A proposal for monitoring patients with heart failure via “smart phone technology”-based electrocardiograms

    A proposal for monitoring patients with heart failure via “smart phone technology”-based electrocardiograms John E. Madias MD, FACC, FAHA PII: DOI: Reference:

S0022-0736(16)30066-8 doi: 10.1016/j.jelectrocard.2016.06.001 YJELC 52240

To appear in:

Journal of Electrocardiology

Please cite this article as: Madias John E., A proposal for monitoring patients with heart failure via “smart phone technology”-based electrocardiograms, Journal of Electrocardiology (2016), doi: 10.1016/j.jelectrocard.2016.06.001

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A proposal for monitoring patients with heart

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failure via “smart phone technology”-based

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electrocardiograms

John E. Madias, MD, FACC, FAHA

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Short Title: Electrocardiograms via smart phone in heart failure

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From the Icahn School of Medicine at Mount Sinai, New York,

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NY, and the Division of Cardiology, Elmhurst Hospital Center, Elmhurst, NY

Correspondence to John E. Madias, MD, Division of Cardiology, Elmhurst Hospital Center, 79-01 Broadway, Elmhurst, NY 11373, Tel:

(718)

334-5005,

[email protected]

Fax:

(718)

334-5990,

e-mail:

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Abstract

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The ubiquitous smart phone/device technology (SPT) has enabled the safe acquisition/transmission (A/T) of clinical and laboratory

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patient data, including the electrocardiogram (ECG). SPT-based

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A/T of the ECG has been found useful in the detection of atrial fibrillation, monitoring of the QTc interval, in patients undergoing antiarrhythmic drug loading, and management of patients with

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acute ST-elevation myocardial infarction. Previous work has

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shown a relationship between changes in the voltage of the ECG

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QRS complexes, with perturbations in the edematous state of various etiologies, including heart failure (HF). It is proposed

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herein to employ serially SPT-based 3-lead ECG A/T for the monitoring and management of patients with HF in their ambient environment. The proposed method will enable patients with HF to acquire/transmit their 3-lead ECG to the caring HF team, using only their smart phone and it takes into consideration the advanced degrees of physical incapacitation and age-related infirmities inherent to the HF population.

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Introduction

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Societies world-wide are severely burdened with the monitoring and management of patients with heart failure (HF).

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Many clinical and laboratory methods have been employed in the

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monitoring of patients with HF in the hospital, clinic, and in the patients' ambient environment via remotely applied technology. The core idea pertains to periodic acquisition/transmission (A/T)

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by the patient or caregivers, information necessary for the

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members of the HF team, to advise the patient about the drug

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regiment and other aspects of management via a "remote control" approach, obviating the inconvenience and cost of frequent visits

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to the hospital. It is beyond the scope of this communication to delve in the various methods proposed and implemented for the in-hospital, clinic, and remote monitoring of patients with HF, about whom vast literature is available. This constitutes a proposal to utilize the AliveCor smartphone electrocardiogram (ECG) to better manage patients with HF. The implementation of protocols, analysis of data, and evaluation of clinical and

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economic impact would be established by a working group of

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interested researchers, based on the approaches recommended in the paper. The readers may want to be directed to a dedicated

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web site (for the establishment of which the author seeks the help

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of his colleagues), where they could read the full proposal, background literature, and may signify interest and register to

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receive communications related to the project.

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Electrocardiogram voltage and body edematous state

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Previous work has shown that there is an inverse relationship between the increase in body weight (BW) and attenuation of

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voltage of the ECG QRS complexes (attQRS) in patients with an edematous state (ES) of diverse etiologies; augmentation of the voltage of the QRS complexes (AuQRS) has been observed in such patients after therapy, particularly diuresis, associated with amelioration of peripheral edema, and BW loss (Fig. 1).1 Subsequent to the original investigation,1 many clinical studies2-21 have revealed several details about the dynamic response of the

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ECG to the body’s ES. Such changes in the voltage are imparted

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to the same degree to all components of the ECG curve, customarily measurements are carried out in QRS complexes (Fig.

