Testing the feasibility of operationalizing a prospective, randomized trial with remote cardiac safety EKG monitoring during a pandemic

Hydroxychloroquine-Chloroquine, QT-Prolongation, and Major Adverse Cardiac Events: A Meta-analysis and Scoping Review

OBJECTIVES

We aimed to evaluate the high-quality literature on the frequency and nature of major adverse cardiac events (MACE) associated with either hydroxychloroquine (HCQ) or chloroquine (CQ).

DATA SOURCES

We searched Medline, Embase, International Pharmaceutical Abstracts, and Cochrane Central from 1996 onward using search strategies created in collaboration with medical science librarians.

STUDY SELECTION AND DATA EXTRACTION

Randomized controlled trials (RCTs) published in English language from January 1996 to September 2022, involving adult patients at least 18 years of age, were selected. Outcomes of interest were death, arrhythmias, syncope, and seizures. Random-effects meta-analyses were performed with a Treatment Arm Continuity Correction for single and double zero event studies.

DATA SYNTHESIS

By study drug, there were 31 HCQ RCTs (n = 6677), 9 CQ RCTs (n = 622), and 1 combined HCQ-CQ trial (n = 105). Mortality was the most commonly reported MACE at 220 of 255 events (86.3%), with no reports of torsades de pointes or sudden cardiac death. There was no increased risk of MACE with exposure to HCQ-CQ compared with control (risk ratio [RR] = 0.90, 95% CI = 0.69-1.17, I2 = 0%).

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

These findings have important implications with respect to patient reassurance and updated guidance for prescribing practices of these medications.

CONCLUSIONS

Despite listing as QT-prolonging meds, HCQ-CQ did not increase the risk of MACE.

KardiaMobile 6L for measuring QT interval in people having antipsychotic medication to inform early value assessment: a systematic review

Background

The indication for this assessment is the use of the KardiaMobile six-lead electrocardiogram device for the assessment of QT interval-based cardiac risk in service users prior to the initiation of, or for the monitoring of, antipsychotic medications, which are associated with an established risk of QT interval prolongation.

Objectives

To provide an early value assessment of whether KardiaMobile six-lead has the potential to provide an effective and safe alternative to 12-lead electrocardiogram for initial assessment and monitoring of QT interval-based cardiac risk in people taking antipsychotic medications.

Review methods

Twenty-seven databases were searched to April/May 2022. Review methods followed published guidelines. Where appropriate, study quality was assessed using appropriate risk of bias tools. Results were summarised by research question; accuracy/technical performance; clinical effects (on cardiac and psychiatric outcomes); service user acceptability/satisfaction; costs of KardiaMobile six-lead.

Results

We did not identify any studies which provided information about the diagnostic accuracy of KardiaMobile six-lead, for the detection of corrected QT-interval prolongation, in any population. All studies which reported information about agreement between QT interval measurements (corrected and/or uncorrected) with KardiaMobile six-lead versus 12-lead electrocardiogram were conducted in non-psychiatric populations, used cardiologists and/or multiple readers to interpret electrocardiograms. Where reported or calculable, the mean difference in corrected QT interval between devices (12-lead electrocardiogram vs. KardiaMobile six-lead) was generally small (≤ 10 ms) and corrected QT interval measured using KardiaMobile six-lead was consistently lower than that measured using 12-lead electrocardiogram. All information about the use of KardiaMobile six-lead, in the context of QT interval-based cardiac risk assessment for service users who require antipsychotic medication, was taken from retrospective surveys of staff and service users who had chosen to use KardiaMobile six-lead during pilots, described in two unpublished project reports. It is important to note that both these project reports relate to pilot studies which were not intended to be used in wider evaluations of KardiaMobile six-lead for use in the NHS. Both reports included survey results which indicated that the use of KardiaMobile six-lead may be associated with reductions in the time taken to complete an electrocardiogram and costs, relative to 12-lead electrocardiogram, and that KardiaMobile six-lead was preferred over 12-lead electrocardiogram by almost all responding staff and service users.

Limitations

There was a lack of published evidence about the efficacy of KardiaMobile six-lead for initial assessment and monitoring of QT interval-based cardiac risk in people taking antipsychotic medications.

