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Pocket Echo and Remote Device Management of Structural Heart Disease
Study Questions:
What is the value of the utilization of a suite of mobile health device assessments (mHealth) compared to standard clinical assessment of patients with structural heart disease (SHD)?
Methods:
The study was performed at a single tertiary care center in India, which serves an underserved population. A total of 253 patients with SHD were randomized to standard care (n = 114) or to mHealth clinics (n = 139). The mHealth assessment included a suite of devices and tests including handheld echocardiography, smart phone derived single-lead electrocardiogram, blood pressure and oximetry, smart phone activity monitoring, point-of-service brain natriuretic peptide testing, and a standardized 6-minute walk test. The primary endpoint was the time to referral for interventional or surgical correction of SHD. Secondary endpoints were cardiovascular hospitalization and/or death.
Results:
Mean follow-up averaged 337 ± 116 days. A previously established diagnosis of SHD with or without prior valve procedure was noted, and 46% and 46% of all patients were classified as New York Heart Association (NYHA) functional class II or III. The predominant form of SHD was rheumatic valvular disease. On follow-up, 85 of 253 patients (34%) underwent treatment for valvular heart disease. The treatment rate was similar at 12 months for the two groups; however, the duration from enrollment to primary outcome was shorter with the mHealth group compared to standard care (83 ± 79 days vs. 180 ± 101 days; p < 0.001). The secondary endpoint of hospitalization or death was noted in 15% of the mHealth group versus 28% of the standard care group (p = 0.012). Data available from the mHealth activity monitoring reclassified 30% of patients to a worse NYHA functional class and 6% to a lower class.
Conclusions:
In a resource-limited medical environment, a multifaceted mHealth diagnostic strategy shortens time to referral for definitive therapy in patients with SHD and is associated with improved outcomes.
Perspective:
This is one of several recent studies that have demonstrated the utility of handheld highly portable echocardiographic instruments for limited evaluation in underserved areas and when employed by non-echocardiographers. In addition to handheld echocardiography, this study used a suite of electronic devices, many incorporated into a smart phone, to record and transmit blood pressure data, pulse oximetry, a single lead rhythm strip, and data regarding physical activity. Additionally, an easily employed 6-minute walk test was incorporated. Using this combination of automated and semi-automated data collection as well as assessment of clinical functional status and limited echocardiography, the authors demonstrated shortened time to definitive therapy for patients with a high prevalence of underlying valvular heart disease. An interesting and not fully explained observation is that all patients had a comprehensive transthoracic echocardiogram performed on a full-service instrument, the results of which were available to the standard care and mHealth clinics. For unclear reasons, it appears that the abbreviated handheld echocardiogram performed at the time of the clinic visit had a greater impact on subsequent timing of care than did the report from a full-service platform. It should be emphasized that this study employed not only handheld echocardiography, but a suite of highly portable electronic testing devices, which could easily be employed in remote underserved areas, further enhancing the value of this type of management.
Keywords: Ambulatory Care, Blood Pressure, Cardiac Surgical Procedures, Diagnostic Imaging, Echocardiography, Electrocardiography, Exercise, Heart Failure, Heart Valve Diseases, Mobile Health Units, Oximetry, Peptides, Referral and Consultation, Telemedicine, Tertiary Care Centers
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