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Introduction: The COVID-19 pandemic has caused a global impact on public health services. Using new strategies through telehealth for the management of patients with congenital heart disease was the challenge. Objective: To describe the experience in telecardiology, and the strategies implemented during the pandemic. Method: Retrospective, qualitative study that includes the period from April 2020 to April 2021. Inquiries were received through the service's official e-mail or telephone. They were classified according to the type of concern and complexity of heart disease using color coding. The responses were asynchronous (by e-mail) or synchronous (videoconferences). The videoconferences were made using a secure platform (Cisco-Webex). Results: From April 2020 to April 2021, a total of 3372 queries were answered. The responses were distributed via e-mail (64.9%), phone calls (1.2%) and videoconferences (14.5%). The most frequent reasons for consultation were the request for missed appointments (68%), and remote clinical monitoring (20%). A total of 2296 families was contacted. Only 14.1% of the inquiries were cited in person. With color coding, a stratification was performed according to urgency. Conclusions: Telehealth proved to be a useful tool for the clinical management of patients with congenital heart disease in their place of origin. It prevented a considerable number of transfers, identified patients at risk rapidly, comforted families, and strengthened ties with local hospitals that make up the health network.
Introducción: La pandemia de COVID-19 ha causado un impacto global en los servicios de salud pública. Utilizar nuevas estrategias a través de la telesalud para el manejo de los pacientes con cardiopatías congénitas fue el desafío. Objetivo: Describir la experiencia en telecardiología y las estrategias implementadas durante la pandemia. Método: Estudio retrospectivo, cualitativo, que comprende el periodo de abril de 2020 a abril de 2021. Se recibieron consultas a través del correo electrónico oficial del servicio o por teléfono. Se clasificaron según tipo de inquietud y complejidad de la cardiopatía utilizando una codificación por colores. Las respuestas a las mismas fueron asincrónicas (correo electrónico) o sincrónicas (videoconferencias). Las videoconferencias se realizaron utilizando una plataforma segura (Cisco-Webex). Resultados: Se contestaron 3372 consultas. Las respuestas fueron distribuidas en correos electrónicos (64.9%), llamados telefónicos (1.2%), videoconferencias (14.5%) y otros métodos (19.4%) Los motivos de consulta más frecuentes fueron la solicitud de turnos suspendidos (68%) y control clínico a distancia (20%). Se pudo establecer contacto con 2296 familias. Solo el 14.1% de las consultas se citó en forma presencial. Con la codificación por colores se logró realizar una estratificación según la urgencia. Conclusiones: La telesalud mostró ser una herramienta útil para el manejo clínico de pacientes con cardiopatías congénitas en su lugar de origen. Evitó un gran número de traslados, identificó pacientes en riesgo, confortó a las familias y fortaleció vínculos con hospitales locales que integran la red de salud.
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COVID-19 , Cardiopatias Congênitas , Telemedicina , Humanos , Criança , Pandemias , Estudos Retrospectivos , Cardiopatias Congênitas/terapiaRESUMO
Resumo Fundamento As doenças cardiovasculares são a principal causa de morte no mundo. Regiões brasileiras geograficamente remotas e de baixa renda carecem de consultas especializadas. Não se tem conhecimento total acerca do manejo por telemedicina dessa população por parte de cardiologistas. Objetivos Analisar a teleconsulta cardiológica na região brasileira com maior número de municípios isolados. Métodos Entre fevereiro de 2020 e outubro de 2021, pacientes da Região Norte do Brasil avaliados por médicos generalistas locais foram encaminhados para avaliação cardiológica por telemedicina. Foram analisados os motivos do encaminhamento, dados demográficos, histórico clínico, exames físicos, exames complementares, medicamentos e prescrições pré e pós-telemedicina (considerou-se p<0,05 como estatisticamente significativo). Resultados Analisamos 653 pacientes. A taxa de frequência foi de 85,7% (53,1% do sexo feminino, idade média: 54,2±6,5 anos). Os principais motivos de encaminhamento foram sintomas cardiovasculares (58,1%) e fatores de risco entre pacientes assintomáticos (13,3%). Apenas 12,6% apresentava alguma doença diagnosticada. A maioria dos pacientes havia passado por exame físico e eletrocardiogramas regulares. Poucos tinham exames complementares recentes. A prescrição de bloqueadores dos receptores da angiotensina (BRA), bloqueadores dos canais de cálcio e estatinas aumentou significativamente, enquanto a de digoxina, betabloqueadores não cardíacos e ácido acetilsalicílico (AAS) diminuiu na primeira teleconsulta. A maioria dos exames complementares solicitados era de baixa complexidade e custo: eletrocardiograma (28,2%), radiografia de tórax (14%), ecocardiograma (64,5%) e exames de sangue (71,8%). Para 2,1% dos pacientes, foram indicadas intervenções, e 8% recebeu alta após a primeira consulta. Conclusão A teleconsulta cardiológica sob demanda contribui para a otimização do tratamento das doenças cardíacas. A maioria dos pacientes foi encaminhada com diagnósticos sindrômicos sem exames complementares prévios. A avaliação especializada solicitada geralmente estava disponível localmente e com baixo custo, mas impedia a alta precoce. Capacitação local poderia otimizar o encaminhamento.
