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Authors

Paweł Balsam, MD, PhD

1st Chair and Department of Cardiology, Medical University of Warsaw,
Warsaw, Poland

Prof. Maciej Banach, MD, PhD, FESC, FAHA

Department of Hypertension, Chair of Nephrology and Hypertension,

Medical University of Lodz, Lodz, Poland;
Polish Mother’s Memorial Hospital Research Institute (PMMHRI),
Lodz, Poland;

Cardiovascular Research Centre, University of Zielona Góra,
Zielona Góra, Poland

Monika Gawałko, MD

1st Chair and Department of Cardiology, Medical University of Warsaw,
Warsaw, Poland

Renata Główczyńska, MD, PhD

1st Chair and Department of Cardiology, Medical University of Warsaw,
Warsaw, Poland

Robert Irzmański, MD, PhD

Department of Internal Medicine and Cardiac Rehabilitation,
Medical University of Lodz, Lodz, Poland

Prof. Zbigniew Kalarus, MD, PhD

DMS in Zabrze, Medical University of Silesia, Katowice, Poland;

Department of Cardiology, Silesian Center for Heart Diseases,
Zabrze, Poland

Joanna Kapusta, PhD

Department of Internal Medicine and Cardiac Rehabilitation,
Medical University of Lodz, Lodz, Poland

Univ.-Prof. Dr. med. Friedrich Koehler, FESC

Charité – Universitätsmedizin Berlin,

Head of the Centre for Cardiovascular Telemedicine,

Charité-Platz 1, D -10117 Berlin, Germany

Dr. Kerstin Koehler, MD

Senior Consultant, Charité – Universitätsmedizin Berlin,

Centre for Cardiovascular Telemedicine,

Charité-Platz 1, D -10117 Berlin, Germany

Monika Kozieł, MD, PhD

1st Department of Cardiology, Silesian Centre for Heart Diseases,
Zabrze, Poland

Paweł Krzesiński, MD, PhD

Associate Professor of Military Institute of Medicine, Department
of Cardiology and Internal Diseases, Military Institute of Medicine,
Warsaw, Poland

Anna Mierzyńska, PhD HSc

Department of Rehabilitation, Centre of Postgraduate Medical
Education, Warsaw, Poland;

Department of Cardiac Surgery, Military Institute of Medicine,
Warsaw, Poland

Prof. Grzegorz Opolski, MD, PhD, FESC

1st Department of Cardiology, Medical University of Warsaw,
Warsaw, Poland

Piotr Orzechowski, MD

Telecardiology Center, Cardinal Stefan Wyszynski National Institute
of Cardiology, Warsaw, Poland

Ewa Piotrowicz, MD, PhD, FESC

Telecardiology Center, Cardinal Stefan Wyszynski National Institute
of Cardiology, Warsaw, Poland

Katarzyna Piotrowicz, MD, PhD

MS Head of Cardiac Rehabilitation Department Military Institute
of Medicine, Warsaw, Poland

Prof. Ryszard Piotrowicz, MD, PhD

Cardinal Stefan Wyszynski National Institute of Cardiology,
Warsaw, Poland;
College of Rehabilitation, Warsaw, Poland

Sławomir Pluta, MD, PhD

1st Department of Cardiology, Silesian Center for Heart Diseases,
Zabrze, Poland

Dominika Szalewska, MD, PhD

Clinic of Rehabilitation Medicine, Faculty of Health Sciences,
Medical University of Gdansk, Poland

Anna Wancerz, MD

1st Chair and Department of Cardiology Medical University of Warsaw,
Warsaw, Poland

Prof. Wojciech Zaręba, MD, PhD, FESC, FACC

Professor of Medicine/Cardiology University of Rochester
Medical Center, Rochester, NY, USA

Foreword

Heart failure is a rapidly growing cause of morbidity, hospitalisation and mortality worldwide, with its prevalence increasing with an individual’s age. In view of pharmacotherapeutic possibilities expanding slowly, more and more importance is being attached to comprehensive care, education and rehabilitation of patients with heart failure. Taking into account an unfavourable prognosis, these measures can significantly improve patients’ quality of life and increase survival.

The pursuit of the most efficient and best use of healthcare resources has inspired medical care professionals to incorporate telemedicine technologies into care programmes.

In this book, drawing upon our own unique experience, we present the possibilities of employing this new technology – called telemedicine – for the care of patients with heart failure in the outpatient phase of care. By using the solutions proposed here providing patients with comprehensive, specialised care and rehabilitation will become possible, which subsequently leads to improved quality of life, reduced number of hospital stays and better prognosis.

Thanks to the work coordinated by Ewa Piotrowicz, Associate Professor in the Telecardiology Centre of the Stefan Cardinal Wyszynski National Institute of Cardiology, within the framework of the TELEREH-HF project, I have the honour to present this world’s first textbook on telecardiology in heart failure to English-speaking readers.

