Andersons pediatric cardiology 2312
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Electrophysiology
Telemedicinehasbeenusedforyearsforsimpletransmissionof
electrophysiologicdatathroughtranstelephoniceventrecordersandpacemaker
evaluations.Remotemonitoringofrhythmdatafrombedsidemonitorsisalso
commonplace.Leveragingapplicationsforsmartphonesandtabletsforrhythm
analysismakesmonitoringofcardiacelectricalactivitydetectionofarrhythmias
andmyocardialinfarctionfeasible.TheSEARCH-AFtrialfromAustralia
evaluatednearly1000patientswithasingle-leadECGdevicebuiltintoan
iPhonecase.Thetechnologywasaccurateandcosteffectiveandhasthe
potentialtopreventstroke.88,89Amodificationoftheexistingsingle-leaddevice
wasusedinarecentstudyforassessmentofSTelevationmyocardialinfarction
(STEMI).Therewasagreementinsixpatients(fourwithSTEMIandtwowith
non-STEMI)whencomparingthesmartphonetracingto12-leadECG.85This
technologycangeneratetracingsofdiagnosticqualityinchildrenwithpositive
usersatisfactionandcouldbeusedtomanagechildrenwithsupraventricular
tachycardiaandatrialfibrillation.90New“biomedicalshirt”technologythat
enablesevenmorepracticalremoteECGmonitoringforchildrenandadultsis
currentlyunderinvestigation.91
TaketheexampleofJ.K.,whoisasavvyteenagerwithahistoryof
intermittentpalpitations.Hehasrecentlystartedtouseawearabledeviceto
trackhisheartrateandrhythminadditiontoaneventmonitorprescribedbyhis
cardiologistforsuspectedpathologictachycardia.Whilewatchingavideoonhis
cell-phone,suddenlyhefeelsapoundingsensationinhischest.Usinghisnew
cell-phonetechnologyhenoticesthathisheartrateis180beats/min.Heinforms
hismom,whostartsdrivinghimtothenearestemergencydepartment10
minutesaway.Ontheway,hetransfershisheartrateinformationtohis
cardiologistoffice,whichgivesthelocalemergencyroomaheads-up.Inthe
emergencydepartment,heisquicklytriagedandconnectedtoa
cardiorespiratorymonitorandconfirmedtobeinsupraventriculartachycardia.A
peripheralintravenouscatheterisstartedwhilevagalmaneuversareattempted.
Inthenextminuteabolusofadenosineconvertshimbacktonormalsinus
rhythmwithaheartrateof70beats/min,bringingrelieftothepatientandhis
mother.
Whilethedetailsoftheaboveeventwereslightlydifferentinreallife,
smartphone-andsmartwatch-basedteleheartrhythmmonitoringisontherise
andispredictedtosoonbeubiquitous.
Mobiledevice–mediatedtelemedicineislikelytotransformdirect-toconsumertelemedicine.KardiaMobilebyAlivecorisamedicaldeviceforhome
telemonitoringthatisFoodandDrugAdministrationclearedandhasreceived
EuropeanConformitymarking,indicatingitconformswithhealth,safety,and
environmentalprotectionstandardsforproductssoldwithintheEuropean
EconomicArea.Kardiausesasingle-leadECGtracingthatisacquiredfor30
secondswithplacementoftwofingersfromeachhandonthedeviceelectrodes.
