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 The SEARCH-AF study has shown that the use of an ECG lead (DI) on an iPhone ECG (iECG, AliveCor KardiaMobile) accurately diagnosed AFib, making this technology feasible for the screening of subclinical AFib in primary care and in the community. 170 In the REHEARSE-AF study, a randomized trial of AFib screening involving 1,001 participants aged ≥ 65 years and with CHA 2 DS 2 -VASc ≥ 2, 171 the participants were randomized to screening with AliveCor KardiaMobile (iECG) twice a week for 12 months (and additional ECG in case of symptoms) or usual routine. The use of iECG increased by almost four times the diagnosis of AFib (HR 3.9, p = 0.007). Smartphones, apps, and cloud storage technology have the potential to change the practice of medicine and the way decisions are made. On smartphone platforms, medical or health care applications can analyze a range of vital signs through built-in sensors, interconnected devices, or peripherals. 171 The transfer of ECG images by multimedia messaging can be a practical, low-cost procedure in telecardiology. 172 These new technologies may increase the detection of arrhythmias, but the real value of these new methods has yet to be evaluated in rigorously conducted studies. 2.7.9. Channelopathies Inherited electrical syndromes are less frequent indications for ICD implantation. However, their management can be challenging because these devices are then implanted in patients who are often younger and less likely to comply with the required follow-up. 174 Electrical abnormalities may occur in these diseases, predisposing the patient to unnecessary shocks and requiring careful programming. 175 The pediatric population, which often has implanted epicardial electrodes, is specifically more vulnerable. In such patients, telemonitoring may be particularly useful for surveillance, early detection, and preventive programming. 176 In the multicenter Brugada registry, the number of outpatient visits was significantly lower in a telemonitoring group compared with a control group (p < 0.001), and there was a trend suggesting that the number of inappropriate shocks was also reduced. 177 2.7.10. Tachycardia and Ventricular Fibrillation Remote patient monitoring can be valuable for prompt assessment of the appropriateness of the detection and the efficacy of the administered therapy. If shock is appropriate, and clinical condition is stable, the physician can reassure the patient without requiring a hospital visit. In a multicenter pilot study, 81% of the episodes of ventricular tachyarrhythmia were analyzed remotely, and in 85% of the cases, no further action was required. 178 The TRUST study demonstrated that remote monitoring allows early detection of ventricular tachyarrhythmias compared with standard follow-up (1 day versus 36 days for ventricular fibrillation and 1 day versus 28 days for ventricular tachycardia, p < 0.001). 179 Other potential benefits of remote monitoring include the prevention of inadequate shocks and appropriate but unnecessary shocks. Inadequate detection due to supraventricular tachyarrhythmias (or T-wave oversensing) may lead to the patient receiving a notification for in-hospital reprogramming or other interventions. 180 Proper delivery of ICD shock for slow, stable ventricular tachycardia may lead to device reprogramming with broader use of painless antitachycardia therapies. Recurrent and self-limited asymptomatic rapid ventricular tachycardia occurring in the ventricular fibrillation window (triggering alerts in some systems, regardless of the administered therapy), can be detected early and, with appropriate intervention, be programmed to prevent electrical storms. In addition, timely treatment of tachycardias may prevent early battery depletion caused by recurrent loads and shock administration. 176,181 2.7.11. Congenital Heart Disease Tele-echocardiography can establish an early diagnosis of congenital heart diseases to guide therapeutic management. 182 A North American multicenter study in 338 paired infants (with and without access to telemedicine) with or without minor heart disease showed a statistically significant reduction in the percentage of infants transferred to a tertiary hospital (10% versus 5%), as well as in total hospital stay and intensive care unit (ICU) stay. 183 Telemedicine increases the ability of pediatric cardiologists to provide higher quality care to a greater number of patients, although high-quality studies evaluating the impact of this intervention are still limited. 2.8. Cardiovascular Teletomography and Teleresonance Despite the apparent similarity between teleimaging and local diagnostic services, divergences between both occur in one fifth of the cases. Specifically, divergences with clinical impact occur in up to 1 to 3% of the cases. We can hypothesize that the reasons for these divergences may be inadequate imaging quality, unavailability of patients’ clinical data (like current and past history and physical examination), limited access to patients’ laboratory tests and other imaging evaluations, fatigue, and simple interobserver variation. The workflow of imaging diagnosis in local hospitals and in telediagnosis may be difficult to distinguish. Generated images are stored in imaging systems (picture archiving and communication system – PACS, for example) and then analyzed by the radiology department (and other specialties working with imaging tests, like cardiology and obstetrics). In teleimaging, the image is transmitted to an external center and analyzed the same way that it would be done locally. Further studies are needed to compare the diagnostic performance of teleimaging versus local imaging. Both may even be assumed to have the same performance, but evidence is critical to confirm our assumptions and can determine not only whether teleimaging can be performed, but also the optimal conditions to be carried out safely and cost-effectively without harm to the patient. 2.8.1. DICOM Standard A new group of services developed in previous years was introduced in 1993, the Digital Imaging and Communications in Medicine (DICOM) standard. The objective was to standardize data and information obtained by imaging methods, normalizing the rules for transmission and storage of medical information. This group of services uses a digital format that associates images with metadata-type information 1030