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1) due to their large amplitude, which ensures accuracy of

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comparisons in serial ECGs. The limb leads are more suitable for QRS voltage monitoring purposes, since the frontal body plane reflects better the body’s ES, than the horizontal plane, which is

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partially influenced by underlying local cardiac currents, and

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regional thoracic electrical properties, and the V1-V6 leads are

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plagued by nonreproducible serial recordings, and inaccurate thoracic lead electrode placement.1,5,12 Contemporary ECG

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machines measure only leads I and II, and calculate the voltage of the remaining 4 limb leads via mathematical algorithms,22,23 lead I and II, or their sum (ΣI+II), are adequate for QRS monitoring.6,15 Accordingly, due to the mathematical relationship between lead aVR and leads I and II (aVR×2 = I+II, considering only absolute numbers),22,23 lead aVR can be employed solely for ECG monitoring.16,21 The sums, of all 6 limb leads (Σ6LbLds),5,12,17 the

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6 precordial leads (ΣPrecLds),5,17,20 and all the 12 ECG leads

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(Σ12Lds),1,2,4,5,17 have been used serially for monitoring of patients with HF.2,8,12,15 All 6 precordial ECG leads, or sums of

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leads V1-V3 (ΣV1-V3), and V4-V6 (ΣV4-V6), particularly the

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later, since they are in proximity to the overloaded with water lung parenchyma, can be used serially when pulmonary edema is present, solely or with peripheral edema.1 Monitoring for the

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assessment of attQRS and AuQRS can be accomplished in the

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presence of left and right bundle branch blocks, and

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intraventricular conduction delays, providing that the above are stable.1,8,10,11 Monitoring for the assessment of attQRS and

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AuQRS via serial tracings is feasible in the presence of electronic temporary or permanent ventricular pacemaking, or biventricular pacing, providing that pacemaking is stable.6 Obviously patients with HF, implanted ICDs, and intrinsic ventricular depolarization qualify for QRS monitoring. Mere “eye-balling” of leads aVR, I and II, or V4-V6, in serial ECGs may suffice for bedside evaluation in-hospital, or at the clinic for monitoring the ES of

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patients with HF.11,17,19 Measurements of the “peak to peak” QRS

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voltage in leads aVR, or the ΣI+II, or any other ECG lead sets, can be accomplished by considering the ECG paper grid, or on the

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computer screen from serial ECG tracings, and then entering the

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results in the patients’ records, for HF monitoring.1-21 “Toggling” between 2, or among many serial ECGs, on the computer screen, while looking specifically at leads aVR, I, II, or

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ΣI+II, provides instantly an insight about the ES of a patient with

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HF.11,17,19 Most of the current ECG machines provide automated

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measurements of the “peak to peak” voltage in mV, to the nearest 10 µV, of all 12 ECG leads, and were used for calculating the

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values inserted in Fig. 1, and illustrations of previous communications.1-21 Finally, manufacturers of ECG machines can be induced to provide automated comparisons (in mV or mm, and graphs) of all individual ECG leads, or specific sets of summated leads, from serial ECGs, for monitoring HF patients. Not only diuresis in patients with HF, but implementation of mechanical (veno-venous) ultrafiltration,1,13 and hemodialysis in

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patients with end-stage renal disease,24 lead to AuQRS in the ECG.

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It has been recently reported that AuQRS predicted better clinical improvement in patients with decompensated HF than N-terminal

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pro-B-type natriuretic peptide.25 Also in another recent study of 32

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consecutive pacemaker-dependent patients with HF, admitted to the hospital “the increased paced QRS amplitude(s) in all ECG variables consequent to BW or fluid loss, after 7 days diuretic

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therapy, were significantly correlated with BW loss”; indeed

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while there was an AuQRS of 55% and 41% in ΣI+II and

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ΣV4-V6, the corresponding BNP values remained unchanged.26 Clinicians are urged to incorporate measurements (or

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“eye-balling”) of ECG QRS complexes voltage in their routine repertoires, while caring for patients with HF. Also it is hoped that the writing groups of guidelines on the diagnosis, monitoring, and management of patients with HF,27 consider the role of the ECG in monitoring patients with HF. Finally, all the above could probably be implemented in patients with implanted cardiac electronic

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devices, using measurements of the QRS voltage in stored or

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recorded intra-cardiac electrograms.

