Effect of Smartphone-Enabled Health Monitoring Devices vs Regular Follow-up on Blood Pressure Control Among Patients After Myocardial Infarction: A Randomized Clinical Trial

Analysis of Demographic and Socioeconomic Factors Influencing Adherence to a Web-Based Intervention Among Patients After Acute Coronary Syndrome: Prospective Observational Cohort Study

BACKGROUND

Although telemedicine has been proven to have significant potential for improving care for patients with cardiac problems, there remains a substantial risk of introducing disparities linked to the use of digital technology, especially for older or socially vulnerable subgroups.

OBJECTIVE

We investigated factors influencing adherence to a telemedicine-delivered health education intervention in patients with ischemia, emphasizing demographic and socioeconomic considerations.

METHODS

We conducted a descriptive, observational, prospective cohort study in consecutive patients referred to our cardiology center for acute coronary syndrome, from February 2022 to January 2023. Patients were invited to join a web-based health educational meeting (WHEM) after hospital discharge, as part of a secondary prevention program. The WHEM sessions were scheduled monthly and used a teleconference software program for remote synchronous videoconferencing, accessible through a standard computer, tablet, or smartphone based on patient preference or availability.

RESULTS

Out of the 252 patients (median age 70, IQR 61.0-77.3 years; n=189, 75% male), 98 (38.8%) declined the invitation to participate in the WHEM. The reasons for nonacceptance were mainly challenges in handling digital technology (70/98, 71.4%), followed by a lack of confidence in telemedicine as an integrative tool for managing their medical condition (45/98, 45.9%), and a lack of internet-connected devices (43/98, 43.8%). Out of the 154 patients who agreed to participate in the WHEM, 40 (25.9%) were unable to attend. Univariable logistic regression analysis showed that the presence of a caregiver with digital proficiency and a higher education level was associated with an increased likelihood of attendance to the WHEM, while the converse was true for increasing age and female sex. After multivariable adjustment, higher education level (odds ratio [OR] 2.26, 95% CI 1.53-3.32; P<.001) and caregiver with digital proficiency (OR 12.83, 95% CI 5.93-27.75; P<.001) remained independently associated with the outcome. The model discrimination was good even when corrected for optimism (optimism-corrected C-index=0.812), as was the agreement between observed and predicted probability of participation (optimism-corrected calibration intercept=0.010 and slope=0.948).

CONCLUSIONS

This study identifies a notable lack of suitability for a specific cohort of patients with ischemia to participate in our telemedicine intervention, emphasizing the risk of digital marginalization for a significant portion of the population. Addressing low digital literacy rates among patients or their informal caregivers and overcoming cultural bias against remote care were identified as critical issues in our study findings to facilitate the broader adoption of telemedicine as an inclusive tool in health care.

Participatory Development of an Integrated, eHealth-Supported, Educational Care Pathway (Diabetes Box) for People With Type 2 Diabetes: Development and Usability Study

BACKGROUND

Type 2 diabetes (T2D) tremendously affects patient health and health care globally. Changing lifestyle behaviors can help curb the burden of T2D. However, health behavior change is a complex interplay of medical, behavioral, and psychological factors. Personalized lifestyle advice and promotion of self-management can help patients change their health behavior and improve glucose regulation. Digital tools are effective in areas of self-management and have great potential to support patient self-management due to low costs, 24/7 availability, and the option of dynamic automated feedback. To develop successful eHealth solutions, it is important to include stakeholders throughout the development and use a structured approach to guide the development team in planning, coordinating, and executing the development process.

OBJECTIVE

The aim of this study is to develop an integrated, eHealth-supported, educational care pathway for patients with T2D.

METHODS

The educational care pathway was developed using the first 3 phases of the Center for eHealth and Wellbeing Research roadmap: the contextual inquiry, the value specification, and the design phase. Following this roadmap, we used a scoping review about diabetes self-management education and eHealth, past experiences of eHealth practices in our hospital, focus groups with health care professionals (HCPs), and a patient panel to develop a prototype of an educational care pathway. This care pathway is called the Diabetes Box (Leiden University Medical Center) and consists of personalized education, digital educational material, self-measurements of glucose, blood pressure, activity, and sleep, and a smartphone app to bring it all together.

RESULTS

The scoping review highlights the importance of self-management education and the potential of telemonitoring and mobile apps for blood glucose regulation in patients with T2D. Focus groups with HCPs revealed the importance of including all relevant lifestyle factors, using a tailored approach, and using digital consultations. The contextual inquiry led to a set of values that stakeholders found important to include in the educational care pathway. All values were specified in biweekly meetings with key stakeholders, and a prototype was designed. This prototype was evaluated in a patient panel that revealed an overall positive impression of the care pathway but stressed that the number of apps should be restricted to one, that there should be no delay in glucose value visualization, and that insulin use should be incorporated into the app. Both patients and HCPs stressed the importance of direct automated feedback in the Diabetes Box.

CONCLUSIONS

After developing the Diabetes Box prototype using the Center for eHealth and Wellbeing Research roadmap, all stakeholders believe that the concept of the Diabetes Box is useful and feasible and that direct automated feedback and education on stress and sleep are essential. A pilot study is planned to assess feasibility, acceptability, and usefulness in more detail.

Tailoring remote patient management in cardiovascular risk management for healthcare professionals using panel management: a qualitative study

BACKGROUND

While remote patient management (RPM) has the potential to assist in achieving treatment targets for cardiovascular risk factors in primary care, its effectiveness may vary among different patient subgroups. Panel management, which involves proactive care for specific patient risk groups, could offer a promising approach to tailor RPM to these groups. This study aims to (i) assess the perception of healthcare professionals and other stakeholders regarding the adoption and (ii) identify the barriers and facilitators for successfully implementing such a panel management approach.

METHODS

In total, nineteen semi-structured interviews and two focus groups were conducted in the Netherlands. Three authors reviewed the audited transcripts. The Consolidated Framework for Implementation Strategies (CFIR) domains were used for the thematic analysis.

RESULTS

A total of 24 participants (GPs, nurses, health insurers, project managers, and IT consultants) participated. Overall, a panel management approach to RPM in primary care was considered valuable by various stakeholders. Implementation barriers encompassed concerns about missing necessary risk factors for patient stratification, additional clinical and technical tasks for nurses, and reimbursement agreements. Facilitators included tailoring consultation frequency and early detection of at-risk patients, an implementation manager accountable for supervising project procedures and establishing agreements on assessing implementation metrics, and ambassador roles.

CONCLUSION

Panel management could enhance proactive care and accurately identify which patients could benefit most from RPM to mitigate CVD risk. For successful implementation, we recommend having clear agreements on technical support, financial infrastructure and the criteria for measuring evaluation outcomes.

Effectiveness of mobile health applications on clinical outcomes and health behaviors in patients with coronary heart disease: A systematic review and meta-analysis

Objective

Mobile health applications (apps) have gained significant popularity and widespread utilization among patients with coronary heart disease (CHD). The objective of this study is to evaluate the effects of mHealth apps on clinical outcomes and health behaviors in patients with CHD.

Methods

Databases were searched from inception until December 2023, including Cochrane Library, PubMed, EMBASE, Web of Science, CINAHL, China National Knowledge Infrastructure (CNKI), Chinese BioMedical Literature Service System (SinoMed), Wanfang Data, China Science and Technology Journal Database (VIP), for randomized controlled trials (RCTs) regarding the effectiveness of mHealth apps in patients with CHD. Two researchers conducted a comprehensive review of the literature, extracting relevant data and evaluating each study's methodological quality separately. The meta-analysis was performed utilizing Review Manager v5.4 software.

Results

A total of 34 RCTs were included, with 5,319 participants. The findings demonstrated that using mHealth apps could decrease the incidence of major adverse cardiac events (RR = 0.68, P = 0.03), readmission rate (RR = 0.56, P < 0.001), total cholesterol (WMD = -0.19, P = 0.03), total triglycerides (WMD = -0.24, P < 0.001), waist circumference (WMD = -1.92, P = 0.01), Self-Rating Anxiety Scale score (WMD = -6.70, P < 0.001), and Self-Rating Depression Scale score (WMD = -7.87, P < 0.001). They can also increase the LVEF (WMD = 6.50, P < 0.001), VO2 max (WMD = 1.89, P < 0.001), 6-min walk distance (6MWD) (WMD = 19.43, P = 0.004), Morisky Medication Adherence Scale-8 score (WMD = 0.96, P = 0.004), and medication adherence rate (RR = 1.24, P = 0.03). Nevertheless, there is no proof that mHealth apps can lower low-density lipoprote in cholesterol, blood pressure, BMI, or other indicator (P > 0.05).

Conclusion

Mobile health apps have the potential to lower the incidence of major adverse cardiac events (MACEs), readmission rates, and blood lipids in patients with CHD. They can also help enhance cardiac function, promote medication adherence, and alleviate symptoms of anxiety and depression. To further corroborate these results, larger-scale, multi-center RCTs with longer follow-up periods are needed.

Association of Remote Patient Monitoring with Mortality and Healthcare Utilization in Hypertensive Patients: a Medicare Claims-Based Study

BACKGROUND

Hypertension management is complex in older adults. Recent advances in remote patient monitoring (RPM) have warranted evaluation of RPM use and patient outcomes.

OBJECTIVE

To study associations of RPM use with mortality and healthcare utilization measures of hospitalizations, emergency department (ED) utilization, and outpatient visits.

DESIGN

A retrospective cohort study.

PATIENTS

Medicare beneficiaries aged ≥65 years with an outpatient hypertension diagnosis between July 2018 and September 2020. The first date of RPM use with a corresponding hypertension diagnosis was recorded (index date). RPM non-users were documented from those with an outpatient hypertension diagnosis; a random visit was selected as the index date. Six months prior continuous enrollment was required.

