Continuing Preventive Care During the COVID-19 Pandemic: Discussion of Recent ASPC Recommendations

Anjali Wagle, MD; Nino Isakadze, MD; Tiffany Eatz, BS; Roger S. Blumenthal, MD, FACC; Seth Shay Martin, MD, MHS, FACC

Disclosures

August 12, 2020

The direct medical and financial effects of the Coronavirus disease 2019 (COVID-19) pandemic have been staggering as healthcare systems and clinicians have risen to the challenge of caring for large numbers of infected patients. To curb viral transmission, many outpatient clinics and pharmacies have limited hours and in-person availabilities. While the implications of these changes are far-reaching across the population, patients with cardiovascular diseases (CVD) are of particular concern for increased morbidity and mortality due to direct exposure to COVID-19 and indirectly from the interruptions in care.

The recent statement from the American Society for Preventive Cardiology provides several recommendations on how clinicians can continue outpatient care and mitigate effects from lapses in health care.[1] Here we summarize and discuss those recommendations.

Impact of Comorbidities on COVID-19 Disease

Patients with pre-existing comorbidities, particularly those with CVD, who become infected with COVID-19 appear to have more severe courses and worse outcomes. Patients with diabetes seem to have a higher risk of severe pneumonia, increases in inflammation, and hypercoagulability compared to patients without comorbidities. Similarly, those with hypertension show increased risk of severe infection.[2,3]

Patients infected with COVID-19 who have CVD have an estimated mortality rate of 10.5%, while those with diabetes have a rate of 7.3%, and those with hypertension a rate of 6.0% compared to an estimated general mortality rate of 3.8%.[4,5] Additionally, of the patients who are infected with COVID-19, high rates of cardiac arrhythmias have been reported. Of 138 patients in a Chinese cohort, 16.7% experienced new onset arrhythmia.[6] Rates of arrhythmias were higher in patients admitted to the intensive care unit compared to ones requiring lower level of care (44.4% vs. 6.9%). A minority of patients have also developed other cardiovascular syndromes including cardiogenic shock, acute myocardial injury, atherosclerotic plaque rupture, and heart failure.[7]

Many patients with CVD, diabetes, or hypertension are also on angiotensin-converting enzyme inhibitors (ACEIs), which upregulates the transmembrane enzyme angiotensin-converting enzyme 2 (ACE2). The SARS-CoV-2 virus was found to utilize ACE2 for cellular internalization, which created some concern about the use of ACEIs and may have inadvertently led some patients to discontinue their use of ACEIs.[8] Alternatively, some have hypothesized protective effects of ACEIs for both disease severity and mortality.[9] Given the lack of clinical data to support the harmful effects of ACEIs, and substantiated evidence of effectiveness of ACEIs in management of hypertension and heart failure, all major societies recommend continuing ACEI or angiotensin receptor blocker (ARB) therapy in patients with COVID-19.

Challenges in Continuity of Care and Outpatient Management

The effects of the COVID-19 pandemic have had far reaching implications beyond those who have the disease. Admissions for acute coronary syndromes, decompensated heart failure, stroke, and ST-segment elevation myocardial infarction catheter lab activations have all decreased.[10,11] The diminished admissions are perhaps in part due to patient reluctance to be hospitalized and guidance from health officials to stay at home. It is critical that healthcare workers educate patients not to delay seeking care when they are experiencing concerning symptoms. Similarly, efforts to provide quality medical care while maintaining social distancing practices have created unique challenges including maintaining rapport through video clinic visits, cardiac rehabilitation opportunities, and medication availability and ensuring care for patients without technologic access.

There are also specific populations where these challenges are having a greater impact including those with lower socioeconomic status or living in rural areas. Access to medication is also especially difficult for elderly patients who are advised to stay home.

Strategies for Improvement

While the COVID-19 pandemic has caused significant changes to our healthcare delivery system, there are many opportunities to mitigate CVD progression and improve health in our society. Clinicians across the country have continued seeing their outpatients in the era of social distancing via telemedicine visits. Telemedicine includes communication between patients and clinicians using audiovisual means without specifying the specific platform used. Dr. Athena Poppas et al. state that "telehealth is in some ways a return to the days of personal home visits."[12] Previously, the Department of Health and Human Services (HHS) had limitations on reimbursement, which stifled widespread use of this modality. However, during the COVID-19 pandemic, HHS has expanded reimbursement for telemedicine visits for all patients via phone or video call to ensure maximum uptake.[13] As of March 30, 2020, it is estimated that approximately 75% of all outpatient cardiology encounters moved to telehealth.[14]

Cardiac rehabilitation (CR) is a potential opportunity for telehealth delivery (called home-based cardiac rehabilitation or HBCR) to decrease the potential lapse of CR that patients experience during the pandemic but also to increase access to this historically underutilized program. However, HBCR currently lacks reimbursement and there is a need for HBCR to advocate for increased reimbursement for sustainability outside of research settings.[15]

Telemedicine can be more effective utilizing remote patient monitoring (RPM) systems, where patients track and record their own data and collect digital biomarkers outside clinic/hospital such as vital signs, heart rhythm, glucose, or weight. Further development of such systems via user-centered design could enhance patient engagement in their care.

There are also creative ways to improve access and adherence to medications during this time. There needs to be removal of barriers to providing appropriate medications including prior authorizations and repeat laboratory tests or approval. Additionally, once patients have their medications, the full care team of nurses and pharmacists can, in their various capacities, call and remind patients, refill medications, and inquire about possible side effects with patients. In fact, the team-based care delivery has potential even outside of medication adherence. Since many primary care providers are being reassigned to inpatient units, there is a vacancy for the care of chronic diseases for outpatients. Carter et al. found that team-based care, with pharmacists and nurses guiding treatment, was associated with improved blood pressure (BP) control.[16]

Coping with Stress or Anxiety and Maintaining Lifestyle Habits

Social distancing has made it more challenging to maintain relationships. When compounded with the pandemic, this may exacerbate mental illnesses such as anxiety and depression. High perceived stress has been associated with a moderately increased risk of incident coronary heart disease.[17] Increased stress levels have also been associated with dietary indiscretion and rising tobacco use.[18,19] Additionally, increasing stay-at-home recommendations and closures of public gyms have made it more difficult to maintain physical activity.

Healthcare providers can continue to promote mental and physical health throughout the pandemic. To ameliorate psychological stressors, patients can be encouraged to stay connected with their loved ones via technology. Patients can be counseled on at-home exercises and healthy diet recommendations to improve their cardiovascular health. Lastly, patients' tobacco habits should be re-visited at every appointment and appropriately directed to online resources, nicotine replacement therapies, and behavioral interventions.

Conclusion

The COVID-19 pandemic has drastically impacted both acute and chronic cardiovascular illnesses. If patients are unable to receive their regular healthcare, the pandemic toll will grow significantly as previously avoidable diseases develop. Healthcare providers are charged with adapting to the challenges to maintain continuity of care for their patients. Since the pandemic has started, there have been incredible acts of flexibility and creativity to maintain healthcare delivery to patients. By continuing to improve on such ideas and adapting them to individual practices, the impact of this pandemic on patients with CVD will be minimized.

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