key: cord-0794681-1z5fky0d
authors: Khera, Amit; Baum, Seth J.; Gluckman, Ty J.; Gulati, Martha; Martin, Seth S.; Michos, Erin D.; Navar, Ann Marie; Taub, Pam R.; Toth, Peter P.; Virani, Salim S.; Wong, Nathan D.; Shapiro, Michael D.
title: Continuity of Care and Outpatient Management for Patients with and at High Risk for Cardiovascular Disease during the COVID-19 Pandemic: A Scientific Statement from the American Society for Preventive Cardiology
date: 2020-05-01
journal: American journal of preventive cardiology
DOI: 10.1016/j.ajpc.2020.100009
sha: fd1d110d381738ba2e184ae376b140fb4c40dff7
doc_id: 794681
cord_uid: 1z5fky0d

Abstract The coronavirus disease 2019 (COVID-19) pandemic has consumed our healthcare system, with immediate resource focus on the management of high numbers of critically ill patients. Those that fare poorly with COVID-19 infection more commonly have cardiovascular disease (CVD), hypertension and diabetes. There are also several other conditions that raise concern for the welfare of patients with and at high risk for CVD during this pandemic. Traditional ambulatory care is disrupted and many patients are delaying or deferring necessary care, including preventive care. New impediments to medication access and adherence have arisen. Social distancing measures can increase social isolation and alter physical activity and nutrition patterns. Virtually all facility based cardiac rehabilitation programs have temporarily closed. If not promptly addressed, these changes may result in delayed waves of vulnerable patients presenting for urgent and preventable CVD events. Here, we provide several recommendations to mitigate the adverse effects of these disruptions in outpatient care. Angiotensin converting enzyme inhibitors and angiotensin receptor blockers should be continued in patients already taking these medications. Where possible, it is strongly preferred to continue visits via telehealth, and patients should be counselled about promptly reporting new symptoms. Barriers to medication access should be reviewed with patients at every contact, with implementation of strategies to ensure ongoing provision of medications. Team-based care should be leveraged to enhance the continuity of care and adherence to lifestyle recommendations. Patient encounters should include discussion of safe physical activity options and access to healthy food choices. Implementation of adaptive strategies for cardiac rehabilitation is recommended, including home based cardiac rehab, to ensure continuity of this essential service. While the practical implementation of these strategies will vary by local situation, there are a broad range of strategies available to ensure ongoing continuity of care and health preservation for those at higher risk of CVD during the COVID-19 pandemic.

other conditions that raise concern for the welfare of patients with and at high risk for CVD during this pandemic. Traditional ambulatory care is disrupted and many patients are delaying or deferring necessary care, including preventive care. New impediments to medication access and adherence have arisen. Social distancing measures can increase social isolation and alter physical activity and nutrition patterns. Virtually all facility based cardiac rehabilitation programs have temporarily closed. If not promptly addressed, these changes may result in delayed waves of vulnerable patients presenting for urgent and preventable CVD events.

Here, we provide several recommendations to mitigate the adverse effects of these disruptions in outpatient care. Angiotensin converting enzyme inhibitors and angiotensin receptor blockers should be continued in patients already taking these medications. Where possible, it is strongly preferred to continue visits via telehealth, and patients should be counselled about promptly reporting new symptoms. Barriers to medication access should be reviewed with patients at every contact, with implementation of strategies to ensure ongoing provision of medications. Team-based care should be leveraged to enhance the continuity of care and adherence to lifestyle recommendations. Patient encounters should include discussion of safe physical activity options and access to healthy food choices. Implementation of adaptive strategies for cardiac rehabilitation is recommended, including home based cardiac rehab, to ensure continuity of this essential service. While the practical implementation of these strategies will vary by local situation, there are a broad range of strategies available to ensure ongoing continuity of care and health preservation for those at higher risk of CVD during the COVID-19 pandemic.

The coronavirus disease 2019 (COVID- 19) pandemic has affected every facet of life and has consumed our international healthcare focus. The immediate objective of managing the critical respiratory and cardiovascular manifestations requiring intensive care of the hospitalized patient is paramount, as are public health efforts to flatten the curve of COVID-19 cases to prevent overwhelming health care system resources.

