Restrictions aimed at curbing the SARS-CoV-2 pandemic have made it necessary to monitor numerous patients with heart failure (HF) through teleconsultation. Telemedicine tools were already known and used before the pandemic. Numerous studies have shown that it is beneficial in reducing heart failure admissions and mortality in these patients.1
This paper describes a group of 71 patients with HF in the Internal Medicine Department of the Hospital Clínico San Carlos in Madrid, who received telephone follow-up during the period from March to September 2020, and analyses which factors contributed to the development of complications such as admission and mortality.
Variables proposed in the infographic on telemedicine in HF, created by the SEMI HF Group, were collected.2 Also baseline patient variables (HF aetiology, history of atrial fibrillation, LVEF, NYHA, BMI, glomerular filtration rate (GFR) according to the CKD-EPI equation and NT-proBNP) and their usual treatment. Changes in treatment, number of emergency department visits, admission and mortality due to HF or SARS-CoV-2 were recorded.
The variables of "emergency department visits”, "admissions” and "mortality” were grouped into a common variable, which was labelled "events”. The total number of patients was divided into two groups according to whether they had events or not and a bivariate analysis was performed.
The mean age of the 71 patients was 87±5.4 years and 77.5% were women. The aetiology of HF was hypertensive in 54.9%, valvular in 26.7% and ischaemic in 15.5% of cases. 91.5% had a history of atrial fibrillation. The mean NYHA score was 2.14±0.66; LVEF was 57%; BMI was 28.2±5.35kg/m2; GFR of 47.1±21.25ml/min/1.73m2 and NT-proBNP of 1610±4701.26pg/mL.
Table 1 shows the variables collected from the SEMI IC group infographic.
Variables of the SEMI IC group infographic.
| Variable (%) | |
|---|---|
| Family support | 92.9 |
| Telecare | 63.4 |
| Problems getting around | 50.7 |
| Falls in the last month | 11.6 |
| Use of salt in food | 7.2 |
| Drinks more than 1.5 litres a day | 17.3 |
| Decreased appetite | 30.5 |
| Forgetting to take medication | 1.4 |
| Dyspnoea | 36.2 |
| Orthopnoea | 11.6 |
| Paroxysmal nocturnal dyspnoea | 4.3 |
| Weight gain | 24.6 |
| Oedema in lower limbs | 18.8 |
| Risk contact for SARS-CoV-2 infection | 5.6 |
| Fever | 8.4 |
| Dry cough | 2.8 |
| Confirmed SARS-CoV-2 infection | 12.7 |
| Dyspnoea at rest | 8.5 |
| Heart rate greater than 120 bpm | 1.4 |
| Systolic blood pressure greater than 200 mmHg | 2.8 |
| Chest pain | 0 |
| Loss of consciousness | 0 |
| Systolic blood pressure less than 80 mmHg | 0 |
| Heart rate lower than 40 bpm | 0 |
In terms of standard treatment, all patients were receiving loop diuretics, 57.7% beta-blockers, 40.8% ACE inhibitors or ARBs, 38.1% aldosterone antagonists, 9.8% angiotensin-neprilysin receptor inhibitors and 22.53% SGLT2 inhibitors. Some change in treatment was made in 57.7% of the patients (42.8% diuretic; 12.9% beta-blocker and 4.4% antihypertensive).
4.2% went to the emergency department for HF, 11.3% were admitted for HF exacerbation and 8.4% died for the same reason, with 16.9% (n=12) of the total having experienced one of the three events. 4.2% died from SARS-CoV-2 infection.
The patients who had had an event experienced a greater deterioration in GFR (32.7±17.85mL/min/1.73m2 vs. 50.8±20.69mL/min/1.73m2; p<0.001), higher level of NT-proBNP (10316.2±5192.3pg/mL vs. 3163.1±3491.1pg/mL; p<0.001), dyspnoea during follow-up (66.7% vs. 30%; p<0.05), dyspnoea at rest (41.7% vs. 11.8%; p<0.01) and their diuretic treatment was modified to a greater extent (83.3% vs. 33.8%; p<0.01).
The impact of restrictions on outpatient follow-up of HF patients during the SARS-CoV-2 pandemic has been previously studied. DiTano et al. described a cohort of 110 patients with stable chronic HF and optimized treatment.3
Compared to the previous cohort, our patients were older and scored worse on the NYHA scale. The main symptom reported was dyspnoea, in a higher proportion than in the Di Tano et al. study, which led to changes in medication, mainly diuretic treatment.
Severino et al. monitored and compared two groups of patients, depending on whether they had face-to-face or telephone check-ups, for 12 months.4 No significant differences were found in hospitalizations or mortality from cardiovascular causes.
Inglis et al., in their systematic review, raised age as one of the factors that could precipitate telemedicine failure in these patients, but found no evidence of this.5 Renal failure, elevated NT-proBNP level and the presence of dyspnoea during follow-up were associated with a higher percentage of events in our sample.
To prevent these from occurring, we propose face-to-face assessment of the patient presenting with dyspnoea, and closer follow-up in those with chronic renal failure or extremely elevated NT-proBNP levels.
The study has been approved by the hospital's clinical research ethics committee.
