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Growing Adoption of Remote Cardiac Pacing

Telecardiology has the potential to revolutionize the way various heart conditions are managed in the primary care setting by reducing the door-to-balloon time, which in turn greatly decreases the patient mortality.

Heart disease has long been the leading cause of death in the country and also around the world. In cardiology, technological advances have been progressively refined and are the launch pad for further advances. Technological progress continues exponentially. Now in-depth collaboration between medics and experts from other sciences is the key to success, moving far beyond the garages of the early ECG pioneers. Recent ECG systems have been designed to improve workflow and simplify operation. With step-by-step operation, touchscreen systems, and connectivity with medical records and information systems, processing an ECG has never been easier. Bluetooth and wireless connection capabilities have made transferring information a breeze.

As the features in the machines have increased over the years, the size of the machine has been shrinking gradually. There are many handheld ECG machines available in the market today, which make it easier to be carried around. Storage and transfer of patient data has become one of the basic requirements of the modern-day ECG equipment. The ability to transfer a patient’s recorded ECG from the ECG equipment to a common database using a USB device or LAN connection helps to serve the common man, where they might not be able to directly contact a cardiologist. With telemedicine application and adoption of wearable devices growing steadily, getting opinions of specialists across different locations will definitely improve the standard of health and have a tremendous positive impact on the healthcare costs.

Technological Advances
As MedTech advances, it is important for hospitals and medical facilities to stay up to date, especially when it comes to ECG systems. Newer ECG systems offer better integration, including interoperability with other software, PCs, and smartphones.

Telecardiology. Among all clinical disciplines, the widest use of telemedicine in the twentieth century has been in cardiology due to the necessity of urgent diagnosis of the cardiovascular system. Telecardiology has been around for quite some time now. Early application of the telecardiology involved the transfer of EKGs via fax and consultation with specialists by telephone. Recently, things have shifted with use cases of telecardiology in areas like remote patient monitoring, EKG, echocardiograms, teleconsultation through video monitoring and rapid interpretation cardiac diagnostic tests and teleconferencing for interventional cardiology. Advancement in cloud technology will take the field into a new era of telecardiology.

Telecardiology devices are small, mobile, and usually operated by a single button. Devices can be moved easily from room to room within a practice and can be taken out into the community or remote areas. It also plays a significant role in allowing the timely diagnosis of ST-segment elevation myocardial infarction (STEMI) prior to hospitalization. This is of critical importance, as a pre-hospital diagnosis of a STEMI reduces door-to-balloon time thus greatly decreasing patient mortality. Telecardiology, thus, has the potential to revolutionize the way various heart conditions are managed in the primary care setting.

Artificial intelligence. Early detection of heart diseases and timely treatment can prevent them. Manually, there are several chances of misses or misdiagnosis. With the help of artificial technology researchers have for the first time found that AI has the ability to diagnose heart attacks. In cardiology, AI has been successfully applied to problems in the diagnosis and the treatment of several diseases like ischemic
heart disease, early repolarization syndrome, atrial flutter/fibrillation (AF), bundle branch block diseases etc. The technology still will not replace a skilled physician who understands the fine points of the art of medicine and the ECG reading; however, AI will reduce the burden of ECG diagnosis that has increased tremendously.

Mobile cardiac telemetry. MCT is a device system that continuously records the electrical beat-to-beat activity of the heart for up to 30 days. The standard technology consists of a small sensor and monitor, attached to the patient’s chest by three leads that patients wear while continuing their normal routine. Recently, patch MCT devices that communicate by Bluetooth to a cell phone-sized monitor have been introduced, which provide one or two ECG leads with application of the patch sensor (which has no lead wires) to the patient’s chest. Direct contact between the patient and monitoring company is constantly maintained, so any event occurrence is instantaneously transmitted to a monitoring center for analysis and response. The patient can also trigger a recording at any time by pushing a record event button on the monitor.

Continuous patch monitoring system. Recently, continuous technological evolution in medical science has led to the development of miniaturized medical devices for continuous cardiac outpatient monitoring. These adhesive ambulatory electrocardiographic monitors or patches have integrated microelectronics for short- to medium-term (days to weeks) continuous cardiac monitoring, and are challenging conventional, widely used multi-lead wearable devices. The patch monitoring system consists of a sensor, a microelectronic circuit with recorder and memory storage, and an internal battery embedded in a relatively flexible synthetic matrix, resin, or other material. They are easy to use, leadless, water resistant, and usually intended for single use.

Smartphone event monitors. Technological advancements have also allowed users to generate rhythm strips from their smartphones or smartwatches. This system uses an external case (that acts as electrodes when touched by the right or left hand of the user) and a downloadable application on a smartphone, which together form an event monitor. The cardiac electrical signal is converted to an ultrasound FM sound signal, and the application in the smartphone then demodulates the signal to a digital EKG tracing. The EKG is generated in real time, and can be stored and instantaneously transmitted by the phone to a secure server for further analysis. These smartphone event monitors can prove to be very convenient, effective, and user-friendly tools for AF screening in the future.

