To the Editor
As a result of the coronavirus disease 2019 (COVID-19) lockdown imposed beginning on 9 March 2020, Italian hospitals were required to postpone or even halt outpatient visits deemed as nonurgent.
The Hypertrophic Cardiomyopathy (HCM) Outpatient Clinic at the Ospedale Policlinico San Martino, Genova, regularly follows patients affected by HCM and cardiac amyloidosis. At the beginning of the COVID-19 lockdown an already operating service for patients’ communications (via telephone and E-mail) was implemented, and each patient with a scheduled visit in the forthcoming weeks (up to 15 May 2020) was contacted by a medical trainee to assess urgency related to her/his medical evaluation. According to information collected via the telemedical contact, patients were divided into ‘stable’ (group-A) and ‘potentially unstable’ (group-B). Patients were deemed as ‘potentially unstable’ if one or more of the following were present: signs and/or symptoms of heart failure, in particular if worsening relatively to the precontact condition; known end-stage HCM; heart failure hospitalization(s) and/or more than three outpatients evaluations in the prior 6 months. Those in group-B received weekly telemedical contact to monitor their conditions.
Forty patients (27 males, median age: 62 years) received a telecontact, of whom 28 were HCM and 12 were cardiac amyloidosis patients. Nineteen patients were deemed as ‘potentially unstable’ (10 cardiac amyloidosis and 9 HCM). The main reason for inclusion in group-B was a recent heart failure hospitalization. Characteristics of patients in group-A versus B are shown in Table 1. As of 7 May 2020 no patients in group-A sought medical attention outside the planned telemedical contacts, and none needed an outpatient visit or hospitalization. In group-B, eight patients needed unplanned medical attention. In four instances, their needs were managed via telecontact without the need for in-person evaluations: two cardiac amyloidosis patients needed optimization of diuretic therapy; two obstructive HCM patients needed optimization of therapy for relief of obstruction. In three other instances, a medical outpatient evaluation was required: two cardiac amyloidosis patients presented worsening heart failure symptoms, and one severely obese HCM patient presented a new-onset atrial fibrillation with high ventricular response. Finally, one cardiac amyloidosis patient required hospitalization due to acute decompensated heart failure.
In this series of cardiomyopathy patients managed during the COVID-19 lockdown in Italy, a strategy of telehealth monitoring was feasible and effective, at least in the short term, with even a subset of patients contacted via E-mail. Telemedical contact by trained staff was able to stratify patients in higher and lower heart failure risk. No unplanned medical contact was required by patients deemed at low heart failure risk; moreover, half of the unplanned medical contacts among those at high heart failure risk was managed via repeated telemedical evaluations.
Though of course not generalizable to the whole HCM and cardiac amyloidosis cardiomyopathy population, our report may offer suggestions for future management of this increasing cohort of patients. Telemedicine interventions have shown a beneficial effect in the management of heart failure patients.1 In current COVID-19 times, telemedicine served as an emergency tool, yet lessons from its impact on healthcare may be exploited for the future.2 In the case of cardiomyopathies such as HCM or cardiac amyloidosis, telehealth monitoring may be useful, in particular for a specific subset of low-risk patients, such as genotype-positive-phenotype-negative relatives. However, strategies of telehealth monitoring have never been specifically assessed in the case of cardiomyopathies. Implementation of telehealth strategies in Cardiomyopathy Units may help adequate followup for all patients and, at the same time, allow a better allocation of resources for in-hospital visits. Many already available tools may be exploited for telehealth strategies, including: telephone-based follow-up, remote monitoring of devices, use of novel portable devices,3 web-based interactive platforms.4 Telehealth monitoring cannot replace in-hospital in-person medical evaluation, but may be a valid practice in the near future.
Conflicts of interest
There are no conflicts of interest.
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