Conclusions

There is insufficient evidence to support a full diagnostic assessment evaluating the clinical and cost effectiveness of KardiaMobile six-lead, in the context of QT interval-based cardiac risk assessment for service users who require antipsychotic medication. The evidence to inform the aims of this early value assessment (i.e. to assess whether the device has the potential to be clinically effective and cost-effective) was also limited. This report includes a comprehensive list of research recommendations, both to reduce the uncertainty around this early value assessment and to provide the additional data needed to inform a full diagnostic assessment, including cost-effectiveness modelling.

Study registration

This study is registered as PROSPERO CRD42022336695.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Evidence Synthesis programme (NIHR award ref: NIHR135520) and is published in full in Health Technology Assessment; Vol. 28, No. 19. See the NIHR Funding and Awards website for further award information.

Diagnostic quality electrocardiogram from a HeartMate 3 supported patient using a smartphone-based recording device

Patients with implantable left ventricular assist devices (LVAD) are at risk of ventricular arrhythmias but these may be hemodynamically tolerated. An electrocardiogram (ECG) is essential to determine whether an LVAD-supported patient is experiencing a ventricular arrhythmia. Access to 12 lead ECG is predominantly in healthcare facilities. Implantable LVAD also cause significant electromagnetic interference leading to artefacts on ECG. We report a patient on Heartmate 3 LVAD with a diagnostic quality 6 lead ECG obtained with an AliveCor device during an episode of sustained palpitations. The AliveCor device may be used for remote identification of ventricular arrhythmias in LVAD patients.

Data-Driven and Technology-Enabled Trial Innovations Toward Decentralization of Clinical Trials: Opportunities and Considerations

Traditional trial designs have well-recognized inefficiencies and logistical barriers to participation. Decentralized trials and digital health solutions have been suggested as potential solutions and have certainly risen to the challenge during the pandemic. Clinical trial designs are now increasingly data driven. The use of distributed clinical data networks and digitization has helped to fundamentally upgrade existing research systems. A trial design may vary anywhere from fully decentralized to hybrid to traditional on-site. Various decentralization components are available for stakeholders to increase the reach and pace of their trials, such as electronic informed consent, remote interviews, administration, outcome assessment, monitoring, and laboratory and imaging modalities. Furthermore, digital health technologies can be included to enrich study conduct. However, careful consideration is warranted, including assessing verification and validity through usability studies and having various contingencies in place through dedicated risk assessment. Selecting the right combination depends not just on the ability to handle patient care and the medical know-how but also on the availability of appropriate technologic infrastructure, skills, and human resources. Throughout this process, quality of evidence generation and physician-patient relation must not be undermined. Here we also address some knowledge gaps, cost considerations, and potential impact of decentralization and digitization on inclusivity, recruitment, engagement, and retention. Last, we mention some future directions that may help drive the necessary change in the right direction.

Feasibility of using KardiaMobile-L6 for QT interval monitoring during the early phase of the COVID-19 pandemic in critical care patients

The electrocardiogram (ECG) represents an essential tool to determine cardiac electrical abnormalities in COVID-19 patients, the effects of anti-SARS-CoV-2 drugs, and potential drug interactions. Smartphone-based heart monitors have increased the spectrum of ECG monitoring however, we are not aware of its reliability in critically ill COVID-19 patients. We aim to evaluate the feasibility and reliability of nurse-performed smartphone electrocardiography for QT interval monitoring in critically ill COVID-19 patients using KardiaMobile-6L compared with the standard 12-lead ECG. An observational comparative study was conducted comparing consecutive KardiaMobile-6L and 12-lead ECG recordings obtained from 20 patients admitted to the intensive care unit with SARS-CoV-2 infection and on invasive mechanical ventilation. The heart rate-corrected QT (QTc) intervals measured by KardiaMobile-6L and 12-lead ECG were compared. In 60 percent of the recordings, QTc intervals measured by KardiaMobile-6L matched those by 12-lead ECG. The QTc intervals measured by KardiaMobile-6 and 12-lead ECG were 428 ± 45 ms and 425 ± 35 ms (p = 0.82), respectively. The former demonstrated good agreement (bias = 2.9 ms; standard deviation of bias = 29.6 ms) with the latter, using the Bland-Altman method of measurement agreement. In all but one recording, KardiaMobile-6L demonstrated QTc prolongation. QTc interval monitoring with KardiaMobile-6L in critically ill COVID-19 patients was feasible and demonstrated reliability comparable to the standard 12-lead ECG.