TheECGrecordingsaretransmittedtoacompatibledevicerunningGoogle
androidorAppleiOSmobileoperatingsystems.Ithasbeenclinicallyvalidated
fortherecordingofsingle-channelleadIECGsinclinicalandcommunity-based
trials.92,93AttheHeartRhythmSociety2016scientificsessions,Beggand
colleaguespresentedacomparativestudyofAliveCormonitorandfoundittobe
superiortoconventionalHoltermonitoringinpatientswithpalpitations,
providingahigherdiagnosticyield,moredetectedarrhythmias,withasimilar
workload.UsingmobiletelemedicinedevicesenablespromptECG
confirmation/exclusionofaprobablearrhythmiccauseofsymptoms,enabling
rapidinterventionforcardiac-relevantcomplaints.94AliveCormonitoringhas
thepotentialtoenhanceevaluationofsymptomaticcollegeathletesbyallowing
trainersandteamphysicianstomakediagnosisinrealtime.95Eventsoflifethreateningwide-complextachycardiahavebeenreportedlyrecordedby
patients96andcompleteheartblockbybystanders97usingthistechnology.This
hasthepotentialofbeingmorewidelyavailableandaccessiblethan
defibrillatorsinpublicplaces.Halcoxandcolleaguesshowedthattelemedicine
screeningwithtwice-weeklysingle-leadiECGinambulatorypatientsaged65
yearsorolderatincreasedriskofstrokeissignificantlymorelikelytoidentify
incidentatrialfibrillationthanroutinecareovera12-monthperiod.98
Therearerandomizedclinicaltrialsunderwaytoinvestigatetheutilityofa
mobiletelemedicineinterventionina“realworld”setting.Participantsarebeing
randomized1:1toreceivetheiHEARTintervention,receivinganiPhone
equippedwithanAliveCormobileECGandaccompanyingKardiaapplication
andbehavioralalteringmotivationaltextmessagesorusualcardiaccarefor6
months.99Intheadultpopulation,postablationofarrhythmias,monitoringusing
amobile-basedplatform,ispreferablecomparedtotraditionaltelemedicine
monitoring.100Intheincreasingtechnologysavvypediatricpopulationandthe
youngparents,onecanimaginemorewidespreadacceptanceofcell-phone–
basedtelemedicineportal.ThereisFDAapprovalforusingmobileECG
monitor:KardiaandKardiaMobileforadultpatients.
Medicalprovidersareembracingmobile-baseddiagnostictools.LeshamRubinowandcolleaguessetupatelemedicinecallcenterwheretransmitted
three-leadECGrecordingswereinstantlydisplayedonamonitorforimmediate
diagnosisbytheon-dutymedicalteam.94Telemedicineallowstransmissionof
cardiacrecordingsbycellularcommunicationatthepushofabutton.Userscan
concomitantlyrelaysymptomsbycellphone,therebyprovidinga
symptom/cardiorhythmcorrelation.Theirset-upallowedforpromptresponseto
abnormaltracings,especiallywhenaccompaniedbysymptomsselectedfromthe
preparedlist.Itenabledtheirstafftoinstructthesubscriber,notifytheir
physician,and/ordispatchamobileintensivecareunittothesceneinamatterof
minutes.
Photoplethysmography(PPG),isanopticalmethodavailableonasmartphone
ortablet,forconsumer-basedtelemedicine,withoutanyadditionalperipheral
deviceslikeKardia.Itmeasureschangesintissuebloodvolumecausedbythe
pulse.101APPGwaveformisacquiredfromafingerilluminatedbyLED
smartphoneflashandwhilethatfingerisalsoincontactwiththephonecamera.
Asoftwareapplication(CardiioRhythm)thenmeasurespulsatilechangesin
lightintensityreflectedandclassifiesrhythmas“regular”or“irregular.”While
thesensitivityandspecificityofopticalPPGislessthanECG-baseddetection,it
isalsoquitehigh.92OnApple'sAppstoreandGoogle'sPlaystore,applications
suchas“iCareHealthMonitor,”“Cardiograph,”“HeartRateMonitor,”anda
fewothersthatusePPGforheart-ratemeasurementhavehadmillionsof
downloads.
Wrist-wearabledeviceslikesmartwatchesarelesswellvalidatedthan
smartphone-baseddevices,butthatislikelyrelatedtothefactthattheyare
newertechnologies.Wangandcolleaguesevaluatedfourwrist-worn,optically
basedheart-ratemonitorsandfoundthattwoofthefourhadsuboptimal
accuracyduringexercise.102Healthcareteamsareworkingwithdevice
manufacturerstoimprovetheirprecisionandaccuracy.103,104Therehavebeen
anecdotalcasereportsoftheAppleWatchusedforcontinuousheart-rate
monitoringinprematureinfants.105However,atthispointthesewearable
smartwatchesareprimarilyhelpfulinsettingsafeandappropriatefitnessgoals,
counselingonotherlifestylechanges,andprovidingoverallfeedbackand
encouragement.IntheirrecentcommentarypublishedinCanadianMedical
