ABC | Volume 113, Nº5, November 2019

Guidelines Guideline of the Brazilian Society of Cardiology on Telemedicine in Cardiology – 2019 Arq Bras Cardiol. 2019; 113(5):1006-1056 In telecardiology, tele-echocardiography is a promising strategy for rationalization of the access to complementary propaedeutics, early diagnosis, prioritization of referrals, and organization of waiting lists. Initial evidence of tele- echocardiography application derive from population-based screening studies, for example, a study conducted in rural India, where more than 1,000 echocardiograms were performed in about 11 hours and transferred to a cloud computing system for expert analysis using telemedicine. 109 The strategy proved feasible and showed good agreement between preliminary field diagnoses and the reports by experts (k = 0.85), and an alarming 16% rate of major abnormalities (including 32.9% of valvular defects). Even in high-income regions like the UK, evidence has shown echocardiographic screening in primary care by nonspecialists to be an attractive strategy, with clinically significant (moderate to severe) valvular disease observed in 6.4% of the asymptomatic population aged ≥ 65 years and associated with socioeconomic factors. 110 The strategy may be especially useful in Brazil, which has a presumably high burden of undiagnosed cardiovascular disease and limitations in the provision of specialized tests, including conventional echocardiography. The tele-echocardiography strategy was first tested in Brazil in a program for screening of rheumatic heart disease (the Rheumatic Valvular Disease Screening Program study; Programa de RastreamentO da VAlvopatia Reumática - PROVAR). The study established, at a research level, a routine for the acquisition of simplified imaging protocols using portable and ultraportable devices by non-physicians (nurses and technologists), which were uploaded to dedicated cloud computing systems for storage and remote expert interpretation. 111,112 In addition to remote diagnosis, telemedicine was also used to train health care professionals on basic echocardiographic principles through interactive online modules. After training, health care professionals with different backgrounds were able to diagnose rheumatic heart disease with accuracy. 111 The project reported a high prevalence of subclinical rheumatic heart disease (4.2%), which is quite significant considering the current impact of the disease on public health. 113 A similar strategy was subsequently applied in primary care. Professionals (physicians, nurses, nurse technicians)from health care centers located in low-income regions of metropolitan areas of Belo Horizonte and Montes Claros received online and in-person training for the acquisition of a simplified echocardiographic protocol with ultraportable devices and support by the project’s field team. Echocardiography was performed in asymptomatic individuals of three age groups (17-20, 35-40, and 60-65 years) as a screening method and in patients on a waiting list to undergo echocardiography or who had this test requested by the family health care team. The results showed that a) the strategy is feasible for the conditions found in Brazil and has the potential to be expanded to other scenarios; b) the prevalence of echocardiographic abnormalities in asymptomatic populations was high (above 20%) in general; c) among patients on a waiting list for echocardiography, more than 50% had no significant abnormalities on screening echocardiography; and d) the correlation with conventional echocardiography was satisfactory. 112 A prediction score was developed from these findings, incorporating clinical data and variables from the simplified echocardiogram. 114 Thus, tele-echocardiography may be a strategy for early diagnosis but is mainly an instrument to prioritize and organize waiting lists in health care systems with limited availability of tests and specialized consultations. However, the incorporation of this model into Brazilian health policies depends on broad regulatory discussions involving authorities, professional councils, and medical societies – especially regarding simplified image acquisition by non-physicians. The adoption of tele-echocardiography (Table 2.1) for the care of disadvantaged remote communities has potential advantages, but this method still lacks robust scientific validation with prospective controlled studies confirming its benefits to patients’ health and cost-effectiveness, among other challenges. 2.2.6. Tele-Education Remote educational activities in cardiology for health care professionals, offering courses, lectures, and learning tools on clinical issues and care management, have the added benefit of improving the quality of care. Educational activities for patients should be encouraged for their health empowerment. In remote municipalities with small populations, PHC is often the only level of local health care, while their health care units receive patients with acute cardiovascular diseases. Thus, telecardiology in PHC not only should qualify the care of chronic diseases but should also support urgent care for ischemic diseases and arrhythmias. Due to the myriad of applications of simple telemedicine tools, cardiology can be considered one of the specialties most sensitive to the use of ICTs. The triad teleconsulting, Table 2.1 – Potential advantages and challenges for the adoption of tele-echocardiography in Brazil Advantages Challenges Allow access to the method at remote locations Lack of standardization of the components of tele-echocardiography Optimization of clinical outcomes Absence of scientific evidence confirming the impact on clinical outcomes Reduction in the cost of transporting human resources to geographically distant areas Absence of scientific evidence confirming cost-effectiveness; questions about reimbursement and system costs Reduction in the cost of transporting patients to tertiary centers Uncertainty about adherence by local health care professionals Reduction in the number of unnecessary echocardiograms Veto of the Brazilian legislation to the work of non-medical operators (sonographers) Lack of guidelines for training of operators Medical-legal uncertainties Legislative issues related to licensing, data storage, privacy, and confidentiality 1025