Assessing the Feasibility of the Virtual Exam in Patients with Heart Failure: Reading the Neck Veins from Afar
- The "virtual visit" as a component of telehealth rapidly emerged in routine clinical practice during the COVID-19 pandemic. However, minimal data are available regarding the accuracy of the physical examination performed over video during such visits.
- To test whether estimation of the jugular venous pressure (JVP), a key component of the physical examination, could be performed remotely, we compared video and bedside JVP estimates to the invasively measured right atrial pressure (RAP) in patients with heart failure.
- Though remote evaluators reported less confidence in their assessments, their estimates of RAP ≥10 mm Hg achieved accuracy similar to bedside evaluations. Further, the remote and the bedside estimates had similar correlations with the invasively-measured RAP. These data support the feasibility of estimation of the RAP remotely over video.
While there previously had been growing interest in telemedicine, the COVID-19 pandemic accelerated its emergence at a pace that could not have been anticipated. In a matter of months, many medical centers incorporated telemedicine into their care delivery model to avoid risk of transmission of SARS-CoV-2 to patients from in-person visits.1 Patients with heart failure (HF) would seem to be an ideal group to be evaluated via telemedicine. They require careful, longitudinal follow-up, yet would be at increased risk for adverse events should they develop COVID-19.
The "virtual visit" offers numerous appealing advantages such as reducing potential exposure to COVID-19, preservation of personal protective equipment, eliminating transportation time and cost, and flexibility for both patients and providers. However, the unprecedented expansion of telemedicine raised concerns about how effectively remotely delivered medical care can match the standard of traditional patient encounters. In particular, it remains uncertain what is lost by the absence of an in-person visit and physical examination.
The ACC/AHA guidelines recommend an assessment of volume status at each encounter with a patient with HF, and an estimate of the jugular venous pressure (JVP) is considered the key maneuver in such assessments.2,3 However, it was entirely unknown whether it would be feasible to estimate the JVP over video. There has been investigative work to estimate JVP via computerized image analysis, but that is not yet commercially available.4
To determine whether physicians can estimate JVP remotely, we compared JVP estimates performed over video with both bedside JVP estimates and the invasively measured right atrial pressure (RAP).5 For this prospective, observational study, we enrolled 31 adults with HF and reduced left-ventricular ejection fraction (≤40%). Each patient underwent one bedside JVP assessment and up to four assessments over video performed by different advanced HF cardiologists. The video assessments were performed using commercially available videoconferencing apps. The remote evaluator provided instructions to a house staff member at bedside who held the camera and repositioned the patient and/or camera as requested by the remote evaluator.
Following these evaluations on the same day, each patient underwent right heart catheterization by a cardiologist blinded to the clinical assessment of JVP. Using linear mixed-effect modeling, we determined the R2 values between both the bedside and remote JVP estimates (multiplied by 0.74 for conversion to mm Hg) with the invasively measured RAP. The evaluators rated their confidence in each estimation of the JVP.
We found significant and comparable correlation of both bedside and remote JVP estimates with invasively measured RAP, yielding R2 values of 0.521 and 0.504, respectively. The JVP estimates and the measured RAP were concordantly low (<10 mm Hg) or high (≥10 mm Hg) in 26 of 28 bedside assessments (93%) and 54 of 61 remote assessments (89%). Of note, remote evaluators did report lower confidence than bedside evaluators despite achieving similar accuracy, suggesting lack of familiarity and comfort with the novel approach of physical examination over video.
Our study was a proof-of-concept for feasibility of remote JVP assessment. We found that discrimination of high versus low JVP could be performed over video with approximately 90% accuracy, comparable to that via bedside evaluation. However, certain limitations of the study are notable. Advanced HF cardiologists performed the estimates of the JVP, and other providers who do not routinely assess neck veins may not have the expertise to achieve comparable results. We also had an investigator holding and manipulating the camera to provide the requested view. Patients may not always have someone who can assist in a remote evaluation when participating in a virtual visit. Furthermore, some patients may lack access to appropriate equipment or internet service to perform a video visit. In such circumstances, it may be appropriate to employ a "hub-and-spoke" model whereby patients attend a local clinic equipped for telecommunication. Remote clinic staff can then complete the visit supported by a "teleconsult" with pertinent specialists located centrally. Such a model has already proven effective at increasing timely access to stroke care.6
While our study examined only JVP evaluation, other exam findings to assess volume status seem amenable to remote evaluation including bendopnea, orthopnea, hepatojugular reflux, peripheral edema, and abdominal distension.1 However, to our knowledge, there have been no studies regarding the accuracy of remote assessment of these components of the clinical examination. Vital signs can also be acquired during a telehealth visit when patients possess the tools to measure their weight, blood pressure, heart rate and oxygen saturation. Patients who intend to follow-up primarily by means of virtual visits could be provided with prefabricated telehealth "kits" including more sophisticated modalities such as single-lead electrocardiograms (ECG) and digital stethoscopes for remote auscultation.