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Supplemental measures and multivariate approaches

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The mechanism leading to attQRS or AuQRS, with increased or decreased peripheral edema, correspondingly, has been shown to be operating via a change of the electrical conductivity (the

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inverse of resistance or impedance) of the conducting medium

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(body volume conductor) “enveloping” the heart (the cardiac

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generator of the depolarizing and repolarizing currents), as per Ohm’s physical law (voltage [V] = current [I] x resistance or

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impedance [R]).1,

4,8,15,17,23,28

Accordingly, peripheral edema or

pulmonary edema, with their increased water content, lead to a decrease in the electrical impedance of the total body volume or lung parenchymal conductors, and a resultant attQRS, while their amelioration effect a decrease water content, leading to AuQRS. Implicit in the above described 1-component model (cardiac generator and transfer body volume or lung conductor), is that the

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resulting changes in the voltage of the transferred electrical

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potentials to the body surface, where they are recorded,23 is an extracardiac physical phenomenon,6 with the heart being the

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active generator of electrical currents, and the surrounding body

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volume conductor, passively modifying what is transferred via its domain, and recorded at the body surface. Work summarized elsewhere17 shows that 2 other compartments (intracardiac mass

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and blood hematocrit (1st compartment), the ES of the heart itself

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(2nd compartment), in addition to the body volume conductor (3rd

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compartment), together constitute a 3-component model, representing what really impacts the phenomenon of attQRS and

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AuQRS. The heart, being an “in series component” of the systemic circulation, is also impacted by the systemic congestion of peripheral edema in patients with HF, via the elevated right atrial pressure, and thus suffers myocardial edema due to its deficient venous and lymphatic drainage.17 Indeed myocardial edema has been shown to emerge rapidly due to HF and myocardial ischemia in a canine model.29 An additional

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dimension to the ES and the ECG interrelations can be attained by

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parallel measurements provided by modalities assessing body electrical bioimpedance, previously used by this author (Quantum,

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Model No. BIA-101Q, RJL Systems, Inc),4 or the Tanita Duo

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scale,30 which provides BW, body fat, and body water percentages. As shown previously, direct measurements of body electrical properties in association with the ECG and BW provide

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an opportunity to evaluate whether the changes in the ECG QRS

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amplitudes detected with changes in BW, are mainly due to

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changes in the body electrical properties, or the ECG provides

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different or additional information.

Electrocardiograms recorded/transmitted via smart devices technology In 2012 the FDA approved a relative inexpensive, smart phone-based technology (SPT) (AliveCor™ ambulatory Heart Monitor, San Francisco, CA USA) (Fig. 2), which can be purchased without prescription,31,32 and has been implemented in 11

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studies demonstrating its feasibility of transmitting to a secure

Portability

and

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server, accessible via website password (Health Insurance Accountability

Act

[US

HIPAA]

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confidentiality/privacy standards compliant), an up

to

a

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30-second single-lead rhythm strip (lead I), or 12-lead ECGs sequentially recorded as single leads, and wirelessly transmitted as a PDF file by e-mail, for interpretation by both automated

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algorithms, or cardiologists.33 Also the ECGs can be transmitted

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as a digitized time/voltage records, in order to have the

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recommended analysis facilitated by having the raw data. Recorded/transmitted single ECG lead I via such SPT facilitated

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the diagnosis of unsuspected atrial fibrillation,34-39 led to the detection of rapid monomorphic ventricular tachycardia, bundle branch block, ventricular bigeminy, sinus bradycardia, and abnormal

ST-segment

depression,40,41

provided

ongoing

monitoring of QT-interval in patients receiving dofetilide, a drug with a potential side effect of QT-interval prolongation,42,43 generated 12-lead ECGs with similar morphologies and time

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intervals to the ones recorded by conventional ECG equipment in

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stable patients (Fig. 3),33 and patients with ST-elevation myocardial infarction.44 This SPT, which includes smart phones

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or devices (iPhone, iPod, Android), in conjunction with the

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AliveCor™ Heart Monitor, and a special application (APP) (Alive ECG),31,33,39,40,42,44 which the patients open on their smartphone, provide a potential platform for a world-wide extension of the

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ECG for the management of patients. The ECGs are transmitted

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from the phone case by frequency modulation of an ultrasound

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signal which is received by the smart phone’s microphone, then demodulated to a digital ECG tracing, which can be viewed in

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real-time or stored, and instantly transmitted by the phone to a secure server, from which it can be accessed for interpretation.38 Considering the ubiquitous presence of smartphones and device worldwide ,39,45 the implications for easy A/T of the ECG implementation in clinical practice is staggering. The Alive ECG APP works in tandem with a phone case with embedded sensors, and when it is held by both hands it provides a 13

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single lead I ECG, which is transmitted by the smart phone (Fig.