However, in this time, there is increasing concern for the welfare of patients with and at high risk for cardiovascular disease (CVD). The purpose of this scientific statement from the American Society for Preventive Cardiology (ASPC) is to highlight the ramifications of the COVID-19 pandemic for outpatient care practices and risk factor modification in patients with and at high risk for CVD. We also provide a series of recommendations to mitigate disruptions of care and enhance the cardiovascular health for these individuals during this pandemic.

Since the beginning of the COVID-19 pandemic, it was recognized that persons with pre-existing comorbidities fared worse. In particular, CVD, hypertension, and diabetes are among the most common cardiovascular comorbidities in persons with COVID-19 (Table 1A) and with severe COVID-19 (Table 1B) across multiple studies.

There are also emerging reports about the relationship between obesity and adverse outcomes in COVID-19 infected patients. (4, 5) It is clear that there are important consequences for the cardiovascular system stemming from COVID-19 infection.

The Centers for Disease Control (CDC) reported that, as of March 28, 2020, patients infected with COVID-19 with at least one underlying health condition or other risk factor had poorer outcomes compared to those without these comorbidities.(6) The most common preexisting conditions in infected patients were diabetes mellitus (10.9%), chronic lung disease (9.2%), and CVD (9.0%). While data on mortality rates according to the presence of different comorbidities are not available yet among U.S. patients infected with COVID-19, a report among 72,314 cases of COVID-19 from the Chinese Center for Disease Control and Prevention notes an overall crude estimated mortality of 3-4%. This was significantly higher among those with CVD (10.5%), diabetes (7.3%), or hypertension (6.0%).(7) Similarly, another report of 1,099 patients from China early in the pandemic demonstrated that the prevalence of coronary artery disease (CAD) in severe vs. non-severe cases was 5.8 vs. 1.8%, respectively. (8) COVID-19 patients with poor outcomes, including intensive care unit admission, mechanical ventilation, or death, more commonly had underlying CAD than those with a more benign course (9.0 vs. 2.0%).

Published studies including at least 100 COVID-19 patients, all from Hubei Province in China, demonstrate a wide variation in the prevalence of established CVD prior to infection, ranging from 4% to 35%.(9,10) However, the largest study of over 1,000 patients from 30 provinces in China demonstrated a prevalence of CAD of only 2.5%.(8) Prevalence estimates were significantly higher for CVD, diabetes, and hypertension in a cohort of COVID-19 infected patients from Italy (Table 1A) . (11) Importantly, the case fatality rate was higher in the Italian cohort than the Chinese cohort, reflecting not only an older age group, but possibly also increased prevalence of CVD, hypertension, and diabetes, as well as obesity. (12) There are important symptoms and consequences of COVID-19 infection related to the cardiovascular system. (13) Elevations in high-sensitivity cardiac troponin were reported in 10-20% of patients, and more than 10% of those who died from COVID-19 had substantial myocardial injury with either elevated troponin levels or cardiac arrest during hospitalization, even in the absence of pre-existing CVD. (14, 15) In a study that included 138 patients infected with COVID-19 in Wuhan, China Guo et al. provide important insights into patients who manifest serum troponin elevations.(9) When comparing mortality rates for patients with and without troponin elevations, hospital mortality was 59.6% vs. 8.9%, respectively. Mortality for patients with established CVD but without troponin elevation was lower but still substantial at 37.5%. There were also linear correlations between serum troponin levels and high sensitivity C-reactive protein and N-terminal pro-brain natriuretic peptide, suggesting associations between myocardial injury, inflammation, and left ventricular stress.

The CDC has reported that 10.9% of patients infected with COVID-19 in the U.S. have diabetes,(6) a rate slightly higher than those reported in China (7.4%)(7) and Italy (8.9%),(11) likely reflecting the higher prevalence of diabetes in the U.S. general population. A meta-analysis of several Chinese studies found that diabetes was 2.3fold more common in those with COVID-19 infection and was associated with adverse outcomes.(18) A Chinese study including 174 consecutive patients infected with COVID-19 demonstrated that those with diabetes and no other comorbidities (n=24) were at higher risk of severe pneumonia, profound increases in inflammation, and hypercoagulability. (19) Biomarkers including IL-6, C-reactive protein, and D-dimer were significantly higher in those with diabetes compared to those without diabetes, suggesting greater levels of inflammation that may lead to rapid deterioration. These initial observations suggest diabetes is associated with poorer outcomes in those with COVID-19 infection.

