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 2.7.3. Emergency Services Brazil has a geographically distributed health care system in which UBSs, emergency care units (ECUs), secondary hospitals, and ambulances are scattered across the country, often at remote locations. Specialized centers are located in advanced care units, like tertiary hospitals, located in major cities. In this context, telemedicine tools can improve emergency management. 133 Telemedicine has different applications in emergency services, ranging from electrocardiographic transmissions associated or not with synchronous teleconsultations to assist in the early diagnosis and management of cases of acute coronary syndrome (ACS); clinical DSSs to help with the diagnosis, management, and prediction of cardiac complications in patients with ACS; 133 transmission of bedside ultrasonographic images before hospital admissions; 134 and image transmission and support in the diagnosis and management of patients with acute stroke. 135 The use of DSSs could increase the adherence to guideline recommendations in the management of patients with ACS, but evidence on its impact on clinical outcomes in this context is still limited. 135 2.7.4. In Systems of Care for Acute Myocardial Infarction Systems of care for AMI integrate preadmission services, hospitals, and hemodynamic services comprising the care of patients with AMI in a given region in order to optimize the management of clinically suspected patients. The proposal of these systems is to delineate the patients’ care flow involving early diagnosis, preadmission care, initial treatment, use of thrombolytic agents, referral to a specialized hospital, and post-event follow-up. They target high-quality, effective, safe care for patients with AMI by optimizing resources and reducing disparities in their access to care. 133,136 Telemedicine services may play a crucial role in AMI systems of care, as they facilitate the communication between a physician in an emergency unit, low-complexity hospital, or pre-hospital admission with cardiologists at the hub or hospital with a hemodynamic center that will receive the patient. Cardiologists can assist in (i) analyzing and interpreting electrocardiograms for accurate and early diagnosis of ST- segment elevation AMI, 132,137 (ii) guiding the best course of action, including the administration or not of thrombolytic agents and other medications, through synchronous teleconsultations, i.e. , real-time communication between the on-site professional and the remote specialist, 137,138 and (iii) monitoring the patient’s clinical condition through telemonitoring, with synchronous data transmission. 137 The incorporation of telemedicine strategies in systems of care for AMI is a worldwide trend. A recent meta-analysis including studies conducted in Europe (11), North America (8), South America (5), Asia (9), and Australia (2), with a total of 16,960 patients, found consistent moderate-quality evidence that telemedicine strategies associated with usual care in this context reduce in-hospital mortality by 37% (RR 0.63, 95%CI 0.55-0.72), with a number needed to treat (NNT) of 29 (95%CI 23-40) when compared with usual care without telemedicine. The study also found poor quality evidence that this intervention can reduce door-to-balloon time (mean difference 28 minutes, 95%CI -35 to -20 minutes) and 30-day (RR 0.62, 95%CI 0.43-0.85) and long-term (RR 0.61 95%CI 0.40-0.92) mortality. 138 In Brazil, Belo Horizonte, Campinas, Salvador, São Paulo, and the Northern Region of Minas Gerais (encompassing 89 municipalities) have published initiatives in this area. 137,139-143 Decreased system delays and increased reperfusion rates have been observed in cases of ST-segment elevation AMI, with evidence of reduced hospital mortality. 139,143,144 A typical telemedicine system comprises a specialized center (hub) and multiple remote care units distributed within a geographic region (spoke centers) connected bidirectionally by a communication channel. The specialized center may be a referral hospital in cardiology, the operation center of an Emergency Mobile Care Service ( Serviço de Atendimento Móvel de Urgência , SAMU), or a telemedicine center. Some systems of care for AMI comprise more than one specialized center, each with specific remote units for regional coverage. 145 The 2015 Telemecardiology Guideline for the Care of Patients with Acute Coronary Syndrome and Other Heart Diseases details models of care using telemedicine systems for the care of patients with ACS. 133 2.7.5. In Controlling the Use of Anticoagulants The strategy of self-management of anticoagulants has been associated with a significantly lower risk of ischemic stroke and all-cause mortality compared with direct treatment with oral anticoagulants, while no significant differences were observed for major bleeding and mortality. However, decreased surveillance is a potential problem for the detection of patients who are unable to take care of their own treatment. A structured education program is required for patients and/ or caregivers and for involved professionals in health care and quality control. 146-148 2.7.6. Cardiac Rehabilitation Guidelines recommend that patients should undergo cardiac rehabilitation after AMI, percutaneous coronary intervention (PCI), or myocardial revascularization. However, rehabilitation is still underused, with participation of only 14–31% of all eligible patients. Patients’ inability to attend the sessions and costs are important barriers. 149 Telehealth interventions using ICTs to enable remote rehabilitation programs can overcome common barriers to rehabilitation access while preserving clinical supervision and prescription of individualized exercise. 150 In a systematic review of 11 studies, the types of intervention were variable and included the use of mobile or computer applications, biosensors, and interventions delivered by landline phone lines. The interventions involved prescription and/or monitoring of the participants’ performance and adherence. All interventions included feedback, education, psychosocial support, and/or behavioral changes via landline phone communications, mobile messaging, e-mail, website use, online tutorial, or online chat. 151 The level of physical activity was higher in the intervention group compared with the usual care group. Compared with face-to-face rehabilitation, the intervention 1028