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2A and 2B).32,37,38,39,41 If more ECG leads or a 12-lead ECG are desired, the AliveCor™ Heart Monitor can be employed with

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adapted electrodes attached to the monitor,33,44 which in turn are

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connected to ECG stickers in the limbs and chestwall (Fig. 2C), with the monitor also connected wirelessly with a smart device, by being held near the smart device. Recording leads V1-V6 in a study

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was accomplished by connecting the negative pole “grounding”

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cable to an adhesive tab in either the left or right arm,44 although

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the left leg may be more appropriate along the recommendations of

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the standard ECG recording format.22,24

Monitoring patients with heart failure with electrocardiograms recorded/transmitted via smart devices technology A system is proposed herein by which, patients with HF, or their designated relatives, or caregivers, can provide the caring team, 3-lead ECGs recorded serially, to facilitate the patients’ 14

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monitoring and management. After they are accessed from a safe

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website,38 such ECGs will be incorporated in the records of the patients, with the associated measurements in mm or mV. For the

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purposes of limiting the number of ECG leads to the essentially

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minimum, it is proposed that ECG leads I, II, and a “quasi-V3/V4” are recorded sequentially and transmitted, which will provide data on the QRS complexes’ voltage in both frontal and horizontal

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body planes.22,23 These 3 bipolar leads will be obtained as follows:

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1) Adhesive ECG tabs33,44 will be placed to the right wrist (RA)

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left wrist (LA), and to the left ankle (or alternatively to the left knee, if the left ankle cannot be reached due to the patients’

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incapacitation) (LL), and at a specific thoracic site immediately below the left breast nipple (LBN), for both males and females. The adoption of such chest landmark for transmitting the “quasi-V3/V4” lead, will ensure the generation of a reproducible precordial lead in serial ECG tracings for the individual patient. The prefix “quasi” for the V3/V4 lead is used herein since the negative pole of the AliveCor™ Heart Monitor will be connected

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to the LL site (as the distant, “indifferent” electrode), and not to

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the Wilson’s central terminal (not yet provided by the AliveCor™ Heart Monitor), as for conventional leads V1-V6 recordings. An

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alternative way for recording this bipolar “quasi-V3/V4” lead is

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by connecting the negative pole of the device to the RA or LA, as done previously for the sequential recording of V1-V6 leads by this technology.44 ECGs can be transmitted with patients being

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supine, sitting, or even standing during recording, since previous

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work has shown that such changes in position do not affect the

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voltage of ECG QRS complexes.46 2) The negative pole (-) of the AliveCor heart monitor (Fig. 2) will be connected to the RA ECG

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adhesive tab via a black cable (insulated wire) and a mini alligator clip from a hardware store,33 the positive pole (+) of the AliveCor™ Heart Monitor will be connected to the LA ECG adhesive tab via a red cable and an alligator clip, and ECG lead I will be recorded. 3) The negative pole will be connected to the RA with the black cable, the positive pole will be connected to the LL with the red cable, and ECG lead II will be recorded. 4) The

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negative pole will be connected to the LL with the black cable, the

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positive pole will be connected to the LBN with the red cable, and ECG lead “quasi-V3/V4” will be recorded. These 3 sequentially

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recorded ECG leads will be wirelessly transmitted via the smart

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phone by e-mail, as separate PDF files, to the server (physician, other members of the HF team, or any designated site), with an associated

message,

if

wished.

The

currently

available

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AliveCor™ Heart Monitor (Fig 2) does not include the cables for

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connections to the limbs and chest, but this can easily be

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accomplished as described herein, and as it was done previously for not only 3 lead ECGs, but even for 12-lead recordings, which

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were found to be comparable to conventional standard ECGs (Fig. 3).33,44 If preliminary work following this proposal shows its usefulness in managing remotely patients with HF, it will be easy to modify the AliveCor™ Heart Monitor,33,44 so that instead of the current 2 poles embedded in its case (Fig 2A), 4 cables (with different colors) for attachment to RA, LA, LL, and LBN, will be included, which will facilitate ECG recording and transmission by

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the patients, or others. Although it would be easy to modify the

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AliveCor, as suggested above, it may be more contributory to the overall objectives of the present proposal, to proceed with what

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is currently available, and used in other cited applications of the

