Telemedicine in Cardiovascular Diseases: Comparison
Please note this is a comparison between versions V2 by Ron Wang and V1 by Nalini Chintalapudi.

Telehealth and telemedicine, if properly used, may offer advantages for both patients and health professionals. As per the World Health Organization (WHO), telemedicine can be defined as “the delivery of medical services, where distance is a basic factor, by all medical care experts utilizing information and communication technologies (ICT) for the exchanging of adequate information for the treatment, diagnosis and avoidance of illness and wounds, exploration and assessment, and for the proceeding with instruction of medical care suppliers, in the purpose of strengthening individuals health and their networks”. Telemedicine includes the protected transmission of clinical information and data, by voice, text, images, or other forms required for the diagnosis, treatment, and patient follow up.

  • telemedicine
  • cardiovascular diseases
  • telecardiology
  • personal care
  • remote consultation

1. Introduction

In recent years, there has been a growing interest in the development of precision medicine approaches in the prevention and treatment of several pathologies with the purpose to offer to patients “the right treatment, to the right patient, at the right time”. In cardiovascular medicine, the potential of precision medicine applies to all stages of disease development and includes risk prediction, preventative measures, and targeted therapeutic approaches [1]. Telehealth and telemedicine enable precision medicine by two routes following data review by a doctor. These include a direct (online) discussion between a patient and doctor regarding a therapy (e.g., change dosing, prescription renewal) and prescriptions to the patient for them to undergo more precise testing and assessment. In both cases, the online session may add information or data to the patient history.

Telehealth and telemedicine, if properly used, may offer advantages for both patients and health professionals [2]. As per the World Health Organization (WHO), telemedicine can be defined as “the delivery of medical services, where distance is a basic factor, by all medical care experts utilizing information and communication technologies (ICT) for the exchanging of adequate information for the treatment, diagnosis and avoidance of illness and wounds, exploration and assessment, and for the proceeding with instruction of medical care suppliers, in the purpose of strengthening individuals health and their networks” [3]. Telemedicine includes the protected transmission of clinical information and data, by voice, text, images, or other forms required for the diagnosis, treatment, and patient follow up.

The telemedicine field applied to CVD is defined as telecardiology [10][4]. Personal medications or treatment can be suggested over video or phone conversations with the pill dispenser at hand. Family members or friends (from different locations) can participate in these visits and understand expert suggestions for improving the health literacy of the entire family. On the other hand, patients can remain at home with comfort, which allows welcoming talks with more involvement in decision making about their cardiac health, e.g., monitoring of blood pressure by taking acute readings with home devices. Frequent telemedicine visits can allow doctors to encourage patients to perform BP checkups. Studies have shown that self-observation improves both BP estimations and medicine adherence [11,12][5][6]. Moreover, hypertension is also an ongoing illness that stands at risk of CVDs and benefits largely from successive telehealth visits.

In this study, we conducted a systematic review analysis to explore the importance of telemedicine services in the provision of personalized care for CVDs. Moreover, we reviewed telecardiology advancements in the last decade and how the world is adopting telemedicine support in daily cardiologic practice.

2. MCurrethodnt Insights on Telemedicine in Cardiovas

Initially, we collected the available literature from high-quality medical libraries such as PubMed (MEDLINE) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). The Scopus (EMBASE) database was used for sorting out non-appearance articles from the two medical libraries. Medical Subject Headings (MeSH) were applied to identify key terms of MEDLINE. Under the ‘cardiovascular diseases and ‘telemedicine’ key terms, we were able to identify 63 and 11 subheadings, respectively, with the help of the MeSH list. The search string with the Boolean operator as ‘telemedicine’ AND ‘cardiovascular diseases’ for PubMed was used. For CINAHL, we included similar MeSH terms to those used in MEDLINE and, for Scopus (EMBASE), Boolean operators such as ‘telemedicine’ OR ‘telehealth’ OR ‘telecardiology’ AND ‘adoption’ OR ‘implementation’ AND ‘personalized care’ OR ‘personal medication’ OR ‘personal care’ AND ‘cardiovascular diseases OR ‘CVD’ OR ‘cardiology’ were applied.

Articles on telemedicine or telehealth in providing personal care for patients with a high risk of CVDs were considered for this research. Articles from peer-reviewed journals, featuring descriptive work in the English language with full text, implementing cross-sectional and mixed methods (including quantitative and qualitative), with telemedicine objectives in cardiovascular care, were included. Exclusion criteria were (a) conference works, (b) abstract-only articles, and (c) articles published before 2011. Studies with irrelevant data on telemedicine and that did not mention telecardiology involvement were excluded from the study.

