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Fedorowski A, Fanciulli A, Raj SR, Sheldon R, Shibao CA, Sutton R. Cardiovascular autonomic dysfunction in post-COVID-19 syndrome: a major health-care burden. Nat Rev Cardiol 2024; 21:379-395. [PMID: 38163814 DOI: 10.1038/s41569-023-00962-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/13/2023] [Indexed: 01/03/2024]
Abstract
Cardiovascular autonomic dysfunction (CVAD) is a malfunction of the cardiovascular system caused by deranged autonomic control of circulatory homeostasis. CVAD is an important component of post-COVID-19 syndrome, also termed long COVID, and might affect one-third of highly symptomatic patients with COVID-19. The effects of CVAD can be seen at both the whole-body level, with impairment of heart rate and blood pressure control, and in specific body regions, typically manifesting as microvascular dysfunction. Many severely affected patients with long COVID meet the diagnostic criteria for two common presentations of CVAD: postural orthostatic tachycardia syndrome and inappropriate sinus tachycardia. CVAD can also manifest as disorders associated with hypotension, such as orthostatic or postprandial hypotension, and recurrent reflex syncope. Advances in research, accelerated by the COVID-19 pandemic, have identified new potential pathophysiological mechanisms, diagnostic methods and therapeutic targets in CVAD. For clinicians who daily see patients with CVAD, knowledge of its symptomatology, detection and appropriate management is more important than ever. In this Review, we define CVAD and its major forms that are encountered in post-COVID-19 syndrome, describe possible CVAD aetiologies, and discuss how CVAD, as a component of post-COVID-19 syndrome, can be diagnosed and managed. Moreover, we outline directions for future research to discover more efficient ways to cope with this prevalent and long-lasting condition.
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Affiliation(s)
- Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.
- Department of Medicine, Karolinska Institute, Stockholm, Sweden.
- Department of Clinical Sciences, Lund University, Malmö, Sweden.
| | | | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert Sheldon
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cyndya A Shibao
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Richard Sutton
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Hammersmith Hospital, National Heart & Lung Institute, Imperial College, London, UK
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Mant J, Modi RN, Charlton P, Dymond A, Massou E, Brimicombe J, Freedman B, Griffin SJ, Hobbs FDR, Lip GYH, McManus RJ, Williams K. The feasibility of population screening for paroxysmal atrial fibrillation using hand-held electrocardiogram devices. Europace 2024; 26:euae056. [PMID: 38411621 PMCID: PMC10946414 DOI: 10.1093/europace/euae056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 02/22/2024] [Indexed: 02/28/2024] Open
Abstract
AIMS There are few data on the feasibility of population screening for paroxysmal atrial fibrillation (AF) using hand-held electrocardiogram (ECG) devices outside a specialist setting or in people over the age of 75. We investigated the feasibility of screening when conducted without face-to-face contact ('remote') or via in-person appointments in primary care and explored impact of age on screening outcomes. METHODS AND RESULTS People aged ≥65 years from 13 general practices in England participated in screening during 2019-20. This involved attending a practice nurse appointment (10 practices) or receiving an ECG device by post (three practices). Participants were asked to use a hand-held ECG for 1-4 weeks. Screening outcomes included uptake, quality of ECGs, AF detection rates, and uptake of anticoagulation if AF was detected. Screening was carried out by 2141 (87.5%) of people invited to practice nurse-led screening and by 288 (90.0%) invited to remote screening. At least 56 interpretable ECGs were provided by 98.0% of participants who participated for 3 weeks, with no significant differences by setting or age, except people aged 85 or over (91.1%). Overall, 2.6% (64/2429) screened participants had AF, with detection rising with age (9.2% in people aged 85 or over). A total of 53/64 (82.8%) people with AF commenced anticoagulation. Uptake of anticoagulation did not vary by age. CONCLUSION Population screening for paroxysmal AF is feasible in general practice and without face-to-face contact for all ages over 64 years, including people aged 85 and over.