The relationship between economic growth and environmental degradation: could West African countries benefit from EKC hypothesis?

There are growing concerns about environmental degradation and economic expansions in West Africa. Although there are several growth-environmental studies in Africa, there is limited empirical research exploring West African countries' potential of benefiting from the environmental Kuznets curve (EKC) hypothesis, with the few studies on this subject reporting diverse results based on selected West African countries. To fill this gap, this study explored the relationship between economic growth and environmental degradation within the EKC framework using 16 West African countries sub-grouped into low-income countries (LICs) and lower-middle-income countries (LMICs) between 1990 and 2018. This study implemented second-generation panel econometric estimators that are robust to cross-sectional dependent and parameter heterogeneity. The empirical results revealed that the data is cross-sectionally dependent, heterogeneous, integrated of order one, 1(1), and cointegrated. Controlling for other environmental determinants, panel estimates from the Augmented Meant Group and Common Correlated Effect Mean Group estimators revealed that economic growth accelerates environmental degradation in West African countries, with a greater impact on LMICs, followed by LICs in West Africa. The results also showed that West African countries especially LMICs could benefit from the EKC hypothesis. On the other hand, growth-environmental degradation among LICs in West Africa shows a monotonous increasing relationship. We found strong evidence to support for feedback hypothesis between economic growth and environmental degradation in LMICs, LICs, and West Africa as a whole. Based on the findings, policy recommendations that consider both LMICs and LICs and West Africa as a whole were offered to policymakers.

At-home ECG monitoring with a real-time outpatient cardiac telemetry system during the COVID-19 pandemic

CONTEXT

During the COVID-19 pandemic, essential in-person electrocardiogram (ECG) recordings became unfeasible, while patients continued to suffer from cardiac conditions. To circumvent these challenges, the cardiology clinic (Long Island Heart Rhythm Center [LIHRC]) at the New York Institute of Technology College of Osteopathic Medicine (NYITCOM) transitioned to a remote real-time outpatient cardiac telemetry (ROCT) service.

OBJECTIVES

The goal of this study is to test the hypothesis that at-home ROCT, provided by the LIHRC, is an effective method of providing ECG monitoring to symptomatic patients during the COVID-19 pandemic.

METHODS

Seventeen patients at the LIHRC that required ECGs between March 11 and August 1, 2020, were included in this study. The patients' medical records were de-identified and reviewed for age, gender, ROCT indications, findings, patient comfort, and ease of use. A retrospective analysis of observational de-identified data obtained from the LIHRC was approved and permitted by the NYITCOM Institutional Review Board (BHS-1465). These FDA-cleared medical devices (DMS-300, DM Software, Stateline, NV) were shipped to the patients' homes and were self-applied through adhesive chest patches. The devices communicated with a cloud-based system that produced reports including a continuous 6-lead ECG and many other cardiovascular parameters. Additionally, a patient-activated symptom recorder was available to correlate symptoms to ECG findings.

RESULTS

Seventeen patients (15 women) from the LIHRC were included in the analysis with an average monitoring duration of 27 h (range, 24-72 h). The patients' ages ranged from 21 to 85 years old with a mean of 37 years old and a standard deviation of 19. ROCT indications included palpitations (n=9), presyncope (n=8), chest pain (n=5), syncope (n=3), and shortness of breath (n=2). One also received ROCT due to short PR intervals observed on a prepandemic ECG. Two patients experienced palpitations while wearing the ROCT device: one had supraventricular tachycardia at 150 beats per minute; the other had unifocal premature ventricular contractions (PVCs) and eventually underwent a successful cardiac ablation. Most patients experienced no symptomatic episodes during ROCT (n=15). The 6-lead ROCT ECG for five of those patients showed arrhythmias including wandering atrial pacemaker (n=2), PVCs (n=2), sinus tachycardia (n=1), premature atrial contractions (PACs) (n=1), ectopic atrial rhythms (n=1), and sinus arrhythmia (n=1). One patient who experienced issues with our device was able to obtain a device from a separate clinic and was found to have bradycardia, PVCs, and nonsustained ventricular tachycardia. Overall, 16/17 (94.1%) patients were monitored effectively with the LIHRC ROCT system, and all (17/17, 100%) patients were monitored effectively with a ROCT system either from the LIHRC or a separate clinic.