It has been proposed that pre-existing hypertension may facilitate the pathogenesis of COVID-19 infection and its sequelae. (20) Estimates of the prevalence of hypertension among Chinese patients infected with COVID-19 range from 9.5% to 34.7%, (21, 22) with the largest study (1,099 patients) reporting a prevalence of 15%. However, these same statements do not recommend initiation of ACEIs/ARBs in the absence of other clinical indications (e.g., hypertension, heart failure, or diabetes).

The COVID-19 pandemic has had a profound effect on health care delivery worldwide. Current guidelines from the CDC recommend that all high-risk individuals, including those with traditional cardiovascular risk factors and/or established atherosclerotic cardiovascular disease (ASCVD), stay at home if possible, primarily to limit potential exposure.(30) Individuals who might have been exposed to COVID-19 are further advised to self-quarantine with separation from others for 14 days, self-monitoring for symptoms or signs of infection. (31) Further, many office based practices have discontinued all but the most urgent face to face visits. While these approaches represent key public health strategies to limit the spread of infection, effort is needed to guard against potential unintended consequences.

For example, it remains to be determined whether patients experiencing worrisome cardiac symptoms (e.g., chest pain, shortness of breath, syncope) will contact emergency medical services or go to the emergency department out of fear that they will be exposed to COVID-19. There are already many reports attesting to the fact that admissions for acute coronary syndromes, decompensated heart failure, and stroke have decreased since the pandemic began. Despite efforts to improve our interaction with patients during this challenging time (detailed later in this document), potential limitations exist. For example, many patients may not be amenable or have appropriate technologic ability to participate in telehealth visits. Those seen virtually may be apprehensive to start new medications or titrate existing ones over a concern that side effects may warrant medical attention. In addition, patients may be hesitant, or even embarrassed, to mention less severe problems believing that their care team has more pressing issues related to the pandemic.

Each of these scenarios represents a challenge to cardiovascular clinicians focused on reducing their patient's near-term and long-term risks. Rising rates of unemployment, loss of health insurance, and concern over the cost of copayments represent additional challenges to be overcome. One estimate suggests that an additional 7.3 million workers (plus their family members) will become uninsured due to loss of healthcare coverage as a result of unemployment during the COVID-19 pandemic.(35) Sadly, underrepresented populations, patients living in rural communities, and those with poorer socioeconomic status are likely to be disproportionately affected. In fact, several recent reports have noted that the COVID-19 pandemic is disproportionately affecting black individuals. As one example, more than 50% of COVID-19 infections and almost 70% of COVID-19 related deaths in Chicago have occurred in black individuals, a group that comprises just 30% of the city's population. (36) Acknowledging the critical issues currently faced by health care systems (e.g., ventilator shortages, limited personal protective equipment, unprecedented financial challenges), there also exists an ongoing need to address barriers to care delivery in the ambulatory setting. To this end, it is important to provide reassurance to patients that they should not hesitate to reach out to their providers with any questions or concerns. Cognizant of the fears they may have about COVID-19, we must help our patients understand that they should seek immediate medical attention for cardiovascular emergencies such as heart attack or strokes, and remind them of the relevant symptoms associated with these events. (37) Innovative solutions are urgently needed to address financial barriers that are likely to significantly limit optimal delivery of preventive care. Finally, it is important to brace for the next large wave of inpatient and ambulatory care that may be coming as a consequence of the disruption in the traditional care for patients with CVD ( Figure) . There is marked heterogeneity in terms of the numbers of COVID-19 infected patients and deaths by state and region.

Population measures to curb COVID-19 infection may have greater net benefit relative to preventable CV events precipitated by healthcare disruptions in high vs. low COVID-19 prevalence areas.