MAIN MEASURES

Outcomes studied within 180 days of index date included (i) all-cause mortality, (ii) any hospitalization, (iii) cardiovascular-related hospitalization, (iv) non-cardiovascular-related hospitalization, (v) any ED, (vi) cardiovascular-related ED, (vii) non-cardiovascular-related ED, (viii) any outpatient, (ix) cardiovascular-related outpatient, and (x) non-cardiovascular-related outpatient. Patient demographics and clinical variables were collected from baseline and index date. Propensity score matching (1:4) and Cox regression were performed. Hazard ratios (HR) and 95% confidence intervals (CI) are reported.

KEY RESULTS

The matched sample had 16,339 and 63,333 users and non-users, respectively. Cumulative incidences of mortality outcome were 2.9% (RPM) and 4.3% (non-RPM), with a HR (95% CI) of 0.66 (0.60-0.74). RPM users had lower hazards of any [0.78 (0.75-0.82)], cardiovascular-related [0.79 (0.73-0.87)], and non-cardiovascular-related [0.79 (0.75-0.83)] hospitalizations. No significant association was observed between RPM use and the three ED measures. RPM users had higher hazards of any [1.10 (1.08-1.11)] and cardiovascular-related outpatient visits [2.17 (2.13-2.19)], while a slightly lower hazard of non-cardiovascular-related outpatient visits [0.94 (0.93-0.96)].

CONCLUSIONS

RPM use was associated with substantial reductions in hazards of mortality and hospitalization outcomes with an increase in cardiovascular-related outpatient visits.

Advancing telemedicine in cardiology: A comprehensive review of evolving practices and outcomes in a postpandemic context

Telemedicine, telehealth, e-Health, and other related terms refer to the exchange of medical information or medical care from one site to another through electronic communication between a patient and a health care provider. As telemedicine infrastructure has changed since the coronavirus disease 2019 (COVID-19) pandemic, this review provides an overview of telemedicine use and effectiveness in cardiology, with emphasis on coronary artery disease in the postpandemic context. Prepandemic studies tend to report statistically insignificant or modest improvements in cardiovascular disease outcome from telemedicine use to usual care. In contrast, postpandemic studies tend to report positive outcomes or comparable acceptance of telemedicine use to usual care. Today, telemedicine can effectively replace in person follow-up visits to produce comparable (but not necessarily superior) outcomes in cardiovascular disease management. A benefit of telemedicine is the potential reduction in follow-up time or time to intervention, which may lead to earlier detection and prevention of adverse events. Nonetheless, barriers remain to effective telemedicine implementation in the postpandemic context. Ensuring accessible and user-friendly telemedicine devices, maintaining adherence to remote rehabilitation procedures, and normalizing use of telemedicine in routine follow-up visits are examples. Current knowledge gaps include the true economic cost of telemedicine infrastructure, feasibility of use in specific cardiology contexts, and sex/gender differences in telemedicine use. Future telemedicine developments will need to address these concerns before acceptance of telemedicine as the new standard of care.

How to Use Costs in Value-Based Healthcare: Learning from Real-life Examples

BACKGROUND

Healthcare organizations measure costs for business operations but do not routinely incorporate costs in decision-making on the value of care.

AIM

Provide guidance on how to use costs in value-based healthcare (VBHC) delivery at different levels of the healthcare system.

SETTING AND PARTICIPANTS

Integrated practice units (IPUs) for diabetes mellitus (DM) and for acute myocardial infarction (AMI) at the Leiden University Medical Center and a collaboration of seven breast cancer IPUs of the Santeon group, all in the Netherlands.

PROGRAM DESCRIPTION AND EVALUATION

VBHC aims to optimize care delivery to the patient by understanding how costs relate to outcomes. At the level of shared decision-making between patient and clinician, yearly check-up consultations for DM type I were analyzed for patient-relevant costs. In benchmarking among providers, quantities of cost drivers for breast cancer care were assessed in scorecards. In continuous learning, cost-effectiveness analysis was compared with radar chart analysis to assess the value of telemonitoring in outpatient follow-up.

DISCUSSION

Costs vary among providers in healthcare, but also between provider and patient. The joint analysis of outcomes and costs using appropriate methods helps identify and optimize the aspects of care that drive desired outcomes and value.

Optimising the implementation of digital-supported interventions for the secondary prevention of heart disease: a systematic review using the RE-AIM planning and evaluation framework

BACKGROUND

mHealth technologies are now widely utilised to support the delivery of secondary prevention programs in heart disease. Interventions with mHealth included have shown a similar efficacy and safety to conventional programs with improvements in access and adherence. However, questions remain regarding the successful wider implementation of digital-supported programs. By applying the Reach-Effectiveness-Adoption-Implementation-Maintenance (RE-AIM) framework to a systematic review and meta-analysis, this review aims to evaluate the extent to which these programs report on RE-AIM dimensions and associated indicators.

METHODS

This review extends our previous systematic review and meta-analysis that investigated the effectiveness of digital-supported programs for patients with coronary artery disease. Citation searches were performed on the 27 studies of the systematic review to identify linked publications that reported data for RE-AIM dimensions. All included studies and, where relevant, any additional publications, were coded using an adapted RE-AIM extraction tool. Discrepant codes were discussed amongst reviewers to gain consensus. Data were analysed to assess reporting on indicators related to each of the RE-AIM dimensions, and average overall reporting rates for each dimension were calculated.

RESULTS

Searches found an additional nine publications. Across 36 publications that were linked to the 27 studies, 24 (89%) of the studies were interventions solely delivered at home. The average reporting rates for RE-AIM dimensions were highest for effectiveness (75%) and reach (67%), followed by adoption (54%), implementation (36%) and maintenance (11%). Eleven (46%) studies did not describe relevant characteristics of their participants or of staff involved in the intervention; most studies did not describe unanticipated consequences of the intervention; the ongoing cost of intervention implementation and maintenance; information on intervention fidelity; long-term follow-up outcomes, or program adaptation in other settings.

CONCLUSIONS

Through the application of the RE-AIM framework to a systematic review we found most studies failed to report on key indicators. Failing to report these indicators inhibits the ability to address the enablers and barriers required to achieve optimal intervention implementation in wider settings and populations. Future studies should consider alternative hybrid trial designs to enable reporting of implementation indicators to improve the translation of research evidence into routine practice, with special consideration given to the long-term sustainability of program effects as well as corresponding ongoing costs.

REGISTRATION

PROSPERO-CRD42022343030.

Mobile health for cardiovascular risk management after cardiac surgery: results of a sub-analysis of The Box 2.0 study

Aims

Lowering low-density lipoprotein (LDL-C) and blood pressure (BP) levels to guideline recommended values reduces the risk of major adverse cardiac events in patients who underwent coronary artery bypass grafting (CABG). To improve cardiovascular risk management, this study evaluated the effects of mobile health (mHealth) on BP and cholesterol levels in patients after standalone CABG.

Methods and results

This study is a post hoc analysis of an observational cohort study among 228 adult patients who underwent standalone CABG surgery at a tertiary care hospital in The Netherlands. A total of 117 patients received standard care, and 111 patients underwent an mHealth intervention. This consisted of frequent BP and weight monitoring with regimen adjustment in case of high BP. Primary outcome was difference in systolic BP and LDL-C between baseline and value after three months of follow-up. Mean age in the intervention group was 62.7 years, 98 (88.3%) patients were male. A total of 26 449 mHealth measurements were recorded. At three months, systolic BP decreased by 7.0 mmHg [standard deviation (SD): 15.1] in the intervention group vs. -0.3 mmHg (SD: 17.6; P < 0.00001) in controls; body weight decreased by 1.76 kg (SD: 3.23) in the intervention group vs. -0.31 kg (SD: 2.55; P = 0.002) in controls. Serum LDL-C was significantly lower in the intervention group vs. controls (median: 1.8 vs. 2.0 mmol/L; P = 0.0002).

Conclusion

This study showed an association between home monitoring after CABG and a reduction in systolic BP, body weight, and serum LDL-C. The causality of the association between the observed weight loss and decreased LDL-C in intervention group patients remains to be investigated.

Examining standardized tools used for the evaluation of mobile health applications for cardiovascular disease

Cardiovascular disease is one of the leading causes of death worldwide. Scarce resources and rising costs are pushing healthcare systems to their limits. There is an urgency to develop, optimize and evaluate technologies that provide more effective care for patients. Modern technologies, such as mobile health (mHealth) applications, can provide relief as a key strategy. To integrate digital interventions into care structures, a detailed impact assessment of all professional mHealth applications is needed. The aim of this study is to analyze the standardized tools used in the field of cardiovascular disease. The results show that questionnaires, usage logs, and key indicators are predominantly used. Although the identified mHealth interventions are specific to cardiovascular disease and thus require particular questions to evaluate apps, the user readiness, usability, or quality of life criteria are non-specific. Therefore, the results contribute to understanding how different mHealth interventions can be assessed, categorized, evaluated, and accepted.

Hypertension management before and under the COVID-19 pandemic: lessons and future directions

Hypertension is a significant risk factor for cardiovascular diseases. The prevalence of hypertension and its complications is increasing yearly, yet it remains inadequately controlled worldwide. It has already been recognized that self-management, including self-measured blood pressure monitoring at home, is more important than office blood pressure monitoring. The practical application of telemedicine using digital technology was already underway. COVID-19 has promoted the popularization of these management systems in primary care, although the COVID-19 pandemic disrupted lifestyle and healthcare access. At the beginning of the pandemic, we were at the mercy of information on whether certain antihypertensive drugs, for example, might pose a risk of infection in the face of unknown infectious diseases. Over the past three years, however, much knowledge has been accumulated. It has been scientifically proven that there is no serious problem in managing hypertension in the same way as before the pandemic. That is to control blood pressure mainly through home blood pressure monitoring and continuing conventional drug therapy while modifying lifestyle. On the other hand, in the New Normal era, it is necessary to accelerate digital hypertension management and the establishment of new social networks and medical systems to prepare for the re-emergence of future pandemics while continuing to protect against infection. This review will summarize the lessons and future directions we learned from the impact of the COVID-19 pandemic on hypertension management. The COVID-19 pandemic has disrupted our daily life, restricted access to healthcare, and altered some of the conventional management of hypertension.