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device.31-44 Also creating the necessary smart phone APPs to accomplish this, is expected to be easy, and could include the means of providing a real precordial V3/V4 lead, recorded via an

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incorporation of a “Wilson’s central terminal”.33,44 Indeed such

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APPs could produce recordings and transmissions of all 3

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proposed ECGs in one PDF with measurements of QRS voltage amplitudes, and comparisons with previous ECG recordings. It is

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imperative for monitoring patients with HF, to employ the above described 3 ECG leads, instead of using only a single ECG lead (lead I), which the AliveCor™ Heart Monitor was designed for,31,38-42 since with the latter attQRS and AuQRS cannot reliably be attributed to perturbations of the HF patients’ considering that merely incidental changes of the QRS frontal axis could produce changes in the QRS complex amplitude, when serial ECGs are

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compared; thus lead II is needed to safeguard from such fallacy.

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Also the inclusion of the “quasi-V3/V4” is needed to provide insight on the direction and amplitude of the QRS vectors in the

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realistic 3-dimentional space, and for changes in the ES of the

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thoracic cavity (pulmonary congestion), instead of the systemic body congestion.

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A further simplification of the proposed recording of the ECG employing solely the AliveCor Heart Monitor, without the

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connecting electrode cables, could be realized by implementing the

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following 3 steps: 1) the monitor is held in such a way that its

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negative pole (-) is touched by the fingers of the right hand and its positive pole (+) is touched by the fingers of the left hand (Fig. 4A) for the recording of smart phone ECG lead I; 2) the monitor is held in such a way that its negative pole (-) is touched by the fingers of the right hand and its positive pole (+) is pressed lightly on the left knee by the left hand (Fig. 4B) for the recording of smart phone ECG lead II; 3) the monitor is held in such a way that its negative pole (-) is touched by the fingers of the right hand and its positive 19

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pole (+) is pressed lightly on the left chestwall overlying the LBN

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(Fig. 4C), for the recording of smart ECG lead “quasi-V3/V4”. Clear instructions to implement the above are provided in Fig 4D.

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Moreover, one can obtain the leads I, II, and “quasi-V3/V4

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AliveCor tracings by holding the monitor within 12 inches of the smartphone, and without it being attached to the phone or phone case. Training of the HF patients, and/or their designated relatives

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or other caregivers will be required, particularly for the purposes of

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learning how one could exert light “local’ pressure, holding the

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smart phone case by the 2 hands (Fig. 4A), or pressing it on the left knee (Fig. 4B) or the chestwall (Fig. 4C), ensuring consistent

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contact with the phone case sensors, without tightening the entire body musculature, which introduces artifacts in the ECG records.52,55 Also artifacts can be further reduced by advising the patients to moisten their fingers prior to touching the smart phone sensors, or to apply multiple fingers to each sensor.55 Some have suggested “placing both electrodes along the left side of the chest”55 for recording a precordial lead. Future experience will

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resolve whether this approach will provide smart phone ECG

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leads with similarity in the amplitude and morphology with conventional V4-V6 ECG leads.

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Regarding implementation of the proposal presented herein,

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issues on patient selection, frequency of observation, derived measures, other variables monitored, analysis, statistical power calculations, need to be worked out and in this direction the

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proposed large group of colleagues, interested in this project, are

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expected to contribute. Perhaps a pilot project on patients

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admitted to the hospital with HF with 2 ECG recordings, using the AliveCor monitor, on admission and at discharge, and another

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one in patients with HF followed in the clinic, with 2 recordings in 2 consecutive clinic appointments with intensification of diuresis in between may be advisable. One should not underestimate the importance of the additional incentives of providing, via these ECG wireless transmissions, bradycardia

information or

about

tachycardia,

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and

incidental

arrhythmias,

atrioventricular

and

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intraventricular conduction delays, as observed previously.47-58

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Finally of great importance would be the empowerment of the patients via this process,54 rendering them valuable participants in

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their care, which is traditionally provided unilaterally by the

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medical system (physicians, other members of the HF team), and patients’ caregivers.

