Technological advances in healthcare have been amazing in my lifetime. In cardiology, this year it’s the 40th anniversary of PCI and the 50th of heart transplant. These techniques have been progressively refined and were the launch pad for further advances. Medical progress continues exponentially. Now in-depth collaboration between medics and experts from other sciences is the key to success, moving far beyond the garages of the early PCI pioneers.
The integration of new technologies into daily practice can at times be more or less helpful. It remains important to evaluate and prove a positive forward step as fashion and trend can sometimes be difficult to ignore, with the opportunity for costly mistakes.
Discussing sports cardiology last month, I was reminded of the diagnostic problem with a patient who was a competitive fell runner. He presented with palpitations at peak exertion and in one his heart rate monitor showed a clear, sudden step up. As always, the question was did he have an arrhythmia, and if so, which one?
His GPS Garmin heart rate monitor, although advanced in many ways, just doesn’t give the medical quality data to answer the question. An event recorder was too bulky to carry and didn’t really produce a good enough quality ECG immediately when he stopped. We talked about the ALIVECor monitor and the more recent facility to use a band for the Apple watch to get symptom rhythm correlation. For on the move, a sports top with integrated ECG may be the best tech for this situation.
Improved fidelity and more convenient rhythm monitoring allows a greater breadth of use and importantly can avoid the time and cost-consuming situation of patients coming to and waiting in hospital for rhythm documentation. A number of studies are and have been exploring this, including the REHEARSE-AF study presented at the recent ECS.
Sometimes the difficulty is not getting the clinical data we need, but knowing if what we have is going to make a difference to patient outcomes. For those patients who have had rhythm disturbances and been treated with CIEDs, we have an ever growing amount of information available, but is it actually helpful?
Benefits of remote monitoring
There are a number of potential ways remote monitoring of pacemaker devices should be for good for patients. In our department, with a population over a large geographical area, our patients greatly appreciated not having to travel to the city, mostly not having to struggle to find a parking space! That is important, but does remote monitoring make a difference to them clinically?
In a high-risk heart failure group it seems intuitive that it’s beneficial to be alerted to increasing ATP therapy and ICD discharges, then being able to take earlier action and potentially abort an electrical storm with its high mortality, for example. The IN-TIME study seemed to support this, but recently the REM-HF trial reported in a similar group that it doesn’t affect the hard end points of patient outcomes, including hospitalisations. The debate continues, but the evidence will more often find equipoise for improvement in care.
One of the concepts I think we all have with the adoption of new tech is that there will be a trade off to the higher up-front costs with the return of saved time and effort. For CIEDs, the cardiac physiologists are pivotal and it was interesting discussing this with them.
Even when patients don’t have to come into the department, physiologist time doesn’t appear to be saved. They still need to review and assess the on-line data and often have more patient follow-up contact as a result of these. One of our team spoke of his frustration with some of the advanced features, particularly the OptiVol on some CRTs. Often it’s just too much information and simply not consistently clinically helpful and, with the support of our heart failure consultant, he switches the feature off.
The practice of medicine changes with technological advances, no, I’m not going to get into the EPR debate here! I wanted to finish with “the heart” of the clinical examination.
Death of the stethoscope?
I was at a fantastic education course this year, and for the first time for a while at a meeting away I was the only cardiologist in the room. I was a little surprised to hear from the floor that “only cardiologists still use stethoscopes for cardiac auscultation nowadays”. I knew that there has been a desire and some movement to the use of hand-held ultrasound (HHU) in A&E and ITU, but didn’t appreciate that it was that stage!
Of course, the death of the stethoscope has been forecast for some time, but with the availability of a true alternative in HHU, this may be coming closer. A good thing, or not?
You do need training and knowledge to do a diagnostic bedside echo. I think cardiologists use echo more often to confirm our stethoscope findings or their clinical suspicions and not having an impression before you put the probe on could increase the risk of missing essential information. It’s true, identifying pericardial effusions and doing simple LV function assessment is all that is needed in some settings, but without suspicion and training to detect it, you may miss the eccentric MR or VSD that is the cause of shock in your patient.
For me, the stethoscope and HHU are complementary tools, and like all tools of the trade, we need to invest in the knowledge, training and proper evaluation for their clinical use and resist the temptation to think that all that is new and shiny is better.
So are all technological advances good? The vast majority certainly are, and those come from identifying true unmet needs in the clinical care of our patients.