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Covid-19 HSE Clinical Guidance and Evidence

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Acute / Maternity, Paediatric Hospital Information - Navigation

Guidance for Heart Failure Management during Covid-19 pandemic

Guidance for Heart Failure Management during Covid-19 pandemic (CD 19-057 001/28.04.20)


Introduction
  • The overriding strategy for the management of patients with heart failure during the Covid-19 pandemic is to keep this cohort well and with minimal need to come into the hospital setting. The outpatient chronic heart failure service is an essential service facilitating this approach. Every effort should be made by hospital management teams to continue this service through the current crisis, as this is vital to avoiding admission to hospital for this cohort.
  • This document was prepared by the National Clinical Programme for Heart Failure in liaison with a sub-group of the Clinical Advisory Group for Heart Failure and will be reviewed periodically during the Covid-19 pandemic.
  • Please refer to Infection and Prevention Control guidance as set out on HPSC.ie: 
General Strategies

Patients with heart failure (HF) are at heightened risk for hospitalization in general, and at heightened risk for a poor outcome if exposed to Covid-19.

  • It is therefore of importance to maintain best management possible with care delivered dominantly in the community, through telephone contact with the GP or the patient or through the use of virtual consultation where this service is available.
  • The GP may also use contact by telephone or video web consult to review the patient where needed, depending on facilities available.  Stable heart failure patients may also be given extended prescriptions to avoid attending healthcare facilities for routine reviews where patients with Covid will be more prevalent. Where it is necessary for face-to-face review, standard PPE precautions should be used in line with IPC guidance on NPSC.ie and the patient should in addition wear a mask.
  • We recommend that in the circumstance of a HF Covid positive patient admitted to hospital that care should be coordinated with the local cardiology / HF team (e.g. by telephone consultation) during inpatient stay and to co-ordinate follow-up at discharge.
  • It is recommended that if at all possible HF medications for HF patients are not modified during admission for Covid infection or if necessary these changes are notified to the HF service.
  • Satellite HF clinics with access to CIT phlebotomy should be set up where possible.
  • There is a concern that the titration of life-prolonging, disease-modifying therapies in HF-reduced ejection fraction may be compromised due to restriction in travel and risk for patients with HF attending health care institutions. Modifications of standard titration strategies may be required reflecting local resources.

 

Specific Patient Situations

New patient referral

  • Following assessment by the GP, the optimal first strategy for a relatively stable presentation would be to obtain a natriuretic peptide level if available and use diuretic for management of features of volume overload.  Telephone contact with the local hospital heart failure service or in the absence of that service the local cardiologist to help guide treatment is also appropriate. Focus on this population should be to avoid referral to the hospital for ongoing care unless deemed clinically necessary by the GP/ HF service/ consultant.
  • A more unstable presentation may require assessment in an outpatient setting having assessed likelihood of Covid infection, using standard IPC precautions as per NPSC.ie.
  • If the patient is a confirmed Covid patient then care should be directed entirely towards remote / telephonic support unless emergent clinical need requires hospital outpatient/ inpatient support.
     

Deteriorating patient

  • In an established HF patient, emerging deterioration should be managed as per normal through assessment and care of any clear precipitating cause and empiric increase in diuretic if the situation indicates emerging volume overload. Careful consideration should be given to Covid infection given the similarity of symptoms between Covid-19 and decompensating HF.
  • Patients who should be considered for referral or discussion with the heart failure unit include:
    • Paroxysmal nocturnal dyspnoea
    • BNP>400 or NTproBNP >2,000pg/ml
    • Baseline diuretic dose >120mg frusemide daily (3mg bumetanide daily)
    • A recent decompensation within last 4 weeks
    • Chest pain suggestive of  ischemia
  • If the patient has a confirmed Covid infection and deteriorating heart failure status is suspected then admission is advised.
     

Follow up of patient discharged following management of acute decompensated heart failure

  • This particular population is at heightened risk for readmission to hospital soon after discharge. Therefore, standard clinic follow up is advised. However, in certain circumstances, a clinic visit may be deemed not to be the appropriate form of follow up.

These include:

  • A lower risk status following discharge (determined by cardiology/ HF team)
  • Patient who might find travel to the outpatient department difficult
  • Patients with a clear “ceiling of care” or resident in a nursing home
  • Established Covid infection until deemed clear of infection
  • In these circumstances, remote care using telephone follow-up discussions with the patient/ GP as appropriate would be a reasonable first approach. Review in the outpatients can be activated if the GP / cardiologist deem it is clinically required.

Health Library Ireland, Health Service Executive. Dr. Steevens' Hospital, Dublin 8. Tel: 01-6352555/8. Email: hli@hse.ie

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