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Affiliation(s)
- Jonathan Mant
- Primary Care Unit, Department of Public Health and Primary Care, Strangeways Research Laboratory, University of Cambridge, 2 Worts’ Causeway, Cambridge CB1 8RN, UK
| | - Rakesh N Modi
- Primary Care Unit, Department of Public Health and Primary Care, Strangeways Research Laboratory, University of Cambridge, 2 Worts’ Causeway, Cambridge CB1 8RN, UK
| | - Peter Charlton
- Primary Care Unit, Department of Public Health and Primary Care, Strangeways Research Laboratory, University of Cambridge, 2 Worts’ Causeway, Cambridge CB1 8RN, UK
| | - Andrew Dymond
- Primary Care Unit, Department of Public Health and Primary Care, Strangeways Research Laboratory, University of Cambridge, 2 Worts’ Causeway, Cambridge CB1 8RN, UK
| | - Efthalia Massou
- Primary Care Unit, Department of Public Health and Primary Care, Strangeways Research Laboratory, University of Cambridge, 2 Worts’ Causeway, Cambridge CB1 8RN, UK
| | - James Brimicombe
- Primary Care Unit, Department of Public Health and Primary Care, Strangeways Research Laboratory, University of Cambridge, 2 Worts’ Causeway, Cambridge CB1 8RN, UK
| | - Ben Freedman
- Heart Research Institute, University of Sydney, Room 3114, Level 3 East, D17 - Charles Perkins Centre, Sydney, NSW 2006, Australia
| | - Simon J Griffin
- Primary Care Unit, Department of Public Health and Primary Care, Strangeways Research Laboratory, University of Cambridge, 2 Worts’ Causeway, Cambridge CB1 8RN, UK
- MRC Epidemiology Unit, School of Clinical Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge CB2 0SL, UK
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, UK
| | - Kate Williams
- Primary Care Unit, Department of Public Health and Primary Care, Strangeways Research Laboratory, University of Cambridge, 2 Worts’ Causeway, Cambridge CB1 8RN, UK
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Jelisejevas J, Regoli F, Hofer D, Conte G, Oezkartal T, Saguner AM, Caputo ML, Grazioli L, Steffel J, Auricchio A, Breitenstein A. Leadless Pacemaker Implantation, Focusing on Patients With Conduction System Disorders Post-Transcatheter Aortic Valve Replacement: A Retrospective Analysis. CJC Open 2024; 6:96-103. [PMID: 38585679 PMCID: PMC10994977 DOI: 10.1016/j.cjco.2023.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 10/09/2023] [Indexed: 04/09/2024] Open
Abstract
Background Impairment of the conduction system is a common complication of transcatheter aortic valve replacement (TAVR), which is typically performed in elderly patients. A leadless pacemaker (LP) may be a suitable option in this frail population, but the available scientific data concerning the efficacy and safety of leadless pacing after TAVR are sparse. The purpose of this analysis was to evaluate the efficacy and safety of LP implantation in patients with relevant bradycardias after TAVR, compared to other indications. Methods Consecutive patients were retrospectively enrolled. Demographics, background heart diseases, interventional parameters, and follow-up data were collected. Results A total of 257 consecutive patients who underwent LP implantation were included. In 26 patients, the device was implanted due to bradycardias after TAVR (TAVR group), whereas the remaining 231 patients were in the population without previous TAVR (non-TAVR group). The mean implantation duration (56 ± 22 minutes in the TAVR group vs 48 ± 20 minutes in the non-TAVR group; P = not significant [NS]) and the implantation success rate (100% in the TAVR group vs 98.7% in the non-TAVR group; P = NS) were similar in the 2 cohorts. No significant differences occurred in pacing parameters (sensing, impedance, and threshold, respectively) between the 2 groups, either at implantation or during follow-up. A total of 8 major periprocedural complications (3.1% of patients in total; 3.8% in the TAVR group vs 3.0% in the non-TAVR group; P = NS) occurred within 30 days, without significant difference between the 2 groups. Conclusions LP implantation appears to be safe and effective in patients after TAVR, and therefore, this procedure is a suitable option for this often old and frail population.