Feasibility of patch-type wireless 12-lead electrocardiogram in laypersons

Various efforts have been made to diagnose acute cardiovascular diseases (CVDs) early in patients. However, the sole option currently is symptom education. It may be possible for the patient to obtain an early 12-lead electrocardiogram (ECG) before the first medical contact (FMC), which could decrease the physical contact between patients and medical staff. Thus, we aimed to verify whether laypersons can obtain a 12-lead ECG in an off-site setting for clinical treatment and diagnosis using a patch-type wireless 12-lead ECG (PWECG). Participants who were ≥ 19 years old and under outpatient cardiology treatment were enrolled in this simulation-based one-arm interventional study. We confirmed that participants, regardless of age and education level, can use the PWECG on their own. The median age of the participants was 59 years (interquartile range [IQR] = 56-62 years), and the median duration to obtain a 12-lead ECG result was 179 s (IQR = 148-221 s). With appropriate education and guidance, it is possible for a layperson to obtain a 12-lead ECG, minimizing the contact with a healthcare provider. These results can be used subsequently for treatment.

Wearable Devices in Cardiovascular Medicine

Wearable devices, such as smartwatches and activity trackers, are commonly used by patients in their everyday lives to manage their health and well-being. These devices collect and analyze long-term continuous data on measures of behavioral or physiologic function, which may provide clinicians with a more comprehensive view of a patients' health compared with the traditional sporadic measures captured by office visits and hospitalizations. Wearable devices have a wide range of potential clinical applications ranging from arrhythmia screening of high-risk individuals to remote management of chronic conditions such as heart failure or peripheral artery disease. As the use of wearable devices continues to grow, we must adopt a multifaceted approach with collaboration among all key stakeholders to effectively and safely integrate these technologies into routine clinical practice. In this Review, we summarize the features of wearable devices and associated machine learning techniques. We describe key research studies that illustrate the role of wearable devices in the screening and management of cardiovascular conditions and identify directions for future research. Last, we highlight the challenges that are currently hindering the widespread use of wearable devices in cardiovascular medicine and provide short- and long-term solutions to promote increased use of wearable devices in clinical care.

A Digital Infrastructure for Cardiovascular Patient Care Based on Mobile Health Data and Patient-Reported Outcomes: Concept Details of the Helios TeleWear Project Including Preliminary Experiences

BACKGROUND

Mobile health (mHealth) approaches are already having a fundamental impact on clinical practice in cardiovascular medicine. A variety of different health apps and wearable devices for capturing health data such as electrocardiograms (ECGs) exist. However, most mHealth technologies focus on distinct variables without integrating patients' quality of life, and the impact on clinical outcome measures of implementing those digital solutions into cardiovascular health care is still to be determined.

OBJECTIVE

Within this document, we describe the TeleWear project, which was recently initiated as an approach for contemporary patient management integrating mobile-collected health data and the standardized mHealth-guided measurement of patient-reported outcomes (PROs) in patients with cardiovascular disease.

METHODS

The specifically designed mobile app and clinical frontend form the central elements of our TeleWear infrastructure. Because of its flexible framework, the platform allows far-reaching customization with the possibility to add different mHealth data sources and respective questionnaires (patient-reported outcome measures).

RESULTS

With initial focus on patients with cardiac arrhythmias, a feasibility study is currently carried out to assess wearable-recorded ECG and PRO transmission and its evaluation by physicians using the TeleWear app and clinical frontend. First experiences made during the feasibility study yielded positive results and confirmed the platform's functionality and usability.

CONCLUSIONS

TeleWear represents a unique mHealth approach comprising PRO and mHealth data capturing. With the currently running TeleWear feasibility study, we aim to test and further develop the platform in a real-world setting. A randomized controlled trial including patients with atrial fibrillation that investigates PRO- and ECG-based clinical management based on the established TeleWear infrastructure will evaluate its clinical benefits. Widening the spectrum of health data collection and interpretation beyond the ECG and use of the TeleWear infrastructure in different patient subcohorts with focus on cardiovascular diseases are further milestones of the project with the ultimate goal to establish a comprehensive telemedical center entrenched by mHealth.

Excess cardiovascular mortality across multiple COVID-19 waves in the United States from March 2020 to March 2022

The COVID-19 pandemic has limited the access of patients with cardiovascular diseases to healthcare services, causing excess deaths. However, a detailed analysis of temporal variations of excess cardiovascular mortality during the COVID-19 pandemic has been lacking. Here we estimate time-varied excess cardiovascular deaths (observed deaths versus expected deaths predicted by the negative binomial log-linear regression model) in the United States. From March 2020 to March 2022 there were 90,160 excess cardiovascular deaths, or 4.9% more cardiovascular deaths than expected. Two large peaks of national excess cardiovascular mortality were observed during the periods of March-June 2020 and June-November 2021, coinciding with two peaks of COVID-19 deaths, but the temporal patterns varied by state, age, sex and race and ethnicity. The excess cardiovascular death percentages were 5.7% and 4.0% in men and women, respectively, and 3.6%, 8.8%, 7.5% and 7.7% in non-Hispanic White, Black, Asian and Hispanic people, respectively. Our data highlight an urgent need for healthcare services optimization for patients with cardiovascular diseases in the COVID-19 era.

Impact of Remote Patient Monitoring on Length of Stay for Patients with COVID-19

Background: Remote patient monitoring (RPM) can be deployed as part of a tiered approach to open up hospital bed availability by allowing earlier discharge of patients with continued virtual monitoring. We describe the impact of RPM on length of stay (LOS) for patients with COVID-19. Methods: We deployed RPM during two COVID-19 surges at a tertiary academic hospital from March to June 2020 as a feasibility pilot to establish the infrastructure for RPM including electronic health record changes and virtual health center (VHC) protocols, and October 2020 to February 2021, during the second surge of COVID-19. Discharging patients received a wearable vital sign monitoring device, allowing real-time data transmission to the VHC using a smart phone application. The data, monitored 24 h a day for 8 days by a technician, had built-in escalation protocols to nurses and/or attending physicians. Results: We compared patients discharged with RPM with those discharged without RPM during both phases using a two-to-one-matched case-control design including age, sex, Charlson comorbidity index, and limited English proficiency. After including discharge with home oxygen therapy as an effect modifier, there was a significant association between shorter LOS and RPM for patients discharging without home oxygen (p = 0.0075) compared with patients not discharging on RPM. Discussion: Our study shows a strong association between a reduction in LOS for patients discharging with RPM but without home oxygen therapy, which can assist with hospital capacity. Conclusions: Home telemonitoring after discharge for patients with COVID-19 may reduce LOS.

Digital Health Interventions in Patient Management Following Acute Coronary Syndrome: A Meta-Analysis of the Literature

OBJECTIVE

Acute coronary syndrome patients should be closely followed-up to maintain optimal adherence to medical treatments and to reduce adverse events. Digital health interventions might provide improved outcomes for patient care by providing closer follow- up, compared to standard care. Thus, in this meta-analysis, we aimed to evaluate the effect of digital health interventions on follow-up in acute coronary syndrome patients.

METHODS

We searched medical databases to obtain all relevant studies comparing digital health interventions with standard care in acute coronary syndrome patients. After reviewing all eligible studies, a meta-analysis was conducted with the remaining 11 randomized controlled studies and 2 non-randomized controlled studies. A modified Jadad scale and Newcastle-Ottawa scale were used to assess the quality of the publications for randomized controlled studies and non-randomized controlled studies, respectively.

RESULTS

This meta-analysis consisted of 7657 patients. The all-cause mortality rate was 49% lower in the digital health intervention cases, compared to those who received standard care [relative risk (RR) = 0.51 (0.37; 0.70), P <.01]. There was a significant decrease in systolic blood pressure in the digital health interventions group, compared to the standard care group [mean difference = -5.28 (-9.47; -1.08), P =.01]. The rate of nonadherence to anti-aggregant drugs was 69% lower in the digital health interventions than in the standard care group [RR = 0.31 (0.20; 0.46), P <.01]. Also, nonadherence rates for statin and beta-blockers were lower in the digital health interventions group. The risk of rehospitalization was observed to be 55% less in the digital health interventions patients, compared to the standard care group [RR = 0.45 (0.30; 0.67), P <.01].

CONCLUSION

Digital health interventions can be effective in follow-up for secondary prevention in acute coronary syndrome patients.

A systematic scoping review of digital health technologies during COVID-19: a new normal in primary health care delivery

This scoping review compiled information concerning digital health technologies (DHTs) evolution to support primary health care (PHC) during COVID-19 and lessons for the future of PHC. The identified literature was published during the COVID-19 peak years (2019-2021), retrieved from PubMed, Scopus, and Google Scholar, as well as hand searched on the internet. Predefined inclusion criteria were used, thematic analysis was applied, and reporting followed the PRISMA for Scoping Reviews. A total of 46 studies were included in the final synthesis (40 articles, one book, two book chapters, one working paper, and two technical reports). These studies scrutinized various aspects of DHTs, entailing 19 types of DHTs with 20 areas of use that can be compressed into five bigger PHC functions: general PHC service delivery (teleconsultations, e-diagnosis, e-prescription, etc.); behavior promotion and digital health literacy (e.g., combating vaccine hesitancy); surveillance functions; vaccination and drugs; and enhancing system decision-making for proper follow-up of ongoing PHC interventions during COVID-19. DHTs have the potential to solve some of the problems that have plagued us even prior to COVID-19. Therefore, this study uses a forward-looking viewpoint to further stimulate the use of evidence-based DHT, making it more inclusive, educative, and satisfying to people's needs, both under normal conditions and during outbreaks. More research with narrowed research questions is needed, with a particular emphasis on quality assurance in the use of DHTs, technical aspects (standards for digital health tools, infrastructure, and platforms), and financial perspectives (payment for digital health services and adoption incentives).

