Personalized Health Systems for Cardiovascular Disease

Personalized Health Systems for Cardiovascular Disease is intended for researchers, developers, and designers in the field of p-health, with a specific focus on management of cardiovascular diseases. Biomedical engineers will benefit from coverage of sensors, data transmission, signal processing, data analysis, home and mobile applications, standards, and all other subject matters developed in this book in order to provide an integrated view of the different and multidisciplinary problems related to p-health systems. However, many chapters will also be interesting to physicians and other professionals who operate in the health domain. Students, MS and PhD level, mainly in technical universities, but also in medical schools, will find in this book a complete view of the manifold aspects of p-health, including technical problems related to sensors and software, to automatic evaluation and correct interpretation of the data, and also some legal and regulatory aspects. This book mainly focuses on the development of technology used by people and patients in the management of their own health.

New wearable and implantable devices allow a continuous monitoring of chronic patients, with a direct involvement of clinical centers and physicians. Also, healthy people are more and more interested in keeping their own wellness under control, by adopting healthy lifestyles and identifying any early sign of risk. This is leading to personalized solutions via systems which are tailored to a specific patient/person and her/ his needs. However, many problems are still open when it comes to p-health systems. Which sensors and parameters should be used? Which software and analysis? When and how? How do you design an effective management plan for chronic pathologies such as cardiovascular diseases? What is useful feedback for the patient or for the clinician? And finally, what are the limits of this approach? What is the view of physicians? The purpose of this book is to provide, from a technical point of view, a complete description of most of the elements which are part of such systems, including the sensors and the hardware, the signal processing and data management procedures, the classification and stratification models, the standards and the regulations, focusing on the state of the art and identifying the new directions for innovative solutions. In this book, readers will find the fundamental elements that must be taken into account when developing devices and systems in the field of p-health.

• Provides an integrated approach to design and development of p-health systems which involves sensors, analysis software, user interfaces, data modeling, and interpretation.
• Covers standards and regulations on data privacy and security, plus safe design of devices.
• Supported by case studies discussing development of actual solutions in the biomedical engineering field.

• Language: English
• Publisher: Academic Press
• Release date: Jan 21, 2022
• ISBN: 9780128190661

Book preview

Chapter 1

Telemonitoring applications in cardiology

James Milner¹ and Lino Gonçalves¹, ²,    ¹Department of Cardiology, Coimbra University Hospital Centre, Coimbra, Portugal,    ²ICBR Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, Universidade de Coimbra, Coimbra, Portugal

Abstract

Healthcare systems are facing increasing difficulties and challenges. Population aging is a global reality, particularly in Western nations, where lower birth rates have progressively led to an inversion of the age pyramid in such a way that for the first time in history the number of people over 65 years old will be higher than the number of children under 5 years of age. Globally, the number of people over 60 years is expected to triple by 2100. The increase in life expectancy is also determinant in these changes, and advances of public health, medicine, and economic development over diseases that limit life expectancy mean that many pathological conditions are now chronic, manageable diseases. The increasing number of older patients with more comorbidities presents a tremendous challenge to governments and healthcare systems. These patients require regular and continuous monitoring by different healthcare providers, in many cases for the duration of their lives. Healthcare systems that are organized around a model focused on the management of acute episodes are clearly insufficient to satisfy the needs of these patients. A suggested new model involves the decentralization of healthcare to the patient’s home, with a progressively bigger involvement of the patient, the family, and community structures in the management of the patient’s conditions, as part of the solution to this problem. In this setting, the use of technologies, devices, and telemedicine systems that help the patient and healthcare providers in monitoring and managing the patient’s health state are becoming essential. The use of these technologies may also play a significant role in reducing healthcare-associated expenses, which are becoming a significant burden in modern societies. This is particularly significant regarding cardiovascular diseases, since these account for close to one-third of all deaths in the United States and are responsible for more deaths than all forms of cancer.

Keywords

Telemonitoring; cardiology; life expectancy; public health; healthcare systems; decentralization

