Advice on clinical and psychological care for heart failure

A webinar on providing care for people living with heart failure during and following COVID-19

This webinar highlights how COVID-19 could impact the physical and psychological health of people living with heart failure. It focuses on discussing new strategies in managing the health of those with heart failure during this challenging time.

Drs, Gavin Oudit and Adrienne Kovacs describe the scientific findings on COVID-19 and Angiotensin converting enzyme 2 (ACE2), and its impact on people with heart failure.

In this webinar they discuss new strategies and care approaches to address the physical and psychological needs of people living with heart failure during and after the pandemic.

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Key guidance from our speakers
Gavin Oudit, clinician-scientist at Mazankowski Alberta Heart Institute  +

Understanding COVID-19 and its pathogenesis is critical for safely continuing current courses of therapy but also designing new therapies. SARS-CoV-2 is more detrimental than the original virus – this strain of the virus evolved to bind to the Angiotensin converting enzyme 2  (ACE2) receptor with very high affinity. This virus binds to ACE2 and downregulates it, but we need it to protect from disease and for the proper functioning of the renin-angiotensin system.

Without ACE2, the body cannot convert inflammatory peptides into protective ones. These have been telling markers in COVID-19 patients with heart failure: having a higher ratio of the inflammatory peptides (indicative of a lack of ACE2) is associated with longer hospitalization and lower survival rate.

ARB drugs block the release of ACE2. Five studies have confirmed that there’s no increased harm in taking ARB/ACE inhibitors. A study showed they might even be beneficial, but further studies are needed to validate this. It is important not to stop ACE inhibitors, ARBs or other heart failure medication unless otherwise advised by your healthcare providers.

COVID-19 has changed the landscape of clinical practice: many clinics have had to transition to virtual care and remote monitoring. This necessitates a reliance on electronic data management – a single place for patient data to be uploaded, safely and reliably.

The pandemic has also opened up our ability to study the efficacy of remote monitoring. The main issue is the accuracy of self-reported patient data. A solution is to get patients into pharmacies and other offices to get proper measurements.

Risk stratification is key for managing our time and patients. For example, for low-risk patients, telephone monitoring can be enough, whereas for high-risk patients, setting up home care would be necessary. These are important lessons for the future: in moving low risk patients to telemedicine, it could lessen wait time down to a week.

Gavin Oudit is a professor at the department of medicine at University of Alberta and holds the Canada Research Chair in Heart Failure.

Adrienne Kovacs, clinical psychologist at Knight Cardiovascular Institute +

There are several intrapersonal and interpersonal challenges that adults with heart failure endure. Reduced social interaction was already an issue, and depression (affecting 1 in 5 people living with heart failure) is associated with higher risk of death and hospitalization. One third of adults with heart failure face cognitive impairment, which can make it difficult to engage in self-care.

Adrienne has seen an increase in anxiety in her patients over the years, and approximately 50% of people living with heart failure have anxiety symptoms. This causes them to avoid strenuous activity, have heart-focused worry and fear, and behaviours of reassurance-seeking. When a patient expresses their worry about their health, ask them specifically what they’re worried about.

Important to remember though were all now facing same stressor (COVID-19) it doesn’t erase anyone’s previous stressors. It’s also important to remember that common stressors don’t lead to common experiences nor reactions – those are dependent on personality, personal circumstance and resilience.

One theme that has emerged from the pandemic, is that empathy has grown. Providers are now better understand living with health uncertainty and the anxieties it can bring, and patients respect for providers has never been higher as they put themselves at risk to care for everyone.

Psychosocial support should be integrated into pandemic care, but also into general health care for those living with heart failure. It is important that we normalize emotional reactions. They are not a sign of weakness, and we should give admiration to those courageously voicing them. The only way to know how someone is thinking, coping, or acting is to ask them directly!

Coping strategies can be behaviour changes (limiting news, self-care, etc.), cognitive changes (monitor self talk and practice acceptance and compassion) and physical changes (breathing, meditation, music, etc.). It’s important to not overwhelm patients with coping strategies. We already ask much so much from them, so try the top 1 or 2 most important things.

Adrienne Kovacs is an associate professor of medicine in the division of cardiovascular medicine at Oregon Health & Science University.

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