key: cord-0780418-hyxj150c
authors: Kancharla, Krishna; Mark Estes, N. A.
title: Mobile Cardiac Monitoring During the COVID‐19 Pandemic: Necessity is the Mother of Invention
date: 2020-08-27
journal: J Cardiovasc Electrophysiol
DOI: 10.1111/jce.14726
sha: 21ec2bdf427ec343511209354eb3cc222e25ee42
doc_id: 780418
cord_uid: hyxj150c

Since the development, commercialization, and initial clinical use of electrocardiographic monitoring in the early 1950s, the technology has evolved currently allowing real‐time telemetry‐based monitoring of multiple physiologic parameters via wireless connectivity on inpatients.(1) This article is protected by copyright. All rights reserved.

electrocardiographic monitoring in the early 1950s, the technology has evolved currently allowing real-time telemetry-based monitoring of multiple physiologic parameters via wireless connectivity on inpatients. 1 Ambulatory electrocardiographic monitoring has been limited by memory, the necessity of hardwiring leads to skin electrodes, and other technologic restraints. 2 Historically only short term (24-48 hours) continuous monitoring (Holter) or longer term intermittent (triggered) monitoring with event or loop recorders have been possible on outpatients. 2 Over the last decade novel leadless monitoring devices allowing extended ambulatory monitoring have been developed. 3 They have emerged as an important diagnostic tool for detection of occult atrial fibrillation, risk stratification, or evaluation of arrhythmias symptoms including palpitations and syncope. 3 With the demands for cardiac monitoring exceeding the capacity of many hospital telemetry units, innovative approaches were essential to continuously assess the rhythm and electrocardiographic intervals during the COVID-19 pandemic. 4, 5 Despite the absence of actionable evidence related to safety and efficacy, both hydroxychloroquine and azithromycin were used for COVID-19 positive patients. Because both drugs can prolong the QT interval inpatient monitoring has been recommended. 6, 7 Novel approaches using mobile cardiac monitoring, previously used exclusively for ambulatory monitoring, have emerged as a clinical tool for inpatients based on this need for greater inpatient monitoring capacity during the COVID-19 pandemic. 4, 5 In this issue of the Journal of JCE, Braunstein and colleagues report the results of an observational study using patch-based mobile cardiac telemetry system previously reserved for the outpatient setting. 8 This approach was used to assess rhythm and QT intervals for COVID-19 positive hospitalized patients in a unit not used previously for telemetry while receiving one or more medications with potential for QT prolongation. The patch-based cardiac monitoring technology (Zio Patch AT (iRhythm Technologies Inc., San Francisco, CA, USA) had been approved by the FDA for arrhythmia monitoring in the outpatient setting 8 This system received emergency FDA approval for inpatient monitoring during COVID 19 pandemic. 8 The study reports 82 patients in whom this mobile patch-based technology was used on an inpatient basis for monitoring of arrhythmias and QT intervals. 8 Thirty-eight percent of patients met the primary outcome, a composite of detection of new arrhythmias and changes in clinical management. New arrhythmias were detected in 29% of patients. QT-interval measurements were feasible in 93% of patients. Among patients who had mobile telemetry strip and 12-lead EKGs on the same day, there was no significant difference between the mobile telemetry strip measurements and the investigator-measured QT-intervals on the 12-lead ECG. 8 The study identified age and heart failure were associated with the primary outcome. Interestingly the study did not find association of arrhythmia to the mortality in this disease condition, but this could be different based on the indication of monitoring. 8 There are previous reports of the feasibility of using a different cardiac monitoring technology during the COVID-19 pandemic. 4, 5 The report in this issue of JCE confirms these and extends arrhythmia and QT monitoring with a different patch based technology. 8 As an observational study there are inherent limitations, including absence of a control group using conventional monitoring. 8 Other limitations include a relatively small number of patients in a single healthcare system and lack of enrollment of consecutive patients. 8 Despite these limitations, the observations that this approach performed well for the detection of arrhythmias, monitoring the QT interval, and inform patient management are valid. In this respect, the report advances the emerging role of a monitoring technology previously reserved for the outpatient setting in management of hospitalized patients. 4, 5, 8 It is evident also that patch-based wireless technology also represents an approach to reduce infection risk to healthcare providers and patients by limiting direct patient contact while preserving personal protective equipment. Mobile cardiac monitoring could potentially be extended to patients needing cardiac monitoring in the setting of other acute illnesses thereby limiting risk of staff exposure and spread of infections to immunocompromised patients. The study estimates 595 minutes of reduced staff viral exposure time during 75 patient care days, by replacing EKGs related to QT monitoring. 8 Patch-based mobile telemetry eliminates the need for a dedicated telemetry unit and staff thereby increasing the availability of patient care locations. 8 This approach might be extended to lower-risk patients hospitalized with cardiac conditions such as those in chest pain centers, syncope units, and patients needing antiarrhythmic drug initiations. As noted by the authors, outpatient transition of monitoring is feasible at the time of hospital discharge. 8 Patch-based monitoring might be initiated even before the patient's arrival to the hospital by first responders without the common loss of important data in the transitions of care. Whether this approach can be extended to other clinical settings and improve patient outcomes at a lower cost is one of many questions best answered based on evidence obtained from appropriately designed prospective multicenter trials. These would include randomization in multicenter trials to novel versus conventional monitoring with appropriate clinical outcomes with cost-benefit analyses.

The investigation of this novel approach in this extremely sick patient population during a pandemic is particularly laudable. Notably the primary driving force for this innovative approach, an unmet clinical imperative, reminds us that commonly in clinical medicine necessity is the mother of invention. 9 While raising the possibility multiple other applications, clinicians should remain mindful of many current limitations of this technology and systems of implementation. With a single lead only EKG monitoring limits the assessment of QT intervals in patients with low T wave amplitudes, poor baselines, or rapid arrhythmias such as atrial fibrillation. Further validation of QT interval measurements with patch-based monitoring are essential. Current technology is limited by absence of real-time access to patient's rhythm by onsite care team providing direct care. Systems of remote monitoring inherently have the potential for delays in communication to the onsite caregivers of critical information. Future advances of the technology need to be accompanied by refinements of systems of implementation. The enhanced storage capacity of patch based remote monitoring presents research as well as clinical advantages. These include the use of artificial intelligence to predict and prevent emerging adverse arrhythmic events. 10, 11 The clinical and economic impact of patchbased monitoring merit additional research with comparison of outcomes and cost to conventional monitoring. While this report and other observational studies represent important initial steps, only robust prospective trials can ultimately provide the highest level of evidence for future patient selection, indications and standards for clinical use of this novel approach to monitoring hospitalized patients.

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