Heart failure is a frightening term for a patient to hear at diagnosis, and for those living with the condition these are frightening times. In the UK, the daily announcement of the latest death toll from covid-19 has often been followed by a qualifying statement that most deaths occurred in patients with a “pre-existing medical condition.” Viewers at home who are young and fit breath a sign of relief, but for the one million people living with heart failure, this is little comfort and instead implies that this is their fate.
People with heart failure do not want to feel “written off” and neither should they be. Our survival analysis published in The BMJ in 2019 led with “heart failure is not the imminent death sentence that the term implies.” Survival is strongly age-dependent, as with most chronic conditions, but if we took 10 people with a new diagnosis of heart failure in the 65-74 year age group, eight or nine would survive a year, six would be alive at five years and three would survive a decade or more. These patients have plenty of years to live if given the chance.
The covid-19 pandemic has taken hold quickly with arguably limited time for health services to prepare. An enormous, and entirely appropriate, effort to divert resources to allow the system to cope with the high number of patients with covid-19 requiring acute hospital care, including ventilatory support, is currently underway. But the risk to people with heart failure comes not just from covid-19, but also from the unintended consequences of the reconfiguration of services during the crisis.
In the UK, patients with heart failure are in the higher risk group advised to “shield” themselves from covid-19 as they are likely to have a worse outcome from the infection. They haven’t been classed in the “extremely vulnerable” group which seems surprising given their limited cardiac reserve. The heart appears to be a particular target for covid-19 with data from China suggesting up to 20% of patients demonstrate myocardial injury.
In addition, the usual heart failure pathway may be interrupted, and patients may feel less able to access care due to concerns about catching the virus. There is some evidence this may be happening already with acute presentations of myocardial infarction and stroke much lower than normal. Data from a previous pandemics have shown an excess all-cause mortality caused by suboptimal management of common conditions in addition to the contagious disease.
So, what can we do to reassure patients and ensure heart failure is well managed despite the pandemic? Timely diagnosis has never been more important to allow initiation of evidence-based treatments proven to improve prognosis and prevent hospitalisation. Patients presenting with new onset breathlessness, ankle swelling, and tiredness should be assessed and have a natriuretic peptide blood test in primary care. Echocardiography and specialist assessment are central to confirming a heart failure diagnosis, including the type and severity, and should still be available particularly for patients with severe symptoms or a very high natriuretic peptide level.
For patients with known heart failure, continuation of current therapy is crucial. Early concerns about the safety of angiotensin converting enzyme (ACE) inhibitors in covid-19, due to the virus infecting cells through the ACE pathway, have been dismissed as entirely speculative and guidance from cardiology societies internationally is to continue these drugs. Patients should also feel able to seek help when needed.
Primary care and outpatient clinics are using remote methods of consulting during the pandemic. Patients can be asked about any deterioration in symptoms (feeling more breathless, increase in ankle swelling, sudden gain in weight) and may be able to measure their own pulse and blood pressure.
For some patients though, a face to face assessment will be needed and can be carried out using personal protective equipment for the safety of both patient and clinician. Hospital admission may be required to manage an acute decompensation and patients should be reassured that infection control measures are in place to minimise their risk of contracting covid-19.
Some patients with severe heart failure, and often multiple other conditions, may have an advanced care plan and do not attempt resuscitation order in place. This shouldn’t be assumed simply because of a heart failure diagnosis, but where needed, anticipatory medication in the community must be available.
Clinical capacity has rightly been diverted to the unprecedented national emergency caused by the coronavirus pandemic. This is a worrying time for the heart failure community who are feeling anxious about the reduction in their regular services, and fearful of the impending threat from covid-19. To avoid health services coming under further strain, both in the short and longer term, the ongoing needs of this significant group of patients must not be forgotten.
Clare J Taylor is a general practitioner and NIHR academic clinical lecturer at the University of Oxford. Her research focuses on heart failure diagnosis and management in primary care.
Competing interests: CT reports personal fees from Vifor and Novartis, outside the submitted work.