Abstract
A 45-year-old woman, without cardiovascular risk factors and affected by chronic migraine, presented to the emergency department due to the onset of a typical chest pain. After performing an ...electrocardiogram she was promptly transported to the Cath lab, with the diagnosis of ST segment elevation myocardial infarction (STEMI), for urgent coronarography. A spontaneous dissection of the first obtuse marginal branch was detected which was treated with two drug eluting stents implantation. A day after the procedure, during a migraine crisis, at the continuous electrocardiographic monitoring it was registered a brief episode of complete atrioventricular block, which regressed spontaneously after a few minutes. For this reason, she underwent atropine test which resulted negative for AV conductance defects. No more episodes were recorded during the hospital stay, however it was decided to implant a loop recorder (Biotronik BIOMONITOR III) before the discharge. The patient received a remote monitoring device in order to allow a closer follow-up in course of the COVID-19-related lockdown, that caused a relevant reduction in the outpatients’ services. A few months later a sinusal pause of about 9 s was recorded with the emergence of an idioventricular rhythm at 25 b.p.m. When contacted by telephone the patient reported being hospitalized because of pulmonary complications of SARS-CoV-2 infection. She referred of being bedridden, without any cardiac monitor and of being asymptomatic for syncope. Thus, she was transferred to a Cardiology Unit dedicated to patients affected by SARS-CoV-2 disease, for further diagnostic investigations. This represents a case in which the remote monitoring technology resulted fundamental in the management of patients with implantable devices, in particular during COVID-19-related lockdown. However, it is at least as much important to encourage the patient to carry the transmitter with him, even in the case of unexpected events or hospitalizations, in order to gain access to all the information store in the CIED which might be useful to the diagnosis of the underlying disease. Biotronik has developed the smallest remote transmitter in commerce (CardioMessenger Smart) which is functional to this kind of use. Moreover, it has an automatic interrogation function which can send the alerts about the arrhythmic events quicker than the other brands and so it’s more practical in situations where the patient is hospitalized in non-cardiological units.
Abstract
Aims
During the Coronavirus Disease 2019 (COVID-19) pandemic in-person visits were reduced to prevent potential risk of exposure. Virtual visits (VVs) represent an innovative model to take ...care of patients with cardiac implantable electronic devices (CIEDs). The aim of this study is to evaluate the safety and feasibility of VV in the management of CIED patients.
Methods and results
We performed a prospective study including all CIED patients who received a VV from July 2020 to July 2021. Blood pressure, arterial oxygen saturation, heart rate, and body weight were registered by the patient. Moreover, we sent to the patient a questionnaire to evaluate the patients’ satisfaction about VV. We enrolled 182 patients in the study period. The mean age of patients was 70.2 ± 13.5 years-old and the majority (61.1%) was male. In two cases, VVs were not performed due to technical issues. Overall, 70.9% of patients utilized a smartphone, while 20.1% and 9% used, respectively, a tablet or a personal computer. The mean duration of VV was 27.8 ± 7.8 min. Patients helped by a caregiver were 64 (35.2%). One urgent/emergent in-person visit was performed in a patient with acute heart failure. Overall, VV was preferred to in-person evaluation.
Conclusion
VV is a safe and feasible approach to follow-up CIED patients. A high degree of patient satisfaction was reached after VV. The use of VV has promising potential and should be implemented beyond COVID-19 period and integrated in the healthcare system as a new model of care.
Abstract
Aims
Remote monitoring (RM) has significantly transformed the standard of care for patients with cardiac electronic implantable devices. It provides easy access to valuable information, such ...as arrhythmic events, acute decompensation manifestations, and device-related issues, without the need of in-person visits.