Supplementary Information

The online version contains supplementary material available at 10.1007/s12553-023-00725-7.

Effectiveness of mHealth Interventions in the Control of Lifestyle and Cardiovascular Risk Factors in Patients After a Coronary Event: Systematic Review and Meta-analysis

BACKGROUND

Coronary artery disease is the main cause of death and loss of disability-adjusted life years worldwide. Information and communication technology has become an important part of health care systems, including the innovative cardiac rehabilitation services through mobile phone and mobile health (mHealth) interventions.

OBJECTIVE

In this study, we aimed to determine the effectiveness of different kinds of mHealth programs in changing lifestyle behavior, promoting adherence to treatment, and controlling modifiable cardiovascular risk factors and psychosocial outcomes in patients who have experienced a coronary event.

METHODS

A systematic review of the literature was performed following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A thorough search of the following biomedical databases was conducted: PubMed, Embase, Web of Science, SciELO, CINAHL, Scopus, The Clinical Trial, and Cochrane. Articles that were randomized clinical trials that involved an intervention consisting of an mHealth program using a mobile app in patients after a coronary event were included. The articles analyzed some of the following variables as outcome variables: changes in lifestyle behavior, cardiovascular risk factors, and anthropometric and psychosocial variables. A meta-analysis of the variables studied was performed with the Cochrane tool. The risk of bias was assessed using the Cochrane Collaboration tool; the quality of the evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation tool; and heterogeneity was measured using the I² test.

RESULTS

A total of 23 articles were included in the review, and 20 (87%) were included in the meta-analysis, with a total sample size of 4535 patients. Exercise capacity measured using the 6-minute walk test (mean difference=21.64, 95% CI 12.72-30.55; P<.001), physical activity (standardized mean difference [SMD]=0.42, 95% CI 0.04-0.81; P=.03), and adherence to treatment (risk difference=0.19, 95% CI 0.11-0.28; P<.001) were significantly superior in the mHealth group. Furthermore, both the physical and mental dimensions of quality of life were better in the mHealth group (SMD=0.26, 95% CI 0.09-0.44; P=.004 and SMD=0.27, 95% CI 0.06-0.47; P=.01, respectively). In addition, hospital readmissions for all causes and cardiovascular causes were statistically higher in the control group than in the mHealth group (SMD=-0.03, 95% CI -0.05 to -0.00; P=.04 vs SMD=-0.04, 95% CI -0.07 to -0.00; P=.05).

CONCLUSIONS

mHealth technology has a positive effect on patients who have experienced a coronary event in terms of their exercise capacity, physical activity, adherence to medication, and physical and mental quality of life, as well as readmissions for all causes and cardiovascular causes.

TRIAL REGISTRATION

PROSPERO (International Prospective Register of Systematic Reviews) CRD42022299931; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=299931.

The effect of telemedicine on secondary prevention of atherosclerotic cardiovascular disease: A systematic review and meta-analysis

Aim

The purpose of this systematic review was to evaluate the efficiency of telemedicine on the secondary level of prevention of patients with arteriosclerotic cardiovascular disease (ASCVD), provide evidence for the application of telemedicine in secondary prevention and promote the development of telemedicine in secondary prevention.

Methods

A computer-based search was conducted in MEDLINE, Embase, Pubmed, EBSCO, CINAHL, the Cochrane Library, and Web of Science. Randomized controlled trials regarding the effect of telemedicine on secondary prevention of ASCVD were included from inception to May, 2022. Meta-analysis was used to compare the results of the included studies by RevMan5.4 software. The Cochrane Collaboration bias risk tool was used to perform risk of bias assessment in this study. Outcomes included risk factors, physical activity and exercise, muscle function, exercise compliance, medication adherence, healthy diet, depression and anxiety, self-efficacy, knowledge score, economy, and safety endpoints. Subgroup analysis was carried out for different main intervention measures included in the literature.

Results

A total of 32 randomized clinical studies (n = 10 997 participants) were included in the meta-analysis. Compared with usual secondary prevention (USP) group, participants in telemedicine of secondary prevention (TOSP) group showed significant improvement in some risk factors including BMI (MD –0.87, p = 0.002), SBP (MD –4.09, p = 0.007) and DBP (MD –2.91, p = 0.0002) when they use the telephone as the intervention. In physical activity and exercise, Patients in TOSP showed an improvement in VO2 Peak (mL⋅kg–1⋅min–1) (OR 1.58, p = 0.02), 6MWT (MD 21.41, p = 0.001), GSLTPA score (MD 2.89, p = 0.005). Effects on medication adherence, exercise compliance, muscle function, healthy diet, economy and self-efficacy were synthesized narratively. Patients in TOSP did not show a reduction in knowledge score, depression, anxiety and safety endpoints.

Conclusion

There is a net benefit of secondary prevention supported by telemedicine (especially when using the telephone as an intervention) in patients with ASCVD in the terms of some risk factors, physical activity and exercise. There are still controversies in the improvement of medication adherence, exercise compliance, muscle function, healthy diet, knowledge score, self-efficacy and economy via telemedicine, which is worth exploring. Larger samples size and longer-term follow-ups are needed in future studies.

Systematic review registration

[https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=330478], identifier [CRD42022330478].

Mobile health vs. standard care after cardiac surgery: results of The Box 2.0 study

AIMS

Postoperative atrial fibrillation (POAF) is a common complication of cardiac surgery, yet difficult to detect in ambulatory patients. The primary aim of this study is to investigate the effect of a mobile health (mHealth) intervention on POAF detection after cardiac surgery.

METHODS AND RESULTS

We performed an observational cohort study among 730 adult patients who underwent cardiac surgery at a tertiary care hospital in The Netherlands. Of these patients, 365 patients received standard care and were included as a historical control group, undergoing surgery between December 2017 and September 2018, and 365 patients were prospectively included from November 2018 and November 2020, undergoing an mHealth intervention which consisted of blood pressure, temperature, weight, and electrocardiogram (ECG) monitoring. One physical outpatient follow-up moment was replaced by an electronic visit. All patients were requested to fill out a satisfaction and quality of life questionnaire. Mean age in the intervention group was 62 years, 275 (70.4%) patients were males. A total of 4136 12-lead ECGs were registered. In the intervention group, 61 (16.7%) patients were diagnosed with POAF vs. 25 (6.8%) patients in the control group [adjusted risk ratio (RR) of POAF detection: 2.15; 95% confidence interval (CI): 1.55-3.97]. De novo atrial fibrillation was found in 13 patients using mHealth (6.5%) vs. 4 control group patients (1.8%; adjusted RR 3.94, 95% CI: 1.50-11.27).

CONCLUSION

Scheduled self-measurements with mHealth devices could increase the probability of detecting POAF within 3 months after cardiac surgery. The effect of an increase in POAF detection on clinical outcomes needs to be addressed in future research.

COVID-19 and Cardiometabolic Health: Lessons Gleaned from the Pandemic and Insights for the Next Wave

Purpose of Review

To review the current evidence regarding the impact of the coronavirus disease 2019 (COVID-19) pandemic on cardiometabolic health, with a focus on strategies to help mitigate adverse effects on population health.

Recent Findings

Individuals with cardiometabolic disease are particularly vulnerable to worse outcomes with COVID-19 infection. In addition, the pandemic itself has had significant deleterious impact on the cardiometabolic health of the population, including declines in physical activity, increases in smoking and alcohol use, worsening blood pressure and glycemic control, and detrimental effects on mental health. Targeted interventions at the patient and community level will be needed to mitigate the long-term consequences of the COVID-19 pandemic on population cardiometabolic health.

Summary

The COVID-19 pandemic has worsened cardiometabolic health, but there are several opportunities and enhanced tools available to counteract these changes.

Efficacy of Phase II Remote Home Rehabilitation in Patients with Acute Myocardial Infarction after Percutaneous Coronary Intervention

Objective

To assess the efficacy of home-based cardiac rehabilitation and traditional outpatient rehabilitation in stage II after percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI).

Methods

From September 2019 to March 2020, 80 AMI patients in Cangzhou Central Hospital were randomly assigned to one of the two groups: the control group or the observation group, 40 cases in each group. The control group received old-fashioned outpatient rehabilitation treatment, and the study group received long-distance family rehabilitation nursing intervention. The blood pressure, examination results, compliance, satisfaction evaluation, incidence of cardiac events, heart rate, quality of life score, and 6-minute walking test were compared between the two groups.

Results

There were no deaths in both groups. There were significant differences in heart failure, unstable angina pectoris, unplanned readmission rate, walking compliance, and 6-minute walking test at 6 months after discharge (P < 0.05). There were substantial variances in left ventricular discharge portion, low-density lipoprotein, medication compliance, satisfaction, and quality of life (P < 0.05); there was substantial inconsistency in the 6-minute walking test concerning the two groups afterwards discharge for 3 months (P < 0.05).

Conclusion

Home rehabilitation is a new home cardiac rehabilitation model with high efficiency, convenience, and whole process monitoring and barrier-free follow-up management. It can effectively improve the cardiac function, workout patience and worth of life expectancy of victims with AMI, improve their self-management awareness and rehabilitation compliance, reduce the risk of cardiac events, and have a positive impact on the prognosis and rehabilitation of patients with AMI.

Recommendations for the Design and Delivery of Transitions-Focused Digital Health Interventions: Rapid Review

Background

Older adults experience a high risk of adverse events during hospital-to-home transitions. Implementation barriers have prevented widespread clinical uptake of the various digital health technologies that aim to support hospital-to-home transitions.

