Submitted by Jennifer T. Thibodeau, MD, MSCS, FHFSA, University of Texas Southwestern Medical Center, Dallas, TX
In the spring of 2020, it seemed as though the entire country shut down due to the COVID-19 pandemic. Only essential personnel were going to work, and people were instructed to stay home and socially distance unless absolutely necessary. However, we realized very quickly that patients with chronic illnesses, such as heart failure, need to follow up regularly with their physicians to keep them as well as possible. This led to a shift from in-person clinic visits to video visits or phone call visits—also known as telehealth or virtual visits.
Initially, patients (and undoubtedly also providers) had some hesitation that virtual visits would be useful. Many thought that there was no way providers would be able to adequately care for patients over a phone or video. However, most components of a clinic visit for heart failure can be done proficiently in video visits:
- Medication reconciliation: During the visit, we review medications, but now we have the added benefit of patients being at home with their pill bottles. If there is any uncertainty, the patient can just go to their medicine cabinets and we can look together at the bottles.
- Obtaining vital signs: Vital signs can be obtained at home if patients have a blood pressure cuff, scale, and pulse oximeter, all of which are available from the local drugstore. These vital signs are important to know with any clinic visit, but in particular with heart failure clinic visits, as medications used for heart failure can also affect blood pressure and heart rate. We also know that rapid weight change can reflect accumulation or loss of fluid.
- Obtaining a thorough history: I ask the same questions over the video visit as I would in the office. For example: What makes you short of breath? How far can you walk before you get short of breath? Can you sleep on one pillow, or do you have to prop yourself up to breathe at night? Do you wake up at night gasping for air? Can you walk up a flight of stairs? When you eat, do you get full very quickly or can you complete a meal? Do you feel your heart racing or skipping beats? Do you have any chest pressure or chest pain? All of these things give a very thorough picture of how patients are doing and whether they might have extra fluid.
- The physical examination: One of the key components of the physical examination for patients with heart failure is to evaluate whether they have extra fluid, which can be proficiently done over video. We know that elevation of the neck veins is one of the key findings on the examination that suggest volume overload. I often say that the neck veins are like a barometer for the heart—if they are higher on the neck, we know that there is extra pressure in the heart, or that the patient has extra fluid. While it seems unfathomable to think that neck veins can be seen over video, we recently published a study showing that the video assessments are nearly as effective as an in-person evaluation and both accurately predict the pressures in the heart!
To evaluate this, I have the patient recline on their couch or recliner, and I examine the neck veins to see if they are elevated, just as we would do in the office. While I’m looking at the neck, I’ll also ask patients to press down on their abdomen and hold the pressure while I’m looking to see if the neck veins go up even more, just as I would do in-person in the clinic. I’ll have patients show me their feet and legs to see if there is any swelling. I’ll also have patients bend forward at the waist while sitting in a chair—as if they are putting on their shoes or socks—to see if they get short of breath while bending (without holding their breath!)—a symptom called “bendopnea.” This part of the exam is very easy to do even over a phone visit without a video. It’s also important to note that all of these findings are evaluated in aggregate. If I am unable to see the neck veins at one visit, for example, but the patient describes that they now have to sleep on three pillows when they used to be able to breathe okay with one pillow, they have a 5 pound weight gain and they have leg swelling, I can be very confident that they have extra fluid and can treat them accordingly.
As use of telehealth has accelerated due to the COVID-19 pandemic, there has also been expansion of “telehealth peripherals,” or technology that can be used as adjuncts to the virtual visit. As mentioned, basic items that patients may already have include a blood pressure cuff, pulse oximeter, and scale. With technological advances, more sophisticated telehealth peripherals may be more readily available to the public and will likely be incorporated into future visits. Such items might include bluetooth stethoscopes that can transmit heart and lung sounds, portable electrocardiograms (or EKGs) that can pair with smart phones and be transmitted to the clinic, wearable devices to monitor blood pressure, heart rhythm, respiratory rate, and more. Some patients already use a CardioMEMS device, which is a monitor placed in the pulmonary artery that can transmit pressure readings that correlate with fluid status. This can be particularly useful as the clinic can be notified when the patient’s reading is “out of range” and treatment can be adjusted as needed.
I currently see at least 60% of my patients virtually, which has been very well received by the vast majority. I find that I can still provide the excellent level of care that my patients deserve and expect, but by doing so virtually, I decrease the potential exposure risk during the pandemic while also allowing patients convenient access to high quality care from within their home or workplace. Furthermore, telehealth provides a unique opportunity, as it allows any loved one to participate in the visit, even if they aren’t in the same physical location!
I believe that the opportunities for utilization of virtual visits are limitless with expansion of telehealth peripherals, increased acceptance by both patients and providers, and willingness for providers and the healthcare community to explore new and innovative approaches to patient care. I look forward to seeing what the future holds for virtual care of heart failure patients!
In March 2021, HFSA365 explores COVID-19 one year in, and how it has impacted heart failure treatment and care. Visit the HFSA Patient Hub to explore tools and resources to help patients stay healthy while living with heart failure. View Heart Failure Awareness 365 activities to stay up-to-date on tips for healthy living for people living with heart failure.