Digital Health and Cardiac Rehabilitation

A paradigm shift offering care continuum of multidisciplinary holistic interventions

Alben Sigamani

Alben Sigamani

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Alben Sigamani is a clinician scientist with 20 years of experience in cardiovascular disease research. After years of working on generating evidence, he serves as the Chief Scientific Officer and Founding Partner at Numen Health. He currently focuses on translating evidence to practice and attaining positive health outcomes.

Digital health platforms have improved access and reliability of non-pharmacological interventions for disease modification, reducing the risk of re-hospitalisation, repeat vascular events, and death. Digital health integration into cardiology practice enables remote access to secondary prevention interventions such as cardiac rehabilitation. Post a coronary event or intervention, and in patients with heart failure, cardiac rehabilitation is strongly recommended.

What is cardiac rehabilitation?

In case of a cardiovascular disease (CVD) diagnosis, cardiac rehabilitation (CR) is an effective modality that enhances the probability of reversal or recovery. CR reduces all-cause mortality and the risk of frequent hospital admissions. In many people, CR also improves the health-related quality of life (QoL). CR helps patients to learn and adopt lessons for secondary prevention. CR also enhances motivation to perform exercise routines and become compliant with lifestyle changes.

Enrolment in a formal cardiac rehabilitation programmeme is evidence-based. A Cochrane review compares home-based to centre-based cardiac rehabilitation showing they were equivalent with added benefits to the patient. Studies in India have reported low availability, affordability, and awareness of cardiac rehabilitation facilities. A comprehensive cardiac rehabilitation facility needs physicians, technicians, nurses, and other health workers and could be expensive. Virtual cardiac rehabilitation delivered at home reduces cost and increases referral and uptake. Studies from the UK and USA have shown that virtual or digital cardiac rehabilitation is effective.

Why digital health?

Digital health is an emerging tool that has the potential to help address health system challenges. ‘digital health’ refers to e-learning, tele-monitoring, text messaging, structured phone support, tele-rehabilitation, tele-consultation, M-health applications, wearables, and artificial intelligence (AI). Managing patients with medical conditions such as CVD, conducting research, and monitoring public health, Digital health modalities can efficiently share medical information with patients, providers, and decision-makers, deliver personalised care, improve patient compliance and adherence, and enable remote patient monitoring and support, disease prediction, and monitoring vital signs.

From the patient's perspective, digital health technologies offer valuable resources for self-management of diseases. Each of these patient-centred care modalities improves the health outcomes of people with CVD. Digital smartphone platforms provide opportunities for active patient participation in their health management. This task-shifting improves clinical outcomes for patients with multiple chronic comorbidities.

Digital health and cardiac rehabilitation

CR is a multi-faceted, medically supervised programme. Core components of guideline-directed therapy include baseline patient assessments, nutritional counselling, risk factor modification (including management of lipids, blood pressure, weight, diabetes mellitus, and smoking), psychosocial interventions, and physical activity counselling and exercise training. AI and machine learning (ML) play essential roles in diagnosis and therapy, including identifying key risk factors, predicting and controlling cardiac arrhythmias, and improving cardiac imaging5. Digital and modern communication technologies deliver personalised care through remote access to patients' instructions, control, and monitoring during physical exercises. Digital health also guides emergency care and records daily clinical data from implanted medical (e.g., pacemakers, defibrillators) or patient wearable devices (blood pressure monitors).

In the primary and secondary prevention of cardiovascular disease, digital technologies such as mobile apps, text messaging, sensor monitoring devices, and online behavioural counselling help understand and change behaviour by providing personalised guidelines for lifestyle changes such as heart-healthy lifestyles, such as medication adherence and positive behaviour change. Particularly against poor diet, smoking, and lack of physical activity, achieve positive health outcomes.

According to a systematic review (2018), smartphone apps reduce re-hospitalisation, improve patient knowledge, quality of life, and mental wellness, and aid in managing CVD risk factors. Smartphone and smartwatch apps can now distinguish between atrial fibrillation and sinus rhythm with sensitivity and specificity similar to electrocardiography (ECG). Mobile apps assist physicians and cardiologists in detecting heart failure. It supports decision making for implanting an implantable cardioverter defibrillator or cardiac resynchronisation therapy. Smartphone apps allow patients to self-perform simple diagnostic tests, such as the six-minute walk test, to assess cardiopulmonary functions, potentially reducing hospital facilities and staff costs. Therefore, digital health technologies help patients improve their health literacy and self-management skills. Similarly, digital health interventions improve access, participation, and cardiac rehabilitation adherence, improving exercise capacity and improve cardiovascular fitness.

Role of digital health in heart failure

Heart failure (HF) is a complex clinical syndrome that imposes a massive clinical, societal, and economic burden. After the age of 60, the prevalence of HF increases by 3.9 per cent, and the number of years lost due to disability has increased by 4.5 per cent in the last 28 years. According to multiple studies, Indians are more vulnerable to ischemic heart disease (IHD) related heart failure with a higher case-fatality rate than western populations. Smoking, high cholesterol, physical inactivity, diabetes, high blood pressure, and obesity are all risk factors for developing IHD, leading to exacerbations and decompensation in HF.

Today, the increasing prevalence of CVD poses challenges to health systems in providing optimal care, and therefore, patient engagement and self-care are becoming increasingly relevant.The internet and smartphone apps are promising tools in cardiology to increase health literacy, which is essential for maintaining health and self-care, as well as understanding health information, medication adherence, and for altering treatment plans to prevent exacerbation of heart failure.

These technologies provide a convenient way to quickly deliver health information to a large cohort of patients, particularly those who lack access to specialised heart failure clinics.  Telehealth technologies allow patients to report symptoms remotely and their needs to their healthcare providers through audio and video interaction. Using asynchronous text-based communication via websites or patient portals helps with basic healthcare needs such as filling prescriptions, receiving test results, scheduling an upcoming screening, and ordering diagnostic tests.

New technology in digital cardiac care

Not only digital technologies target physicians and patients, but also the general public. ECG, angiography, echocardiography, digital subtraction angiography, and photoplethysmography (PPG) are some of the digital diagnostic tools used in cardiology. PPG is a highly researched, non-invasive, low-cost, and convenient diagnostic tool that can detect heart rate with an average 1–1.5 per cent error rate using a smartphone. Applying deep machine learning to PPG data also helps categorise patients' risk of hypertension. Artificial intelligence facilitates faster interpretation of ECG data and even detects signals and patterns humans cannot recognise.

Why a paradigm shift?

Evidence from clinical trials adopting digital health intervention for CR have not yet translated into clinical practice. Gaps exist in gathering insights into measurable changes seen in how interventions improve health literacy, social interactions and self monitoring health parameters. Scientific statements from the American Heart Association (AHA) and the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) suggest which core components of CR to focus and on how is a technology used in digital interventions for CR to achieve comprehensiveness of these programmes. Digital health is creating a paradigm shift from evidence-based healthcare to evidence-based well-being. We believe greater adoption of digital health tools will change practices of referring and remaining compliant with cardiac rehabilitation. With higher adoption of cardiac rehabilitation, we will see lower incidences of re-hospitalisation and improved quality of life.

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