COVID-19 sparks increased telehealth use for arrhythmia management
The COVID-19 pandemic has been a catalyst for rapid adoption of telehealth to remotely manage and monitor patients with arrhythmias, which will continue even after the pandemic passes, the authors of a multi-society practice update wrote.
The practice update, which was published in the Journal of the American College of Cardiology, was prepared by arrhythmia experts and representatives from the American Heart Association, American College of Cardiology, Heart Rhythm Society and several other organizations from Europe, Asia Pacific and Latin America.
“These technologies are here to stay,” Niraj Varma, MD, PhD, professor of medicine and cardiac electrophysiologist at Cleveland Clinic and chair of the writing group, told Healio. “Patients and doctors have found them very useful. We would like the accessibility to these technologies to increase on a worldwide basis because we anticipate that they are going to be integrated with general medical practice in the future.”
COVID-19 may increase arrhythmia risk
Reported rates of cardiac arrhythmias in patients with COVID-19 are 7.9% in New York City and 16.7% in Wuhan, China, and may be related to the disease itself, according to the document. Patients who are hospitalized for COVID-19 may already have arrhythmias, develop new arrhythmias or have increased risk for arrhythmias from COVID-19 therapies.
Increased incidence of arrhythmias and the pressures of both limiting face-to-face interactions and personal protective equipment shortages have led to an increased use of telehealth technologies. The document recommends using wireless monitoring strategies in high-risk patients who require close surveillance to protect health care workers from COVID-19 exposure and to preserve personal protective equipment, according to the document.
“Many of these technologies exist, they’re available and they’ve been put to good use during the COVID-19 epidemic,” Varma said in an interview. “That has illustrated how useful they are. By virtue of monitoring techniques and/or telehealth visits, they have helped with maintaining patient care and protecting caregivers. Some of the technologies have proved especially useful, and others, more exploratory, provided a valuable experience for future development.”
Telemetry can be used for inpatient monitoring if concerns arise regarding clinical deterioration, or for patients with CV risk factors and/or those who are taking QT-prolonging medications. This approach is not necessary for patients without these concerns. If telemetry cannot be used due to exceeded capacities, for example, other technologies can be used including mobile devices, patch monitoring and smartphone ECG monitors.
For outpatients, remote patient management can be achieved through virtual clinics.
“This supplements social distancing measures and reduces the risk of transmission, especially for the older and more vulnerable populations,” Varma and colleagues wrote. “It also becomes a measure to control intake into emergency rooms and outpatient facilities and to permit rapid access when necessary to subspecialists.”
The area of electrophysiology is somewhat ideal for virtual consultations, as pre-obtained data including ECGs, coronary angiography and cardiac imaging can be reviewed electronically, according to the document. Patients with implantable cardiac electronic devices (eg, pacemakers, defibrillators) already usually have embedded remote monitoring capability. The safety and efficacy of this was established a decade ago by the landmark TRUST randomized trial (chaired by Varma), and 5 years ago, an expert HRS consensus issued a class 1a recommendation for its use. Adoption has been spurred during the pandemic. Wireless BP devices and direct-to-consumer mobile ECGs can further complement the telehealth visit. Other information that can be integrated into clinician workflow include wearable/mobile health and clinical data.
If additional diagnostic information is required, ambulatory rhythm monitors can be used to avoid in-person contact, according to the document. For example, patch monitors can be mailed to patients and self-applied. Conventional clinic visits may be required occasionally to assess the impact of frailty or comorbidities on procedural risk or to talk with multiple members of the family when planning for high-risk procedures. These discussions can also be done through telephone-only visits.
Several barriers stand in the way of telehealth implementation such as lack of infrastructure, inadequate reimbursement, limited technical skills and lack of access due to poor internet access, according to the document.
“All stakeholders should collaborate to address these challenges and promote the safe and effective use of digital health during the current pandemic,” Varma and colleagues wrote. “In recent months, regulations have been eased to permit consults with new patients, issuing prescriptions and obtaining consents. In that sense, the COVID-19 pandemic may serve as an opportunity to evolve correct technologies into indispensable tools for our future cardiological practice.”
Risk-benefit assessment for drugs
Digital health tools have facilitated the use of drugs being tested to treat COVID-19. Although none have been shown to be curative, potential COVID-19 therapies such as hydroxychloroquine and azithromycin may exert QT-prolonging effects and require a risk-benefit adjudication before initiating these drugs to patients, according to the document.
“In the absence of clear efficacy data, treatment options should be individualized taking into account their proarrhythmic potential for torsade de pointes, which may be enhanced by concomitant administration of other QT-prolonging drugs (eg, antiarrhythmics, psychotropics, etc),” Varma and colleagues wrote.
A baseline 12-lead ECG should be performed in patients that require initiation of drugs in an inpatient setting that exert a QT-prolonging effect. Information from the ECG can be used to stratify patients as low risk or high risk. Telemetry or other remote devices can be used to assess corrected QT a second time after patients receive two doses, as this information can help identify corrected QT reactors, according to the document. The FDA cautioned against the use of chloroquine or hydroxychloroquine in an outpatient setting. These drugs ultimately may be replaced by other more efficacious agents, but if these share similar adverse cardiac effects, then safety can be ensured by applying the digital monitoring tools shown here, Varma told Healio.
“This is an international document, so there are different levels of penetration of mobile health tools around the world,” he said. “[Approximately] 70% or so of the world now has internet access and probably possesses a smart device, so the possibilities are huge.”
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Niraj Varma, MD, PhD, can be reached at email@example.com.