Methods and results
Starting 1 March, 332 patients were introduced to an RM programme during the Italian lockdown to limit the risk of in-hospital exposure to severe acute respiratory syndrome-coronavirus-2. Patients were categorized into two groups based on the modality of RM delivery home (n = 229) vs. office (n = 103) delivered. The study aimed at assessing the efficacy of the new follow-up protocol, assessed as mean RM activation time (AT), and the need for technical support. In addition, patients’ acceptance and anxiety status were quantified via the Home Monitoring Acceptance and Satisfaction Questionnaire and the Generalized Anxiety Disorder 7-item scale. AT time was less than 48 h in 93% of patients and 7% of them required further technical support. Despite a higher number of trans-telephonic technical support in the home-delivered RM group, mean AT was similar between groups (1.33 ± 0.83 days in home-delivered vs. 1.28 ± 0.81 days in office-delivered patients; P = 0.60). A total of 28 (2.5%) urgent/emergent in-person examinations were required. A high degree of patient satisfaction was reached in both groups whereas anxiety status was higher in the office-delivered group.
Conclusions
The adoption of RM resulted in high patient satisfaction, regardless of the modality of modem delivery; nonetheless, in-office modem delivery was associated with a higher prevalence of anxiety symptoms.
Abstract
Aims
Over the last decades, both the improvement in cardiovascular prevention programmes and the advancement in medical and invasive therapies facing ischaemic heart disease have granted an ...outstanding reduction in mortality rates. However, coronary heart disease remains, by far, the most common disease in developed countries, and the progressive ageing of population leads to a constantly increasing prevalence of chronic coronary syndrome (CCS). The consequence is an unsustainable demand for access to collapsing hospital clinic and doctor’s office. The dramatic Covid-19 era has become the testing ground for alternative ways to deliver healthcare avoiding in-hospital contacts, thus affirming the validity of telemedicine as a key tool to improve the patient journey. In our centre, video consults have been integrated to CCS patients’ clinical care pathway, not only preventing the risk of contagion but also laying the groundwork for a paradigm shift in clinical care course.
Methods and results
Since pandemic outbreak, Lazio Region offered to its inhabitants free of charge teleconsulting for both primary care and specialist referral. At the cardiovascular department of Fondazione Policlinico Gemelli IRCCS, this opportunity has been recently applied to optimize the chronic coronary syndrome patient journey. Specifically, videoconsulting has been used in different steps of CCS clinical course, replacing both in-person first visit and follow-up consultation after percutaneous myocardial revascularization. Being CCS a context in which the therapy optimization or the transition to higher level tests are mainly indicated by symptoms, these remote consultations could work as well as in-hospital visits to assess risk stratification and to consequently arrange the best therapeutic–diagnostic pathway. Besides, as COVID-19 pandemic caused significant delays, further remote visits have addressed the need to keep in contact with patients waiting for coronary angiography and to reassess their urgency criteria. In our department, over last 9 months, 141 patients have been examined and followed-up through teleconsulting, amounting to 34.1% of all supplied visits. Despite a high median age (67 ± 19.7 years), the drop-out rate of the contacted patients due to inability or denial was quite low (7.5%) and this high adherence to videoconsulting suggests time is ripe for a full telemedicine employment in clinical care course. In the cohort of patients waiting for coronary angiography, a telemedical reassessment led to a significant rate of priority class switch (42.7%), probably preventing adverse cardiac events in those individuals with worsening symptoms (systematically evaluated using Seattle Angina Questionnaire). Of note, the implementation of this parallel virtual pathway for these patients allowed us to decrease the waiting times for in-person visits at our CCS clinic, with an estimated time reduction of almost 3 months. This result supports our idea that the adoption of a remote pathway for chronic illness management, like CCS, may provide more opportunities for treatment of severe cases at in-person clinics that are often overcrowded.
Conclusions
In conclusion, all the potential of telehealth to empower primary and specialty health care is gradually emerging, and CCS seems the perfect setting for an integrated physical and virtual health system.
Pre-partecipation ECG screening of large populations has a significant socioeconomic impact. Technological progress now allows for high-tech-low-cost ECG screening using validated smartphone-based ...devices capable of guiding to the correct performance of a 12‑lead ECG by layman with no medical background.
We enrolled 728 (364, 52% males) individuals, aged 12–13 years who underwent ECG screening with a smartphone 12‑lead ECG during school hours by layman volunteers. Correct electrodes placement was provided by a validated image-processing algorithm by the smartphone camera in the App. ECG interpretation was via a telecardiology platform and alterations classified following current standards.