Access and adherence to medications can be challenging in the best of times; the COVID-19 pandemic threatens to make matters worse. Today, patients must contend with closed providers' offices and limited access to ambulatory care services.

Those of advanced age are sequestered at home while many younger individuals are newly unemployed. Income streams are down; savings have plummeted; many have lost or will lose health insurance.(35) Baseline temporal and monetary deficits already impede access and adherence to medications. Currently, 1 in every 8 Americans with CVD misses or delays taking medications due to cost, (38) and the COVID-19 crisis will only increase these numbers. Compounding this, there are concerns that supply chains may be threatened, including numerous pharmaceutical ingredients that rely on manufacturers in China. (39) Importantly, older individuals who are at highest risk of COVID-19 and associated morbidity are also the same group with greatest use of prescription medications. Early evidence suggests that while most are continuing to make regular trips to the pharmacy for medication refills, they are also increasing their risk of potential exposure and hampering efforts at social distancing. (40) Furthermore, this group is most at risk for exacerbation of their underlying CVD, with worsening of congestive heart failure and angina when missing medications, at a time when fear of COVID-19-related hospitalization contributes to delayed evaluation. (34) Of particular interest are higher tier preventive medications such as PCSK9 inhibitors, and in some cases other lipid lowering and novel anti-diabetic medications.

These drugs can have an extensive prior authorization process, have higher copayments, and can require repeat laboratory testing for re-authorization, which may limit renewals. These time consuming processes and higher patient costs result in high abandonment rates even in normal times, (41) and present greater challenges during the COVID-19 pandemic.

Social or physical distancing is the act of deliberately increasing the space between people to avoid spreading an illness, and is the most important recommendation from CDC as a community mitigation strategy to limit the spread of COVID-19. (42) However, social distancing does not mean social isolation.

Nonetheless, the impact of this crisis can increase stress, depression, and anxiety in adults and children. In fact, more than half of the respondents to a survey in China reported moderate-to-severe psychologic impact of the COVID-19 outbreak. (43) Additionally, the psychological strain of loneliness can manifest physiologically and exacerbate existing medical conditions. Based on experiences from prior outbreaks, (44) those identified to be most susceptible to the stress of this crisis include those at the greatest risk for COVID-19 infection, children and teens, people with mental health conditions, particularly those with prior substance abuse issues, healthcare professionals, and first responders.

Perceived stress has long been associated with increased risk of CVD.(45) Acute stressful triggers like a natural disaster (46) or even a sporting match (47) can potentially trigger a myocardial infarction. Social isolation/loneliness (48) and depression (49) are also associated with increased CVD risk, possibly through dysregulation of the autonomic nervous system, sympathetic system activation with increased heart rate and blood pressure, hypercoagulability, and inflammatory activation which can trigger acute plaque rupture or demand myocardial ischemia. Thus, there is concern that the current crisis may exacerbate pre-existing CVD or precipitate an acute cardiac event.

Furthermore, as discussed below, perceived stress can trigger unhealthy behaviors such as smoking, dysregulated eating, poor sleep, and reduced activity. In addition, psychologic stressors can worsen glycemic control in patients with diabetes and worsen body weight through increased energy intake.(50,51)

A healthy lifestyle remains the foundation of all CVD prevention efforts.

Unfortunately, the current COVID-19 crisis presents challenges to the implementation and optimization of lifestyle efforts including physical activity, nutrition, weight management, and smoking cessation. Nevertheless, aggressive promotion of a healthy lifestyle should continue and there are unique opportunities that can be leveraged for cardiovascular health promotion, even amidst the crisis.

One of the many consequences of the current COVID-19 crisis is that physical activity levels have markedly decreased globally as a result of policies and messaging that encourage staying at home, tele-working, and social distancing. 

Cardiac rehabilitation (CR) is the cornerstone of secondary prevention in our healthcare system, but there has been little innovation in the delivery of these programs over the last 30 years. This slow pace of CR innovation has become a glaring issue as COVID-19 has disrupted the traditional provider facility-based CR delivery model.

