Patrick Campbell

In the wake of the coronavirus disease 2019 (COVID-19) pandemic, remote patient monitoring and implementation of telemedicine approaches have gone from fringe topics to centerstage. While, for most, the revelation during this unique time period has been that telemedicine options provide a viable alternative for many patients, there are certain specialties that are more difficult to transfer into a digital space.

Without regard to specialty, this time period has led to stringent evaluations and reevaluations of thousands of medical procedures and routines. A major topic of discussion in the realm of telemedicine even before the pandemic was home monitoring of patients with cardiovascular diseases. In a study presented at a conference earlier in 2020, Kazem Rahimi, MD, and a team examined the effects of home monitoring on quality of life in patients with heart failure. Rahimi refers to the trial as one of the rigorous, in terms of design and criteria, to examine the topic and, while it failed to reach statistical significance, provided valuable insight into what else is needed in terms of technology and home monitoring to make this a viable option for all patients.

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Kazem Rahimi, MD, discusses the prospect of home monitoring for heart failure patients and how technology needs to improve before it is a viable option for most patients.

Kazem Rahimi, MD: Home Monitoring for Cardiology Patients

A simple solution could cut time and streamline care for stroke patients, according to results of a randomized controlled trial conducted in Germany.

In the study, use of a large display alarm clock in a hospital’s computed tomography (CT) room contributed to more streamlined care—suggesting implementation of such an approach could help to achieve the American Heart Association/American Stroke Association’s target recommendation of 60 minutes or less from the time a 

 patient arrives to the hospital to the time of clot-busting treatment.

"Time is brain. Minutes are easily lost in acute stroke management, despite standard protocols," said study author Klaus Fassbender, MD, professor of neurology at Saarland University Medical Center in Homburg, Germany, 

. "The stroke alarm clock is a low-cost intervention and an efficient way to quickly deliver life-saving treatment to acute stroke patients."

With the goal of identifying cost-effective means of improving acute stroke management, Fassbender and more than a dozen colleagues sought to determine whether a feedback-demanding stroke clock could help streamline care. With this in mind, investigators designed a randomized controlled study to assess whether a large display alarm clock installed in the CT room, which is where admission, diagnostic work-up and intravenous thrombolysis occurred, at the Saarland University Medical Center.

The alarm clock installed in the room was designed to provided alarms at the end of 3 specific time periods. The first time period lasted 15 minutes, the second lasted 20, and the third lasted 30 minutes. The first time period marked the amount of time it should take to complete the neurological exam, the second time period represented the amount of time it should take to complete CT scanning and international normalized ratio determination by point-of-care (POC) laboratory, and the third time period represented the time it should take to begin intravenous thrombolysis.

Physicians were required to provide feedback in the form of pressing a button when the alarm sounded. Investigators pointed out the alarm could be avoided by pressing the button prior to the time period ending.

The primary end point of the study was time to therapy decision, which investigators defined as the end of all guideline-recommended diagnostic work-up required for decision-making for or against reanalyzing treatments. Secondary end points for the study included time for door-to-end of neurological examination, end-of-POC laboratory, end-of-native CT, end-of-CT angiography, and, if indicated, start of intravenous thrombolysis and thrombectomy, and achievement of recanalization.

In total, 107 patients were included in the trial. Of these, 56 were randomized to the alarm clock group and 51 were randomized to standard care. Investigators pointed out demographic and medical characteristics, including final diagnoses, were similar between the study arms.

Upon analysis, results indicated time from door to end of all indicated diagnostic work-up (treatment decision time; 16.73 vs 26.00 minutes, 

 <.001), end of neurological examination (7.28 vs 10.00 minutes, 

 <.001), end of CT (11.17 vs 14.00 minutes, 

=.002), end of CT angiography (14.00 vs 17.17 minutes, 

=.001), end-of-POC laboratory testing (12.14 vs 20.00 minutes, 

<.001), and start of intravenous thrombolysis (18.83 vs 47.00 minutes, 

=.016) were improved for patients randomized to the alarm clock group.

