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      Letter to the Editor: Pulmonary Artery Pressure Monitoring during the COVID-19 Pandemic in New York City

      letter
      , MD MSc, , MD, , MD, , MD, , MD *
      Journal of Cardiac Failure
      Elsevier Inc.
      Telemedicine, Heart failure, COVID-19

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          Abstract

          To the Editor Almufleh. et al 1 describe the impact of the Coronavirus disease 2019 (COVID-19) pandemic on 21 patients with heart failure (HF) monitored with the implantable CardioMEMS-3 system in Massachusetts before and after March 11th 2020 when a state of emergency was declared. Pulmonary artery pressure (PAP) volatility in the post COVID-19 period increased, with higher frequency of patients crossing pulmonary artery diastolic (PAD) thresholds, but concomitant increase in clinician calls and interventions and a reduction in HF hospitalizations. The authors conclude that effective remote monitoring management was at least partly at play in preventing hospital admissions in this small cohort. We also conducted a retrospective chart and remote monitoring review of 49 patients with wireless implantable hemodynamic monitoring (W-IHM), of whom 40 were actively followed at our institution from February 1st to April 22nd (pre-COVID-19 and during COVID-19 period) in New York. The first confirmed case of COVID-19 in New York State (NYS) was on March 1st. On March 22nd, the “NYS on Pause Program” went into effect with a statewide stay-at-home mandate including closure of non-essential businesses. It was during this time that NYS was the global epicenter of the COVID-19 pandemic. As of July 15, 2020, 404,775 patients tested positive for COVID-19 in New York State (NYS) which represented the highest number of cases in the United States at that time. 2 We similarly aimed to ascertain whether stay-at-home mandates would result in changes in pulmonary artery diastolic pressures among patients with HF and W-IHM. In our larger cohort, we made the following observations: 1) the rate of W-IHM transmissions by patients increased as did the number of interventions by clinicians (phone calls, text messages and video encounters) during the pandemic; 2) there was no significant difference in the mean PADP prior to and during COVID-19 (19.4 ± 5.6 mmHg and 18.9 ± 6.7 mmHg (p = 0.654) respectively), nor was there a difference in the mean HR (79.9 ± 14.4 vs. 78.9 ± 15.3 bpm (p = 0.8105) respectively) (Figure 1 ); 3) the number of HF hospitalizations was lower during the pandemic. Figure 1 (A & B) Trends in Average Pulmonary Artery Diastolic Pressure and Heart Rate: Pre- COVID-19 (February1, 2020 to February 29, 2020) and during COVID-19 (March 22, 2020 to April 22, 2020. Figure 1 Patients transmitted readings an average of 17.8 ± 9.1 times per month in the period pre-COVID 19 compared to 18.9 ± 9.9 times per month during COVID-19 (p=0.526). During the latter period, individuals had a range of 0 to 4 interventions in a month, and of those, 13 (32.5%) had an increase in diuretics, 8 (20%) had a decrease in diuretics, and 1 (2.5%) had a change in guideline directed medical therapy. Similarly, during COVID-19, individuals had a range of 0 to 5 interventions in a month, and of those, 16 (40%) had an increase in diuretics, 7 (17.5%) had a decrease in diuretics, and 1 (2.5%) had a change in guideline directed medical therapy. Our study has similar limitations to those reported by Almufleh et al, in that generalizability is limited due to the small cohort size and retrospective study design. Behavioral changes as a result of home isolation during the COVID-19 pandemic may be bidirectional. Increased anxiety may drive poor dietary choices. Conversely, a reduction in daily activity may decrease autonomic tone and result in increased medication compliance, daily weight monitoring and transmission of PAP via W-IHM. As COVID-19 continues to spread and result in morbidity and mortality, reliance on remote monitoring is likely to increase. We agree with Almufleh et al that vigilant monitoring, and in particular management of remote monitoring devices, may at least in part explain the decrease in HF hospitalizations despite patient reluctance to seek medical care; however, we failed to find the initial PAP volatility reported in Boston. More reports are needed to determine the effects of social changes inflicted by COVID-19 restrictions on congestion, compliance and outcomes among patients with HF and W-IHM.

