Effect of Smartphone-Enabled Health Monitoring Devices vs Regular Follow-up on Blood Pressure Control Among Patients After Myocardial Infarction: A Randomized Clinical Trial

ESC working group on e-cardiology position paper: use of commercially available wearable technology for heart rate and activity tracking in primary and secondary cardiovascular prevention-in collaboration with the European Heart Rhythm Association, European Association of Preventive Cardiology, Association of Cardiovascular Nursing and Allied Professionals, Patient Forum, and the Digital Health Committee

Commercially available health technologies such as smartphones and smartwatches, activity trackers and eHealth applications, commonly referred to as wearables, are increasingly available and used both in the leisure and healthcare sector for pulse and fitness/activity tracking. The aim of the Position Paper is to identify specific barriers and knowledge gaps for the use of wearables, in particular for heart rate (HR) and activity tracking, in clinical cardiovascular healthcare to support their implementation into clinical care. The widespread use of HR and fitness tracking technologies provides unparalleled opportunities for capturing physiological information from large populations in the community, which has previously only been available in patient populations in the setting of healthcare provision. The availability of low-cost and high-volume physiological data from the community also provides unique challenges. While the number of patients meeting healthcare providers with data from wearables is rapidly growing, there are at present no clinical guidelines on how and when to use data from wearables in primary and secondary prevention. Technical aspects of HR tracking especially during activity need to be further validated. How to analyse, translate, and interpret large datasets of information into clinically applicable recommendations needs further consideration. While the current users of wearable technologies tend to be young, healthy and in the higher sociodemographic strata, wearables could potentially have a greater utility in the elderly and higher-risk population. Wearables may also provide a benefit through increased health awareness, democratization of health data and patient engagement. Use of continuous monitoring may provide opportunities for detection of risk factors and disease development earlier in the causal pathway, which may provide novel applications in both prevention and clinical research. However, wearables may also have potential adverse consequences due to unintended modification of behaviour, uncertain use and interpretation of large physiological data, a possible increase in social inequality due to differential access and technological literacy, challenges with regulatory bodies and privacy issues. In the present position paper, current applications as well as specific barriers and gaps in knowledge are identified and discussed in order to support the implementation of wearable technologies from gadget-ology into clinical cardiology.

Wearable Sensing and Telehealth Technology with Potential Applications in the Coronavirus Pandemic

Coronavirus disease 2019 (COVID-19) has emerged as a pandemic with serious clinical manifestations including death. A pandemic at the large-scale like COVID-19 places extraordinary demands on the world's health systems, dramatically devastates vulnerable populations, and critically threatens the global communities in an unprecedented way. While tremendous efforts at the frontline are placed on detecting the virus, providing treatments and developing vaccines, it is also critically important to examine the technologies and systems for tackling disease emergence, arresting its spread and especially the strategy for diseases prevention. The objective of this article is to review enabling technologies and systems with various application scenarios for handling the COVID-19 crisis. The article will focus specifically on 1) wearable devices suitable for monitoring the populations at risk and those in quarantine, both for evaluating the health status of caregivers and management personnel, and for facilitating triage processes for admission to hospitals; 2) unobtrusive sensing systems for detecting the disease and for monitoring patients with relatively mild symptoms whose clinical situation could suddenly worsen in improvised hospitals; and 3) telehealth technologies for the remote monitoring and diagnosis of COVID-19 and related diseases. Finally, further challenges and opportunities for future directions of development are highlighted.

Early blood pressure assessment after acute myocardial infarction: Insights using digital health technology

Objective

There is rising interest in digital health in preventive cardiology, particularly for blood pressure (BP) management. In a digital health study of early BP assessment following acute myocardial infarction (AMI), we sought to examine feasibility and the (1) proportion of post-AMI patients with controlled BP and hypotension, and (2) association between prior cardiovascular disease (CVD) and BP post-AMI.

Methods

In this substudy of the parent Myocardial infarction, COmbined-device, Recovery Enhancement (MiCORE) study, type 1 AMI patients were enrolled between October 2017 and April 2019. Participants self-monitored their BP through 30 days after hospital discharge using an FDA-approved wireless BP monitor connected with a smartphone application. Linear mixed-effects models assessed the association between prior CVD and BP trajectory post-discharge, adjusting for antihypertensive medications and a propensity score inclusive of CVD risk factors.

Results

Sixty-eight AMI patients (mean age 58 ​± ​10 years, 75% male, 68% white race, 68% history of hypertension, 24% prior CVD) provided 2638 measurements over 30 days. The percentage of BP control <130/80 ​mmHg was 59.6% (95% CI: 54.3–64.9%) and <140/90 ​mmHg was 83.7% (95% CI: 80.3–87.2%). The percentage of systolic BP ​<90 ​mmHg was 1.1% (95% CI: 0.17–2.0%) and the percentage of diastolic BP ​<60 ​mmHg was 3.9% (95% CI: 2.6–5.2%). Prior CVD was associated with 12.2 ​mmHg higher mean daily systolic BP during admission (95% CI: 3.5–20.9 ​mmHg), which persisted over follow-up. There was no association between prior CVD and diastolic BP.

