Is Telemedicine an useful tool for Atrial Fibrillation?

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1 THIRD INTERNATIONAL TELEMEDICINE WORKSHOP by SIT at Exposanità 2008: Is Telemedicine an useful tool for Atrial Fibrillation? Data from Italy and China PhD Jun Ma Tongji University in Shanghai, P.R.C. Bologna, 2008 May, 31

2 Atrial Fibrillation (AF) The most common significant heart rhythm disturbance Incidence increases with age and the development of structural heart disease Common cause of stroke (10-15% of all strokes) Associated with significant cardiovascular morbidity and mortality Tends to recur in at least half the patients being treated with antiarrhythmic drug therapy and interventional therapy.

3 AF accounts for 1/3 of all pts discharges with arrhythmia as principal diagnosis 4% Atrial Flutter 6% PVCs 9% SSS 6% PSVT 18% Unspecified 34% Atrial Fibrillation 8% Conduction Disease 3% SCD Baily D. J Am Coll Cardiol. 1992; 19: 41A. 10% VT 2%VF

4 Prevalence of different types of AF and Age Data from the population study PREALENCE( %) ~ 40~ 50~ 60~ 70~ 80~ AGE( y) Val ve AF Nonval ve AF l one AF

5 Relative risk of Stroke in Patients with AF Compared with Patients Without AF 8 6 Framingham Regional heart study Whitehall China survey 12.1% vs 2.3% RR(%) Stroke

6 The Epidemiology of AF in China and Other Countries 50 yr, USA (CHS), single ECG yr, UK, single ECG yr, Netherlands, single ECG & medical record yr, UK, single ECG yr, Netherlands, single ECG yr, USA, medical record yr, UK, single ECG review results 60 yr, Australia, triennial survey % 40 yr, Japan, single ECG yr, Hong Kong, single ECG yr, main land, China, single ECG yr, Denmark, singles ECG yr, West Germany, single ECG yr, India, single ECG 0.1 Patients with AF in China 8 million Hu, HRS 06

7 Percent of Hospitalization in Patients with AF is Increasing in China 9.0% 8.0% 7.65% 7.90% 8.16% 7.90% % of hospitalization 7.5% 7.0% 6.5% 6.0% Average Qi W, et al. Chinese J Cardiol, 2003 ; 31 :

8 AF Treatment Options Rate Control Maintenance of SR Stroke Prevention Pharmacologic Class IA, C, III Prevention: ACE, ARB, Stantins Non- Pharmacologic Catheter ablation Pacing Implantable atrial defibrillator Surgery maze Pharmacologic Ca 2+ blockers β-blockers Digitalis Non- Pharmacologic AVN ablation and pace Pharmacologic Warfarin Aspirin Ximelagatran Non- Pharmacologic Removal/ isolation left atrial appendage

9 How to monitor and evaluate the efficiency of managements Does the Telemedicine have superiority on that?

10 What is telemedicine? Telemedicine is an umbrella term that encompasses any medical activity involving an element of distance. Telecardiology enables a cardiologist at one site to diagnose patients, deliver health care, provide therapy, or consult with another physician or paramedical personnel at a remote site.

11 The Greatest impact To improve the quality of medical service. To increase the efficiency. To expand the access of the healthcare delivery system to the rural population and developing countries.

12 Devices Ambulatory Holter monitor Event -triggered monitor ECG telemeter monitor Loop event recorder Mobile telemetry

13 Basic Operative flow-chart Cardiologists Patients Service Central Information collection

14

15 Telecardiology in AF The main Role suppose to be: To monitor the episode of AF and record it for diagnosis. To find out the asymptomatic AF patient. To follow up the efficiency of the drug management and ablation.

16 The studies in Italy The Telecar (tele-assistance cardiology) project: It was an example of tele-assistance between health centers of the Region Lazio in Italy between 1989 and The Boario Home Care project which suppose to apply telemedicine to cardiovascular disease patients in order to demonstrate the life-saving and functional recovery from 1998 to present. Et al.

17 The Results They reached their maturity and many positive results even if we can consider them preliminary in the field of Telemedicine. However, most of them focused on the general comparison of the mortality. AF was not the key issue of these studies.

18 The studies in China Yang H. The technology development of TELE electrocardiogram monitoring. Fu D, et al, The study of transtelephonic electrocardiography in clinical application. Hua W, et al. Clinical application of tele- electrocardiography. Tang Y, et al. Design of a cardiac monitoring system using mobile communications.

19 Telecardiology in china Holter Holter (24 /48 hours) has been widely implemented as a routine screening examination in most Chinese hospitals for the suspected arrhythmia, presyncope or syncope. Transtelephonic ECG had also been proved to detect arrhythmia among outpatients after acute myocardial infarction Transtelephonic ECG

20 Telecardiology in china The application of telecardiology is still a young and growing discipline. Telecardiology is defined in some urbanized cities featured with high income and mature welfare because of the extra cost and relative low diagnostic yield.

21 The Epidemical Investigation of AF in China Fourteen Natural Populations, 13 Different Provinces

22 Incidence of AF Stratified by Age and Sex in Chinese Population Rate per Men (n=13358) Women (n=15521) Overall Age Group, y Data collected from 13 natural populations from 14 different provinces across China Hu D, et al Chin J Intern Med; in press.

23 Difference in Trend between Paroxysmal AF and Persistent AF 8% 7% 6% per si stent AF par oxys mal AF 5% 4% 3% 2% 1% 0% 30~ 40~ 50~ 60~ 70~ 80~ Hu D, et al Chin J Intern Med; in press.

24 UK: Hill JD et al. J R Coll Gen Pract 1987; 37: Similar trends and relatively lower prevalence of AF in China compared with USA, Australia and UK % China FHS, USA Australia UK years FHS: the Framingham study. Wolf PA et al. Sroke 1991; 22: Australia: Lake FR, et al. Aust NZ Med 1989; 19:

25 Prevalence of Antiplatelet and Anticoagulation in Chinese Patients with AF Warfarin 2% Aspirin 58% None 35% Warfarin 7% Aspirin 38% None 60% Hospitalized patients Qi W, et al. Chinese J Cardiol, 2003 ; 31 : population investigation Hu D, et al Chin J Intern Med; in press

26 Atrial fibrillation : A Long Way to Go!

27 May be telemedicine would be a better way let us to go ahead!

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