However, investigators noted the there was no significant difference in time to start of thrombectomy and functional outcomes at day 90 between the study arms. In the aforementioned statement, Fassbender noted the study was not designed to evaluate long-term outcomes and noted the need for larger studies to confirm the effect of the clock on outcomes.

"A limitation of this study was its size. We need more patients to determine whether accelerated acute stroke management with the clock translates to less death and disability long-term,” Fassbender added.

Effects of a Feedback-Demanding Stroke Clock on Acute Stroke Management

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Could an alarm clock in the room where stroke care is performed contribute to more streamlined care?

"Stroke Clock" Could Help Streamline Care of Acute Stroke Patients

New research from a George Institute for Global Health-led team suggests rates of recurrent heart attacks have declined but also revealed the declines seen in recent years were not equal between sexes.

While results indicated rates of recurrent events have declined from 2008-2017, data indicates the decline among men was slower than that among women and the risk for recurrent events and death remain high in 

"We expected to see a decline in the rate of events, however, we did not expect the rates to differ between the sexes,” said lead investigator Sanne A. E. Peters, PhD, senior lecturer at The George Institute for Global Health, 

. “It may be that the improvements in men were achieved before our study period, leaving less room for improvement in the most recent decade. It could also be that the attention paid to heart disease in women over recent years has resulted in the greater gains.”

With significant advances in care and management of cardiovascular health in recent decades, investigators sought to further our understanding of declines in events between men and women who had suffered a previous event. To do so, they designed their study as an analysis of data from the MarketScan and Medicare databases between 2008-2017.

In total, investigators identified 770,408 women and 700,477 men who had a myocardial infarction during the aforementioned time frame for analysis. To avoid including duplicate patients, investigators excluded beneficiaries in the Marketscan database 65 years and younger and beneficiaries 66 years of age or older from the Medicare database. Inclusion criteria for the study were an overnight hospitalization for myocardial infarction of less than 30 days, live in the US, and have continuous coverage from 365 days prior to their admission date through the discharge date.

For the purpose of the analysis, investigators chose recurrent myocardial infarction, recurrent coronary heart disease (CHD) event, heart failure hospitalization, or death within 365 days of hospitalization. Investigators used Poisson regression models to estimate women-to-men risk ratios (RR) for each outcome in each calendar year. Of note, these models were adjusted for age, sex/ethnicity, region of residence, Medicare-Medicaid dual eligible, diabetes and use of insulin, history of CHD, history of stroke, history of heart failure prior to hospitalization, incident heart failure during the hospitalization, and a slew of other factors.

Upon analysis, the age-standardized recurrent myocardial infarction rates per 1000 person-years decreased from 89.2 to 72.3 in women from 2008-2017 and from 94.2 to 81.3 among men during that same time frame (

 <.001). For recurrent CHD event rates, investigators noted declines from 166.3 to 133.3 in women and from 198.1 to 176.8 in men during that same time period (

For heart failure hospitalization, rates decreased from 177.4 to 158.1 in women and from 162.9 to 156.1 among men (

.001). For all-cause mortality, investigators observed rates decreased from 403.2 to 389.5 in women and from 436.1 to 417.9 in men (

=.82). Additionally, investigators found rate ratios of 0.90 (0.86-0.93) for recurrent myocardial infarction, 0.80 (0.78-0.82) for recurrent CHD events, 0.99 (0.96-1.01) for heart failure hospitalization, and 0.82 (0.80-0.83) for all-cause mortality when comparing risk for women versus men.

“Regardless of the improvements, the rates of recurrent events in people who survived a heart attack are still very high in both sexes. Patients should speak with their doctors to ensure that the get the right treatments to prevent secondary events and must make sure that they adopt or maintain a healthy lifestyle," added Peters.