Objective

To guide the development of a digital health intervention to support transitions from hospital to home (the Digital Bridge intervention), the specific objectives of this review were to describe the various roles and functions of health care providers supporting hospital-to-home transitions for older adults, allowing future technologies to be more targeted to support their work; describe the types of digital health interventions used to facilitate the transition from hospital to home for older adults and elucidate how these interventions support the roles and functions of providers; describe the lessons learned from the design and implementation of these interventions; and identify opportunities to improve the fit between technology and provider functions within the Digital Bridge intervention and other transition-focused digital health interventions.

Methods

This 2-phase rapid review involved a selective review of providers’ roles and their functions during hospital-to-home transitions (phase 1) and a structured literature review on digital health interventions used to support older adults’ hospital-to-home transitions (phase 2). During the analysis, the technology functions identified in phase 2 were linked to the provider roles and functions identified in phase 1.

Results

In phase 1, various provider roles were identified that facilitated hospital-to-home transitions, including navigation-specific roles and the roles of nurses and physicians. The key transition functions performed by providers were related to the 3 categories of continuity of care (ie, informational, management, and relational continuity). Phase 2, included articles (n=142) that reported digital health interventions targeting various medical conditions or groups. Most digital health interventions supported management continuity (eg, follow-up, assessment, and monitoring of patients’ status after hospital discharge), whereas informational and relational continuity were the least supported. The lessons learned from the interventions were categorized into technology- and research-related challenges and opportunities and informed several recommendations to guide the design of transition-focused digital health interventions.

Conclusions

This review highlights the need for Digital Bridge and other digital health interventions to align the design and delivery of digital health interventions with provider functions, design and test interventions with older adults, and examine multilevel outcomes.

International Registered Report Identifier (IRRID)

RR2-10.1136/bmjopen-2020-045596

The Box—eHealth in the Outpatient Clinic Follow-up of Patients With Acute Myocardial Infarction: Cost-Utility Analysis

Background

Smartphone compatible wearables have been released on the consumers market, enabling remote monitoring. Remote monitoring is often named as a tool to reduce the cost of care.

Objective

The primary purpose of this paper is to describe a cost-utility analysis of an eHealth intervention compared to regular follow-up in patients with acute myocardial infarction (AMI).

Methods

In this trial, of which clinical results have been published previously, patients with an AMI were randomized in a 1:1 fashion between an eHealth intervention and regular follow-up. The remote monitoring intervention consisted of a blood pressure monitor, weight scale, electrocardiogram device, and step counter. Furthermore, two in-office outpatient clinic visits were replaced by e-visits. The control group received regular care. The differences in mean costs and quality of life per patient between both groups during one-year follow-up were calculated.

Results

Mean costs per patient were €2417±2043 (US $2657±2246) for the intervention and €2888±2961 (US $3175±3255) for the control group. This yielded a cost reduction of €471 (US $518) per patient. This difference was not statistically significant (95% CI –€275 to €1217; P=.22, US $–302 to $1338). The average quality-adjusted life years in the first year of follow-up was 0.74 for the intervention group and 0.69 for the control (difference –0.05, 95% CI –0.09 to –0.01; P=.01).

Conclusions

eHealth in the outpatient clinic setting for patients who suffered from AMI is likely to be cost-effective compared to regular follow-up. Further research should be done to corroborate these findings in other patient populations and different care settings.

Trial Registration

ClinicalTrials.gov NCT02976376; https://clinicaltrials.gov/ct2/show/NCT02976376

International Registered Report Identifier (IRRID)

RR2-10.2196/resprot.8038

Clarifying responsibility: professional digital health in the doctor-patient relationship, recommendations for physicians based on a multi-stakeholder dialogue in the Netherlands

Background

Implementation of digital health (eHealth) generally involves adapting pre-established and carefully considered processes or routines, and still raises multiple ethical and legal dilemmas. This study aimed to identify challenges regarding responsibility and liability when prescribing digital health in clinical practice. This was part of an overarching project aiming to explore the most pressing ethical and legal obstacles regarding the implementation and adoption of digital health in the Netherlands, and to propose actionable solutions.

Methods

A series of multidisciplinary focus groups with stakeholders who have relevant digital health expertise were analysed through thematic analysis.

Results

The emerging general theme was ‘uncertainty regarding responsibilities’ when adopting digital health. Key dilemmas take place in clinical settings and within the doctor-patient relationship (‘professional digital health’). This context is particularly challenging because different stakeholders interact. In the absence of appropriate legal frameworks and codes of conduct tailored to digital health, physicians’ responsibility is to be found in their general duty of care. In other words: to do what is best for patients (not causing harm and doing good). Professional organisations could take a leading role to provide more clarity with respect to physicians’ responsibility, by developing guidance describing physicians’ duty of care in the context of digital health, and to address the resulting responsibilities.

Conclusions

Although legal frameworks governing medical practice describe core ethical principles, rights and obligations of physicians, they do not suffice to clarify their responsibilities in the setting of professional digital health. Here we present a series of recommendations to provide more clarity in this respect, offering the opportunity to improve quality of care and patients’ health. The recommendations can be used as a starting point to develop professional guidance and have the potential to be adapted to other healthcare professionals and systems.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07316-0.

Management of cardiovascular disease using an mHealth tool: a randomized clinical trial

Atherosclerotic cardiovascular disease (ASCVD) is a leading cause of death and morbidity worldwide. This randomized controlled, single-center, open-label trial tested the impact of a mobile health (mHealth) service tool optimized for ASCVD patient care. Patients with clinical ASCVD were enrolled and randomly assigned to the intervention or control group. Participants in the intervention group were provided with a smartphone application named HEART4U, while a dedicated interface integrated into the electronic healthcare record system was provided to the treating physicians. A total of 666 patients with ASCVD were enrolled, with 333 patients in each group. The estimated baseline 10-year risk of cardiovascular disease was 9.5% and 10.8% in the intervention and control groups, respectively, as assessed by the pooled cohort risk equations. The primary study endpoint was the change in the estimated risk at six months. The estimated risk increased by 1.3% and 1.1%, respectively, which did not differ significantly (P = 0.821). None of the secondary study endpoints showed significant differences between the groups. A post-hoc subgroup analysis showed the benefit was greater if a participant in the intervention group accessed the application more frequently. The present study demonstrated no significant benefits associated with the use of the mHealth tool in terms of the predefined study endpoints in stable patients with ASCVD. However, it also suggested that motivating patients to use the mHealth tool more frequently may lead to greater clinical benefit. Better design with a positive user experience needs to be considered for developing future mHealth tools for ASCVD patient care.Trial Registration: ClinicalTrials.gov NCT03392259.

Methods Used to Evaluate mHealth Applications for Cardiovascular Disease: A Quasi-Systematic Scoping Review

In the face of demographic change and constantly increasing health care costs, health care system decision-makers face ever greater challenges. Mobile health applications (mHealth apps) have the potential to combat this trend. However, in order to integrate mHealth apps into care structures, an evaluation of such apps is needed. In this paper, we focus on the criteria and methods of evaluating mHealth apps for cardiovascular disease and the implications for developing a widely applicable evaluation framework for mHealth interventions. Our aim is to derive substantiated patterns and starting points for future research by conducting a quasi-systematic scoping review of relevant peer-reviewed literature published in English or German between 2000 and 2021. We screened 4066 articles and identified n = 38 studies that met our inclusion criteria. The results of the data derived from these studies show that usability, motivation, and user experience were evaluated primarily using standardized questionnaires. Usage protocols and clinical outcomes were assessed primarily via laboratory diagnostics and quality-of-life questionnaires, and cost effectiveness was tested primarily based on economic measures. Based on these findings, we propose important considerations and elements for the development of a common evaluation framework for professional mHealth apps, including study designs, data collection tools, and perspectives.

Exercise-based cardiac rehabilitation for coronary heart disease

BACKGROUND

Coronary heart disease (CHD) is the most common cause of death globally. However, with falling CHD mortality rates, an increasing number of people living with CHD may need support to manage their symptoms and prognosis. Exercise-based cardiac rehabilitation (CR) aims to improve the health and outcomes of people with CHD. This is an update of a Cochrane Review previously published in 2016.

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of exercise-based CR (exercise training alone or in combination with psychosocial or educational interventions) compared with 'no exercise' control, on mortality, morbidity and health-related quality of life (HRQoL) in people with CHD.

SEARCH METHODS

We updated searches from the previous Cochrane Review, by searching CENTRAL, MEDLINE, Embase, and two other databases in September 2020. We also searched two clinical trials registers in June 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of exercise-based interventions with at least six months' follow-up, compared with 'no exercise' control. The study population comprised adult men and women who have had a myocardial infarction (MI), coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI), or have angina pectoris, or coronary artery disease.