1.1 Background

Healthcare systems are facing increasing difficulties and challenges. Population aging is a global reality, particularly in Western nations, where lower birth rates have progressively led to an inversion of the age pyramid, in such a way that for the first time in history the number of people over 65 years old will be higher than the number of children under 5 years of age (Why Population Aging Matters: A Global Perspective, 2017). Globally, the number of people over 60 years is expected to triple by 2100 (World Population Prospects: Key findings & advance tables, 2017). The increase in life expectancy is also determinant in these changes, and advances of public health, medicine, and economic development over diseases that limit life expectancy mean that many pathological conditions are now chronic, manageable diseases. The increasing number of older patients with more comorbidities presents a tremendous challenge to governments and healthcare systems. These patients require regular and continuous monitoring by different healthcare providers, in many cases for the duration of their lives. Healthcare systems that are organized around a model focused on the management of acute episodes are clearly insufficient to satisfy the needs of these patients. A suggested new model involves the decentralization of healthcare to the patient’s home, with a progressively bigger involvement of the patient, the family, and community structures in the management of the patient’s conditions, as part of the solution to this problem. In this setting, the use of technologies, devices, and telemedicine systems that help the patient and healthcare providers in monitoring and managing the patient’s health state are becoming essential. The use of these technologies may also play a significant role in reducing healthcare-associated expenses, which are becoming a significant burden in modern societies. This is particularly significant regarding cardiovascular diseases, since these account for close to one-third of all deaths in the United States and are responsible for more deaths than all forms of cancer (Benjamin et al., 2019).

Broadly, telemedicine is a unique entity that involves patient management based on telecommunications. Telemedicine applications in cardiology have witnessed a significant growth in the past few years and are expected to become a staple in clinical practice. The need for and implementation of telemedicine strategies was further escalated by the 2020 COVID-19 pandemic, which placed a significant strain on healthcare structures and forced physicians and organizations to reorganize and to implement new strategies in order to continue to deliver high-quality healthcare in outpatient settings without compromising patient and healthcare provider safety.

Uses of telemedicine in cardiovascular medicine are varied and encompass an array of different applications, including remote interactions between patient and healthcare provider by telephone or videoconference, remote transmission of information derived from home measurements (which can include self-reported symptoms and measures of simple parameters such as blood pressure, heart rate, or weight), the use of web-based or smartphone apps, and activity-tracking devices that have gained significant popularity in the past few years, which has even led the U.S. Food and Drug Administration to approve the Apple Watch as a medical device for atrial fibrillation diagnosis, following publication from the Apple Heart Study investigators in 2019 (Perez et al., 2019). Other telemedicine applications include remote monitoring of cardiac implantable electronic devices, such as implantable loop recorders, pacemakers, and implantable defibrillator-cardioverters. Telemedicine applications aim to improve the healthcare provided to patients, their quality of life, and even hard outcomes such as hospitalization rates and all-cause mortality. We will address some of these applications in this chapter.

1.2 Telemonitoring applications in cardiology

1.2.1 Remote Monitoring for CIED

Remote home monitoring of cardiac implantable electronic devices (CIED) began over a decade ago. Since then, extensive evidence has been collected regarding their usefulness in early detection of significant arrhythmias, as well as maintaining a continuous surveillance of the system’s performance, allowing for early detection of generator battery depletion and lead dysfunction. Beyond their obvious clinical significance, the implementation of remote monitoring of CIED into everyday clinical practice has contributed to a better optimization of healthcare resources.

Atrial fibrillation (AF), the most common arrhythmia in clinical practice (Nieuwlaat et al., 2005), is often asymptomatic and may remain undetected by patients. Early diagnosis of AF is of utmost importance, since it is the most common arrhythmia in clinical practice, with an incidence that increases with age (Zulkifly, Lip, & Lane, 2018). This is particularly significant because AF patients are frequently hospitalized and have a fivefold increase in the risk of stroke (Nieuwlaat et al., 2005; Zulkifly et al., 2018). European Registries showed that up to 50% of patients with AF are not actually treated (Nieuwlaat et al., 2005), which is unsurprising, since most patients with AF are asymptomatic and may receive a diagnosis only following a thrombotic complication. Early detection is particularly important in patients carrying CIED, since they have an even higher prevalence of AF than the rest of the population.

Several studies have concluded on the usefulness of CIED for the documentation of episodes of AF. CIED may emit alerts of many natures, and AF accounts for over 50% of the alerts emitted by remote home-monitoring systems (Lazarus, 2007). The Asymptomatic Atrial Fibrillation and Stroke Evaluation in Pacemaker Patients and the Atrial Fibrillation Reduction Atrial Pacing Trial concluded that detection by CIED of these arrhythmias was associated with an increased risk of thromboembolic events (including ischemic stroke) (Hohnloser et al., 2006). Consequently, it is easy to understand that remote, automatic monitoring may help in detecting these arrhythmias at an earlier stage, allowing for a timely therapeutic adjustment (including oral anticoagulation) in order to prevent long-term complications. In fact, home monitoring has been showed to reduce stroke risk by 9%–18% when compared to conventional regular, presential scheduled visiting (Ricci, Morichelli, Gargaro, Laudadio, & Santini, 2009). Furthermore, the Cardiovascular Outcome for People Using Anticoagulation Strategies trial showed that remote monitoring of CIED reduced hospital admissions due to stroke or atrial arrhythmias (Mabo et al.,