Trends in Recurrent Coronary Heart Disease Following Myocardial Infarction Among US Women and Men Between 2008 and 2017

While rates of recurrent events have declined, the rates of decline have not been equal between sexes and risk of recurrent events still pose a serious risk to heart attack survivors.

Recurrent Events Declining, But Remain a Serious Risk for Heart Attack Survivors

An unspoken concern for many following a heart attack, new research suggests resumption of sexual activity following a heart attack was associated with increased chances for long-term survival.

An analysis of nearly 500 patients aged 65 or younger, results suggest those who maintained or increased their frequency of sexual activity following a heart attack reduced their risk of death by 35% compared to those who decreased or abstained from sexual activity following their heart attack.

“Sexuality and sexual activity are markers of wellbeing,” said lead investigator Yariv Gerber, PhD, professor of epidemiology at Tel Aviv University , 

. “Resumption of sexual activity soon after a heart attack may be a part of one’s self-perception as a healthy, functioning, young and energetic person. This may lead to a healthier lifestyle generally.”

For many the idea of returning to vigorous physical activity after myocardial infarction can be intimidating. While previous studies have examined a link between resuming sexual activity and improvements in survival following myocardial infarction, investigators pointed out they failed to assess the impact of resuming sexual activity in the period immediately after the event.

With this in mind, Gerber and a team of colleagues designed the current study with the goal of assessing the impact of resuming or abstaining sexual activity within the first 6 months following acute myocardial infarction. Pulling data from the Israel Study of First Acute Myocardial Infarction, investigators identified 495 patients who met their inclusion criteria for the study.

The Israel Study of First Acute Myocardial Infarction enrolled more than 1600 patients from 1992-1993, however for inclusion in the analysis, patients needed to provide information related to sexual activity before hospitalization and during a second interview 3-6 months detailing sexual activity after hospitalization. In total, 560 patients met these criteria but 65 were eliminated as they reported no sexual activity at baseline.

Of the 495 patients included, 90% were men and the mean age was 53±8 years. From the interviews, investigators determined 73% of patients were sexually active at least once a week prior to the index event. Additionally, 88% of patients resumed sexual activity after the event but only 60% of the total cohort reported similar frequency of sexual activity before and after the event. Based on these results, investigators categorized 263 patients into a group defined by maintained or increased frequency of sexual activity 3-6 months following myocardial infarction and 232 into a group defined by a decrease or entirely abstaining from sexual activity following myocardial infarction.

During the follow-up period, which had a median length of 22 years, 43% of patients included in the current study died. Upon analysis, investigators found maintaining or increasing sexual activity frequency was inversely associated with all-cause mortality (HR, 0.65; 95% CI, 0.48-0.88) when compared against abstaining or reducing frequency. Furthermore, results revealed the inverse association was more robust for non-cardiovascular mortality (HR, 0.56; 95% CI, 0.36-0.85) than cardiovascular mortality (HR, 0.90; 95% CI, 0.53-1.51).

In the aforementioned statement, Gerber noted the observational nature of the study prevents investigators from drawing direct conclusions on the link between sexual activity and increased survival and, because of this, cautions against overinterpretation of results.

“Numerous physical and psychosocial health parameters are required for maintaining regular sexual activity,” Gerber added. “In light of this, the net benefit of sexual activity itself is still a matter of debate.”

Resumption of sexual activity after acute myocardial infarction and long-term survival,

European Journal of Preventive Cardiology.

New data suggest resuming or increasing sexual activity shortly after myocardial infarction could reduce risk of mortality. 

Author | Patrick Campbell

Articles

Kazem Rahimi, MD: Home Monitoring for Cardiology Patients

"Stroke Clock" Could Help Streamline Care of Acute Stroke Patients

Recurrent Events Declining, But Remain a Serious Risk for Heart Attack Survivors

Resuming Sexual Activity Post-Heart Attack Could Increase Survival