Conclusion

The digital health program was feasible and ~40% of post-AMI patients who engaged in it had uncontrolled BP according to recent guideline cutpoints, while hypotension occurred rarely. The gap in BP control was especially large in patients in whom AMI represented recurrent CVD. These data suggest an opportunity for more aggressive secondary prevention early after MI as care models integrate digital health.

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Digital health reveals home blood pressure trends during early recovery after an event.

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~40% of early MI patients had mean daily blood pressure exceeding the guideline goal of <130/80 ​mmHg.

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Hypotension occurred rarely over 30 days post-MI.

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The gap in BP control was especially large in patients in whom MI represented recurrent CVD.

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There is opportunity for more aggressive secondary prevention early after MI as care models integrate digital health.

Telemonitoring for Patients With COVID-19: Recommendations for Design and Implementation

Despite significant efforts, the COVID-19 pandemic has put enormous pressure on health care systems around the world, threatening the quality of patient care. Telemonitoring offers the opportunity to carefully monitor patients with a confirmed or suspected case of COVID-19 from home and allows for the timely identification of worsening symptoms. Additionally, it may decrease the number of hospital visits and admissions, thereby reducing the use of scarce resources, optimizing health care capacity, and minimizing the risk of viral transmission. In this paper, we present a COVID-19 telemonitoring care pathway developed at a tertiary care hospital in the Netherlands, which combined the monitoring of vital parameters with video consultations for adequate clinical assessment. Additionally, we report a series of medical, scientific, organizational, and ethical recommendations that may be used as a guide for the design and implementation of telemonitoring pathways for COVID-19 and other diseases worldwide.

Paradigm Shifts in Cardiac Care: Lessons Learned From COVID-19 at a Large New York Health System

The coronavirus disease-2019 (COVID-19) pandemic has overwhelmed healthcare systems around the world, resulting in morbidity, mortality, and a dramatic economic downturn In the United States. Urgent responses to the pandemic halted routine hospital workflow in an effort to increase hospital capacity, maintain staffing, and ration protective gear. Most notably, New York saw the largest surge of COVID-19 cases nationwide. Healthcare personnel and physician leaders at Northwell Health, the largest healthcare system in New York, have worked together to successfully implement operational changes resulting in a paradigm shift in cardiac care delivery. In this manuscript, we detail specific protocol adjustments made in our cardiology department, cardiology service line, and healthcare system in the face of the COVID-19 pandemic. We discuss the sustainability of this shift moving forward and the opportunity to optimize care for cardiovascular patients in the post COVID-19 era.

Contemporary and Future Concepts on Hypertension in African Americans: COVID-19 and Beyond

Background

Cardiovascular disease related mortality is the leading cause of death in the United States, with hypertension being the most prevalent and potent risk factor. For decades hypertension has disproportionately affected African Americans, who also have a higher burden of associated comorbidities including diabetes and heart failure.

Methods

Current literature including guideline reports and newer studies on hypertension in African Americans in PubMed were reviewed. We also reviewed newer publications on the relationship between COVID-19 and cardiovascular disease.

Findings

While APOL1 has been theorized in the epidemiology of hypertension, the increased prevalence and associated risks are primarily due to environmental and lifestyle factors. These factors include poor diet, adverse lifestyle, and social determinants. Hypertension control can be achieved by lifestyle modifications such as low sodium diet, weight loss, and adequate physical activity. When lifestyle modifications alone do not adequately control hypertension, a common occurrence among African Americans who suffer with greater prevalence of resistant hypertension, pharmacological intervention is indicated. The efficacy of renal denervation, and the use of sodium-glucose cotransporter 2 and aminopeptidase A inhibitors, have been studied for treatment of resistant hypertension. Furthermore, the recent COVID-19 crisis has been particularly devastating among African Americans who demonstrate increased incidence and poorer health outcomes related to the disease.

Conclusion

The disparities in outcomes, which are largely attributable to a greater prevalence of comorbidities such as hypertension and obesity, in addition to adverse environmental and socioeconomic factors, highlight the necessity of specialized clinical approaches and programs for African Americans to address longstanding barriers to equitable care.

State-of-the-Art review: Hypertension practice guidelines in the era of COVID-19

The global burden of hypertension (HTN) is immense and increasing. In fact, HTN is the leading risk factor for adverse cardiovascular disease outcomes. Due to the critical significance and increasing prevalence of the disease, several national and international societies have recently updated their guidelines for the diagnosis and treatment of HTN. In consideration of the COVID-19 pandemic, this report provides clinicians with the best strategies to prevent HTN, manage the acute and long-term cardiac complications of HTN, and provide the best evidence-based care to patients in an ever-changing healthcare environment. The overarching goal of the various HTN guidelines is to provide easily accessible information to healthcare providers and public health officials, which is key for optimal clinical practice. However, the COVID-19 pandemic has challenged the ability to provide safe care to the most vulnerable hypertensive populations throughout the world. Therefore, this review compares the most recent guidelines of the 2017 American College of Cardiology/American Heart Association and multiple U.S. societies, the 2018 European Society of Cardiology/European Society of Hypertension, the 2019 National Institute for Care and Health Excellence, and the 2020 International Society of Hypertension. While a partial emphasis is placed on the management of HTN in the midst of COVID-19, this review will summarize current concepts and emerging data from the listed HTN guidelines on the diagnosis, monitoring, management, and evidence-based treatments in adults.