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          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 with over 92,000 deaths. 1 COVID-19 has impacted healthcare systems worldwide affecting care and outcomes of non-COVID cardiovascular illnesses. 2 , 3 However, impact on 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’ concern of 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 with pulmonary artery pressure (PAP) sensors 57 days before and after March 11, 2020 (declaration of state of emergency in Massachusetts). Patients with a left ventricular assist device or heart transplantation 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/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 HF events (combining ED visits and HF hospitalizations (HFH)) were examined. Paired sample t-tests or Wilcoxon signed-rank tests were utilized for continuous variables depending on their distribution. Pearson Chi-square or Fisher's 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 Twenty-one patients met our inclusion criteria (mean age 60 ± 15 years, 14 (67%) women; 12 (57%) had preserved ejection fraction (LVEF≥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 11th, respectively, p>0.05 for all). (Figure 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. Figure 1 Area chart showing trend in deviation from threshold pulmonary artery pressure over time. PAP = pulmonary artery pressure Figure 1 DISCUSSION In this small cohort of high-risk patients managed with an implantable PAP monitor, PAP volatility increased during the COVID-19 pandemic, which may be due to reduced access to healthy food and exercise venues in the context of social distancing regulations. The increase in PAP volatility was effectively managed with 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 lower rates of HFH in our cohort are not entirely related to patients’ reticence to seek medical care, but at least partly due to effective remote management. The pandemic has strained healthcare systems worldwide, highlighting the need for effective strategies for remote management of patients with HF. A single-center Italian study reported 49% reduction in ED visits for HF in the post-COVID period but with nearly 3-fold increase in mortality in hospitalized patients, reflecting reluctance to seek medical care. 6 In comparison, our study revealed stable clinical course and fewer HFHs, albeit in a small sample size, reflecting the potential role of PAP monitoring in managing patients particularly amidst 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. 7 , 8 This analysis, however, should be viewed in the context of important limitations including small sample size, retrospective study design, highly selected patient cohort and short follow-up duration which cannot rule out the possibility of rebound increase in HFH as COVID-19 pandemic subsides. Larger studies are needed to validate the above findings. Declaration of Competing Interest ASD reports consulting from Abbott, Alnylam, Amgen, AstraZeneca, Biofourmis, Boston Scientific, Boehringer-Ingelheim, DalCor, Merck, Novartis, Relypsa, Regeneron. He also reports research Grants from AstraZeneca, Novartis, Alnylam. MMG reports institutional research support from Abbott. MRM reports payment made to his institution from Abbott for consulting. Consultant fees from Portola, Bayer, Xogenex, and Baim Institute for Clinical Research, Medtronic, Janssen, NuPulseCV, Leviticus, FineHeart, and Mesoblast. Other authors have no relevant disclosures.
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            Author and article information

            Contributors
            Journal
            J Card Fail
            J. Card. Fail
            Journal of Cardiac Failure
            Elsevier Inc.
            1071-9164
            1532-8414
            14 August 2020
            14 August 2020
            Affiliations
            [0001]Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
            Author notes
            [* ]Corresponding Author: Anuradha Lala, MD, Zena and Michael A. Wiener Cardiovascular Institute, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, One Gustave 1 Levy Place, Box 1030, New York, NY, 10129; Phone: 212-241-7300 anu.lala@ 123456mountsinai.org
            Article
            S1071-9164(20)30907-6
            10.1016/j.cardfail.2020.08.003
            7427572
            32805377
            51f0e57f-5489-4ecb-99ee-7b2d9d17f3e2
            © 2020 Elsevier Inc. All rights reserved.

            Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

            History
            : 30 July 2020
            : 6 August 2020
            : 6 August 2020
            Categories
            Article

            Pharmacology & Pharmaceutical medicine
            telemedicine,heart failure,covid-19
            Pharmacology & Pharmaceutical medicine
            telemedicine, heart failure, covid-19

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