Once the literature search was done, the four authors independently assessed every article in two phases. In the first phase, duplicated or similar papers extracted from the three databases were removed by reading abstracts. This analysis was conducted by the conventional approach of reading the article title and abstract. After applying inclusion and exclusion criteria, the quality evolution of each selected item was done based on the Newcastle–Ottawa Scale (NOS) that ranged from 0–9 [13]. The NOS defined each study in three ways as poor (0–4), moderate (5–6), and good (7–9). These scores were based on some filters such as study selection, comparability, and outcome. Various quality parameters such as demonstration, coherence, risk factors, and others were also considered. The quality scores of selected articles calculated using the above parameters were recorded in an excel sheet to calculate whether a selected study was suitable for final consideration or not.

3.cular RDisesultases

All 19 studies considered suitable for our analysis were conducted in developed nations. This suggests that telemedicine technologies in CVD prevention are more ready to be adopted in developed areas. Considering cost constraints in telemedicine implementation, governments or private bodies should provide financial support. A high number of studies (15/19, 78.94%) were funded by external organizations including public (11/15, 73.3%) and private bodies (4/15, 26.7%) (Refer Table 1 ).

The use of telemedicine as a support to cardiology was introduced more than 100 years ago in Australia with the use of the telegraph from Barrow Creek Telegraph Station. In 1905, Einthoven transmitted electrocardiographs using the telephone line. A further evolution of this experience dated in 1910 with tele-auscultation transmitted through the telephone lines. In 1935, the first tele-electrocardiographic service was established in Lviv in the Ukraine. In 1938, the International Radio Medical Center (C.I.R.M.) in Rome received by radiotelegraphy an electrocardiogram from a passenger ship. In the last 10 years of the last century and at the beginning of this century, telemedicine started to move from the experimental phase to large-scale experiences, and its practical applications related to cardiology are entering in the standards of medical practice.
In this systematic review, we attempted to understand the positive effects of telemedicine and telehealth technologies on controlling cardiovascular diseases. The assessment of articles incorporated in this study explained that each article obeyed the NOS quality checklist and scored at least 7 (NOS ≥ 7), indicating scientific rigorousness of the study selection. In addition to highlighting the telemedicine effectiveness in CVD management, this work described the recent advancements in the last decade. Through this work, the key aspects of telemedicine in terms of evaluation of its role in the perspective of CVD personal care were identified. We found 19 quality research studies from Australia, China, France, Italy, Netherlands, and the United States, among others.
During serious pandemics such as COVID-19, a huge decrease in hospitalization and expanded self-administration by patients embodies the financial discernment of telemedicine since it can decrease patient flow to hospitals. Telemedicine has provided a chance to see remote patients, which has helped doctors in checking and monitoring conditions that the patient or their close family can easily follow. Those patients infected with COVID-19 are commonly associated with hypertension, CVD, and diabetes. In this pandemic, there have been other situations raising concern for the personal safety of patients who are at high risk for CVD. In such cases, the adoption of cardiac rehabilitation techniques is mandatory, including cardiac rehab in a home, which can guarantee the continuity of these mandatory services [7].

Some medical hospitals launched telemedicine via 4G tablets to provide chronic care including CVD and chronic heart failure. Patients are equipped with Bluetooth biometric devices (e.g., pulse oximeter) to measure blood pressure, oxygen levels, weight, and temperature [37]. These devices automatically record and transmit data that can be used for improved home care monitoring. Remote monitoring of implanted devices is usually associated with the transmission of recorded data via an external transmitter to the provided database. The patient data are transmitted daily. This can improve clinical outcomes [38], enhance patient satisfaction [39], and save patient data.

The effect of technological advancements on financial issues in healthcare has exceptionally exposed the divergence between the innovation cost and the change (either increase or decrease) in medical resource utilization because of the clinical impact of this technology. For instance, current telemedical technologies can provide personal care to cardiac arrest patients, certainly amplifying the treatment costs in long-term care for stroke survivors. The difference in quality and cost gained has been highly influenced by the cost-effectiveness of telehealth technologies in the prevention of cardiovascular diseases. We identified two studies that mentioned the development of telemedicine tools, namely, the consumer navigation of electronic cardiovascular tools (CONNECT) [8] and a novel system based on mobile internet, cloud computing in management of hypertension, and experts in the monitoring of physical activity among heart disease patients [9]. These tools need to be enhanced to function for long-term care, and a time framework should be designed to estimate the quality of care of CVD risk patients.