Abstract Background Cardiovascular diseases are the leading cause of adult mortality. Geographically remote and low-income Brazilian regions lack specialized consultations. The telemedicine management of this population by cardiologists is not fully known. Objectives To analyze cardiology teleconsultation in the Brazilian region with the highest number of isolated cities. Methods From February 2020 to October 2021, patients from the North Region of Brazil evaluated by local general practitioners were referred for cardiological evaluation by telemedicine. Referral reasons, demographics, clinical history, physical examinations, tests, medications, and prescriptions pre- and post-telemedicine were analyzed (p<0.05 was considered statistically significant). Results We analyzed 653 patients. The attendance rate was 85.7% (53.1% female, mean age: 54.2±6.5 years). The main reasons for referral were cardiovascular symptoms (58.1%) and risk factors among asymptomatic patients (13.3%). Only 12.6% had a diagnosed disease. Most patients had regular physical examinations and electrocardiograms. Few had recent complementary tests. The prescription of angiotensin receptor blockers (ARBs), calcium channel blockers and statins was significantly increased, while that of digoxin, noncardiac beta-blockers and acetylsalicylic acid (ASA) was decreased at the first teleconsultation. Most of the tests requested were of low complexity and cost: electrocardiogram (28.2%), chest X-ray (14%), echocardiogram (64.5%) and blood tests (71.8%). For 2.1% of patients, interventions were indicated, and 8% were discharged after the first consultation. Conclusion On-demand cardiology teleconsultation contributes to heart disease treatment optimization. Most patients were referred with syndromic diagnoses without previous complementary tests. The specialist workup requested was usually available locally and at a low cost but precluded early discharge. Local training could optimize the referral.
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Objetivo: compreender as principais complicações ocasionadas pelo vírus SARS-CoV-2 no sistema cardíaco do público idoso. Métodos: trata-se de uma revisão sistemática da literatura de abordagem qualitativa e característica descritivo-exploratória realizada no ano de 2020. Resultados: as complicações cardíacas mais prevalentes na população idosa foram miocardite, arritmias, insuficiência cardíaca, infarto agudo, choque cardiogênico, lesão miocárdica aguda e parada cardiorrespiratória. O principal biomarcador cardíaco foi a troponina, apresentando elevação superior ao percentil 99°, evidenciando a necessidade de tratamento em Unidade de Terapia Intensiva. Considerações Finais: o aparecimento desse vírus causou grande prejuízo no campo da saúde, especialmente a população idosa, que apresenta risco elevado de óbito ao contrair essa doença. Destarte, é de extrema importância se ater a mensuração da troponina sérica no público alvo e realizar monitorização longitudinal, utilizando para tal a telecardiologia, uma vez que diminuem as chances de contaminação entre infectado e profissional de saúde
Objective: to understand the main complications of SARS-CoV-2 in the elderly cardiac system. Methods: systematic literature review conducted in 2020. Results: the most prevalent cardiac complications in the elderly population were myocarditis, arrhythmias, heart failure, acute infarction, cardiogenic shock, acute myocardial injury and cardiorespiratory arrest. The main cardiac biomarker was troponin, showing an elevation above the 99th percentile, evidencing the need for treatment in the Intensive Care Unit. Final Considerations: the appearance of this virus has caused great damage in the health field, especially the elderly population, who is at high risk of death when contracting this disease. Therefore, it is important to stick to the measurement of serum troponin in the target audience and perform longitudinal monitoring, using telecardiology for this purpose, since they reduce the chances of contamination between infected and health professionals
Objetivo: comprender las principales complicaciones del SARS-CoV-2 en el sistema cardíaco anciano. Métodos: revisión sistemática de la literatura realizada en 2020. Resultados: las complicaciones cardíacas más prevalentes en la población anciana fueron miocarditis, arritmias, insuficiencia cardíaca, infarto agudo, shock cardiogénico, lesión miocárdica aguda y parada cardiorrespiratoria. El principal biomarcador cardíaco fue la troponina, mostrando una elevación por encima del percentil 99, evidenciando la necesidad de tratamiento en la Unidad de Cuidados Intensivos. Consideraciones finales: la aparición de este virus ha provocado un gran daño en el campo de la salud, especialmente en la población anciana, que se encuentra en alto riesgo de muerte al contraer esta enfermedad. Por tanto, es importante ceñirse a la medición de troponina sérica en el público objetivo y realizar un seguimiento longitudinal, utilizando para ello la telecardiología, ya que reducen las posibilidades de contaminación entre los infectados y los profesionales sanitarios