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Affiliation(s)
- Julius Jelisejevas
- Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - François Regoli
- Fondazione Cardiocentro Ticino, Lugano, Switzerland
- Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland
| | - Daniel Hofer
- Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Giulio Conte
- Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | | | - Ardan M. Saguner
- Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | | | | | - Jan Steffel
- Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
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Fedorowski A, Kulakowski P, Brignole M, de Lange FJ, Kenny RA, Moya A, Rivasi G, Sheldon R, Van Dijk G, Sutton R, Deharo JC. Twenty-five years of research on syncope. Europace 2023; 25:euad163. [PMID: 37622579 PMCID: PMC10450792 DOI: 10.1093/europace/euad163] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 05/30/2023] [Indexed: 08/26/2023] Open
Abstract
Over the last 25 years, the Europace journal has greatly contributed to dissemination of research and knowledge in the field of syncope. More than 400 manuscripts have been published in the journal. They undoubtedly improved our understanding of syncope. This symptom is now clearly differentiated from other forms of transient loss of consciousness. The critical role of vasodepression and/or cardioinhibition as final mechanisms of reflex syncope is emphasized. Current diagnostic approach sharply separates between cardiac and autonomic pathways. Physiologic insights have been translated, through rigorously designed clinical trials, into non-pharmacological or pharmacological interventions and interventional therapies. The following manuscript is intended to give the reader the current state of the art of knowledge of syncope by highlighting landmark contributions of the Europace journal.
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Affiliation(s)
- Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, Eugeniavägen 3, 171 76 Solna, Stockholm, Sweden
- Department of Medicine, Karolinska Institute, Solnavägen 1, 171 77 Solna, Stockholm, Sweden
- Department of Clinical Sciences, Lund University, 214 28 Malmö, Sweden
| | - Piotr Kulakowski
- Department of Cardiology, Medical Centre for Postgraduate Education, Grochowski Hospital, Ul. Grenadierow 51/59, 04-073 Warsaw, Poland
| | - Michele Brignole
- Department of Cardiology, S. Luca Hospital, IRCCS, Istituto Auxologico Italiano, Piazzale Brescia 20, 20149 Milan, Italy
| | - Frederik J de Lange
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Rose Anne Kenny
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, 152-160 Pearse St, Dublin, Ireland
- Mercer Institute for Successful Ageing, St. James Hospital, James St, Dublin 8, D08 NHY1Ireland
| | - Angel Moya
- Department of Cardiology, Hospital Universitari Dexeus, Carrer de Sabino Arana 5-19, 08028 Barcelona, Spain
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy
| | - Robert Sheldon
- Department of Cardiac Sciences, University of Calgary, Libin Cardiovascular Institute, 3310 Hospital Drive NW, Calgary, Alberta T2N 4N1, Canada
| | - Gert Van Dijk
- Department of Neurology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ, Nijmegen, The Netherlands
| | - Richard Sutton
- Department of Cardiology, Hammersmith Hospital, National Heart & Lung Institute, Imperial College, Du Cane Road, London, W12 0HS, United Kingdom
| | - Jean-Claude Deharo
- Assistance Publique − Hôpitaux de Marseille, Centre Hospitalier Universitaire La Timone, Service de Cardiologie, Marseille, France and Aix Marseille Université, C2VN, 264 Rue Saint-Pierre, 13005 Marseille, France
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Sandberg EL, Halvorsen S, Berge T, Grimsmo J, Atar D, Fensli R, Grenne BL, Jortveit J. Fully digital self-screening for atrial fibrillation with patch electrocardiogram. Europace 2023; 25:euad075. [PMID: 36945146 PMCID: PMC10227758 DOI: 10.1093/europace/euad075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 02/23/2023] [Indexed: 03/23/2023] Open
Abstract