Photoplethysmographic-based smart devices. Several downloadable applications have been developed (both for iOS and Android users) for smartphones that use photoplethysmographic (PPG)-based algorithms to detect atrial fibrillation or normal sinus rhythm. These applications do not require external hardware, and use only the phone’s camera and light. The user puts his right index or second finger on the sensor, and the signal recorded is then processed through an app with
built-in algorithms for AF detection. PPG-based technology has been extended to wearables such as smartwatches.

Future Directions
Patient care is changing – it is becoming more personalized, with more emphasis placed on compliance and efficacy. With maturing technologies in batteries and wireless communication, remote monitoring will only become more mainstream as it provides a new way to deliver monitoring and care outside the traditional healthcare setting. The way in which doctors’ care for patients will change dramatically and the role patients play in their own healthcare will increase. Remote monitoring plays a key role in delivering this promise. And with the availability of a variety of smart devices and apps, cardiac monitoring has a very bright future. These device systems and apps attempt to integrate monitoring tools into an everyday lifestyle, thereby ensuring compliance to its best. Smartphone monitors and patches have the potential to replace traditional event and holter monitors for diagnostic purposes in the future.

Second Opinion

Dr Sameer Gupta
Consultant – Interventional Cardiology and Peripheral Intervention,
Metro Hospital and Heart Institute

The Future of ECG Machines
Heart disease is one of the most common causes of mortality in India. With one in four Indians succumbing to heart disease, it has been the focus of innovation and research for prevention, diagnosing, and treatment. In spite of all the advancements in testing, an ECG remains the first test for screening and diagnosis of heart disease. Many thousands of ECGs are being performed every day in India alone.

Technology Trends
High-end devices accounted for only 15 percent of the market share but with many Indian companies entering this sector, the devices will get cheaper and will gain market share. There has also been considerable innovation in technology with devices becoming smaller and more portable. Some machines have the option of transmitting the ECG to a doctor at a remote location for prompt diagnosis. Other more novel devices are the size of a credit card and require a smart phone to work. According to recent studies, wearable devices like smart watches are accurately picking up cardiac arrhythmias. Moreover majority of these newer devices are paperless and the ECG can be easily stored in the patient’s record for future reference.

Future Growth
The ability to remotely transmit an ECG for quick and accurate diagnosis is changing the landscape of rural healthcare. Allied professionals in remote areas can now get a prompt diagnosis that translates into immediate medical attention and treatment. The higher end machines also use an algorithm to give a provisional diagnosis on the ECG. Depending on the center this information is very useful for screening purposes where a trained personnel may not be available. However, the ECG always needs to be interpreted in the clinical context of the patient and not as a standalone metric.

In the modern day a thermometer, blood pressure machine, and a glucometer have become household products. As machines get smaller, more portable, and less costly, an ECG machine also has the potential to join the same league, especially for patients with pre-existing heart disease. However, given the complexity of reading an ECG, a physician input will almost always be required to correlate the findings clinically.

Though a 12-lead ECG is a requirement for diagnosing a heart attack, a 2–3-lead ECG would be enough to accurately diagnose an arrhythmia. There are many smart phone apps that are being used across the world for diagnosing arrhythmias. Wearable devices like smart watches and smart cloths are also able to provide some of this information and have a promising future. At a recent international cardiology conference, smart watches picked up abnormal heart rhythms more than 90 percent of times. With time there will be improvement in the accuracy of this technology.

With affordable healthcare being a major focus of healthcare delivery in India, all solutions will have to be cost efficient. Most major players recognize this challenge and are developing ingenious ways of making it more affordable for the Indian market.

Second Opinion

Dr Vikas Kohli
Director, Delhi Child Heart Center
Founder Trustee, Child Heart Foundation

ECG remains a basic investigation in emergency care and for screening. Practically no large or small institution can function without an ECG machine. The equipment is mostly independent of other attachments, is portable, and non-bulky. Though there are several vendors in the market, the aim of an ECG machine remains the same, to produce a reliable 12-lead ECG. Most machines would have electric input and a battery backup and most can store several of the studies of ECG for some duration of time. The storage function may be in-built or may be SD card based.

There is an option in these machines to be connected to a hospital network for instant reading by a cardiologist working in another room. In addition, peripheral primary care hospitals can be connected to the network of a larger hospital for reading by a professional. Though most machines can give a basic reading of the ECG, after input of age and sex of patient, but this may not be reliable in most instances and requires human intervention to finalize the reading. There has been a movement to develop smaller machines and Indian scientists at BARC have developed an ECG machine the size of a credit card though not the same thickness. The machine does have analogue input and can transmit the image of the ECG live to an android tablet or a phone over a telecom network.

In addition, there has been movement toward using a mobile phone to generate an ECG with or without an attachment to the phone. Though there is only one FDA approved such device which is available worldwide, it does produce an authentic ECG which can be sent as a PDF file to the doctor who would read it instantly. This comes under the category of loop recorders. The ECG quality is good and a cardiologist can diagnose arrhythmia and change management of patient at the same time. More advances maybe coming forth, including patch-based ECG monitoring systems which may record and send data via a sim card in the sticky patch. This may be extended to pregnant women for monitoring heartbeat of the fetus. This may also revolutionize the way atrial fibrillation is diagnosed and treated.

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