Prof. Tomasz Hryniewiecki, MD, PhD

Managing Director

Cardinal Stefan Wyszynski National Institute of Cardiology

Preface

Telecardiology in heart failure

In this time of Covid-19 pandemic, telemedicine is experiencing a rapid development and considerable interest. It is defined as the application of advanced telecommunication technology for diagnostic, monitoring and therapeutic purposes. It enables data transmission from the patient’s whereabouts or his/her primary care provider to a specialized medical call centre. Telecardiology is a highly developed medical discipline involving almost every aspect of cardiology, including acute coronary syndromes, arrhythmias, congestive heart failure, sudden cardiac arrest and others. In particular telecardiology in heart failure is a rapidly expanding specialty in modern medicine and the publication of the present book is highly valuable: in fact, this is one of the first monographs dedicated to this matter worldwide.

The authors are researchers and scientists with extensive experience in implementing telemedicine in clinical practice acquired during the original and valuable TELEREH-HF project. The book thoroughly analyses the state of play in the use of telemedicine in the process of care for patients with heart failure, enriching it with the authors’ own experience. They presented practically all the aspects related to the comprehensive tele-management of patients with heart failure in an accessible and expert way.

At the beginning, definitions of concepts and procedures related to the use of telemedicine are presented, which makes the issues discussed easier to understand. The following chapters present the available procedures, whose implementation allows to create a comprehensive tele-management for patients with heart failure. Therefore, telecare including telephone support and remote monitoring of patients were discussed. In addition, attention was paid to the emerging possibilities of non-invasive haemodynamic remote monitoring and especially home-based use impedance cardiography, lung impedance, bioimpedance analysis. The chapter on cardiac hybrid telerehabilitation is unique. The authors implement this procedure in practice and are pioneers in this field. The TELEREH-HF project was the first multicentre study to show that hybrid telerehabilitation is effective, safe and accepted by patients. This procedure seems to be a necessary stage in the new tele-management model of care for heart failure patients.

In a following chapter, the authors proved that remote monitoring of cardiac implantable electronic devices is a very important element of tele-management. The authors also discussed the possibilities of telemonitoring hemodynamic data, such as the left atrial pressure and the pulmonary artery pressure.

The authors of the book promote a holistic, multidisciplinary approach to the problem of care for patients with heart failure, and therefore one should pay attention to the chapter devoted to the remote psychological support for patients with heart failure.

The objective approach to the analysis of the state of affairs makes the authors devote a whole chapter to discussing the restrictions that are currently associated with the use of telemedicine in patients with heart failure.

The introduction of new technologies to medicine requires new legal regulations and creates ethical dilemmas. The book also contains a chapter devoted to this topic.

In addition to a comprehensive presentation of the state of play, the authors also discuss new trends in the development of monitoring of patients with heart failure: remote-monitored pharmacotherapy (pill in the pocket, intelligent pill, i-pill), the use of artificial intelligence, lab-on-a-chip, vocal markers.

In the postscript, the concept of using telemedicine in comprehensive, long-term, coordinated care for patients with heart failure in Poland is presented.

The reader will also find the attachment at the end of the book very useful. The authors present in it, in a tabular manner recommendations for individual telemedicine procedures: classes I, IIa, IIb, III according to the definition used by ESC.

In conclusion, it is hoped that the present publication will promote even further the implementation of telecardiology in heart failure.

Prof. Massimo Francesco Piepoli, MD, PhD, FESC, FHFA, FACC

Director, Heart Failure Unit, Cardiology Department – Guglielmo da Saliceto Polichirurgico Hospital Cantone del Cristo, I-29121 Piacenza, Italy