DATA COLLECTION AND ANALYSIS

We screened all identified references, extracted data and assessed risk of bias according to Cochrane methods. We stratified meta-analysis by duration of follow-up: short-term (6 to 12 months); medium-term (> 12 to 36 months); and long-term ( > 3 years), and used meta-regression to explore potential treatment effect modifiers. We used GRADE for primary outcomes at 6 to 12 months (the most common follow-up time point).  MAIN RESULTS: This review included 85 trials which randomised 23,430 people with CHD. This latest update identified 22 new trials (7795 participants). The population included predominantly post-MI and post-revascularisation patients, with a mean age ranging from 47 to 77 years. In the last decade, the median percentage of women with CHD has increased from 11% to 17%, but females still account for a similarly small percentage of participants recruited overall ( < 15%). Twenty-one of the included trials were performed in low- and middle-income countries (LMICs). Overall trial reporting was poor, although there was evidence of an improvement in quality over the last decade. The median longest follow-up time was 12 months (range 6 months to 19 years). At short-term follow-up (6 to 12 months), exercise-based CR likely results in a slight reduction in all-cause mortality (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.73 to 1.04; 25 trials; moderate certainty evidence), a large reduction in MI (RR 0.72, 95% CI 0.55 to 0.93; 22 trials; number needed to treat for an additional beneficial outcome (NNTB) 75, 95% CI 47 to 298; high certainty evidence), and a large reduction in all-cause hospitalisation (RR 0.58, 95% CI 0.43 to 0.77; 14 trials;  NNTB 12, 95% CI 9 to 21; moderate certainty evidence). Exercise-based CR likely results in little to no difference in risk of cardiovascular mortality (RR 0.88, 95% CI 0.68 to 1.14; 15 trials; moderate certainty evidence), CABG (RR 0.99, 95% CI 0.78 to 1.27; 20 trials; high certainty evidence), and PCI (RR 0.86, 95% CI 0.63 to 1.19; 13 trials; moderate certainty evidence) up to 12 months' follow-up. We are uncertain about the effects of exercise-based CR on cardiovascular hospitalisation, with a wide confidence interval including considerable benefit as well as harm (RR 0.80, 95% CI 0.41 to 1.59; low certainty evidence). There was evidence of substantial heterogeneity across trials for cardiovascular hospitalisations (I2 = 53%), and of small study bias for all-cause hospitalisation, but not for all other outcomes. At medium-term follow-up, although there may be little to no difference in all-cause mortality (RR 0.90, 95% CI 0.80 to 1.02; 15 trials), MI (RR 1.07, 95% CI 0.91 to 1.27; 12 trials), PCI (RR 0.96, 95% CI 0.69 to 1.35; 6 trials), CABG (RR 0.97, 95% CI 0.77 to 1.23; 9 trials), and all-cause hospitalisation (RR 0.92, 95% CI 0.82 to 1.03; 9 trials), a large reduction in cardiovascular mortality was found (RR 0.77, 95% CI 0.63 to 0.93; 5 trials). Evidence is uncertain for difference in risk of cardiovascular hospitalisation (RR 0.92, 95% CI 0.76 to 1.12; 3 trials). At long-term follow-up, although there may be little to no difference in all-cause mortality (RR 0.91, 95% CI 0.75 to 1.10), exercise-based CR may result in a large reduction in cardiovascular mortality (RR 0.58, 95% CI 0.43 to 0.78; 8 trials) and MI (RR 0.67, 95% CI 0.50 to 0.90; 10 trials). Evidence is uncertain for CABG (RR 0.66, 95% CI 0.34 to 1.27; 4 trials), and PCI (RR 0.76, 95% CI 0.48 to 1.20; 3 trials). Meta-regression showed benefits in outcomes were independent of CHD case mix, type of CR, exercise dose, follow-up length, publication year, CR setting, study location, sample size or risk of bias. There was evidence that exercise-based CR may slightly increase HRQoL across several subscales (SF-36 mental component, physical functioning, physical performance, general health, vitality, social functioning and mental health scores) up to 12 months' follow-up; however, these may not be clinically important differences. The eight trial-based economic evaluation studies showed exercise-based CR to be a potentially cost-effective use of resources in terms of gain in quality-adjusted life years (QALYs).

AUTHORS' CONCLUSIONS

This updated Cochrane Review supports the conclusions of the previous version, that exercise-based CR provides important benefits to people with CHD, including reduced risk of MI, a likely small reduction in all-cause mortality, and a large reduction in all-cause hospitalisation, along with associated healthcare costs, and improved HRQoL up to 12 months' follow-up. Over longer-term follow-up, benefits may include reductions in cardiovascular mortality and MI. In the last decade, trials were more likely to include females, and be undertaken in LMICs, increasing the generalisability of findings. Well-designed, adequately-reported RCTs of CR in people with CHD more representative of usual clinical practice are still needed. Trials should explicitly report clinical outcomes, including mortality and hospital admissions, and include validated HRQoL outcome measures, especially over longer-term follow-up, and assess costs and cost-effectiveness.

Connected healthcare: Improving patient care using digital health technologies

Now more than ever, traditional healthcare models are being overhauled with digital technologies of Healthcare 4.0 increasingly adopted. Worldwide, digital devices are improving every stage of the patient care pathway. For one, sensors are being used to monitor patient metrics 24/7, permitting swift diagnosis and interventions. At the treatment stage, 3D printers are under investigation for the concept of personalised medicine by allowing patients access to on-demand, customisable therapeutics. Robots are also being explored for treatment, by empowering precision surgery, rehabilitation, or targeted drug delivery. Within medical logistics, drones are being leveraged to deliver critical treatments to remote areas, collect samples, and even provide emergency aid. To enable seamless integration within healthcare, the Internet of Things technology is being exploited to form closed-loop systems that remotely communicate with one another. This review outlines the most promising healthcare technologies and devices, their strengths, drawbacks, and opportunities for clinical adoption.

Virtual visits in cardiovascular disease: a rapid review of the evidence

Given the high prevalence of cardiovascular disease (CVD) in Canada and globally, as well as the staggering cost to human life and health systems, there is an urgent need to understand the successful applications of telemedicine in cardiovascular medicine. While telemedicine in cardiology is well documented, reports on virtual care in the form of synchronous, real-time communication between healthcare providers and patients are limited. As a result of the immediate suspension of ambulatory services for cardiology in Alberta, Canada, due to the Coronavirus Disease 2019 pandemic, we undertook a rapid review on the impact of non-virtual visits in cardiovascular ambulatory settings on patients’ healthcare utilization and mortality. Evidence from 12 randomized control trials and 7 systematic reviews was included in the rapid review, with the majority of papers (n = 15) focusing on telemedicine in heart failure. Based on our appraisal of evidence from the last 5 years, virtual visits are non-inferior, or more effective, in reducing hospitalizations and visits to emergency departments in patients with CVD compared to traditional standard in-clinic/ambulatory care. The evidence for a superior effect of virtual visits in reducing mortality was not supported in this review. While telemedicine is an appropriate tool for CVD follow-up care, more research into the efficacy of different components of telemedicine and virtual visits is required.

The feasibility of home self-assessment of vital signs and symptoms: A new key to telehealth for individuals?

Objective

During the COVID-19 pandemic, social distancing and self-isolation called for innovative, readily implementable, and effective short-term health solutions. The objective of this study was to assess the feasibility of self-assessment of vital signs and symptoms with electronic transmission of results, by self-isolating individuals with positive SARS-CoV-2 polymerase chain reaction (PCR) test. The secondary objective was to describe the association between the presence of abnormal vital signs and severe symptoms as well as their evolution over time.

Method

Participants with positive SARS-CoV-2 PCR test were asked to perform twice daily standardized vital signs measurements and self-assessment of symptoms for 14 consecutive days. All data were transmitted electronically through a mobile application and a web-based platform. Participants were provided with decision support tools based on the severity of their condition and a weekly nurse practitioner telephone follow-up. Abnormal values for vital signs and severe symptoms were determined. Per participant and per days, proportions of abnormal vital signs and severe symptoms were calculated.

Results

Data from 46 participants (mean age 54.1 ± 6.9 years, 54% male) were available for analysis. On average, participants performed the standardized self-assessment for 12.3 ± 3.4 days (89% performed at least 7 measurement days and 61% completed all 14 days). The highest proportions abnormal values for vital signs were for oximetry (20.1%) and respiratory rate (12.1%). The highest proportions of severe symptoms were for fatigue (16.9%) and myalgia. (10.2%). The combined proportion of abnormal vital signs and severe symptoms was maximal on day 1 with 20.3% of total measurements, with a linear decrease to 3.5% on day 14.

Conclusion

Remote initiation of home measurements of vital signs and symptoms, self-management of these measures, accompanied by a decision support tool and supported by preplanned nurse follow-up are feasible. This could allow to opening up new insight for the care of sick individuals.

The Box: Methods and Results of a Real World Experience of mHealth Implementation in Clinical Practice

Background

Mobile health (mHealth) is an emerging field of scientific interest worldwide. Potential benefits include increased patient engagement, improved clinical outcomes, and reduced health care costs. However, mHealth is often studied in projects or trials, and structural implantation in clinical practice is less common.

Objective

The purpose of this paper is to outline the design of the Box and its implementation and use in an outpatient clinic setting. The impact on logistical outcomes and patient and provider satisfaction is discussed.

Methods

In 2016, an mHealth care track including smartphone-compatible devices, named the Box, was implemented in the cardiology department of a tertiary medical center in the Netherlands. Patients with myocardial infarction, rhythm disorders, cardiac surgery, heart failure, and congenital heart disease received devices to measure daily weight, blood pressure, heart rate, temperature, and oxygen saturation. In addition, professional and patient user comments on the experience with the care track were obtained via structured interviews.

Results

From 2016 to April 2020, a total of 1140 patients were connected to the mHealth care track. On average, a Box cost €350 (US $375), not including extra staff costs. The median patient age was 60.8 (IQR 52.9-69.3) years, and 73.59% (839/1140) were male. A median of 260 (IQR 105-641) measurements was taken on a median of 189 (IQR 98-372) days. Patients praised the ease of use of the devices and felt more involved with their illness and care. Professionals reported more productive outpatient consultations as well as improved insight into health parameters such as blood pressure and weight. A feedback loop from the hospital to patient to focus on measurements was commented as an important improvement by both patients and professionals.

Conclusions

In this study, the design and implementation of an mHealth care track for outpatient follow-up of patients with various cardiovascular diseases is described. Data from these 4 years indicate that mHealth is feasible to incorporate in outpatient management and is generally well-accepted by patients and providers. Limitations include the need for manual measurement data checks and the risk of data overload. Moreover, the tertiary care setting in which the Box was introduced may limit the external validity of logistical and financial end points to other medical centers. More evidence is needed to show the effects of mHealth on clinical outcomes and on cost-effectiveness.

