HRS/EHRA/APHRS/LAHRS/ACC/AHA worldwide practice update for telehealth and arrhythmia monitoring during and after a pandemic

Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), started in the city of Wuhan late in 2019. Within a few months, the disease spread toward all parts of the world and was declared a pandemic on March 11, 2020. The current health care dilemma worldwide is how to sustain the capacity for quality services not only for those suffering from COVID-19 but also for non-COVID-19 patients, all while protecting physicians, nurses, and other allied health care workers.


| NEED FOR D I G ITAL HE ALTH DURING THE COVID -19 PANDEMIC
occur in up to 6% of hospitalized patients with COVID-19 infection. 3 There have also been several case reports of atrioventricular block in hospitalized patients, which is otherwise rarely described during viral illness. 4,5 Although the residual left ventricular dysfunction and arrhythmic risk are currently unknown, preliminary pathophysiological, 6 histological, 7 and imaging 8 data suggest that SARS-CoV-2 infection holds the potential to induce durable myocardial changes predisposing to arrhythmias or heart failure.
Electrocardiographic monitoring and inpatient monitoring services may become necessary but face the potential hurdles of limited telemetry wards, contamination of equipment and infection of health-care personnel, and shortage of personal protective equipment. 9,10 In parallel, there is a continued responsibility to maintain care of COVID-19-negative patients with arrhythmias. These pressures have led to inventive utilization and adaptation of existing telemedicine technologies as alternative options.
This document discusses how digital health may facilitate electrophysiology practice for patients with arrhythmia, whether hospitalized for COVID-19 or not. The representation of authors from some of the most severely affected countries, such as China, Spain, Italy, and the United States, is a tribute from our worldwide community to those colleagues who have worked on the front lines of the pandemic.

| MONITORING S TR ATEG IE S DURING A PANDEMI C : HERE TO S TAY
In light of the current pandemic, monitoring strategies should focus on selecting high-risk patients in need of close surveillance and using alternative remote recording devices to preserve personal protective equipment and protect health-care workers from potential contagious harm.

| Inpatient
For inpatient monitoring, telemetry is reasonable when there is concern for clinical deterioration (as may be indicated by acute illness, vital signs, or sinus tachycardia), or in patients with cardiovascular risk factors and/or receiving essential QT-prolonging medications.
Telemetry is generally not necessary for persons under investigation without concern for arrhythmias or clinical deterioration and in those not receiving QT-prolonging drug therapy. In situations in which a hospital's existing telemetry capacity has been exceeded by patient numbers or when conventional telemetry monitoring is not feasible, such as off-site or nontraditional hospital units, mobile devices may be used, for example, mobile cardiac outpatient telemetry (MCT) as an adjunctive approach to support inpatient care. [11][12][13][14][15] The majority of MCT devices can provide continuous arrhythmia monitoring using a single-lead electrocardiogram (ECG) and allow for real-time and offline analysis of long-term ECG data. Telemetry can be extended using patch monitoring. 16,17 Smartphone ECG monitors are wireless and have also been utilized during the current pandemic. Information is limited, however, on how parameters such as QTc measured on a single-(or limited number) lead ECG can reliably substitute for 12-lead ECG information. 18,19 In one study, QT was underestimated by smartphone single-lead ECG. 20

