Giulia Dellegrottaglie

Telecardiology improves quality of diagnosis and reduces delay to treatment in elderly patients with acute myocardial infarction and atypical presentation.

Aim To assess whether telemedicine technology applied to public emergency healthcare system improves overall quality of home diagnosis in case of acute myocardial infarction among elderly patients, often characterized by higher rates of atypical presentation. Methods About 27 841 patients from Apulia (Italy) who called public emergency healthcare number ‘118’ underwent home ECG evaluation. Data were transmitted with a mobile telephone support to a telecardiology ‘hub’ active continuously (24/7). Data from elderly patients (>70 years) were compared with younger ones. Results Thirty-nine percent of patients complained of chest (or epigastric) pain; ST elevation acute myocardial infarction (STEMI) was diagnosed in 1.9% of patients enrolled; 50.2% of patients with STEMI were above 70 years of age. Among STEMI patients older than 70 years, atypical presentation was detected in 32% [95% confidence interval (CI): 26.8–38.1] of patients (vs. 11% 95% CI: 7.8–15.5, P<0.001). Rate of atypical STEMI presentation, immediately diagnosed, thanks to telecardiology, rose up from 9.2% (95% CI: 5–17%) in the class of age 60–69 years to 25.6% (95% CI: 20–35%) in the class of age 70–79 years, to 35.2% (95% CI: 26–45%) in the class 80–89, and to 46.1% (95% CI: 26–67%) in the class greater than 89 years of age (P<0.01 in all cases). Number needed to treat (to avoid a single missed STEMI diagnosis) was 9.4 (95% CI: 6.4–12.9) for patients younger than 70 years versus 3.1 (95% CI: 2.6–3.7) among those older than 70 years (P<0.001).

Telecardiology applied to a region-wide public emergency health-care service.

Aim To assess feasibility and reliability of telecardiology technologies applied to a region-wide public emergency health-care service. Methods About 27,841 patients from all over Apulia (19.362 km2, 4 million inhabitants) were referred from October 2004 until April 2006 to public emergency health-care number “118” and underwent ECG evaluation according to a previously fixed inclusion protocol. Data recorded were transmitted with mobile telephone support to a telecardiology “hub” active 24-h a day. Hospitalization or further examinations were arranged by emergency physicians on the basis of ECG diagnosis and consultation. Results Thirty-nine percent of patients complained of chest pain (CP) or epigastric pain, 26% loss of consciousness, 10% breathlessness, and 7% palpitations. Atrial fibrillation (AF) was diagnosed in 11.68% of patients and ST-elevation acute myocardial infarction (STEMI) in 1.91%. Among patients with CP, ECG showed STEMI in only 3.84% of cases, theoretically eligible for fibrinolysis or primary PCI; patients with STEMI complained of CP in 78.94% of cases. Of the patients, 65.28% with STEMI were from small towns without coronary care units, thus benefiting from an immediate pre-hospital diagnosis. Among patients with palpitations, only 10.27% of subjects showed ECG signs of supra-ventricular tachycardia and 25.18% of AF; other subjects avoided further improper hospitalization or emergency department monitoring. Conclusions This first region-wide leading experience shows the feasibility and reliability of telecardiology applied to a public emergency health-care service. Telemedicine protocols would probably be useful in lowering the number of improper hospitalizations and shortening delay in the diagnosis process of some heart diseases.

Atrial fibrillation with symptoms other than palpitations: incremental diagnostic sensitivity with at-home tele-cardiology assessment for emergency medical service

Background: Clinical presentation of atrial fibrillation (AF) is usually represented by palpitations; nevertheless, atypical presentation of AF with symptoms other than palpitations may be not uncommon in elderly patients. This study therefore aimed to evaluate incremental diagnostic value of tele-medicine at-home assessment in patients who called emergency medical service (EMS). Methods: A total of 27,841 consecutive EMS patients referred for suspected heart disease underwent ECG assessment with a mobile ECG-recorder device. ECGs were transmitted with mobile-phone support to a tele-cardiology ‘hub’ active 24/7 where a cardiologist read the ECGs. Rate of prevalence of AF, age of patients, and symptoms were analysed. Results: AF was diagnosed in 11.67% of patients who underwent ECG examination. Typical symptoms were complained by 6.56% of whole patients, only 14.05% of patients with AF: rate of subjects with AF and typical symptoms significantly decreased with age (<65 years 29.58%, 65–75 years 17.06%, >75 years 10.35%, p < 0.001). Number needed to diagnose an AF with atypical presentation (number needed to treat) decreased from 45 (<65 years) to 9 (65–75 years) and 5 (>75 years) (p < 0.001). Tele-cardiology support increased the rate of at-home diagnosis of AF from two-fold (in 40-year-olds) up to four-fold (60-year-olds) and seven-fold (70-year-olds). Conclusions: AF with symptoms other than palpitations is a common finding in elderly EMS patients. Tele-cardiology support improves the sensitivity of diagnosis of AF in elderly EMS patients and is useful in at-home identification of subjects with AF and atypical presentation.

