support for patients suffering from HF. Authors' thoughts indirectly highlight how there is still hesitancy in considering remote monitoring as a core‐part of the standard clinical care, in contrast with a demonstrated cost‐effectiveness benefit of these practices both from a clinical and an economic point of view.

Reasons to explain such reluctance lie in cultural and logistic issues. The successful development of telemedicine must go through a fair balance between a ‘high‐tech’ and a ‘high‐touch’ assistance, aiming to maintain a patient‐focused healthcare system. Further, the spread of remote monitoring requires a robust implementation of a dedicated organization model ensuring the adequate formation of the professionals involved (e.g. trained nurses), a clear definition of roles, responsibilities and liabilities, a universal recognition of medical actions that can be performed remotely along with their traceability, the actual implementation of these measures by patients and last but not least their reimbursement. On the other hand, it must be acknowledged that while remote monitoring could successfully work to prevent HF hospitalization, it could be less effective to prevent patients' underestimation of ACS‐related symptoms. However, if an effective remote contact system had already existed before the COVID‐19 outbreak, patients might have been more likely to seek medical attention for serious illnesses. COVID‐19 outbreak could have represented a singular pilot context to boost e‐health programmes and to understand patients' acceptance of such integrated assistance. Unfortunately, it highlighted major organizational gaps that should be absolutely addressed soon, particularly in case of a second wave of the infection. Let us work pro‐actively in this direction and change the motto to: ‘COVID‐19 alert: seek your healthcare professionals if you feel unwell’!