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Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Troponina , Saúde do Idoso , COVID-19/complicações , Cardiopatias/etiologia , Equipe de Assistência ao Paciente , Choque Cardiogênico , Telecardiologia , Parada Cardíaca , Insuficiência Cardíaca , Unidades de Terapia Intensiva , MiocarditeRESUMO
Background: Congenital heart disease (CHD) affects 1% of all newborns and is a major public health problem. Most children with CHD benefit from early diagnosis to optimize management. However, in many places there are no specialized professionals to do so. Introduction: A screening method for CHD was developed between two states in Northeast Brazil. It was based upon the performance of an echocardiogram by local pediatricians with support of pediatric cardiologists through telemedicine. Objective: To determine if the continuous performance of examinations together with online supervision increased the level of understanding of the pediatricians about the echocardiograms. Methods: Pediatricians received online support to perform echocardiograms for 7 years (2012-2018). Although the project aimed to teach them to acquire images and send to the cardiologists for analysis and interpretation, they were encouraged to describe their own diagnostic impressions. The level of agreement between pediatricians and cardiologists was calculated. Results: A large number (n = 3,951) echocardiograms was analyzed. From them, 2,818 were classified as abnormal, inconclusive, or normal by both the pediatricians and the cardiologists. The 7-year analysis demonstrated an overall agreement of 63.7%. As for the final diagnosis, it was possible to compare 1,457 echocardiograms. The combined analysis of the 7 years demonstrated agreement in 62.2%. Discussion: The screening of CHD under online support led to more in-depth learning of echocardiography by the pediatricians. This approach potentialized the accuracy of the screening through the years. Conclusion: By enrolling in a telemedicine-based screening program, the pediatricians' degree of understanding of echocardiography increased considerably.
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Cardiopatias Congênitas , Telemedicina , Brasil , Criança , Ecocardiografia , Cardiopatias Congênitas/diagnóstico por imagem , Humanos , Recém-Nascido , PediatrasRESUMO
Background The global burden of rheumatic heart disease is nearly 33 million people. Telemedicine, using cloud-server technology, provides an ideal solution for sharing images performed by non-physicians with cardiologists who are experts in rheumatic heart disease. Objective We describe our experience in using telemedicine to support a large rheumatic heart disease outreach screening programme in the Brazilian state of Minas Gerais. Methods The Programa de Rastreamento da Valvopatia Reumática (PROVAR) is a prospective cross-sectional study aimed at gathering epidemiological data on the burden of rheumatic heart disease in Minas Gerais and testing of a non-expert, telemedicine-supported model of outreach rheumatic heart disease screening. The primary goal is to enable expert support of remote rheumatic heart disease outreach through cloud-based sharing of echocardiographic images between Minas Gerais and Washington. Secondary goals include (a) developing and sharing online training modules for non-physicians in echocardiography performance and interpretation and (b) utilising a secure web-based system to share clinical and research data. Results PROVAR included 4615 studies that were performed by non-experts at 21 schools and shared via cloud-telemedicine technology. Latent rheumatic heart disease was found in 251 subjects (4.2% of subjects: 3.7% borderline and 0.5% definite disease). Of the studies, 50% were preformed on full functional echocardiography machines and transmitted via Digital Imaging and Communications in Medicine (DICOM) and 50% were performed on handheld echocardiography machines and transferred via a secure Dropbox connection. The average time between study performance date and interpretation was 10 days. There was 100% success in initial image transfer. Less than 1% of studies performed by non-experts could not be interpreted. Discussion A sustainable, low-cost telehealth model, using task-shifting with non-medical personal in low and middle income countries can improve access to echocardiography for rheumatic heart disease.
