To the Editor
Almufleh. et al
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.
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.
(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.
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.