AIMS Atrial fibrillation (AF) is the most common arrhythmia worldwide. The AF is associated with severe mortality, morbidity, and healthcare costs, and guidelines recommend screening people at risk. However, screening methods and organization still need to be clarified. The current study aimed to assess the feasibility of a fully digital self-screening procedure and to assess the prevalence of undetected AF using a continuous patch electrocardiogram (ECG) monitoring system. METHODS AND RESULTS Individuals ≥65 years old with at least one additional risk factor for stroke from the general population of Norway were invited to a fully digital continuous self-screening for AF using a patch ECG device (ECG247 Smart Heart Sensor). Participants self-reported clinical characteristics and usability online, and all participants received digital feedback of their results. A total of 2118 individuals with a mean CHA2DS2-VASc risk score of 2.6 (0.9) were enrolled in the study [74% women; mean age 70.1 years (4.2)]. Of these, 1849 (87.3%) participants completed the ECG self-screening test, while 215 (10.2%) did not try to start the test and 54 (2.5%) failed to start the test. The system usability score was 84.5. The mean ECG monitoring time was 153 h (87). Atrial fibrillation was detected in 41 (2.2%) individuals. CONCLUSION This fully digitalized self-screening procedure for AF demonstrated excellent feasibility. The number needed to screen was 45 to detect one unrecognized case of AF in subjects at risk for stroke. Randomized studies with long-term follow-up are needed to assess whether self-screening for AF can reduce the incidence of AF-related complications. CLINICAL TRIALS NCT04700865.
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Affiliation(s)
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ullevaal, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Trygve Berge
- Department of Medical Research and Department of Internal Medicine, Vestre Viken Hospital Trust, Baerum Hospital, Rud, Norway
| | - Jostein Grimsmo
- Department of Cardiac Rehabilitation, LHL-hospital Gardermoen, Jessheim, Norway
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ullevaal, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Rune Fensli
- Faculty of Engineering and Science, University of Agder, Grimstad, Norway
| | - Bjørnar Leangen Grenne
- Clinic of Cardiology, St. Olavs Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jarle Jortveit
- Department of Cardiology, Sorlandet Hospital, Postboks 416 Lundsiden, 4604 Arendal, Norway
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Xing LY, Diederichsen SZ, Højberg S, Krieger DW, Graff C, Olesen MS, Nielsen JB, Brandes A, Køber L, Haugan KJ, Svendsen JH. Electrocardiographic markers of subclinical atrial fibrillation detected by implantable loop recorder: insights from the LOOP Study. Europace 2023; 25:euad014. [PMID: 37068888 PMCID: PMC10227658 DOI: 10.1093/europace/euad014] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 01/10/2023] [Indexed: 04/19/2023] Open
Abstract
AIMS Insights into subclinical atrial fibrillation (AF) development are warranted to inform the strategies of screening and subsequent clinical management upon AF detection. Hence, this study sought to characterize the onset and progression of subclinical AF with respect to 12-lead electrocardiogram (ECG) parameters. METHODS AND RESULTS We included AF-naïve individuals aged 70-90 years with additional stroke risk factors who underwent implantable loop recorder (ILR) monitoring in the LOOP Study. Using data from daily ILR recordings and the computerized analysis of baseline ECG, we studied empirically selected ECG parameters for AF detection (≥6 min), cumulative AF burden, long-lasting AF (≥24 h), and AF progression. Of 1370 individuals included, 419 (30.6%) developed AF during follow-up, with a mean cumulative AF burden of 1.5% [95% CI: 1.2-1.8]. Several P-wave-related and ventricular ECG parameters were associated with new-onset AF and with cumulative AF burden in AF patients. P-wave duration (PWD), P-wave terminal force in Lead V1, and interatrial block (IAB) further demonstrated significant associations with long-lasting AF. Among AF patients, we observed an overall reduction in cumulative AF burden over time (IRR 0.70 [95% CI: 0.51-0.96]), whereas IAB was related to an increased risk of progression to AF ≥24 h (HR 1.86 [95% CI: 1.02-3.39]). Further spline analysis also revealed longer PWD to be associated with this progression in AF duration. CONCLUSION We identified several ECG parameters associated with new-onset subclinical AF detected by ILR. Especially PWD and IAB were robustly related to the onset and the burden of AF as well as progression over time.