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Programas de Rastreamento/organização & administração , Cardiopatia Reumática/diagnóstico , Telemedicina/organização & administração , Brasil , Computação em Nuvem , Segurança Computacional , Estudos Transversais , Ecocardiografia/métodos , Humanos , Capacitação em Serviço , Estudos Prospectivos , Fatores de TempoRESUMO
We present a case of a newborn from a remote, underserved area in the inland of Paraíba, a state from Northeast Brazil. She presented with clinical cyanosis at birth. With the aid of telemedicine, a neonatologist under online cardiology supervision performed a screening echocardiogram. The session established the diagnosis of simple transposition of the great vessels in the baby's first few hours of life. During the same telemedicine session, the necessary arrangements for transferal to a larger maternity center took place. The baby was maintained stable on prostaglandins and was subsequently transferred to a tertiary cardiac center in the neighboring State, Pernambuco. She underwent anatomical correction at day 10, presented no surgical or postoperative complications, and was discharged home at the age of 21 days. She is now over three years old and continues her follow-up care mostly at her hometown, with local pediatricians under online supervision by a cardiologist in a virtual outpatient clinic. The establishment of a Pediatric Cardiology Network, with the aid of telemedicine, can produce a major impact on the access to specialized health care for poor regions of developing countries.
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Cardiologia/métodos , Pediatria/métodos , Consulta Remota/métodos , Telemedicina , Transposição dos Grandes Vasos/diagnóstico por imagem , Brasil , Feminino , Humanos , Recém-NascidoRESUMO
AIMS: Although an increasing prevalence of atrial fibrillation (AF) has been reported worldwide, there are few studies from low- and middle-income countries. Our objective is to assess the prevalence of AF and the associated medical conditions in Brazilian primary care patients. METHODS AND RESULTS: This is an observational retrospective study. Patients ≥5 years of age from primary care centres of 658 municipalities in Minas Gerais, Brazil, who performed digital electrocardiograms (ECGs) by a public telehealth service in 2011 were assessed. Clinical data were self-reported, and ECGs were interpreted by a team of trained cardiologists using standardized criteria. To assess the relation between clinical characteristics and AF, odds ratios were estimated by logistic regression. A total of 262 685 primary care patients were included, mean (SD) age of 50.3 (19.3) years, 59.6% female. Hypertension was reported in 32.0%, family history of coronary heart disease in 15.0%, diabetes in 5.4%, hyperlipidaemia in 2.8%, Chagas disease in 2.9%, and 7.1% reported current smoking. The prevalence of AF was 1.8% overall: 2.4% in men (ranging from 0.001% from 5-19 years old to 14.6% in nonagenarians) and 1.3% in women (ranging from 0.001% from 5-19 years old to 8.7% in nonagenarians) (P < 0.001). The prevalence of AF increased with advancing age. The comorbidities associated with AF were Chagas disease, previous myocardial infarction, hypertension, and chronic obstructive pulmonary disease. Vitamin K antagonist use was reported by 1.5% of patients. CONCLUSION: The prevalence and age distribution of AF were similar to studies in high-income countries. The proportion of patients who reported the use of anticoagulants was alarmingly low. Our findings point out the necessity to formulate effective treatment strategies for AF in Brazilian primary care settings.