Coronary heart failure is a major risk factor for CVD. A randomized controlled trial (RCT) among 223 patients (mean age = 56.4 ± 9.0) with CHD assigned into two groups, Cardio Fit ( n = 115, mean age = 56.7 ± 9.0) and usual care ( n = 108, mean age = 56.0 ± 9.0), was carried out to assess the effects of online coaching on physical activity intervention for CHD patients by comparing usual care over 1 year [33]. The Cardio Fit group received a personally tailored physical activity regimen and access to a secure website for activity planning and tracking. Online training was also given to the Cardio Fit group, and they were in email contact with an exercise specialist. In contrast, the usual care group received physical activity guidance from their cardiologist. The authors found that at the two-time points (every 6 months), the Cardio Fit group took an average of 764 (12% absolute difference) more steps per day than the usual care group. Furthermore, it was shown that patients with heart failure can be discharged from the hospital to evaluate medication adherence via telephone [46].

However, most of the available literature associated with clinical trials and pilot projects provided short-term results. A few were associated with long-term usage of telemedicine in CVD care [10][11][12][13]. Some clinical trials reported the efficacy of telemedicine rather than effectiveness [14][15][16][17][18]. One study presented a community-based survey of CVD risk factors to evaluate the potentiality of telemedicine [19], and another study reported follow-up data of CVD patient health status or clinical outcomes who participated in telecardiology services [20]. Other reports on telemedicine involvement in CVD care produced a strong assumption regarding the possible benefit to health status monitoring although the availability of limited patient administrative data.

Telemonitoring reduces the readmission of patients with heart failure and significantly decreases contact with specialized nurses on this matter [47]. Some studies highlighted that telemedicine and telemonitoring applications have the potential to transmit diagnostic images, data, or reports, virtually connecting the patients and health professional in the screening of CVD; telemedicine via telephone communication is particularly useful in the early detection of CVDs, thus reducing costs [27,28,29]. The study by Koehler et al. [48] randomized 1571 patients with heart failure to assess the effect of remote patient management intervention on unplanned cardiovascular admission and mortality. The authors randomly assigned the patients into two groups to receive remote patient management ( n = 796) or usual care ( n = 775). The percentage of days lost due to unplanned cardiovascular hospital admission or death from all causes was significantly reduced in patients allocated to remote patient management (ratio: 0.80; 95% CI: 0.60–1.00, p-value = 0.0460) when compared to usual care [17]. In this regard, supporting telemedicine interventions in patients with heart failure can reduce unplanned cardiovascular hospitalizations and all causes of mortality.

According to the literature, telemedicine has the benefit of saving time and providing personal care for the patient. Physicians have to consider the shortcomings of these technologies, whereas telemedicine could be expensive for hospitals or small healthcare centers to provide. Simultaneously, if the patient prefers direct visits to a doctor, telemedicine is not an ideal solution. Therefore, the doctor has to maintain bonding with a patient to make them comfortable with the new technologies. We also have to consider the fact that no service is perfect, and telemedicine is no exception. Studies have continuously proven that telemedicine can save money, time, and lives.

43. Conclusions

The overall findings of this work highlight the importance of telemedicine and telehealth technologies in the management of personal care among CVD patients. Moreover, they provide evidence of the benefits of cardiovascular care when using telemedicine in developed nations. Many studies are available on telemedicine applications, but sophisticated qualified studies are still very few, and the generalization of most evaluation outcomes is rather limited. However, one positive finding is that the world is now understanding the importance of these technologies because of significant challenges introduced by COVID-19. There has at least been a start in some developing countries, with public bodies ready to improve the economic situation through the adoption of telemedicine. We strongly suggest future developments for the provision of medical services through telemedicine, along with necessary training for both patients and providers, thus resulting in better healthcare and enhanced patient satisfaction.


