The ESC Digital congress was a bold and
successful initiative of the European Society of Cardiology, and took place in
Tallin, a few days ago. The location was not chosen by hazard, as Estonia has
99% of health data digitized and 99% of prescriptions are digital. Prof.
Viigimaa exposed the architecture of the Estonian Electronic helth system in a
at the beginning of the congress.
of digital healthcare
was reviewed by Prof. Martin Cowie in an excellent presentation,
where he highlighted that we need to identify barriers and find appropriate
solutions on this emerging sector. We will always find at the center of our
care the patient and his family, and this aspect should not be overlooked or
forgotten, especially in this rapid-digitalized era.
Patient care, patient empowerment
and nursing issues
were also addressed by Prof. Donna
Fitzimons and ACNAP President-Elect
Lis Neubeck, with accent on developing the short and longer path to
action which have in center the patient and the nurse (as midlevel team
member). Digital nursing sessions drawed a lot of constructive comments, with Donna Fitzimons opinioned that
if the patient is art ease at using online interaction with a “digital” nurse
(avatar talking and guiding the patient by means of AI), then we should use
this technology mainly to prevent, and not to treat. Find below the interesting
slides from the presentations and their link
to full presentations.
A very interesting session addressed the issue
of preparing the healthcare force for
the digital future chaired by ACCA President
Susanna Price. Even though some solutions have been highlighted in a
paper, like as the need for a culture of learning (develop extensive
learning environment, encourage innovation and dare to fail), building a strong
learning infrastructure and developing a multi-professional and collaborative
approach to learning, these approaches are unachievably in the current state of
the medical system in Europe, where most of the current medical personnel are
disengaged or over-fatigued, doctors and nurses are burned-out.
Does technology make things worse for the
medical workers? Can artificial intelligence and automation ease things? See
all the debate here.
The same issue was addressed in another session.
While trying to find solutions for the future, present issues of healthcare
professionals and the digital boom relate to lack of trust and poor experience
with new technologies, difficulty to interact with technology, fear of change. This
is maybe where artificial intelligence could make the difference, as it can
improve healthcare efficiency and delivery and could replace human involvement
in some tasks of the medical industry, as suggested Dr. Casado Arroyo. However,
for the moment, present algorithms are not completely in their mature stage.
Cybersecurity was a hot topic. Dr. Avi Fischer
resumed some of the important cautions to take in reducing cybersecurity risks,
sharing responsibility between
stakeholders-healthcare facilities, patients, providers, and manufacturers of
cybersecurity should be a priority
during the design and development phase of the medical device and the issue
should be addressed in a “Bolt-On to Integrated” fashion;
if a vulnerability is found,
communication and coordinated actions between stakeholders and healthcare
facilities are vital. Development and involvement of government structures to
assure security is very important.
The participants also expressed the
urgent need for developing secured protocols to transmit data.
A special session to electronic medical record (EMR) can be accessed here.
The consensus was that even though EMR are an efficient data base that can help
health professionals in decision making, it is also time consuming. A new concept
that consists on “less keyboard, more patient contact” should be adopted,
because according to one study, for every hour
physicians provide direct clinical face time to patients, nearly 2 additional
hours is spent on EHR and desk work within the clinic day, and outside
office hours, physicians spend another one
to two hours of
personal time each night
doing additional computer
and other clerical
work. Dr. Nico
highlighted an important limitation of EMR used in Europe (vs. US), notably in
Europe we use more than 30 languages that makes data collection difficult, and
that should probably be aimed by a future Horizon 2020 project.
Augmented, mixed and virtual reality discussions were
divided into cardiologist-related and patient-related. The 3 terms are
intercorrelated and should not be confused one with another, here is their
meaning and a schematic representation:
Virtual reality (VR) immerses users in a fully artificial digital
Augmented reality (AR) overlays virtual objects on the real-world
Mixed reality (MR) not just overlays but anchors virtual objects to
the real world.