| Outpatient
The principles of remote patient management, crossing geographic, social, and cultural barriers, can be extended to outpatient care and are important to maintain continuity of care for non-COVID-19 patients. [21][22][23] Virtual clinics move far beyond simple telephone contacts by integrating information from photos, video, mobile heart rhythm, and mobile health devices recording ECG, and remote cardiovascular implantable electronic device (CIED) interrogations. 24 A variety of platforms have been developed and used specifically to provide telehealth to patients via video teleconferencing 25,26 (Table 1). Most health-care centers have expanded use of telemedicine, with some reporting 100% transformation of in-person clinic visits to telemedicine-based visits in order to maintain care for non-COVID-19 patients, thus obviating their need to come to the hospital or clinic.
This supplements social distancing measures and reduces the risk of transmission, especially for the older and more vulnerable populations. It also becomes a measure to control intake into emergency rooms and outpatient facilities and to permit rapid access when necessary to subspecialists.
Electrophysiology is well placed for virtual consultations. All preobtained data, including ECGs, ambulatory ECG monitoring, cardiac imaging, and coronary angiography can be adequately reviewed electronically. Digital tools such as direct-to-consumer mobile ECG (Table 2) and wireless blood pressure devices can be used to further complement the telehealth visit without in-person contact. CIED, wearable/mobile health, and clinical data can be integrated into clinician workflow.
Additional diagnostic information might be obtained without in-person contact using home enrollment of prescribed ambulatory rhythm monitors. Patch monitors can be mailed to patient homes and easily self-affixed, unlike Holter monitors with cables and electrodes requiring placement by health-care workers. In some cases, new or follow-up telehealth visits will require an adjunctive in-person visit to perform a 12-lead ECG, ECG stress test, echocardiogram, or other diagnostic procedures. Occasionally, conventional clinic visits are required to accurately assess the impact of comorbidities or frailty on procedural risk, or to allow comfortable discussion with multiple family members when planning procedures with high risk. Telephone-only visits (ie, without video) may allow for a broader reach owing to ease and ubiquitous accessibility as a communication strategy for immediate access for urgent matters.
There are many barriers to implementation, such as inadequate reimbursement, licensing/regulatory and privacy issues, lack of infrastructure, resistance to change, lack of access/poor Internet coverage, restricted financial resources, and limited technical skills (eg, in the elderly patient population). Some telehealth and remote ECG monitoring technologies may be simply unaffordable and/or unavailable, leading to different levels of uptake within communities and across the globe. All stakeholders should collaborate to address these challenges and promote the safe and effective use of digital health during the current pandemic. In recent months, regulations have been eased to permit consults with new patients, issuing prescriptions, and obtaining consents. In that sense, the COVID-19 pandemic may serve as an opportunity to evolve current technologies into indispensable tools for our future cardiological practice.

| THER APY FOR COVID -19 AND P OTENTIAL ELEC TRI C AL EFFEC TS
No specific cure exists for COVID-19. 28 investigated in ongoing trials but also have been used off label in many parts of the world. These may exert QT-prolonging effects 31 (Table 3) and, since recent observational data have questioned their efficacy, require a careful risk-benefit adjudication. 32

| Electrocardiographic monitoring during clinical trials
Several double-and multi-arm blind randomized controlled trials are underway worldwide for COVID-19 outpatients utilizing different medications that may prolong the QT interval. 52

| THE FUTURE: D I G ITAL MED I CINE C ATALY ZED BY THE PANDEMI C
The COVID-19 public health emergency has forced changes to traditional norms of health-care access and delivery across all continents. 10 It has accelerated adoption of telemedicine and all aspects of digital health, regarded as a positive development. Today's new reality will likely define medicine going forward. Many monitoring and diagnostic testing aspects of both inpatient and outpatient care will be increasingly served by digital medicine tools.  12 Wearable and smartphone-based devices allow convenient real-time monitoring for arrhythmias on a long-term basis owing to the comfort associated with their small size and ease of use while reducing patient and health-care worker exposure. Remote CIED monitoring has existed for decades. 24 It is strongly endorsed by professional societies, but in practice only a fraction of its diagnostic and therapeutic capabilities has been utilized-until now. 59 Since the start of the pandemic, utilization of wireless communication with CIEDs has grown exponentially, permanently altering the future of device follow-up. Patient outcomes may be improved with intensive device-based monitoring compared with traditional in-clinic evaluations at regular intervals. 60 Recent data indicate that in-person CIED evaluation can be extended safely to at least biennially when daily digital connectivity is maintained. 61 Remote monitoring has the potential advantage of detecting and alerting caregivers (and in the future-patients directly) about important parameter changes, enabling earlier patient hospitalization, even during a presymptomatic phase. 62 Connectivity permits longitudinal follow-up, with advantages ranging from individual disease management to assessment of penetration of recommended therapies into communities. 60 for data management (and mechanism for relay to patient and caregiver), interoperability with EMR, application of predictive analytics, cybersecurity (and with it the capability for limited forms of remote CIED programming), and reimbursement. [64][65][66] In summary, the crisis precipitated by the pandemic has catalyzed the adoption of remote patient management across many specialties and for heart rhythm professionals, in particular. This practice is here to stay-it will persist even if other less arrhythmogenic treatment strategies evolve for COVID-19 and after the pandemic has passed. This is an opportunity to embed and grow remote services in everyday medical practice worldwide.