Piacenza, April 20, 2020

Sample

Authors

Foreword

Preface

1. Introduction to telecardiology

2. Heart failure – a 21st century epidemic

3. Definition of eHealth and the telemonitoring process

3.1. Introduction

3.2. eHealth and telemedicine – definitions

3.3. Types of telemedicine services

3.4. eHealth in heart failure

3.5. Polish experience gained from the TELEREH-HF project

3.6. Summary

4. E-education and self-monitoring

4.1. Mobile applications

4.2. Websites

4.3. Summary

5. Telephone support and telemonitoring of patients with heart failure

5.1. Introduction

5.2. Telephone support and telemonitoring in heart failure

5.3. “Doc-to-Doc” telecardiology

5.4. “Doc-to-Patient” telecardiology

5.5. Practical implementation

5.6. Data from published studies

5.7. The TELEREH-HF randomized clinical trial

5.8. Summary

6. Non-invasive methods of haemodynamic monitoring

6.1. Introduction

6.2. Impedance cardiography

6.3. Lung impedance

6.4. Electromagnetic technologies

6.5. Spectroscopy, electrical bioimpedance

6.6. Summary

7. Remote monitoring of therapeutic implantable devices

7.1. Definition

7.2. Description of the method

7.3. Recommendations

7.4. Evaluated parameters

7.5. A review of clinical trials of telemonitoring

7.6. Development of telemonitoring in Poland

7.7. Innovations in telemonitoring of cardiac implantable devices

7.8. Summary

8. Remote monitoring of implantable haemodynamic devices

8.1. Introduction

8.2. Monitoring of right ventricular systolic pressure and pulmonary arterial diastolic pressure

8.3. Pulmonary artery pressure monitoring

8.4. Left atrial pressure monitoring

8.5. Left ventricular assist devices and biventricular assist devices

8.6. Summary

9. Hybrid cardiac telerehabilitation

9.1. Introduction

9.2. Remote exercise monitoring

9.3. Effectiveness of cardiac telerehabilitation

9.4. Hybrid cardiac telerehabilitation – technology and organisation

9.5. Benefits and limitations of hybrid cardiac telerehabilitation

9.6. Hybrid cardiac telerehabilitation within the TELEREH-HF project

9.7. Summary

10. Remote psychological support for patients with heart failure

10.1. Main psychological problems and quality of life in people with heart failure – key definitions

10.2. Psychological interventions in the treatment of heart failure

10.3. Psychological assistance with modern forms of communication

10.4. The influence of telecare on the psychological functioning of patients with heart failure

10.5. Psychological support from other medical staff members

10.6. Summary

11. New possibilities for monitoring of patients with heart failure

11.1. Remote monitoring of pharmacotherapy

11.2. Varia

11.3. Summary

12. Benefits and limitations of telemedicine in patients with heart failure

12.1. Introduction

12.2. Benefits and limitations

12.3. Digitisation of health protection and organisation

12.4. Summary

13. Postscript, i.e. telemedicine in comprehensive, coordinated care for patients with heart failure in Poland

1.

Introduction to telecardiology

Wojciech Zaręba

The idea of diagnosing and treating patients at a distance has a long history. On March 22nd in 1905, Willem Einthoven, recognised as the father of electrocardiography, transmitted electrocardiograms (ECGs) from the hospital to his laboratory 1.5 km away via the telephone line. The growing popularity of telephone and radio communication in the early 20th century stimulated scientists’ imagination and the idea of “The Radio Doctor”, which appeared on the cover of Radio News magazine, was proposed in 1924 (Fig. 1.1) [1].

Figure 1.1. Proposed ‘The Radio Doctor’ technology presented on the cover of the April 1924 issue of Radio News magazine.

Sourced from: [1].

A year later, in February 1925, Hugo Gernsback published in the prestigious Science and Invention magazine the description of the telemedicine device, which he called The Radio Teledactyl (from the Greek tele – far and dactyl – finger) to indicate that this device would facilitate “feeling the patient at a distance” (Fig. 1.2.) [2].

Radio-medical consultations were already held in the 1920s and 1930s in Norway, Italy, France and the USA, mainly with patients on board of ships and on remote islands [3, 4]. In 1948, the first radiographic images were sent via telephone between West Chester and Philadelphia, 24 km apart [5]. The first transmissions of ECGs by radio were made by Norman Jeffrey Holter in 1947, which started an era of radio-electrocardiography [6].

Figure 1.2. The Teledactyl — historical concept of telemedicine presented by Hugo Gernsback in the Science and Invention magazine in 1925.

In the early 1960s, video communication was first used in the USA to consult patients. For instance, the Massachusetts General Hospital in Boston established video communication with a nurses’ station at Boston Logan Airport [7]. This communication was then enriched with the transmission of ECGs, stethoscope sounds and microscopy images. Many other applications of telemedicine were implemented for remote consultations with the transmission of signals and images [8]. The dawn of the era of space conquests in the USSR and the USA contributed greatly to further development of transmitting vital signs of animals and humans that were launched into space.

In Poland, Professor Zdzisław Askanas’s team began using telemetry for the transmission of ECG signals in the early 1960s. During the years 1986–1987, as a young assistant at the Cardiology Division at the Medical Academy of Lodz (directed by Professor Halina Pracka), I teletransmitted signal-averaged ECGs recorded in an XYZ lead configuration to evaluate ventricular late potentials. ECG recordings took place in the hospital and were transmitted by the Łucz television dish (borrowed from Lodz television) to the Institute of Physics at Lodz University (about 3 km from the hospital). One television transmission dish was installed on the roof of the hospital, and the other on the roof of the Institute of Physics, in which there was a Mera 400 computer that averaged the ECG signal with recording of ventricular late potentials. This innovative solution was achieved in cooperation with Professor Wielisław Olejniczak’s team from Lodz University. Professor Wielisław Olejniczak was a visionary who helped advancing pioneering telemedicine solutions to my scientific work, which led to my doctoral degree in 1988. Because of the progressive computerisation and development of mobile networks, telemedicine has become a part of everyday practice in many areas of medicine.

Telecardiology, which enables transmission of ECG signals, heart rate and data from the implanted devices (pacemakers, defibrillators), has become a daily reality. Patients with heart failure require particularly intensive care, which is usually provided on an outpatient basis. Telemedicine in heart failure can be used for early diagnosis of health status deterioration, assessment of treatment, medication monitoring, assessment of physical activity, delivery of cardiac rehabilitation, as well as for monitoring of implantable devices. All these applications of telemedicine aim to improve patient’s health, physical capacity, and quality of life, and to reduce the risk of hospitalisation or death.