The 2 main applications
in medicine targets the patients and of course the doctors.
For patients, one
of the presenters suggested that VR will do for patient education what
Google Maps has done for navigation, thus it “will transform learning
experiences by better retention and recall, it will improve patient journey and
will determine behavioral change by challenging health beliefs through
For doctors, Dr. Dariusz Dudek
explained how a pioneer programe of mixed reality that is currently used in
Poland helps cardiologists choose a better punction site for TAVI, with
expectancy in the very near future to have VR mask that will allow
cardiologists to have echo, CT and eventually other 3D reconstructions in the
corner of their eyes, while a cardiac intervention is taking place. Other
important applications are stroke recovery and cardiac rehabilitation.
One of the worries highlighted was that this
new technology could cause anxiety in healthy fit subjects, translating into
unnecessary consultations either by their general practitioner either by their
cardiologist, as presented by Prof.
Martin Cowie. 57% of subjects from the “Apple heart” study thought
to seek medical attention after having an alarm from a smart device.
Even though wearables and connected devices
impact sometimes positively our daily lives (sleep apnea analysis app, selfie
to quantify oedema app, accelerometers incorporated into devices that quantify
daily effort, smartphone-based blood pressure measurement by transdermal
optimal imaging, etc), Dr.
Klaus Witte highlighted that there is increased concern that
wearables and connected devices impact negatively the society by increased (but
unnecessary) cost to the consumer and increases (but unnecessary) cost to the
medical system (by over-investigating a healthy person thus launching a battery
of tests like holter ECG, echocardiography, stress test). With this in mind,
there was a unanimous consensus that medical wearables and connected devices
should target special groups of populations if we want to avoid death, strokes
or hospitalizations and the clinical benefit of these kind of devices should be
carefully thought and evaluated.
Digital technology can help healthcare by
providing new tools for diagnosis and therapy delivery, redesigning clinical
pathways, individualized risk stratification and individualized care, patient
empowerment, support to precision medicine (thus fewer medical errors), and
telemonitoring. Digital technology and connected devices (tablets, wearables,
apps) will enhance decision making of health professionals only if there is a
direct link towards a clinical benefit, and maybe they would have a huge impact
if they could be directly linked also to EMR. In real life, adoption of digital
technology in healthcare depends on validation, easy integration of workflow
& prescription pathways and ability to reduce work.
Consumers could think that by using digital
technology and connected devices, they take control over their health; this is
partially false because alarms issued by devices could translate into
unnecessary consultations and increased cost to overall health system by doing
unnecessary tests in otherwise healthy subjects. Narrowing the indications and
the target population for the use of this devices should be a priority.
And finally, some punctual issues need rapid
and clear solutions: stricter security protocols should be incorporated in data
transmission, regulations should be adopted for all digital technology (there
are too many devices and few regulations), the huge amount of data (that is
collected from all digital technology) needs to be transformed into
From new smart stethoscopes to
digital health investments and studies looking at the use of new technologies,
2018 was a remarkable year for innovation in telecardiology. The biggest news,
however, came from Apple receiving FDA clearance for an algorithm detecting
atrial fibrillation and an ECG to be built into its latest Apple Watch series.
Here is a summary of some of the key developments in the area from the past
year, presented in a timely manner.
January: New products
launches AI-enabled, wireless stethoscope called Stethee
At the beginning of the year,
Australian company M3DICINE launched a wireless stethoscope called Stethee that
works with an accompanying app, available for both iOS and Android. M3DICINE
says Stethee captures, filters and amplifies the sounds of a patient’s heart or
lungs, and the audio is then sent to users’ Bluetooth-enabled devices or wired
headphones. The platform’s AI engine, called Aida, analyzes heart and lung
sounds to build personal biometric signals, according to a statement from the
company. Aida also tags geolocation and environmental data, which, encrypted
and anonymized, can be reported back in the form of quantitative reports (data
that is clinically actionable), and clinicians can view them through an online
portal. The company said it worked in the development of Stethee with designers
and engineers from the Massachusetts Institute of Technology and clinical
experts from Mayo Clinic, among others. M3DICINE received FDA clearance for the
product in 2017.