Late phase of COVID-19 pandemic in General Cardiology. A position paper of the ESC Council for Cardiology Practice

Cardiovascular (CV) engagement in coronavirus disease 2019 (COVID-19) is a huge determinant of prognosis during the acute phase of the disease. However, little is known about the potential chronic implications of the late phase of COVID-19 and about the appropriate approach to these patients. Heart failure, type 1 and type 2 myocardial infarction, arrhythmias, myocarditis, pulmonary fibrosis, and thrombosis have been shown to be related to severe acute respiratory syndrome coronavirus 2 infection, and a 'long COVID-19' illness has been recognized with fatigue, chest pain, and dyspnoea among the most frequent symptoms reported after discharge from hospital. This paper focuses on some open questions that cardiologists are going to face during the next months in a general cardiology outpatient clinic, in particular how to evaluate a 'post-COVID' patient during follow-up of CV complications of the acute phase and how to manage new CV symptoms that could be the consequence, at least in part, of heart/vessels and/or lung involvement of the previous virus infection. Present symptoms and signs, history of previous CV disease (both preceding COVID-19 and occurring during viral infection), and specific laboratory and imaging measurements during the acute phase may be of interest in focusing on how to approach the clinical evaluation of a post-COVID patient and how to integrate in our standard of care the new information on COVID-19, possibly in a multidisciplinary view. Dealing with the increased COVID-associated CV risk burden and becoming acquainted with potential new e-cardiology approaches aimed at integrating the cardiology practice are relevant new challenges brought by severe acute respiratory syndrome coronavirus 2 infection and its sequelae.

Impact of activity trackers on secondary prevention in patients with coronary artery disease: a systematic review and meta-analysis

AIMS

Coronary artery disease (CAD) is related to high rates of morbidity and mortality among cardiovascular diseases (CVDs). Activity trackers have been used in cardiac rehabilitation (CR) in the last years. However, their effectiveness to influence outcomes after CAD is debated. This review summarizes the latest data of impact of activity trackers on CVD risk and outcomes: peak oxygen consumption (VO2), major adverse cardiovascular events (MACE), quality of life (QoL), and low-density lipoprotein-cholesterol (LDL-C).

METHODS AND RESULTS

Articles from 1986 to 2020 in English were searched by electronic databases (PubMed, Cochrane Library, and Embase). Inclusion criteria were: randomized controlled trials of CAD secondary prevention using an activity tracker which include at least peak VO2, MACE, QoL, or LDL-C as outcomes. Meta-analysis was performed. After removing duplicates, 604 articles were included and the screening identified a total of 11 articles. Compared to control groups, intervention groups with activity trackers significantly increased peak VO2 [mean difference 1.54; 95% confidence interval (CI) (0.50-2.57); P = 0.004] and decreased MACE [risk ratio 0.51; 95% CI (0.31-0.86); P = 0.01]. Heterogeneity was low (I2 = 0%) for MACE and high (I2 = 51%) for peak VO2. Intervention with an activity tracker also has positive impact on QoL. There was no between-group difference in LDL-C.

CONCLUSION

CR using activity trackers has a positive and multi-faceted effect on peak VO2, MACE, and QoL in patients with CAD.

Modeling Recurrence in Idiopathic Subglottic Stenosis With Mobile Peak Expiratory Flow

OBJECTIVES/HYPOTHESIS

We sought to establish normative peak expiratory flow (PEF) data for patients with idiopathic subglottic stenosis (iSGS), evaluate whether immediate changes in PEF after a procedure predict long-term treatment response, and test if a decline in longitudinal PEF is associated with disease recurrence.

STUDY DESIGN

International, prospective, 3-year multicenter cohort study of 810 patients with untreated, newly diagnosed, or previously treated iSGS.

METHODS

iSGS patients consented and enrolled in the North American Airway Collaborative (NoAAC) iSGS¹⁰⁰⁰ cohort recorded PEF data on a mobile smartphone app. Cox regression tested the associations between the magnitude of postoperative PEF improvement and longitudinal 90-day PEF decline with the risk of disease recurrence.

RESULTS

Within the NoAAC iSGS¹⁰⁰⁰ cohort, 810 patients participated in a 3-year prospective study comparing surgical treatment efficacy and 385 had appropriate PEF measurements and follow-up data. Of those patients, 42% (161/385) required at least one operation during study follow-up. The mean PEF preceding operative intervention was 241 L/min (95% confidence interval [CI]: 120-380) corresponding to a predicted PEF of 52%. The mean increase in PEF following a procedure was 111 L/min (95% CI: 96-125 L/min). Interestingly, the magnitude of immediate PEF improvement was not predictive of disease recurrence (hazard ratio [HR] for 100 L/min increase = 0.90, 95% CI: 0.60-1.00). However, recurrence was associated with the magnitude of PEF decline over 90 days (30% vs. 10% decline, HR = 2.2, 95% CI: 1.5-3.0).

CONCLUSIONS

We provide normative PEF data on a large iSGS patient cohort. The degree of PEF improvement immediately after surgery was not associated with a longer procedure-free interval. However, a 30% decline in PEF over 90 days was associated with elevated risk of disease recurrence.

LEVEL OF EVIDENCE

2 Laryngoscope, 2021.

Integrating Digital Technologies and Public Health to Fight Covid-19 Pandemic: Key Technologies, Applications, Challenges and Outlook of Digital Healthcare

Integration of digital technologies and public health (or digital healthcare) helps us to fight the Coronavirus Disease 2019 (COVID-19) pandemic, which is the biggest public health crisis humanity has faced since the 1918 Influenza Pandemic. In order to better understand the digital healthcare, this work conducted a systematic and comprehensive review of digital healthcare, with the purpose of helping us combat the COVID-19 pandemic. This paper covers the background information and research overview of digital healthcare, summarizes its applications and challenges in the COVID-19 pandemic, and finally puts forward the prospects of digital healthcare. First, main concepts, key development processes, and common application scenarios of integrating digital technologies and digital healthcare were offered in the part of background information. Second, the bibliometric techniques were used to analyze the research output, geographic distribution, discipline distribution, collaboration network, and hot topics of digital healthcare before and after COVID-19 pandemic. We found that the COVID-19 pandemic has greatly accelerated research on the integration of digital technologies and healthcare. Third, application cases of China, EU and U.S using digital technologies to fight the COVID-19 pandemic were collected and analyzed. Among these digital technologies, big data, artificial intelligence, cloud computing, 5G are most effective weapons to combat the COVID-19 pandemic. Applications cases show that these technologies play an irreplaceable role in controlling the spread of the COVID-19. By comparing the application cases in these three regions, we contend that the key to China's success in avoiding the second wave of COVID-19 pandemic is to integrate digital technologies and public health on a large scale without hesitation. Fourth, the application challenges of digital technologies in the public health field are summarized. These challenges mainly come from four aspects: data delays, data fragmentation, privacy security, and data security vulnerabilities. Finally, this study provides the future application prospects of digital healthcare. In addition, we also provide policy recommendations for other countries that use digital technology to combat COVID-19.

Lifestyle and Treatment Adherence Intervention after a Coronary Event Based on an Interactive Web Application (EVITE): Randomized Controlled Clinical Trial Protocol

Coronary heart disease is one of the main causes of morbimortality around the world. Patients that survive a coronary event suffer a high risk of readmission, relapse and mortality, attributed to the sub-optimal control of cardiovascular risk factors (CVRF), which highlights the need to improve secondary prevention strategies aimed at improving their lifestyle and adherence to treatment. Through a randomized controlled clinical trial, this study aims to evaluate the effect of an intervention involving an online health application supported by a mobile telephone or tablet (mHealth) on lifestyle (diet, physical activity, and tobacco consumption) and treatment adherence among people with coronary heart disease after percutaneous coronary intervention. The sample will comprise 240 subjects (120 in each arm: intervention and usual care). They are assessed immediately and nine months after their hospital discharge about sociodemographic, clinical, CVRF, lifestyle, and treatment adherence characteristics. The educative intervention, involving a follow-up and self-monitoring, will be performed using an online mHealth tool consisting of an application for mobile phones and tablets. The quantitative primary outcomes from the two groups will be compared using an analysis of covariance (ANCOVA) adjusted for age and gender. A multivariate analysis will be performed to examine the association of the intervention with lifestyle habits, the control of CVRFs, and outcomes after discharge in terms of the use of health services, emergency visits, cardiovascular events and readmissions.

Cardiac Rehab in the COVID Era and Beyond: mHealth and Other Novel Opportunities

Purpose of Review

The COVID-19 pandemic has forced many center-based cardiac rehabilitation (CBCR) programs to close or limit their usual offerings. In order for patients to continue to benefit from CR, programs need to rapidly adapt to the current environment. This review highlights ways CR has evolved, and reviews the history of CR and recent advancements in telemedicine including remote patient monitoring, and mobile health that can be applied to CR.

Recent Findings

Despite that initial studies indicate that home-based CR (HBCR) is safe and effective, HBCR has faced several challenges that have prevented it from becoming more widely implemented. Many previous concerns can now be addressed through the use of new innovations in home-based healthcare delivery.

Summary

Since its inception, CR has become increasingly recognized as an important tool to improve patient mortality and quality of life in a broad range of cardiac diseases. While there has been little need to modify the delivery of CR since the 1950s, COVID-19 now serves as the necessary impetus to make HBCR an equal alternative to CBCR.

Potential of eHealth smart technology in optimization and monitoring of heart failure treatment in adults with systemic right ventricular failure

Aims

Patients with a systemic right ventricle (sRV) in the context of transposition of the great arteries (TGA) after atrial switch or congenitally corrected TGA are prone to heart failure and arrhythmias. This study evaluated feasibility, patient adherence, and satisfaction of a smart technology-based care pathway for heart failure treatment optimization in these patients.