Though the in-person, facility-based approach has advantages such as providing social support and helping patients cope with depression after their cardiac event, it has also presented a barrier to many who do not have access to the facility. Despite carrying a Class IA indication, CR is already grossly underutilized; less than 20% of eligible patients participate in CR programs. (61) Virtually all facility-based CR programs have been shut down to prevent spread of COVID-19. This disruption prevents access to the full spectrum of CVD prevention.

CR is likely more critical at this time, as its use is associated with reduced hospitalizations for cardiovascular events. Indeed, participants in CR demonstrate a marked reduction in reinfarction (odds ratio 0.53) and death (odds ratio 0.74). (62) Therefore, continued or increased virtual participation in CR may not only prevent recurrent cardiac events but perhaps free up hospital resources for COVID-19 patients, especially as a second wave of COVID-19 and/or related infectious disease is expected in the late fall/early winter.

To minimize exposure for patients and health care providers, routine maintenance "preventive" cardiology visits can be either rescheduled or held virtually.

When possible, there is a strong preference to maintaining visits virtually, rather than delaying or deferring care due to many potential adverse consequences as described above. Further, health system information technology infrastructure can be leveraged for additional targeted virtual visits to those most vulnerable and at highest CVD risk.

While virtual visits are commonly referred to as telemedicine or telehealth, herein we will use the term telehealth to align with recent Medicare terminology for coverage changes. (63) Preventive cardiology practices are the ideal setting for telehealth, as visits are less reliant on in office testing and a detailed physical examination but rather more focused on counseling. Further, lifestyle interventions require increased visit frequency, which can be facilitated by shorter, regular telehealth visits. At each visit, patients should be counseled to promptly report any new or concerning cardiac symptoms to their health care team, and to not delay seeking care for any severe symptoms due to fears over COVID-19.

Recognizing that some patients and providers may not have access to HIPAA Patient data of interest includes blood pressure, heart rate, weight, glucose, heart rhythm, and more. Such objective information may inform management plans that keep patients safely at home during the COVID-19 pandemic and beyond.

CMS issued reimbursement codes to incentivize use of RPM in practice and recently added new codes specifically for home blood pressure monitoring ( Table 2) . Finally, the best way to safeguard drug access during times of stress is to guarantee it during times of normalcy. When this crisis has receded, we must immediately adopt lessons learned about improving and facilitating medication access and adherence. We must also be prepared for the onslaught of the newly uninsured and financially strapped that will face extensive challenges to access essential affordable medications.

Although acute cardiovascular care delivery and subsequent outpatient follow-up is primarily dependent on CVD specialists, chronic long-term delivery of CVD is delivered predominantly by primary care providers. The shortage of physicians in the United States, including those in primary care,(74) is even more apparent in the context of the COVID-19 pandemic. Primary care physicians and specialists are being pulled to cover essential inpatient medical services, further straining effective primary care delivery for control of CVD risk factors.

Therefore, leveraging the entire cardiovascular team to deliver effective CVD care has now become even more important. These members of the cardiovascular care Expanded use of telehealth in the current environment also allows increased scheduling flexibility and opportunity for various members of the care team (e.g. physicians, advanced practice clinicians, pharmacists and dietitians) to interact with a patient virtually in one visit to provide comprehensive preventive care. Some of the time and effort for the office staff responsible for scheduling patient visits and returning patient calls could be diverted towards coordination between various members of the care team to deliver holistic care, which in turn should also improve patient experience.

Which of these combinations work best for a particular practice will depend on the scope of practice laws applicable to the state in which the practice is located.

Simultaneous evaluation of the effectiveness of these models will also allow an opportunity to expand use of these team-based care delivery models after the COVID-19 pandemic.