raises $5m after receiving FDA clearance for its Duo smart heart monitor
Californian company Eko Devices
announced in February that it raised $5m in a Series A funding round, after
securing 510 (k) FDA clearance in 2017 for its smart heart monitor Duo, a
combined digital stethoscope and ECG. Clinicians can use the portable cardiac
device as a screening tool or prescribe it to outpatients – Duo pairs with an app
to enable remote monitoring and diagnosis by a specialist. In 2015, the company
received FDA clearance for the Core smart stethoscope.
announces results from two studies
In March, AliveCor unveiled the
findings of two studies at the American College of Cardiology’s 2018 Annual
Scientific Session, looking at the use of its portable ECG devices.
A Cleveland Clinic study set out
to identify whether the company’s medical device accessory KardiaBand, which is
FDA-cleared, for Apple Watch could differentiate between atrial fibrillation
and normal heart rhythm. Findings indicated that KardiaBand detected atrial
fibrillation and normal synus rhythm with an accuracy (interpreted with 93
percent sensitivity and 84 percent specificity) that they said was “comparable
to clinicians interpreting the same ECGs”.
A second study indicated that
the device paired with AI technology could detect hyperkalemia (commonly
associated with congestive heart failure and chronic kidney disease). More than
two million ECGs linked to four million serum potassium values reportedly
collected between 1994 and 2017 and prospective data from an AliveCor
smartphone ECG device were used in the development of the AI algorithm.
AliveCor said this could be commercialised through the KardiaBand for Apple
Watch at the time. In September, it announced that its KardiaK Software
Platform had achieved FDA Breakthrough Device Status, which means that the FDA
will consider it on a track for accelerated clearance that is specific for
devices “demonstrating the potential to address unmet medical needs for
life-threatening or irreversibly debilitating diseases or conditions”. AliveCor
planned at the time to use the solution for home-based hyperkalemia detection
to help support patients with kidney disease.
University of Turku, Finland detecting atrial fibrillation
A mobile app developed at the
University of Turku’s Department of Future Technologies in Finland detected
atrial fibrillation with a 96 percent accuracy in a study of three hundred
patients with heart problems – half with atrial fibrillation – carried out by
the university and the Heart Centre of the Turku University Hospital. The
project was carried out as a blind study, with the hospital sending the
University measurement data for analysis. In a press announcement issued in
March, it was explained that the app could be commercialised through the
University spin-off company Precordior.
Steth IO unveils
digital stethoscope integrated into a smartphone’s case
Steth IO launched in April a
digital stethoscope integrated into a smartphone’s case that works with an
accompanying app, allowing clinicians to listen and measure heart rates or lung
sounds by holding the mobile up to a patient’s chest. The device received FDA clearance in 2016.
behavioral economics to support patients with cardiovascular disease
published in the Journal of the American Heart Association in June found
that combining wearable devices with “personalized goal-setting” and a
financial incentive led to an increase in levels of physical activity among
ischemic heart disease patients involved in the trial. However, researchers
found that wearables alone were not effective in generating improvements in
physical activity levels.
The study included 105 patients
with ischemic heart disease, taking place over a period of 24 weeks, but
researchers noted that limitations of the study included the fact that the only
levels of physical activity evaluated were based on steps. However, they argued
that the findings indicated that “digital health interventions that leverage
insights from behavioral economics offer a promising approach to change health
behaviors among patients with cardiovascular disease”.
