Management of a heart failure patient during a pandemic: A telemedicine success story A ventricular cardiac arrhythmia detected by a mobile phone application

Abstract

Remote patient monitoring (RPM) is rapidly gaining popularity for the management of heart failure (HF) patients. We present a case involving a 63-year-old male with ischemic cardiomyopathy, in which an RPM application on a mobile phone successfully identified slow ventricular tachycardia (VT). Patient's implanted defibrillator failed to detect the VT event due to the heart rate falling below its VT detection threshold. The rapid detection of VT by the RPM system triggered an immediate response from the HF team. This case underlines the multiple roles that RPM can take in identifying major adverse events in HF patients.

Introduction

Remote patient monitoring (RPM) is becoming increasingly relevant in the management of patients with heart failure (HF). We present a case in which a RPM application on a mobile phone successfully identified a ventricular tachycardia (VT), a potentially lethal cardiac arrhythmia. Patient's implanted defibrillator had failed to detect the VT event but the fact the RPM system detected a tachycardia with a drop in blood pressure triggered an immediate response from the HF team and avoided a bad outcome for this patient. This case nicely underlines the multiple roles that RPM can take in identifying major adverse events in HF patients.

Case report

Context

A 63-year-old male was followed at the HF clinic for ischemic cardiomyopathy with a left ventricular ejection fraction of 25%. In 2018, he received an implantable cardiac defibrillator (ICD) for primary prevention. Two years later, he experienced a first episode of VT at 170 bpm with decompensated HF. To reduce the risk of VT recurrence, patient's medication was optimized (Beta blockers were up-titrated). In 2020, during the COVID-19 pandemic, he joined a new HF telemonitoring program (TakeCare™, Greybox Solutions; available on both Android and iOS platforms) at our institution, and was daily self-reporting his weight, blood pressure, heart rate, and symptoms. All these data were followed by a nurse at the HF clinic on a dedicated dashboard, 5 days a week from 8 am to 4 pm. Physicians had access to the platform if needed. This telemonitoring program was a service offered to each patient within our HF clinic and immediately became part of the standard of care in the context of the COVID-19 pandemic. Patient's consent was obtained to report the following event.

Two intriguing alerts

On 1 February 2021, the nurse received two alerts for this patient: an unusual tachycardia at 120 bpm and a low blood pressure (80/52 mmHg, see Figure 1). The patient was contacted by telephone and denied any symptoms of HF, although he noted some fatigue. A remote interrogation of his ICD was performed by the arrhythmia team which confirmed the heart rate of 120 bpm but whose specific rhythm remained undetermined. The patient was asked to come to the HF clinic the same day. Physical examination showed a regular rhythm at 130 bpm. Blood pressure was 84/64 mmHg, O₂ saturation 98% on room air and oral temperature was 37.2 °C. The rest of the examination was unremarkable with no signs of right or left HF.

Figure 1.

Blood pressure and heart rate data entered by the patient on his mobile app.

An unexpected finding

An electrocardiogram (EKG) was performed at our HF clinic and demonstrated a slow VT at 128 bpm (Figure 2(a)). This rate was below the ICD's detection zone of 150 bpm. The patient was promptly managed by the arrhythmia team who initially attempted to overdrive the VT using rapid ventricular pacing. Since it was not effective, an electrical cardioversion was performed. A few weeks later, the patient underwent an elective VT ablation (see Figure 2(b) for post-ablation EKG), without recurrence at one year of follow-up.

Figure 2.

(a) Electrocardiogram (EKG) showing a slow ventricular tachycardia; (b) patient's EKG after ablation.

Discussion

HF is a severe chronic disease characterized by poor quality of life, frequent hospitalizations, and low survival rates despite modern medical therapy and multidisciplinary clinical care. Over the past few years, in the context of the COVID-19 pandemic, RPM systems have helped healthcare providers monitor patients at home by providing daily data on their health status, allowing them to intervene quickly when necessary.^1,2 Most scientific evidence suggests that the appropriate use of RPM can significantly improve all-cause mortality and hospitalizations for HF. ³ The originality of the case presented here does not lie in the early detection by an RPM system of a pre-decompensated stage of HF but rather in the circumstances in which this detection was performed. Although the patient had an ICD comprising an embedded remote monitoring system, it did not report any abnormalities and a similar situation has been described previously. ⁴ It was the transmission of patient's vital signs via the mobile application that revealed a new event, allowing rapid intervention and preventing an adverse outcome.

Slow VT (<150 bpm) is a common cause of decompensation in HF patients. Its diagnosis can be challenging since most episodes are undetected (and therefore untreated) due to the use of high detection thresholds to avoid inappropriate shocks. ⁵ Being able to detect such arrhythmia in a timely manner was crucial to prevent hemodynamic instability, emergency room visits, or hospitalization, especially for this patient with a low ejection fraction. Remote detection of incessant slow VT with an ICD capable of home monitoring has been reported in the past. ⁶ But to our knowledge, this is the first reported case of slow VT discovered after using a mobile application in an HF patient with an ICD.

The current infrastructure of HF clinics in Quebec and more widely in Canada does not yet allow all patients to benefit from this type of RPM technology. However, in May 2020, the HF clinic at our institution implemented an RPM solution (with the support of the Ministry of Innovation of Quebec) and offered it to any patient (or its caregiver) with a mobile device (smartphone or tablet). Through this mobile application, patients could enter manually (or via Bluetooth if they had connected objects) their temperature, saturation, weight, blood pressure, and heart rate. They also regularly answered a questionnaire to assess their HF and potential COVID-19 symptoms. These data were checked on a web dashboard by a nurse, every working day. In the event of abnormal data, an alert was generated, and the nurse called the patient according to protocol. More than 300 patients have been followed in this program, which is still currently active in our institution but whose long-term sustainability is uncertain in the Quebec healthcare ecosystem, depending on its cost-effectiveness or the development of new features such as digital therapeutics solutions.

Conclusion

In a post-COVID-19 era, where the future of telemedicine is uncertain (at least on a large scale), this case illustrates that it retains its usefulness. Selected populations such as those at high risk of a major cardiac event may still greatly benefit from this type of technology. As we navigate this evolving landscape, the collaboration between technology and healthcare providers is crucial. It allows us to an accurate assessment of the clinical needs, adaptation of technology to meet those needs, and ultimately, measurement of its overall impact on our patients.