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 with telehealth was more effective in improving the level of physical activity, exercise adherence, diastolic BP, and LDL-cholesterol, with poor- to moderate-quality evidence. Telehealth rehabilitation was similar to face-to-face rehabilitation in maximal aerobic exercise capacity and other modifiable cardiovascular risk factors. 151 The Telehab III study was a prospective, randomized, multicenter controlled trial with patients undergoing cardiac rehabilitation. In all, 140 patients were randomized to a conventional rehabilitation group or a 24-week Internet- based telerehabilitation group associated with conventional rehabilitation. The additional telerehabilitation program showed improvement in physical fitness and quality of life and induced persistent health benefits. 152 A clinical trial conducted in China randomized 98 patients with NYHA I-III functional class heart failure to an 8-week home-based teleconsultation exercise training program or usual outpatient follow-up. Statistically significant improvements were observed in the experimental group in terms of quality of life and result in the 6-minute walking distance test compared with the control group. These results confirm that physical training via teleconsultation is an effective alternative method for cardiac rehabilitation. 153 The noninferiority, randomized controlled trial REMOTE- CR tested the effects and costs of cardiac rehabilitation by real-time teleconsultation in 162 patients with heart failure and demonstrated this to be a cost-effective alternative that can enhance the scope of rehabilitation. 154 Home-based cardiac rehabilitation is an alternative to increase patients’ engagement in the program by presenting greater flexibility and activity options, offering choices based on the patients’ values and preferences, and allowing the implementation according to the patients’ daily routine. 155 The association of cardiac rehabilitation with conventional rehabilitation has been shown to be more effective and efficient compared with a conventional rehabilitation program alone, as it reduced the rates of readmission due to cardiovascular causes and improved quality of life during the study period. 156 2.7.7. Remote Monitoring by Implantable Devices Pacemaker telemonitoring has not significantly improved quality of life and number of cardiovascular events, but provided early detection and treatment of events, reducing hospital admissions and visits (routine and emergency) at lower costs compared with hospital follow-up. 157 Implantable cardiac defibrillators (ICDs) or resynchronization defibrillators are another type of implantable monitoring systems. Some of these devices may be equipped with software for multiparametric monitoring of, for example, thoracic impedance and right ventricular filling pressure with measurements captured by a right ventricular lead. A groundbreaking study published in 2008 showed their clinical benefits in patients with NYHA functional class III heart failure. 158 The IN-TIME trial later tested a similar strategy using multiparametric monitoring devices (ICDs and resynchronization defibrillators). The parameters evaluated in the trial included events like ventricular and atrial tachyarrhythmia, low percentage of biventricular pacing, increased frequency of ventricular extrasystoles, decreased patient activity, and abnormal intracardiac electrogram. Abnormalities in these parameters triggered a structured phone contact. The group allocated to telemonitoring had a significant reduction in combined clinical outcomes and total mortality. 159 Other similar studies have also shown a reduction in combined clinical outcomes, often related to a decreased need for face-to-face visits. 160 Results from an unselected population cohort study also indicated benefits of remote monitoring with information from ICD/cardiac resynchronization therapy (CRT) on mortality. 161 However, a meta-analysis 162 of 11 randomized trials evaluating 5,703 patients showed no consistent results on clinical outcomes. The meta-analysis showed that device telemonitoring was associated with a reduction in the total number of planned, unplanned, and emergency room visits (RR 0.56, 95%CI 0.43-0.73, p < 0.001). However, rates of cardiac-related hospitalization (RR 0.96, 95%CI 0.82-1.12, p = 0.60), the composite endpoints of emergency visits, unplanned hospital visits, or hospitalizations (RR 0.99, 95%CI 0.68-1.43, p = 0.96), and total and cardiac mortality were also similar between groups. 162 2.7.8. Atrial Fibrillation Patients with atrial fibrillation (AFib) comprise a special group, considering that, among other things, AFib has been accounted for approximately 60% of pacemaker and CRT/ defibrillator (CRT-Ds) alerts and nearly 10% of all ICD alerts in a worldwide database. 163 Remote monitoring has excellent sensitivity (95%) in detecting AFib, a feature that becomes even more important, considering that 90% of the detected episodes were asymptomatic. 164,165 The potential benefits of remote monitoring include detection and early reaction ( e.g. , drug therapy, device reprogramming, or electrical cardioversion) to prevent atrial remodeling and serious adverse events related to AFib. The IMPACT trial has shown that the detection of asymptomatic AFib via remote monitoring considerably shortened the time to anticoagulation initiation (3 days versus 54 days) but was not associated with reduced rates of stroke, systemic embolism, and bleeding. 166 In the preclinical phase of an arrhythmia, telemedicine screening may detect asymptomatic AFib. 89 In a pilot study, the daily transmission of electrocardiographic data by phone facilitated the diagnosis of asymptomatic paroxysmal AFib. 90 In large cohorts, telecardiology services improved the management of patients with AFib and detected new cases of arrhythmia. 167 Support by telemedicine can improve the diagnosis of silent AFib. 168 Bilgi et al. 169 demonstrated that home-based electrocardiographic assessment supported by telecardiology increased the sensitivity of the diagnosis of AFib in elderly individuals and was useful in identifying individuals with AFib and atypical symptoms at home. 169 The electrocardiogram (ECG) was recorded and transmitted by a smartphone to a 24/7 telecardiology center and evaluated by a cardiologist. The telecardiology support increased two times (40 years), four times (60 years), and seven times (70 years) the rate of AFib diagnosed at home. 1029