Source: Journal of the
American Heart Association study
health app and Garmin wearables integration
In August, Garmin International
announced that its wearable devices featuring optical heart rate would become
compatible with the Cardiogram heart health app. Using data from wearables, the
Cardiogram app provides insights to help users understand the effects of
activity and sleep on their overall health. Working with the Department of
Cardiology of the University of California, San Francisco, Cardiogram has
combined data from optical heart rate sensors and an AI-based algorithm called
DeepHeart developed by them for the detection of major conditions. Clinical
studies indicated that DeepHeart had demonstrated that it could detect the
following: atrial fibrillation, sleep apnea, hypertension, and diabetes.
Cardiogram co-founder Johnson
Hsieh explained in a statement that there had been high demand for the app to
support Garmin wearables, integrated through an application programming
interface (API) to enable access to insights generated.
Regulatory news, new products
further into healthcare with first FDA clearance
In September, Apple made waves
in the digital health world after announcing that it had received FDA De Novo
clearance for an algorithm to detect atrial fibrillation from heart rate data
and an ECG to be built into its Series 4 Apple Watch by adding electrodes to
the digital crown and the back of the device. Users can take an ECG in around
half a minute. The ECG waveform and its classifications, along with any other
symptoms recorded, are saved in the Apple Health app, and a PDF can be shared
Network Open study
Findings from a study
released by JAMA Network Open in September
last year showed that, in a cluster randomized trial of 326 patients with
uncontrolled hypertension, home blood pressure telemonitoring combined with
pharmacist management lowered blood pressure more than usual care in the first
18 months. However, results indicated significantly lower blood pressure in the
group that received the intervention for up to 24 months and not through the
entire 54 months. Researchers argued in the study that “long-term maintenance
strategies may be needed” in order for the effects to be sustained over the
course of multiple years.
Source: JAMA Network
AliveCor announced in November that a research
version of its mobile technology could identify STEMI (ST-elevation myocardial
infarction), after a study found that it was able to detect the condition with
“good correlation and high sensitivity”, according to a press announcement,
compared to a standard 12-lead ECG or traditional ECG technology. Two months
before that, AliveCor announced that it was working on a six-lead smartphone
ECG, labelled Project Triangle.
Source: Company presentation and interview
with US outlet CNBC
Labs start-up raises $6.75m in seed funding
Myia Labs announced towards the
end of 2018 that it secured $6.75m in seed funding, and the interesting part
was that the round saw participation from the American College of Cardiology.
The start-up uses data from wearables to monitor patients with chronic illnesses,
examining metrics such as heart
rate, blood pressure and others, and applies machine learning to issue alerts
to those caring for them in case major changes are identified.
#Sensium is a wireless system that monitors vital signs (temperature, respiration and ECG) in the low-risk post-surgery patients. It costs 20€/patient. The nurse is alerted if any of the parameters is abnormal and takes action.
#Sensordot is a device that can measure ECG, motion, blood pulse flow and respiration with autonomy of 24h.
#LabPad is a smart device that tests INR in 5 seconds… costs around 700€. Very useful for our patients under VKA.
#mawi wrist band is an ingenious device similar to the FitBit, however, it is able to provide a 1channel ECG.
Even though I found all the devices and software very interesting, I would say that the @mawi wrist band has by far the biggest potential, due to its capability to provide a 1 channel ECG and due to its low price (around 30€).
#Cardiologs is a cloud-based start-up that uploads 7 days holter ECG and interprets it faster and more accurate.
#Carnalife is a portable telemedical system combining artificial intelligence and augmented reality simulations of CT and MRI scans
#implicity gathers all pacemaker and defibrillator brands under one platform, interprets data and sends it quickly to cardiologists for appropriate response. @escardio
#Cardiomatics is a cloud-driven tool for ECG analysis
- Head of Interventional Cardiology, Centre Hospitalier Montluçon, France - Editor in chief CCRJ (Cardiology Case Reports Journal) - Editor in chief secondary JFCC (Journal Francophone de Cas Cliniques)
- FESC : Fellow of the European Society of Cardiology
- ESC Research Grant winner