Prehospital telemedicine electrocardiogram triage for a regional public emergency medical service: is it worth it? A preliminary cost analysis.

Telemedicine has been shown to improve quality of health‐care delivery in several fields of medicine; its cost‐effectiveness, however, is still a matter of debate.

Pre-hospital electrocardiogram triage with tele-cardiology support is associated with shorter time-to-balloon and higher rates of timely reperfusion even in rural areas: data from the Bari- Barletta/Andria/Trani public emergency medical service 118 registry on primary angioplasty in ST-elevation myocardial infarction

Background: We report the preliminary data from a regional registry on ST-elevation myocardial infarction (STEMI) patients treated with primary angioplasty in Apulia, Italy; the region is covered by a single public health-care service, a single public emergency medical service (EMS), and a single tele-medicine service provider. Methods: Two hundred and ninety-seven consecutive patients with STEMI transferred by regional free public EMS 1-1-8 for primary-PCI were enrolled in the study; 123 underwent pre-hospital electrocardiograms (ECGs) triage by tele-cardiology support and directly referred for primary-PCI, those remaining were just transferred by 1-1-8 ambulances for primary percutaneous coronary intervention (PCI) (diagnosis not based on tele-medicine ECG; already hospitalised patients, emergency-room without tele-medicine support). Time from first ECG diagnostic for STEMI to balloon was recorded; a time-to-balloon <1 h was considered as optimal and patients as timely treated. Results: Mean time-to-balloon with pre-hospital triage and tele-cardiology ECG was significantly shorter (0:41±0:17 vs 1:34±1:11 h, p<0.001, –0:53 h, –56%) and rates of patients timely treated higher (85% vs 35%, p<0.001, +141%), both in patients from the ‘inner’ zone closer to PCI catheterisation laboratories (0:34±0:13 vs 0:54±0:30 h, p<0.001; 96% vs 77%, p<0.01, +30%) and in the ‘outer’ zone (0:52±0:17 vs 1:41±1:14 h, p<0.001; 69% vs 29%, p<0.001, +138%). Results remained significant even after multivariable analysis (odds ratio for time-to-balloon 0.71, 95% confidence interval (CI) 0.63–0.80, p<0.001; 1.39, 95% CI 1.25–1.55, p<0.001, for timely primary-PCI). Conclusions: Pre-hospital triage with tele-cardiology ECG in an EMS registry from an area with more than one and a half million inhabitants was associated with shorter time-to-balloon and higher rates of timely treated patients, even in ‘rural’ areas.

Rationale and design for a cardiovascular screening and prevention study with tele-cardiology in Mediterranean Italy: The CAPITAL study (CArdiovascular Prevention wIth Telecardiology in ApuLia)

thenewgroup is the increase inmorbidity, factors thathavebeen seen to increase perioperative mortality [2–4], with an objective increase in Group Bs logistic EuroSCORE, despite a significant decrease in periinterventional mortality and complications. This reduction in mortality is observed not only in patients treated with TAVI [1,5], but also of patients who undergo surgery. This morbi-mortality reduction in comparison of the exclusively surgical patients of both groups (A vs. B1) can be due to the profile changes; there are a lower incidence of mitral insufficiency, COPD, patientswith EFb40%, a significant reduction of the number of 19 mmaortic prosthesis implanted (a factor associated with low output and a high post operative transvalvular gradient) [6], a lower percentage of patients with high NYHA functional class and also factors that are not assessed by the EuroSCORE [7]. In conclusion, the TAVI in our hospital has allowed us to increase the number of patients treated for severe aortic stenosis, at the expense of high surgical risk patients, modifying the profile of those undergoing valve replacement surgery. Despite this, there has been a significant reduction in the global mortality of patients treated for AS. None declared. The authors thank Dr. Rodríguez-Bailón, of the Echocardiography Unit in Hospital Virgen de la Victoria, for her essential collaboration. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [8].

