Heart Failure With Preserved Ejection Fraction: Current Status and Future Opportunities - Episode 21

Heart Failure Management During COVID-19

The program is closed with a discussion on how the coronavirus pandemic has affected the standard protocol for treating patients with heart failure.

Jaime Murillo, MD: How has COVID-19 [coronavirus disease 2019] affected the management of heart failure? It has been significant. We keep track of the utilization of the ED [emergency department] space, for instance, and back in the months of March and April, we saw utilizations around 45% to 50%, and it has slowly trended up. As of last month, it was close to 94%. Office visits are dismal. Many offices are closed, so we’re talking about utilization rates around 12% for 1 month in several parts of the country. It has slowly risen back up, so it may be around 80% now.

Interestingly, the pharmacy was not affected by COVID-19. You may be surprised to hear that. You can probably explain this with 2 things. The first is that, when people thought that everything was going to get closed, they quickly rushed to fill their medications. We see a spike around the month of February beginning, when COVID-19 was starting, and the utilization ran up to 100%, maybe with some dips and ups. In general, that’s the only area. If you look at outpatient, inpatient, and ED utilization, those took a huge dip during COVID-19.

The bad part about it is that the main patients who needed attention did not seek care because they didn’t want to go to the ED and leave the hospital infected with COVID-19. That was a major fear, and it continues to be so in many places. They didn’t have access to their office either because their doctors closed their offices. What we have seen and what we haven’t even seen the whole effect of is that a lot of patients who are now coming to seek care are sicker. They require longer lengths of stays in the hospital or a prolonged length of a stay. They have more comorbidities because their conditions were not treated on a timely basis. Many have probably died because of this, sadly.

As you know, there are some parts of the country where the incidence of “sudden death” went up 5000%. I bet it’s not all COVID-19. I bet a lot of that, especially in the cardiovascular space, is brought about by heart attacks and even heart failure. Patients who probably had fatal arrhythmias secondary to heart failure died at home because they didn’t gain appropriate, timely access to care, because they were afraid of COVID-19. It has certainly created a lot of that. This highlights and underscores the importance of instituting a system whereby we can have a better contact with the patients by providing those 2 strategic approaches: first, digital access, and second, care at home.

Another good question is about how to ensure that we get to those patients before they either have an exacerbation of heart failure or, even better, before they get diagnosed with heart failure. There’s a lot of work on the predictive analytics side, which is something for which we have a huge opportunity to utilize machine learning tools and better discriminate the models that we use to ascertain which populations are at risk and start a collaboration between those scientists and the clinicians. We sometimes see models that don’t quite make sense clinically when it comes to putting them into practice. There is a huge opportunity to use predictive analytics to predict either new onset heart failure or exacerbation.

Another area where we have another huge opportunity is with the creation of standardized protocols. I know I’m not saying anything new. There are many systems that already have this standardization. But if you’re utilizing a chart in a way that makes the doctor’s life easier by saying, “If you go into this protocol, you’ll have access to guidelines-based therapy, so you can treat your patients and don’t have to think much about it,” then that’s great.

What would be even better would be putting those protocols in the hands of people who are not necessarily at the top of the licensure scale. This means that cardiologists and primary care doctors can supervise that standardized approach and have nurses, pharmacists, or even nonclinicians—obviously being adequately supervised—provide the standardized protocols to patients on a regular basis because we know a cardiologist or a primary care physician doesn’t always have the time to contact those patients. If they can use those standardized protocols for the treatment of heart failure, we will have another good opportunity to prevent admissions when they’re using guidelines-based therapies.