Heart Disease Between Visits: Watching the Signs That Come First

Coronary artery disease is part of CKM Syndrome, and heart disease of all kinds shares the same problem as other chronic conditions: the patient lives with it every day, and the care team sees a few minutes of it a year.

The early signs are at home

For many cardiac patients, trouble shows up first in simple things the patient can report: a few pounds of weight gained in a few days, new swelling in the ankles, more breathlessness lying flat or on exertion, or missed medications. These are easy questions to ask and easy answers to trend.

A short daily check-in

With the PDS™ Patient Data System, the cardiology or primary care team chooses the questions, such as today’s weight, swelling, breathlessness and whether medications were taken. Patients answer in about thirty seconds on their own phone. When a trend crosses a threshold the team set, CareConnect™ raises an alert so EBM can reach the patient and escalate to the physician.

That gives the cardiologist something the office visit cannot: a record of how the patient actually did since the last change in therapy.

Heart and lungs together

Heart disease and respiratory disease often overlap. 70% of Medicare and Medicaid COPD patients also have a CKM condition, which is why COPD and cardiac care work best when they share data. Hybrid Overnight Oximetry supports cardio-pulmonary care as a Practice-Based Protocol (PBP), and untreated obstructive sleep apnea is a frequent, often missed companion to heart disease.

One channel for the whole team

A cardiac patient may also see a nephrologist, an endocrinologist and a primary care physician. CareConnect™ connects all of them with the patient in one place, so a change one clinician notices reaches the others.

EBM does not add work to the clinic. Our team handles the between-visit workload, escalates what needs attention and documents everything, while physicians stay in control of every clinical decision. There are no CPT codes required, no payer qualification, and no hiring, equipment purchase or IT build-out. Anyone in the chronic population can participate, regardless of age, diagnosis or insurance type.

Part of our series on CKM Syndrome and chronic disease. Related conditions: Copd, Type 2 diabetes, hypertension, chronic kidney disease, excess weight.