In This Article
- Health care providers should work to minimize exposure risk for themselves and their patients
- Patients should be counseled to avoid hesitation and seek help in a health emergency
- Providers can utilize telehealth and virtual visit platforms in order to engage patients in both lifestyle interventions and medication management for primary and secondary CVD prevention
In an effort to maintain social distancing and prevent community transmission during the COVID-19 pandemic, many hospitals are postponing or canceling elective or non-urgent appointments and procedures. In this Q&A, Jay Khambhati, MD, cardiology fellow, Tinamarie Desmarais, RN, clinical research nurse, Kathleen C. Traynor, RN, MS, FAACVPR, co-director and Pradeep Natarajan, MD, MMSc, co-director of the Cardiovascular Disease Prevention Center at Massachusetts General Hospital, describe how providers can ensure their patients at risk for cardiovascular disease (CVD) can stay healthy.
Q: What should providers know about keeping their patients with CVD safe during this time?
A: Health care providers should work to minimize patient exposure risk to COVID-19 through minimizing nonurgent encounters, tests and procedures, as well as informing patients of COVID-19 prevention measures expressed in CDC recommendations along with state and federal guidelines. Similar to patients, health care providers should regularly use soap and water or an alcohol-based rub to wash their hands for at least 20 seconds, clean high-touch surfaces, practice physical distancing, avoid touching their face, follow good respiratory hygiene and utilize masks when physical distancing is not possible.
Ensuring patients' chronic medical conditions are under control and no acute or threatening medical conditions are being neglected continues to be a unique challenge to the health care community. Given the context of the COVID-19 pandemic, patients may fear pursuing higher levels of medical care for urgent and life-threatening cardiac conditions. Patients should be counseled to avoid hesitation and to seek help in a health emergency. Health care providers and patients with CVD can work together to utilize telehealth or virtual health platforms to closely manage a number of chronic cardiovascular conditions, including heart failure, diabetes, hypertension, coronary artery disease and atrial fibrillation. Home blood pressure and weight monitoring can serve as objective measures to facilitate clinical decision making. Fully leveraging all capabilities of the electronic medical record (EMR) to communicate securely with patients is an important augment to care and patients should be encouraged to activate their individual patient portals if not already done.
Deferring routine cardiac ultrasonography in patients who do not pose significant short-term risk should be considered in the near term to minimize the risk of transmission of COVID-19 to both health care workers and patients, and to preserve personal protective equipment (PPE) for health care systems. Short-term clinical benefit should be determined by the ordering clinician, and appropriate use criteria for transthoracic (TTE) and transesophageal echocardiograms (TEE) should be applied in all cases. If there is no significant risk for morbidity and mortality and minimal short-term clinical benefit, routine TTE should be deferred in the short term. TEE carries a higher risk of spread of COVID-19 due to the potential for aerosolization of the virus during the procedure. Other imaging modalities (including CT, MRI) should be considered while weighing the risks for other modalities and keeping proper sterilization procedures to safely perform these studies in mind.
Lastly, treadmill or bicycle stress echocardiograms should be converted to pharmacologic nuclear stress tests if deemed absolutely necessary or deferred in the short term. If sonography is urgently indicated, focused, abbreviated protocols should be employed in order to minimize the risk of transmission to both patients and health care providers.
Q: What can providers do to help their patients with CVD prevention during this time?
A: Providers can utilize telehealth and virtual visit platforms in order to engage patients in both lifestyle interventions and medication management for primary and secondary CVD prevention. Maintaining connections with your patients during this exceptional time is critical. Providers should also continue to refer and seek the help of beneficial resources and programs such as Cardiac Rehabilitation and other credible lifestyle management programs and resources. Massachusetts residents eligible for traditional center-based cardiac rehabilitation could be newly enrolled in a new virtual cardiac rehabilitation hosted by the Mass General Cardiovascular Disease Prevention Center.
Q: What can providers do to encourage your patients to continue their routines, treatment and care?
A: Health care providers should encourage patients to follow healthy dietary patterns as recommended by the 2019 AHA/ACC prevention guidelines. Ensuring that patients have access to a diet rich in vegetables, fruits, whole grains, lean vegetable or animal protein, fish, seeds and nuts is important for weight control and mitigating classic CVD risk factors. Similarly, providers should recommend avoiding calorie-dense and poor nutritional options, including sugar-sweetened beverages, excessive red meat, saturated fats, trans fats, prepackaged foods rich in sodium and refined carbohydrates. A novel challenge will be for providers to encourage a daily routine incorporating both social distancing while simultaneously recommending physical activity of moderate intensity for at least 30 minutes a day/150 minutes a week. Utilizing low-cost or free virtual health and exercise platforms online can further reinforce these recommendations.
Providers should ensure access and adherence to critical cardiovascular medications, including aspirin, P2Y12 inhibitors, statins and other lipid-lowering agents, anti-hypertensives, rate control agents, rhythm control agents and anticoagulation therapies, through telehealth and virtual visit counseling and providing 90-day prescriptions with sufficient refills.
Q: What's the best way to get the most out of a virtual visit with a patient?
A: Virtual and telehealth visits are critical for routine health maintenance encounters in order to minimize the risk for patient exposure to COVID-19. The virtual space can provide a number of unique opportunities for both patients and clinical providers. By utilizing weight scales, home blood pressure monitoring, thermometers and pulse oximeters, health care providers can obtain important objective data in addition to discussing the presence of disease-related symptoms over the phone or over video-conferencing. Unfortunately, the opportunity to perform a thorough physical exam may be lost. Providers can create multiparty virtual chats or conference calls with the patient, key health care proxies and multidisciplinary health teams (primary care providers, subspecialty providers, etc) to deliver highly efficient care.
Video conferencing can provide further context of an individual's living situation, including who the patient lives with, the presence and location of home medications, potential fall risks and many more variables related to health. In turn, this can further assist providers in individualizing delivery of care for complex, chronic health conditions, especially in older patients.
Lastly, telehealth or virtual visits may provide health care workers with a unique avenue to understand the presence of socioeconomic disparities in care that may be exacerbated within the context of COVID-19. Understanding a patient's capability to self-isolate and details of their living situation may allow providers to inform patients of essential resources to mitigate the spread of disease.
Q: What resources can providers share with their patients to continue their CVD prevention at home?
From the American Heart Association:
- What heart patients should know about coronavirus
- Health emergency? Don't hesitate to get help
- Do's and don'ts of social interaction during a pandemic
- My life check, AHA simple 7
From the American College of Cardiology:
From the Centers for Disease Control and Prevention:
Q: How can providers help to reassure their CVD patients during the pandemic?
A: The COVID-19 pandemic has understandably created elevated anxiety and stress across the United States and globally. Reassurance, addressing patient concerns, assistance with formulating short-term, individualized medical plans of care and reinforcing healthy coping strategies to uncertainty may alleviate this sense of anxiety. Providing context of the illness and reminding patients that the vast majority of those infected will exhibit very mild symptoms may reassure patients. A healthy diet, remaining well hydrated, routine exercise, avoiding sedentary behavior and limiting excessive, negative messaging may further help alleviate anxiety. Online and application-based platforms may help address anxiety and depression. Providers can help address socioeconomic disparities by linking patients to essential resources, and referrals to mental health services should be provided when appropriate.
Learn more about the Cardiovascular Disease Prevention Center at Mass General
Refer a patient to the Corrigan Minehan Heart Center