Initial Experience of A Heart Failure Disease Management Clinic During the Covid-19 Era

The COVID-19 pandemic has necessitated significant alterations in ambulatory heart failure (HF) care, primarily with the introduction of telemedicine. We describe our initial experience caring for patients in the COVID-19 era in the Johns Hopkins Heart Failure Bridge Clinic (JHHFBC), an ambulatory disease management and diuresis clinic aimed at preventing hospitalizations. The JHHFBC sees about 2500 patients per year with 25% of those patients needing intravenous diuretics in the clinic. Starting March 16, 2020, we implemented a COVID-specific workflow incorporating telemedicine, which the clinic had previously not been utilizing. Patient visit outcomes were adjudicated, including change in diuretic dosing, intravenous diuretic administration, and need for hospitalization. From March 16, 2020 to April 24, 2020 we had 116 patients seen 164 times (Figure 1). The average age of patients was 61 ± 14 years, 50% female, and 70% Black. Average left ventricular ejection fraction was 25 ± 21% with 45% nonischemic cardiomyopathy, 14% ischemic cardiomyopathy, 6% amyloid, 35% had heart failure with preserved ejection fraction. The majority of patients were New York Heart Association (NYHA) class II or III (109, 94%). Reasons for clinic referral included an equal frequency of post hospital discharge, worsening HF symptoms and routine follow up. Of the 96 telemedicine visits, 23% resulted in oral diuretic dose adjustment and 6 patients were referred for in-person visits. Of the 68 in-person visits, 34 (50%) resulted in intravenous diuretic administration in clinic, with 8 referrals to the emergency department or for direct admission. There were 2 referrals for cardioversion and 3 referrals to hospice by the clinic. Two of 16 clinic patients that were tested for Covid 19 were positive. We found that HF patients could be effectively managed via telemedicine, however a subset still benefit from in-person assessment and access to ambulatory intravenous diuresis to avoid hospitalization. We hope these initial experiences will lend insights to optimization of future outpatient HF care, including the use of telemedicine, even after the current global health emergency.