Methods and results

Patients with symptomatic sRV failure eligible for initiation of sacubitril/valsartan were provided with four smartphone compatible devices (blood pressure monitor, weight scale, step counter, and rhythm monitor) and were managed according to a smart technology-based care pathway. Biweekly sacubitril/valsartan titration visits were replaced by electronical visits, patients were advised to continue measurements at least weekly after titration. Data of 24 consecutive sRV patients (median age 47 years, 50% female) who participated in the smart technology-based care pathway were analysed. Median home-hospital distance was 65 km (maximum 227 km). Most patients (20, 83.3%) submitted weekly measurements; 100% submitted prior to electronical visits. Titration conventionally occurs during a hospital visit. By implementing eHealth smart technology, 68 such trips to hospital were replaced by virtual visits facilitated by remote monitoring. An eHealth questionnaire was completed by 22 patients (92%), and 96% expressed satisfaction. After titration, 30 instances of remote adjustment of heart failure medication in addition to scheduled outpatient clinic visits occurred, one (4%) heart failure admission followed, despite ambulant adjustments. Five patients (21%) sent in rhythm registrations (n = 17), of these 77% showed sinus rhythm, whereas supraventricular tachycardia was detected in the remaining four registrations.

Conclusion

These data suggest that implementation of a smart technology-based care pathway for optimization of medical treatment sRV failure is feasible with high measurement adherence and patient satisfaction.

ESC working group on e-cardiology position paper: use of commercially available wearable technology for heart rate and activity tracking in primary and secondary cardiovascular prevention-in collaboration with the European Heart Rhythm Association, European Association of Preventive Cardiology, Association of Cardiovascular Nursing and Allied Professionals, Patient Forum, and the Digital Health Committee

Commercially available health technologies such as smartphones and smartwatches, activity trackers and eHealth applications, commonly referred to as wearables, are increasingly available and used both in the leisure and healthcare sector for pulse and fitness/activity tracking. The aim of the Position Paper is to identify specific barriers and knowledge gaps for the use of wearables, in particular for heart rate (HR) and activity tracking, in clinical cardiovascular healthcare to support their implementation into clinical care. The widespread use of HR and fitness tracking technologies provides unparalleled opportunities for capturing physiological information from large populations in the community, which has previously only been available in patient populations in the setting of healthcare provision. The availability of low-cost and high-volume physiological data from the community also provides unique challenges. While the number of patients meeting healthcare providers with data from wearables is rapidly growing, there are at present no clinical guidelines on how and when to use data from wearables in primary and secondary prevention. Technical aspects of HR tracking especially during activity need to be further validated. How to analyse, translate, and interpret large datasets of information into clinically applicable recommendations needs further consideration. While the current users of wearable technologies tend to be young, healthy and in the higher sociodemographic strata, wearables could potentially have a greater utility in the elderly and higher-risk population. Wearables may also provide a benefit through increased health awareness, democratization of health data and patient engagement. Use of continuous monitoring may provide opportunities for detection of risk factors and disease development earlier in the causal pathway, which may provide novel applications in both prevention and clinical research. However, wearables may also have potential adverse consequences due to unintended modification of behaviour, uncertain use and interpretation of large physiological data, a possible increase in social inequality due to differential access and technological literacy, challenges with regulatory bodies and privacy issues. In the present position paper, current applications as well as specific barriers and gaps in knowledge are identified and discussed in order to support the implementation of wearable technologies from gadget-ology into clinical cardiology.

Wearable Sensing and Telehealth Technology with Potential Applications in the Coronavirus Pandemic

Coronavirus disease 2019 (COVID-19) has emerged as a pandemic with serious clinical manifestations including death. A pandemic at the large-scale like COVID-19 places extraordinary demands on the world's health systems, dramatically devastates vulnerable populations, and critically threatens the global communities in an unprecedented way. While tremendous efforts at the frontline are placed on detecting the virus, providing treatments and developing vaccines, it is also critically important to examine the technologies and systems for tackling disease emergence, arresting its spread and especially the strategy for diseases prevention. The objective of this article is to review enabling technologies and systems with various application scenarios for handling the COVID-19 crisis. The article will focus specifically on 1) wearable devices suitable for monitoring the populations at risk and those in quarantine, both for evaluating the health status of caregivers and management personnel, and for facilitating triage processes for admission to hospitals; 2) unobtrusive sensing systems for detecting the disease and for monitoring patients with relatively mild symptoms whose clinical situation could suddenly worsen in improvised hospitals; and 3) telehealth technologies for the remote monitoring and diagnosis of COVID-19 and related diseases. Finally, further challenges and opportunities for future directions of development are highlighted.

Early blood pressure assessment after acute myocardial infarction: Insights using digital health technology

Objective

There is rising interest in digital health in preventive cardiology, particularly for blood pressure (BP) management. In a digital health study of early BP assessment following acute myocardial infarction (AMI), we sought to examine feasibility and the (1) proportion of post-AMI patients with controlled BP and hypotension, and (2) association between prior cardiovascular disease (CVD) and BP post-AMI.

Methods

In this substudy of the parent Myocardial infarction, COmbined-device, Recovery Enhancement (MiCORE) study, type 1 AMI patients were enrolled between October 2017 and April 2019. Participants self-monitored their BP through 30 days after hospital discharge using an FDA-approved wireless BP monitor connected with a smartphone application. Linear mixed-effects models assessed the association between prior CVD and BP trajectory post-discharge, adjusting for antihypertensive medications and a propensity score inclusive of CVD risk factors.

Results

Sixty-eight AMI patients (mean age 58 ​± ​10 years, 75% male, 68% white race, 68% history of hypertension, 24% prior CVD) provided 2638 measurements over 30 days. The percentage of BP control <130/80 ​mmHg was 59.6% (95% CI: 54.3–64.9%) and <140/90 ​mmHg was 83.7% (95% CI: 80.3–87.2%). The percentage of systolic BP ​<90 ​mmHg was 1.1% (95% CI: 0.17–2.0%) and the percentage of diastolic BP ​<60 ​mmHg was 3.9% (95% CI: 2.6–5.2%). Prior CVD was associated with 12.2 ​mmHg higher mean daily systolic BP during admission (95% CI: 3.5–20.9 ​mmHg), which persisted over follow-up. There was no association between prior CVD and diastolic BP.

Conclusion

The digital health program was feasible and ~40% of post-AMI patients who engaged in it had uncontrolled BP according to recent guideline cutpoints, while hypotension occurred rarely. The gap in BP control was especially large in patients in whom AMI represented recurrent CVD. These data suggest an opportunity for more aggressive secondary prevention early after MI as care models integrate digital health.

•

Digital health reveals home blood pressure trends during early recovery after an event.

•

~40% of early MI patients had mean daily blood pressure exceeding the guideline goal of <130/80 ​mmHg.

•

Hypotension occurred rarely over 30 days post-MI.

•

The gap in BP control was especially large in patients in whom MI represented recurrent CVD.

•

There is opportunity for more aggressive secondary prevention early after MI as care models integrate digital health.

Telemonitoring for Patients With COVID-19: Recommendations for Design and Implementation

Despite significant efforts, the COVID-19 pandemic has put enormous pressure on health care systems around the world, threatening the quality of patient care. Telemonitoring offers the opportunity to carefully monitor patients with a confirmed or suspected case of COVID-19 from home and allows for the timely identification of worsening symptoms. Additionally, it may decrease the number of hospital visits and admissions, thereby reducing the use of scarce resources, optimizing health care capacity, and minimizing the risk of viral transmission. In this paper, we present a COVID-19 telemonitoring care pathway developed at a tertiary care hospital in the Netherlands, which combined the monitoring of vital parameters with video consultations for adequate clinical assessment. Additionally, we report a series of medical, scientific, organizational, and ethical recommendations that may be used as a guide for the design and implementation of telemonitoring pathways for COVID-19 and other diseases worldwide.

Paradigm Shifts in Cardiac Care: Lessons Learned From COVID-19 at a Large New York Health System

The coronavirus disease-2019 (COVID-19) pandemic has overwhelmed healthcare systems around the world, resulting in morbidity, mortality, and a dramatic economic downturn In the United States. Urgent responses to the pandemic halted routine hospital workflow in an effort to increase hospital capacity, maintain staffing, and ration protective gear. Most notably, New York saw the largest surge of COVID-19 cases nationwide. Healthcare personnel and physician leaders at Northwell Health, the largest healthcare system in New York, have worked together to successfully implement operational changes resulting in a paradigm shift in cardiac care delivery. In this manuscript, we detail specific protocol adjustments made in our cardiology department, cardiology service line, and healthcare system in the face of the COVID-19 pandemic. We discuss the sustainability of this shift moving forward and the opportunity to optimize care for cardiovascular patients in the post COVID-19 era.

Contemporary and Future Concepts on Hypertension in African Americans: COVID-19 and Beyond

Background

Cardiovascular disease related mortality is the leading cause of death in the United States, with hypertension being the most prevalent and potent risk factor. For decades hypertension has disproportionately affected African Americans, who also have a higher burden of associated comorbidities including diabetes and heart failure.

Methods

Current literature including guideline reports and newer studies on hypertension in African Americans in PubMed were reviewed. We also reviewed newer publications on the relationship between COVID-19 and cardiovascular disease.

Findings

While APOL1 has been theorized in the epidemiology of hypertension, the increased prevalence and associated risks are primarily due to environmental and lifestyle factors. These factors include poor diet, adverse lifestyle, and social determinants. Hypertension control can be achieved by lifestyle modifications such as low sodium diet, weight loss, and adequate physical activity. When lifestyle modifications alone do not adequately control hypertension, a common occurrence among African Americans who suffer with greater prevalence of resistant hypertension, pharmacological intervention is indicated. The efficacy of renal denervation, and the use of sodium-glucose cotransporter 2 and aminopeptidase A inhibitors, have been studied for treatment of resistant hypertension. Furthermore, the recent COVID-19 crisis has been particularly devastating among African Americans who demonstrate increased incidence and poorer health outcomes related to the disease.

Conclusion

The disparities in outcomes, which are largely attributable to a greater prevalence of comorbidities such as hypertension and obesity, in addition to adverse environmental and socioeconomic factors, highlight the necessity of specialized clinical approaches and programs for African Americans to address longstanding barriers to equitable care.