Telehealth virtual visits may also benefit via information gathered from other technologies available for remote monitoring of patients. Novel heart rhythm sensors, including smart watches, can provide electrocardiographic data that would previously have required cumbersome equipment.7,8 Remote dielectric sensing (ReDS™) estimates the fluid content of pulmonary tissue based on the dielectric properties across the thorax.9,10 Interrogation of implanted electrical devices (e.g. ICDs or pacemakers) can provide information about a patient's clinical status through assessments of heart rate variability, heart rhythm, activity levels and thoracic impedance. Finally, the implantable CardioMEMS device has demonstrated utility in improving hemodynamics via outpatient monitoring of pulmonary artery pressure leading to a reduction of HF admissions in some NYHA class 3 patients.11,12 However, further studies are needed to demonstrate efficacy before these approaches are incorporated routinely into telehealth visits for patients with HF.
For telehealth visits to be successful, there needs to be buy-in by providers, as well as patients. Patients need to be assured that these visits provide value to them. Physicians need to know how best to conduct a virtual visit, including an understanding of the strengths and limitations of this approach. While research in this area is limited, a recent study showed that virtual visits following hospital admissions for HF were non-inferior to in-person visits in terms of clinical outcomes and showed a trend toward reduced no-show rates.13
For now, one can consider telemedicine an emerging field. Telehealth did offer a means to provide some level of continuity of care of patients with cardiovascular conditions during the COVID-19 pandemic.1 However, the evidence base regarding the value of the virtual exam is miniscule, and further studies are needed to determine its strengths and limitations. Our study demonstrated that evaluation over video accurately discriminated high versus low JVP in the vast majority of subjects and was comparable to bedside evaluation. We believe that an additional evidence base needs to accrue if telemedicine is to remain a viable approach in the care of patients with HF once the risks of COVID-19 transmission are no longer present.
- Gorodeski EZ, Goyal P, Cox ZL, et al. Virtual visits for care of patients with heart failure in the era of COVID-19: a statement from the Heart Failure Society of America. J Card Fail 2020;26:448-56.
- Thibodeau JT, Drazner MH. The role of the clinical examination in patients with heart failure. JACC Heart Fail 2018;6:543-51.
- Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: executive summary. J Am Coll Cardiol 2013;62:e147-239.
- Abnousi F, Kang G, Giacomini J, et al. A novel noninvasive method for remote heart failure monitoring: the EuleriAn video Magnification apPLications In heart Failure studY (AMPLIFY). Npj Digit Med 2019;2:80.
- Kelly SA, Schesing KB, Thibodeau JT, Ayers CR, Drazner MH. Feasibility of remote video assessment of jugular venous pressure and implications for telehealth. JAMA Cardiol 2020;5:1194-95.
- Schwamm LH, Chumbler N, Brown E, et al. Recommendations for the implementation of telehealth in cardiovascular and stroke care: a policy statement from the American Heart Association. Circulation 2017;135:e24-e44.
- Sana F, Isselbacher EM, Singh JP, Heist EK, Pathik B, Armoundas AA. Wearable devices for ambulatory cardiac monitoring: JACC State-of-the-Art Review. J Am Coll Cardiol 2020;75:1582-92.
- Perez MV, Mahaffey KW, Hedlin H, et al. Large-scale assessment of a smartwatch to identify atrial fibrillation. N Engl J Med 2019;381:1909-17.
- Amir O, Ben-Gal T, Weinstein JM, et al. Evaluation of remote dielectric sensing (ReDS) technology-guided therapy for decreasing heart failure re-hospitalizations. Int J Cardiol 2017;240:279-84.
- Abraham WT, Anker S, Burkhoff D, et al. Primary results of the sensible medical innovations lung fluid status monitor allows reducing readmission rate of heart failure patients (smile) trial. J Card Fail 2019;25:938.
- Heywood JT, Jermyn R, Shavelle D, et al. Impact of practice-based management of pulmonary artery pressures in 2000 patients implanted with the CardioMEMS sensor. Circulation 2017;135:1509-17.
- Abraham WT, Adamson PB, Bourge RC, et al. Wireless pulmonary artery haemodynamic monitoring in chronic heart failure: a randomised controlled trial. Lancet 2011;377:658-66.
- Gorodeski EZ, Moennich LA, Riaz H, Jehi L, Young JB, Tang WHW. Virtual versus in-person visits and appointment no-show rates in heart failure care transitions. Circ Heart Fail 2020;13:e007119.
Keywords: Heart Failure, COVID-19, Heart Rate, Blood Pressure, Prospective Studies, Stethoscopes, Internship and Residency, Stroke Volume, Personal Protective Equipment, Specialization, Follow-Up Studies, Atrial Pressure, Pulmonary Artery
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