A total of 741 ECGs were recorded, of which 13(2%) were technically not interpretable. Mean PR, QRS and QTc were: 145 ± 22, 85 ± 19 and 387 ± 57 msec. No QTc prolongation was observed. Mean QRS axis was 15°; 26 (4%) patients presented an iRBB. T-wave inversion from V1-V3 was present in 145 (21%) subjects. Twenty-one(3%) patients were referred to second level examination: deep Q-waves in inferior leads in 12(1.6%), ventricular ectopics in 5(0.7%), anterior T-waves inversions V1-V4 in 3(0.4%); extreme right axis deviation in 1(0.3%). Second line investigations did not provide any definitive diagnosis. Total project costs (material equipment and human cost) was 14.460€, 19.51€ per individual. The potential net saving with respect to current pre-participation screening cost was 19%.
Layman 12‑lead Smartphone-ECG population screening proved feasible and effective, with a rate of non-interpretable ECG of <5%. Potential cost-saving in ECG screening and recording was 19%, providing an appealing opportunity when large campaigns should be addressed also in developing countries.
•Pre-partecipation ECG screening of large populations has significant socioeconomic impact. Technological progress allows for high-tech-low-cost ECG screening using smartphone-based devices capable of guiding a user with no medical background to perform a12-lead ECG.•We enrolled 728 (364, 52% males) individuals, aged 12–13 years who underwent ECG screening with a smartphone 12-lead ECG during school hours by layman volunteers.•Twenty-one(3%) patients were referred to second level examination, reasons were: deep Q-waves in inferior leads in 12(1.6%), ventricular ectopics in 5(0.7%), anterior T-waves inversions V1-V4 in 3(0.4%); extreme right axis deviation in 1(0.3%).•Total project costs was 14.460€, 19.51€ per individual. The potential net saving with respect to current pre-participation screening cost in ECG recording and interpretation was 19%.
Early in the COVID-19 pandemic, cardiology clinics rapidly implemented telemedicine to maintain access to care. Little is known about subsequent trends in telemedicine use and visit volumes across ...cardiology subspecialties. We conducted a retrospective cohort study including all patients with ambulatory visits at a multispecialty cardiovascular center in Northern California from March 2019 to February 2020 (pre-COVID) and March 2020 to February 2021 (COVID). Telemedicine use increased from 3.5% of visits (1200/33,976) during the pre-COVID period to 63.0% (21,251/33,706) during the COVID period. Visit volumes were below pre-COVID levels from March to May 2020 but exceeded pre-COVID levels after June 2020, including when local COVID-19 cases peaked. Telemedicine use was above 75% of visits in all cardiology subspecialties in April 2020 and stabilized at rates ranging from over 95% in electrophysiology to under 25% in heart transplant and vascular medicine. From June 2020 to February 2021, subspecialties delivering a greater percentage of visits through telemedicine experienced larger increases in new patient visits (r = 0.81,
= 0.029). Telemedicine can be used to deliver a significant proportion of outpatient cardiovascular care though utilization varies across subspecialties. Higher rates of telemedicine adoption may increase access to care in cardiology clinics.
The remote follow-up of pacemakers and implantable cardiac defibrillators (ICDs) usually includes scheduled checks and alert transmissions. However, this results in a high volume of remote data ...reviews to be managed. We measured the relative contribution of scheduled and alert transmissions to the detection of relevant conditions, and the workload generated by their management.
At our center, the frequency of remote scheduled transmissions is 4/year. Moreover, all system-integrity and clinical alerts are turned on for wireless notification. We calculated the number of transmissions received from January to December 2020, and identified transmissions that necessitated in-hospital access for further assessment and transmissions that required clinical discussion with the physician. For all alert transmissions, we identified whether the alert was clinically meaningful (i.e. center was not previously aware of the condition and no action had yet been taken to treat it).