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Fibrilação Atrial/epidemiologia , Atenção Primária à Saúde , Adolescente , Adulto , Distribuição por Idade , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/uso terapêutico , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/tratamento farmacológico , Brasil/epidemiologia , Criança , Pré-Escolar , Comorbidade , Bases de Dados Factuais , Eletrocardiografia , Feminino , Humanos , Lactente , Recém-Nascido , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Valor Preditivo dos Testes , Prevalência , Estudos Retrospectivos , Fatores de Risco , Distribuição por Sexo , Fumar/efeitos adversos , Fumar/epidemiologia , Telemedicina , Fatores de Tempo , Adulto JovemRESUMO
BACKGROUND: An optimal model for telemedicine use in the international care setting has not been established. Our objective was to describe variables associated with patient outcome during the implementation of an international pediatric cardiac critical care (PCCC) telemedicine program. MATERIALS AND METHODS: A retrospective review was performed of clinical records and a telemedicine database of patients admitted to the cardiac intensive care unit (CICU) at the Fundacion Cardiovascular de Colombia, Bucaramanga, Colombia, during the initial 10 months of our program, compared with patients admitted during a previous period. Information collected included demographic data, cardiac diagnosis and associated factors, Risk Adjustment for Congenital Heart Surgery (RACHS)-1 classification, and perioperative events. Primary outcome was composed of CICU and hospital mortality. Secondary outcomes were CICU and hospital length of stay (LOS). RESULTS: Of the 553 patients who were included, teleconsultation was done for 71 (12.4%), with a total of 156 encounters, including 19 for patients on extracorporeal membrane oxygenation. Three hundred twenty-one recommendations were given, and 42 real-time interventions were documented. RACHS-1 distribution was similar between study periods (p=0.427). Teleconsulted patients were significantly younger (44 versus 24 months; p=0.03) and had higher surgical complexity than nonteleconsulted patients (p=0.01). RACHS-1 adjusted hospital survival was similar between study periods. CICU and hospital LOS intervals were significantly shorter in the telemedicine period (10 versus 17 days [p=0.02] and 22 versus 28 days [p<0.001]). In surgical cases, preoperative CICU LOS was significantly shorter (3 versus 6 days; p<0.001). Variables associated with hospital mortality were higher RACHS-1 categories, lower weight, bypass time longer than 150 min, and use of circulatory arrest, as well as the presence of sepsis or necrotizing enterocolitis. Those associated with increased LOS were lower weight, extracorporeal membrane oxygenation, and cross-clamp time longer than 60 min. CONCLUSIONS: An international telemedicine service in PCCC was associated with lower CICU and hospital LOS. Prospective telemedicine interventions aimed to decrease mortality and LOS should focus on patients with higher RACHS-1 categories, lower-weight infants, and those with prolonged operative time and selective perioperative complications.
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Cuidados Críticos/métodos , Cardiopatias Congênitas/cirurgia , Consulta Remota , Adolescente , Adulto , Criança , Pré-Escolar , Colômbia/epidemiologia , Feminino , Cardiopatias Congênitas/epidemiologia , Mortalidade Hospitalar , Humanos , Lactente , Recém-Nascido , Unidades de Terapia Intensiva Pediátrica , Tempo de Internação/estatística & dados numéricos , Masculino , Pennsylvania , Estudos Retrospectivos , Resultado do TratamentoRESUMO
One of the main reasons that leads to a low adoption rate of telemedicine systems is poor usability. An aspect that influences usability during the reporting of findings is the input mode, e.g., if a free-text (FT) or a structured report (SR) interface is employed. The objective of our study is to compare the usability of FT and ST telemedicine systems, specifically in terms of user satisfaction, efficiency and general usability. We comparatively evaluate the usability of these two input modes in a telecardiology system for issuing electrocardiography reports in the context of a statewide telemedicine system in Brazil with more than 350.000 performed tele-electrocardiography examinations. We adopted a multiple method research strategy, applying three different kinds of usability evaluations: user satisfaction was evaluated through interviews with seven medical professionals using the System Usability Scale (SUS) questionnaire and specific questions related to adequacy and user experience. Efficiency was evaluated by estimating execution time using the Keystroke-Level Model (KLM). General usability was assessed based on the conformity of the systems to a set of e-health specific usability heuristics. The results of this comparison provide a first indication that a structured report (SR) input mode for such a system is more satisfactory and efficient with a larger conformity to usability heuristics than free-text (FT) input. User satisfaction using the SUS questionnaire has been scored in average with 58.8 and 77.5 points for the FT and SR system, respectively, which means that the SR system was rated 18.65 points higher than the FT system. In terms of efficiency, the completion of a findings report using the SR mode is estimated to take 8.5s, 3.74 times faster than using the FT system (31.8s). The SR system also demonstrated less violations to usability heuristics (8 points) in comparison to 14 points observed in the FT system. These results provide a first indication that the usage of structured reporting as an input mode in telecardiology systems may enhance usability. This also seems to confirm the advantages of the usage of structured reporting, as already described in the literature for other areas such as teleradiology.