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Affiliation(s)
- Lucas Yixi Xing
- Department of Cardiology, Copenhagen University Hospital – Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
- Department of Cardiology, Zealand University Hospital Roskilde, 4000 Roskilde, Denmark
| | - Søren Zöga Diederichsen
- Department of Cardiology, Copenhagen University Hospital – Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
- Department of Cardiology, Bispebjerg Hospital, Copenhagen University Hospital, 2400 Copenhagen, Denmark
| | - Søren Højberg
- Department of Cardiology, Bispebjerg Hospital, Copenhagen University Hospital, 2400 Copenhagen, Denmark
| | - Derk W Krieger
- Department of Neurology, Mediclinic City Hospital, Dubai, United Arabic Emirates
- Department of Neuroscience, Mohammed Bin Rashid University of Medicine and Health Science, Dubai, United Arabic Emirates
| | - Claus Graff
- Department of Health Science and Technology, Aalborg University, 9220 Aalborg, Denmark
| | - Morten S Olesen
- Department of Cardiology, Copenhagen University Hospital – Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Jonas Bille Nielsen
- Department of Cardiology, Copenhagen University Hospital – Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
| | - Axel Brandes
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, 5000 Odense C, Denmark
- Department of Cardiology, Odense University Hospital, 5000 Odense, Denmark
- Department of Cardiology, University Hospital of Southern Denmark Esbjerg, 6700 Esbjerg, Denmark
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital – Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Ketil Jørgen Haugan
- Department of Cardiology, Zealand University Hospital Roskilde, 4000 Roskilde, Denmark
| | - Jesper Hastrup Svendsen
- Department of Cardiology, Copenhagen University Hospital – Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
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Khanji MY, Gallagher AM, Rehill N, Archbold RA. Remote consultations: review of guiding themes for equitable and effective delivery. Curr Probl Cardiol 2023; 48:101736. [PMID: 37075908 PMCID: PMC10108552 DOI: 10.1016/j.cpcardiol.2023.101736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 04/06/2023] [Indexed: 04/21/2023]
Abstract
The global coronavirus disease (COVID) -19 pandemic has led to a rapid transformation in the ways in which outpatient care is delivered. The need to minimise the risk of viral infection and transmission through social distancing resulted in the widespread adoption of remote consultations, traditional face-to-face appointments ceasing almost overnight in many specialties. The transition to remote consultations had taken place far faster than anticipated and under crisis conditions. As we work towards the 'new normal', remote consultations have become an integral part of outpatient provision in secondary care. Adapting to this change in clinical practice requires a judicious approach to ongoing service development to ensure safe, effective, and equitable care for all patients. Medical societies have provided some initial guidance around effective delivery. In this article we discuss the potential benefits, limitations, types of remote consultations, and factors that require consideration when deciding on patient suitability for remote consultation in a hospital setting. We use cardiology as a specialty exemplar, although many of the principles will be equally applicable to other medical specialities.
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Affiliation(s)
- Mohammed Y Khanji
- Newham University Hospital, Barts Health NHS Trust, London, E13 8SL, United Kingdom; Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, EC1A 7BE, UK; NIHR Barts Biomedical Research Centre, William Harvey Research Institute, Queen Mary; Cardiovascular Disease Prevention and Proactive Care, UCLPartners, London, UK.
| | - Angela M Gallagher
- Newham University Hospital, Barts Health NHS Trust, London, E13 8SL, United Kingdom; Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, EC1A 7BE, UK; Cardiovascular Disease Prevention and Proactive Care, UCLPartners, London, UK
| | - Nirandeep Rehill
- Cardiovascular Disease Prevention and Proactive Care, UCLPartners, London, UK; UCLPartners Academic Health Science Network, London, UK
| | - R Andrew Archbold
- Newham University Hospital, Barts Health NHS Trust, London, E13 8SL, United Kingdom; Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, EC1A 7BE, UK; Cardiovascular Disease Prevention and Proactive Care, UCLPartners, London, UK
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