Of 8545 transmissions received from 1697 pacemakers and ICDs, 5766 (67%) were scheduled and 2779 (33%) were alert transmissions received from 764 patients (45%); 499 (9%) scheduled transmissions required clinical discussion with the physician, but only 2 of these necessitated in-hospital visits for further assessment. Of the alert transmissions, 664 (24%) required clinical discussion, and 75 (3%) necessitated in-hospital visits. The proportion of alerts judged clinically meaningful was 7%.
Scheduled transmissions generate 67% of remote data reviews for pacemakers and ICDs, but their ability to detect clinically relevant events is very low. A strategy that relies exclusively on alert transmissions could ensure continuity of patient monitoring while reducing the workload at the center.
•In a remote follow-up service, two-thirds of remote data reviews are generated by scheduled data transmissions.•Scheduled transmissions display far less ability to detect clinically relevant events than automatic alerts.•A strategy based on alert transmissions could ensure continuity of patient monitoring while reducing the workload.
Introducción: La pandemia de COVID-19 ha causado un impacto global en los servicios de salud pública. Utilizar nuevas estrategias a través de la telesalud para el manejo de los pacientes con ...cardiopatías congénitas fue el desafío. Objetivo: Describir la experiencia en telecardiología y las estrategias implementadas durante la pandemia. Método: Estudio retrospectivo, cualitativo, que comprende el periodo de abril de 2020 a abril de 2021. Se recibieron consultas a través del correo electrónico oficial del servicio o por teléfono. Se clasificaron según tipo de inquietud y complejidad de la cardiopatía utilizando una codificación por colores. Las respuestas a las mismas fueron asincrónicas (correo electrónico) o sincrónicas (videoconferencias). Las videoconferencias se realizaron utilizando una plataforma segura (Cisco-Webex). Resultados: Se contestaron 3372 consultas. Las respuestas fueron distribuidas en correos electrónicos (64.9%), llamados telefónicos (1.2%), videoconferencias (14.5%) y otros métodos (19.4%) Los motivos de consulta más frecuentes fueron la solicitud de turnos suspendidos (68%) y control clínico a distancia (20%). Se pudo establecer contacto con 2296 familias. Solo el 14.1% de las consultas se citó en forma presencial. Con la codificación por colores se logró realizar una estratificación según la urgencia. Conclusiones: La telesalud mostró ser una herramienta útil para el manejo clínico de pacientes con cardiopatías congénitas en su lugar de origen. Evitó un gran número de traslados, identificó pacientes en riesgo, confortó a las familias y fortaleció vínculos con hospitales locales que integran la red de salud.
Cardiovascular disease (CVD) is one of the most widespread health problems with unpredictable and life-threatening consequences. The electrocardiogram (ECG) is commonly recorded for computer-aided ...CVD diagnosis, human emotion recognition and person authentication systems. For effective detection and diagnosis of cardiac diseases, the ECG signals are continuously recorded, processed, stored, and transmitted via wire/wireless communication networks. But long-term continuous cardiac monitoring system generates huge volume of ECG data daily. Therefore, a reliable and efficient ECG signal compression method is highly demanded to meet the real-time constraints including limited channel capacity, memory and battery-power of remote cardiac monitoring, ECG record management and telecardiology systems. In such scenarios, the main objective of the ECG signal compression is to reduce the data rate for effective transmission and/or storage purposes without significantly distorting the clinical features of different kinds of PQRST morphologies contained in the recorded ECG signal. Numerous ECG compression methods have been proposed by exploiting the intra-beat correlation, inter-beat correlation and intra-channel correlation of the ECG signals. This paper presents a prospective review of wavelet-based ECG compression methods and their performances based upon findings obtained from various experiments conducted using both clean and noisy ECG signals. This paper briefly describes different kinds of compression techniques used in the one-dimensional wavelet-based ECG compression methods. Then, the performance of each of the wavelet-based compression methods is tested and validated using the standard MIT-BIH arrhythmia databases and performance metrics. The pros and cons of different wavelet-based compression methods are demonstrated based upon the experimental results. Finally, various practical issues involved in the validation procedures, reconstructed signal quality assessment, and performance comparisons are highlighted by considering the future research studies based on the recent powerful digital signal processing techniques and computing platform.
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