  1. Currie, G.; Delles, C. Precision medicine and personalized medicine in cardiovascular disease. In Advances in Experimental Medicine and Biology; Springer New York LLC: New York, NY, USA, 2018; Volume 1065, pp. 589–605.
  2. Sagaro, G.G.; Battineni, G.; Amenta, F. Barriers to Sustainable Telemedicine Implementation in Ethiopia: A Systematic Review. Telemed. Rep. 2020, 1, 8–15.
  3. World Health Organization. A Health Telematics Policy in support of WHO´s Health-for-All Strategy for Global Health Development. In Proceedings of the WHO Group Consultation on Health Telematics, Geneva, Switzerland, 1–16 December 1997.
  4. Molinari, G.; Molinari, M.; Di Biase, M.; Brunetti, N.D. Telecardiology and its settings of application: An update. J. Telemed. Telecare 2018.
  5. Bliziotis, I.A.; Destounis, A.; Stergiou, G.S. Home versus ambulatory and office blood pressure in predicting target organ damage in hypertension: A systematic review and meta-analysis. J. Hypertens. 2012.
  6. Fletcher, B.R.; Hartmann-Boyce, J.; Hinton, L.; Mcmanus, R.J. The effect of self-monitoring of blood pressure on medication adherence and lifestyle factors: A systematic review and meta-analysis. Am. J. Hypertens. 2015.
  7. Khera, A.; Baum, S.J.; Gluckman, T.J.; Gulati, M.; Martin, S.S.; Michos, E.D.; Navar, A.M.; Taub, P.R.; Toth, P.P.; Virani, S.S.; et al. Continuity of care and outpatient management for patients with and at high risk for cardiovascular disease during the COVID-19 pandemic: A scientific statement from the American Society for Preventive Cardiology. Am. J. Prev. Cardiol. 2020.
  8. Neubeck, L.; Coorey, G.; Peiris, D.; Mulley, J.; Heeley, E.; Hersch, F.; Redfern, J. Development of an integrated e-health tool for people with, or at high risk of, cardiovascular disease: The Consumer Navigation of Electronic Cardiovascular Tools (CONNECT) web application. Int. J. Med. Inform. 2016.
  9. Reid, R.D.; Morrin, L.I.; Beaton, L.J.; Papadakis, S.; Kocourek, J.; McDonnell, L.; D’Angelo, M.E.S.; Tulloch, H.; Suskin, N.; Unsworth, K.; et al. Randomized trial of an internet-based computer-tailored expert system for physical activity in patients with heart disease. Eur. J. Prev. Cardiol. 2012.
  10. DeFilippis, E.M.; Reza, N.; Donald, E.; Givertz, M.M.; Lindenfeld, J.A.; Jessup, M. Considerations for Heart Failure Care During the COVID-19 Pandemic. JACC Hear. Fail. 2020, 8, 681–691.
  11. Santamore, W.P.; Homko, C.J.; Kashem, A.; McConnell, T.R.; Bove, A.A. Using a telemedicine system to decrease cardiovascular disease risk in an underserved population: Design, use, and interim results. In Proceedings of the Annual International Conference of the IEEE Engineering in Medicine and Biology, Loyn, France, 23–26 August 2007; Volume 2007, pp. 3701–3704.
  12. Flodgren, G.; Rachas, A.; Farmer, A.J.; Inzitari, M.; Shepperd, S. Interactive telemedicine: Effects on professional practice and health care outcomes. Cochrane Database Syst. Rev. 2015, 2015.
  13. Abraham, W.T.; Adamson, P.B.; Bourge, R.C.; Aaron, M.F.; Costanzo, M.R.; Stevenson, L.W.; Strickland, W.; Neelagaru, S.; Raval, N.; Krueger, S.; et al. Wireless pulmonary artery haemodynamic monitoring in chronic heart failure: A randomised controlled trial. Lancet 2011, 377, 658–666.
  14. Vernooij, W.P.; Kaasjager, H.A.H.; Van Der Graaf, Y.; Wierdsma, J.; Grandjean, H.M.H.; Hovens, M.M.C.; De Wit, G.A.; Visseren, F.L.J. Internet based vascular risk factor management for patients with clinically manifest vascular disease: Randomised controlled trial. BMJ 2012.
  15. Bosworth, H.B.; Olsen, M.K.; McCant, F.; Stechuchak, K.M.; Danus, S.; Crowley, M.J.; Goldstein, K.M.; Zullig, L.L.; Oddone, E.Z. Telemedicine cardiovascular risk reduction in veterans: The CITIES trial. Am. Heart J. 2018.
  16. Widmer, R.J.; Allison, T.G.; Lennon, R.; Lopez-Jimenez, F.; Lerman, L.O.; Lerman, A. Digital health intervention during cardiac rehabilitation: A randomized controlled trial. Am. Heart J. 2017.
  17. Zullig, L.L.; Oakes, M.M.; McCant, F.; Bosworth, H.B. Lessons learned from two randomized controlled trials: CITIES and STOP-DKD. Contemp. Clin. Trials Commun. 2020.
  18. Coley, N.; Rosenberg, A.; van Middelaar, T.; Soulier, A.; Barbera, M.; Guillemont, J.; Steensma, J.; Igier, V.; Eskelinen, M.; Soininen, H.; et al. Older Adults’ Reasons for Participating in an eHealth Prevention Trial: A Cross-Country, Mixed-Methods Comparison. J. Am. Med. Dir. Assoc. 2019.
  19. Joubert, J.; Nkomazana, O.; Mompati, K.; Joubert, L.; Preux, P.M.; La Croix, P.; Laing, J.; Korn, S.; Mbogwe, B.; Tsima, B.; et al. A community survey of cardiovascular risk factors in an urban population in Botswana exploring potential for telemedicine. Eur. Res. Telemed. 2014.
  20. Brunetti, N.D.; Dellegrottaglie, G.; De Gennaro, L.; Di Biase, M. Telemedicine pre-hospital electrocardiogram for acute cardiovascular disease management in detainees: An update. Eur. Res. Telemed. 2015.