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Conclusions

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The ubiquitous presence of SPT has facilitated A/T of clinical and

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laboratory patients’ data, including the ECG. Previous work on the relationship of changes in the ECG QRS voltage amplitude

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and the ES of patients with HF led to the proposal herein to use SPT to monitor longitudinally patients with HF, via frequent SPT-based A/T of a 3-lead ECG. Particularly attractive is the prospect of employing the smart phone solely, without connecting electrode cables, for recording the 3-lead ECG, which would be expected to enhance the feasibility of implementing this monitoring modality by patients with HF, irrespective of their

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possible frailties, and incapacitation. Employment of the above

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may have life-saving, mind-boggling implications for the management of patients with HF, and the cost of medicine on a

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world scale. Also this paradigm may open the door for other

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applications, which may lead to a real transformation of the practice of medicine.

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Post Scriptum

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There will be supplemental material for the interested readers

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available on line.

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Conflicts of interest The author does not have any competing interests to disclose.

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electrocardiogram complexes: a description of a heretofore

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Association

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statement

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part I: The electrocardiogram and its technology: a scientific

Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology

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Foundation; and the Heart Rhythm Society: endorsed by the

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International Society for Computerized Electrocardiology.

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Circulation 2007;115:1306-1324. 23. Comprehensive Electrocardiology, P.W. Macfarlane, A. van

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Oosterom, O. Pahlm, P. Kligfield, M. Janse, J. Camm. (Eds.), Springer, 2010, London, UK, pp. 348, 377. 24. Madias JE, Narayan V. Augmentation of the amplitude of electrocardiographic QRS complexes immediately after hemodialysis: a study of 26 hemodialysis sessions of a single patient, aided by measurements of resistance, reactance, and impedance. J Electrocardiol. 2003;36:263-71.

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25. Durmus E, Hunuk B, Erdogan O. Increase in QRS amplitudes

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is better than N-terminal pro-B-type natriuretic peptide to predict clinical improvement in decompensated heart failure. J

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Electrocardiol. 2014;47:300-5.

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26. Sheng F, Chen B, He M, Zhang M, Shen G, Zhao X. The effect of diuresis on the amplitude of paced QRS complexes in pacing-dependent patients with heart failure. Ann Noninvasive

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Electrocardiol. 2015 Jun 24. doi: 10.1111/anec.12286. [Epub

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ahead of print].

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27. Yancy CW, Jessup M, Bozkurt B, et al; 2013 ACCF/AHA guideline for the management of heart failure: a report of the

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American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62:e147-239. 28. Madias JE. Mechanism of attenuation of the QRS voltage in heart failure: A hypothesis. Europace. 2009:11:995-1000.

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29. Salisbury PF, Cross CE, Rieben PA, Sodi-Pallares D.

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Physiologic and electrocardiographic correlations in

experimental left heart failure. Am J Physiol. 1965;209:928-34.

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30.http://www.amazon.com/Tanita-BF680W-Scale-Monitor-Athl

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etic/dp/B0009V1YPU (accessed last on 4/22/16). 31. AliveCor.com. http://alivecor.com (accessed last on 4/22/16). 32. Garabelli P, Albert D, Reynolds D. Accuracy and novelty of

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an inexpensive iPhone-based event recorder. Paper presented at:

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Heart Rhythm Scientific Sessions; May 11, 2012; Boston, MA.

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Abstract IA02-1.

33. Baquero GA, Banchs JE, Ahmed S, Naccarelli GV, Luck JC.

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Surface 12 lead electrocardiogram recordings using smart phone technology. J Electrocardiol. 2015;48:1-7. 34. Lowres N, Freedman SB, Redfern J, et al. Screening Education And Recognition in Community pharmacies of Atrial Fibrillation to prevent stroke in an ambulant population aged ≥65 years (SEARCH-AF stroke prevention study): a crossectional

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10.1136/bmjopen-2012-001355. Print 2012

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study protocol. BMJ Open. 2012 Jun 25;2(3). pii: e001355. doi:

35. Tarakji KG, Wazni O, Callahan T, et al. Evaluating the

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efficacy and feasibility of a novel wireless recording system

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using smart phone in monitoring patients after atrial fibrillation ablation procedure: the iTransmit study. Paper presented at: Heart Rhythm Scientific Sessions; May 8, 2014; San Francisco,

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CA. Abstract AB07-04.

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36. Lowres N, Neubeck L, Salkeld G, et al. Feasibility and

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cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies:

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the SEARCH-AF study. Thromb Haemost. 2014;111:1167-1176. 37. Tarakji KG, Wazni OM, Callahan T, et al. Using a novel wireless system for monitoring patients after the atrial fibrillation ablation procedure: The iTransmit study. Heart Rhythm. 2015;12:554-9. 38. Lau JK, Lowres N, Neubeck L, et al. iPhone ECG application for community screening to detect silent atrial fibrillation: a novel

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technology to prevent stroke. Int J Cardiol. 2013;165:193-4.