Exercise training and obesity in Italian children directly assessed by primary school teachers with tele-cardiology support: a pilot experience.

Society of Cardiovascular Computed Tomography. J Am Coll Cardiol 2007;49:378–402. [5] Sarwar A, Shaw LJ, Shapiro MD, et al. Diagnostic and prognostic value of absence of coronary artery calcification. JACC Cardiovasc Imaging 2009;2:675–88. [6] Mieres JH, Makaryus AN, Redberg RF, Shaw LJ. Noninvasive cardiac imaging. Am Fam Physician 2007;75:1219–28. [7] Nicoll R, Henein MY. Calcific cardiac disease: a comprehensive investigation into its true nature. Int J Cardiol 2010;145:599–600. [8] Rennenberg RJ, Kessels AG, Schurgers LJ, van Engelshoven JM, de Leeuw PW, Kroon AA. Vascular calcifications as a marker of increased cardiovascular risk: a metaanalysis. Vasc Health Risk Manag 2009;5:185–97. [9] NiemanK, Galema TW, Neefjes LA, et al. Comparison of the value of coronary calcium detection to computed tomographic angiography and exercise testing in patients with chest pain. Am J Cardiol 2009;104:1499–504. [10] Bartel AG, Behar VS, Peter RH, Orgain ES, Kong Y. Graded exercise stress tests in angiographically documented coronary artery disease. Circulation 1974;49:348–56.

The CAPITAL study (CArdiovascular Prevention wIth Telecardiology in ApuLia): preliminary results.

Background The CArdiovascular Prevention wIth Telecardiology in ApuLia (CAPITAL) study aimed to investigate the prevalence of cardiovascular risk factors, the status of cardiovascular prevention, and the compliance to international scientific societies’ guidelines on cardiovascular prevention in a Mediterranean region. Methods The CAPITAL study was based on the assessment of cardiovascular risk and compliance to guidelines on cardiovascular prevention, and on an electrocardiogram screening with remote telemedicine support performed in pharmacies of Apulia (Italy); the study was expected to enroll 10 000 consecutive patients accessing their usual pharmacy. Results In the first 1000 patients enrolled, 16% were smokers, 9% diabetic, 26% hypertensive, 43% overweight, and 23% obese; 37% of the patients treated with antihypertensive drugs did not achieve the target levels, regardless of the number of antihypertensive drugs given, and 60% of subjects treated with lipid-lowering drugs did not achieve the target levels. Twenty-two per cent of the patients subjected to the lipid-lowering drugs did not check their cholesterol levels in the past 12 months, and 21% of those taking antihypertensive drugs did not check their blood pressure levels. Left ventricular hypertrophy was detected at electrocardiogram examination in 3.4% of the cases, and in 2.6% of the patients with unknown hypertension: 52% of the hypertensive patients were not checked with an electrocardiogram in the past 12 months, 44% of the diabetic patients, and 44% of subjects treated with lipid-lowering drugs. Conclusions The awareness, therapy, and control of cardiovascular risk factors in a Mediterranean real-world population are unsatisfactory. There is a large scope of an improvement in the control of cardiovascular risk factors. Telemedicine support and pharmacy-based assessment may be helpful in implementing strategies aimed at the improvement of cardiovascular prevention.

2014 Failed Influenza Vaccination Winter Campaign: Impact on Emergency Medical Service Calls Assessed by Telemedicine.

To the Editor: Increased workloads for emergency medical service (eMs) and numbers of patients accessing emergency Departments and hospitalized for cardiorespiratory complications are observed during influenza epidemics. Widespread complications of influenza epidemics, however, are actually limited by the wide use of vaccination, warmly recommended in subjects at risk for severe cardio-respiratory complications, such as those with history of cardiovascular disease or chronic pulmonary disease, or elderly subjects.1 In the fall of 2014 fall, just before a scheduled influenza vaccination campaign in Italy, some cases of unexpected deaths apparently following influenza vaccination were reported by Italian newspapers and television networks, with huge ripples on social media.2 Fears were further amplified by imprudent initiatives adopted by magistrates and healthcare surveillance authorities, which seized several lots of influenza vaccines for careful examination, suspecting possible vaccine toxicity.3,4 several weeks of terrorism rumors and frightening newspaper titles were therefore followed by a 15% to 30% decrease in the total amount of vaccination coverage against the 2014–2015 influenza season.5,6 Vaccine coverage in Apulia, according to available estimates, did not exceed 50% even in high-risk categories.7 1 2 3 4 5 6 7 8 9 week 250 300 350 400 450