There are several strategies to reduce stress, anxiety and depression.(80) First, it is important for patients to remain connected with family and friends through phone or other technologies. More severe symptoms of stress and anxiety should be addressed with a health care specialist via telehealth. Further, meditation programs have been shown to reduce multiple negative dimensions of psychological stress and could be helpful. (81, 82) Yoga, specifically incorporating mindful breathing may also be beneficial to reduce anxiety, depression and sleep disorders, although many such trials used these techniques for longer periods of times.(83) Physical activity, as discussed below, can play an important role in ameliorating stress and anxiety. While stress and anxiety are often accompanied by increased alcohol consumption, as is already being reported in the COVID-19 pandemic,(56) patients should be counseled to avoid this temptation given the adverse effects of excessive alcohol intake on lipids, weight and CVD risk. (84) Finally, despite the urge to follow pandemic trends, those experiencing excess stress or anxiety should consider limiting time spent watching and reading news related to the pandemic, including social media discussions.

Physical activity should continue to be promoted even during this crisis, and there are opportunities for exercise that can be done at home. Many government policies that enforce quarantines/lockdowns still allow for daily outdoor exercise, provided safe physical distancing is upheld. Even if constraints mandate solely exercising indoors, many group exercise classes are available virtually, either with previously recorded videos or real-time live classes that engage with others on-line. Individuals can be encouraged to find a virtual work-out buddy to facilitate a commitment to daily exercise and enhancing social connections. Daily exercise routines and step counts can be logged to track accountability. Smart phones and devices can be used to promote activity through activity-trackers and activity-promoting games.

More time at home represents an opportunity to involve the whole family in exercise, educate children about the importance of regular activity, and introduce exercise as part of joyful routines to be maintained once outdoor restrictions have been lifted.

With thoughtful planning, many healthy products can still be purchased. Health care professionals should assess patient access to food items and changes in dietary patterns, and provide information regarding low cost, nutritionally dense foods.

Examples include low-sodium canned vegetables and legumes, frozen vegetables, frozen fruits with no added sugars, oatmeal, and other whole grains. Additionally, dry/canned beans and nuts are good sources of plant-based protein and fiber with a longer shelf-life. Encouragement of other healthier coping strategies for stress management, other than stress eating, such as meditation and exercise cannot be overemphasized.

Telehealth preventive visits represent an opportunity to inquire about smoking and the use of electronic nicotine delivery systems (ENDS) products. Moreover, during these telehealth visits, providers should continue to provide counselling on tobacco cessation. Patients can also be directed to several excellent online resources and programs that can be harnessed during this period to assist with tobacco 

There are several viable options to provide CR to individuals remotely. Currently, CR centers are attempting to quickly implement CR via telehealth (i.e., home-based CR or "HBCR"). Health are waiving all fees during the COVID-19 pandemic for access to the software without Bluetooth-connected devices. These vendors represent options for delivery of Phase II HBCR for low-to moderate-risk patients. For high-risk patients, such as those with left ventricular assist devices and heart transplant recipients, these programs are not ideal from an exercise standpoint but still provide useful education on nutrition, the importance of medication adherence, and other lifestyle modification strategies. There is also a great opportunity to combine HBCR with innovative digital health and wearable technology such as remote ECG monitors, as well as "smart shirts" (e.g. https://www.chronolife.net) with embedded sensors and electrodes that can transmit real time physiologic data to CR "monitoring centers." During these unprecedented times, there is a clear need to deploy innovative and value-based strategies such as HBCR and facilitate their integration as part of the standard of care.

The COVID-19 pandemic is a generation-defining event which will have long lasting ramifications for the health of our population and for the health care system, including those involved in the practice of preventive cardiology. We face the immense dual challenge of attending to the onslaught of acute critical illness in COVID-19 patients, while ensuring ongoing continuity of care and health preservation strategies for those at higher risk of CVD. Despite the challenges, ignoring the latter could result in in a sizeable increase of preventable CVD events that present in delayed waves for months and years to come.

Summary recommendations for best practices in the outpatient management of patients with and at high-risk for CVD during the COVID-19 pandemic can be found in Table 3 . The situation in each city, state and region regarding the COVID-19 crisis is variable in terms of number and severity of cases, strain on and capacity of the health care system, and socio-demographics of the local populations. Furthermore, the choice of how to best adopt and incorporate these recommendations will vary as well.

Nonetheless, there are a broad range of considerations, tools, and strategies available to promote and preserve the health of the populations at higher risk of CVD in the outpatient setting during this crisis. Collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified healthcare professional, qualified by education, training, licensure/ regulation (when applicable) requiring a minimum of 30 minutes of time, each 30 days).

Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment. (Initial set-up and patient education of monitoring equipment).

Device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days. (Initial collection, transmission, and report/summary services to the clinician managing the patient).

Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/ physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month. (Interpretation of the received data and interaction with patient on a treatment plan by a clinician).

Home Blood Pressure 99473 Self-measured blood pressure using a device validated for clinical accuracy; patient education/training and device calibration.

Separate self-measurements of two readings one minute apart, twice daily over a 30-day period (minimum of 12 readings), collection of data reported by the patient and/or caregiver to the physician or other qualified health care professional, with report of average systolic and diastolic pressures and subsequent communication of a treatment plan to the patient.

Online digital evaluation and management service, for an established patient, for up to 7 days cumulative time during the 7 days; 5-10 minutes (99421), 11-20 minutes (99422), or >21 minutes (99423).

Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified healthcare professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.

Initial inquiry should be initiated by patient; verbal consent to bill required. Documentation required.

Remote Evaluation of Pre-Recorded Patient Information

Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment. 1. Angiotensin converting enzyme inhibitors and angiotensin receptor blockers should be continued in patients already taking these medications. There is no recommendation to initiate these therapies in the absence of other clinical indications (e.g., hypertension, heart failure, or diabetes). 2. Where possible, it is strongly preferred to continue patient visits via telehealth rather than delaying or deferring visits. 3. Patients should be counseled to promptly report any new or concerning cardiac symptoms and not delay evaluation for severe symptoms. 4. Barriers to medication access should be reviewed with patients, with implementation of strategies to ensure ongoing provision of medications during the crisis. 5. Team-based care should be leveraged and enhanced to improve delivery of guideline directed cardiovascular care and adherence to lifestyle related recommendations. 6. Physical activity should continue to be promoted with safe distancing for outdoor activities and recommendations for several opportunities for exercise that can be done at home. 7. Health care professionals should assess patient access to food items and changes in dietary patterns, with recommendations and encouragement for healthy food options. 8. Adaptive strategies for cardiac rehabilitation should be implemented including home based cardiac rehabilitation, potentially involving innovative platforms, to ensure continuity of this essential service.

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Meditation programs for psychological stress and well-being: a systematic review and meta-analysis

Meditation and Cardiovascular Risk Reduction: A Scientific Statement From the American Heart Association

Yogic Breathing and Mindfulness as Stress Coping Mediate Positive Health Outcomes of Yoga

Association of alcohol consumption with selected cardiovascular disease outcomes: a systematic review and meta-analysis

ACC Expert Consensus Decision Pathway on Tobacco Cessation Treatment: A Report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents

ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Effects of emotion regulation strategies on smoking craving, attentional bias, and task persistence

Cardiac rehabilitation and risk reduction: time to "rebrand and reinvigorate

Telehealth exercisebased cardiac rehabilitation: a systematic review and meta-analysis

Home-Based Cardiac Rehabilitation: A Scientific Statement From the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology

Clinical Effectiveness of Lifestyle Health Coaching: Case Study of an Evidence-Based Program

Guidepoint Global, Regeneron, Sanofi, Novartis, Novo Nordisk SSM-current research support from the American Heart Association, Aetna Foundation, National Institutes of Health, the David and June Trone Family Foundation, and CASCADE FH. He has served as a consultant to Akcea, Amgen, Esperion, Kaneka, Novo Nordisk, Quest Diagnostics, Sanofi, Regeneron, and REGENXBIO. He is a co-inventor on a system to estimate LDL cholesterol levels, patent application pending. He is a founder of and holds equity in Corrie Health

Department of Veterans Affairs, World Heart Federation, Tahir and Jooma Family; Honorarium: American College of Cardiology (Associate Editor for Innovations

Steering Committee Member: Patient and Provider Assessment of Lipid Management (PALM) registry

Adapted with permission from Victor Tseng, MD ** The chronology, magnitude of impact, and duration of the second and third waves are for illustrative purposes only. At present, there are no publicly available models that can provide specificity regarding estimates.