CONCLUSIONS

With the unique challenges of the COVID-19 pandemic, physicians can use this innovative ROCT method to prevent infection and diagnose cardiac diseases. Most patients and staff were able to utilize the system without issues. Therefore, this system may also be utilized to deliver patient-centered care to those with limited mobility when coupled with a telemedicine visit.

Systematic review and meta-analysis of randomized trials of hydroxychloroquine for the prevention of COVID-19

Background

Recruitment into randomized trials of hydroxychloroquine (HCQ) for prevention of COVID-19 has been adversely affected by a widespread conviction that HCQ is not effective for prevention. In the absence of an updated systematic review, we conducted a meta-analysis of randomized trials that study the effectiveness of HCQ to prevent COVID-19.

Methods

A search of PubMed, medRxiv, and clinicaltrials.gov combined with expert consultation found 11 completed randomized trials: 7 pre-exposure prophylaxis trials and 4 post-exposure prophylaxis trials. We obtained or calculated the risk ratio of COVID-19 diagnosis for assignment to HCQ versus no HCQ (either placebo or usual care) for each trial, and then pooled the risk ratio estimates.

Results

The pooled risk ratio estimate of the pre-exposure prophylaxis trials was 0.72 (95% CI: 0.58–0.90) when using either a fixed effect or a standard random effects approach, and 0.72 (95% CI: 0.55–0.95) when using a conservative modification of the Hartung-Knapp random effects approach. The corresponding estimates for the post-exposure prophylaxis trials were 0.91 (95% CI: 0.72–1.16) and 0.91 (95% CI: 0.62–1.35). All trials found a similar rate of serious adverse effects in the HCQ and no HCQ groups.

Discussion

A benefit of HCQ as prophylaxis for COVID-19 cannot be ruled out based on the available evidence from randomized trials. However, the “not statistically significant” findings from early prophylaxis trials were widely interpreted as definite evidence of lack of effectiveness of HCQ. This interpretation disrupted the timely completion of the remaining trials and thus the generation of precise estimates for pandemic management before the development of vaccines.

The future is now: our experience starting a remote clinical trial during the beginning of the COVID-19 pandemic

Background

The World Health Organization declared the outbreak of SARS-CoV-2 a pandemic on February 11, 2020. This organism causes COVID-19 disease and the rapid rise in cases and geographic spread strained healthcare systems. Clinical research trials were hindered by infection control measures discouraging physical contact and diversion of resources to meet emergent requirements. The need for effective treatment and prevention of COVID-19 prompted an untested investigational response. Trial groups adapted approaches using remote enrolment and consenting, newly developed diagnostic tests, delivery of study medications and devices to participants’ homes, and remote monitoring to ensure investigator/enrollee safety while preserving ethical integrity, confidentiality, and data accuracy.

Methods

Clinical researchers at our community health system in the USA undertook an outpatient randomized open-label study of hydroxychloroquine (HCQ) prophylaxis versus observation of SARS-CoV-2 infection in household COVID-19 contacts. Designed in March 2020, challenges included COVID-19 infection in the research group, HCQ shortage, and lack of well-established home SARS-CoV-2 tests and remote ECG monitoring protocols in populations naive to these procedures. The study was written, funded, and received ethical committee approval in 4 months and was completed by September 2020 during a period of fluctuating infection rates and conflicting political opinions on HCQ use; results have been published. Singular methodology included the use of a new RNA PCR saliva SARS-CoV-2 home diagnostic test and a remote smartphone-based 6-lead ECG recording system.

Results

Of 483 households contacted regarding trial participation, 209 (43.3%) did not respond to telephone calls/e-mails and 90 (18.6%) declined; others were not eligible by inclusion or exclusion criteria. Ultimately, 54 individuals were enrolled and 42 completed the study. Numbers were too small to determine the efficacy of HCQ prophylaxis. No serious treatment-related adverse events were encountered.

Conclusions

Flexibility in design, a multidisciplinary research team, prompt cooperation among research, funding, ethics review groups, and finding innovative study approaches enabled this work. Concerns were balancing study recruitment against unduly influencing individuals anxious for protection from the pandemic and exclusion of groups based on lack of Internet access and technology. An issue to address going forward is establishing research cooperation across community health systems before emergencies develop.

Trial registration

ClinicalTrials.govNCT04652648. Registered on December 3, 2020.