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39. RACGP iPhone ECG screening by practice nurses and receptionists for atrial fibrillation in general practice: the qualitative

pilot

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GP-SEARCH

study.

[accessed last on 4/22/16].

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http://www.racgp.org.au/afp/2014/may/iphone-ecg-screening/

40. Saxon LA. Ubiquitous wireless ECG recording: a powerful

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2013;24:480-483.

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tool physicians should embrace. J Cardiovasc Electrophysiol.

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41. Waks JW, Fein AS, Das S. Wide complex tachycardia recorded with a smartphone cardiac rhythm monitor. JAMA

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Intern Med. 2015;175:437-9. 42. Chung EH, Guise KD. QTC intervals can be assessed with the AliveCor heart monitor in patients on dofetilide for atrial fibrillation. J Electrocardiol. 2015;48:8-9. 43. Muhlestein JB. QTC intervals can be assessed with the AliveCor heart monitor in patients on dofetilide for atrial fibrillation. J Electrocardiol. 2015;48:10-1.

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44. Muhlestein JB, Le V, Albert D, et al. Smartphone ECG for

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evaluation of STEMI: Results of the ST LEUIS Pilot Study. J Electrocardiol. 2015;48:249-59.

mobiles.

VentureBeat;

2012

[

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U.S.

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45. Hardawar D. The magic moment: smartphones now half of all

http://venturebeat.com/2012/03/29/the-magic-moment-smartpho nes-now-half-of-all-u-s-mobiles/ (accessed last on 4/22/16)].

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46. Madias JE. Comparability of the standing and supine standard

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electrocardiograms and standing sitting and supine stress

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electrocardiograms. J Electrocardiol. 2006;39:142-9.

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Legends to figures Figure 1: A 55 year old man with HF experienced a 12% gain of his weight over the course of 5 months, and in the process revealed, by a comparison of ECGs A and B, aQRS in Σ6LbLds, ΣPrecLds, and Σ12Lds loss in voltage by 34%, 37%, and 36%, correspondingly. Figure 2: AliveCor™ Heart Monitor with embedded electrodes in

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the back of the iPhone case (A), used for the studies of Refs. #33,

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35-41; an ECG is acquired by holding the phone case by placing the fingers of each hand on the electrodes, which via modulated

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ultrasound transmit the ECG recording (B). Reproduced with

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permission from Saxon.40 AliveCor™ Heart Monitor with 5th generation iPod Touch (C), used for the pilot study of Ref. #43. Reproduced with permission from Muhlestein et al.44

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Figure 3: Standard 12-lead ECG with an AliveCor generated

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ECG, recorded at the same sitting, using the same limb and chest

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tabs showing left bundle branch block, similar morphologies and amplitudes,

in

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tachycardia-induced

55

year

old

male

cardiomyopathy,

due

patient to

with

rapid

a

atrial

fibrillation. Reproduced with permission from Baquero et al.33 Figure 4: Method to record/transmit a 3-lead ECG (A, B, and C) employing only the smart phone, without the use of attached electrode cables, with instructions (D), for holding (A), and placing the device on the left knee (B), and left precordial thoracic wall, overlying the left breast nipple (C).

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Highlights

Societies world-wide are severely burdened with the monitoring

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and management of patients with heart failure (HF). Many

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clinical and laboratory methods have been employed in the monitoring of patients with HF in the hospital, clinic, and in the patients' ambient environment via remotely applied technology.

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The core idea pertains to periodic acquisition/transmission by the

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patient or caregivers, information necessary for the members of

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the HF team, to advise the patient about the drug regiment and other aspects of management via a "remote control" approach,

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obviating the inconvenience and cost of frequent visits to the hospital. The ubiquitous smart phone/device technology (SPT) has enabled the safe acquisition/transmission of clinical and laboratory patient data, including the electrocardiogram (ECG). SPT-based recording/transmission of the ECG has been found useful in the detection of atrial fibrillation, monitoring of the QTc interval in patients undergoing antiarrhythmic drug loading, and

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management of patients with acute ST-elevation myocardial

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infarction. Previous work has shown a relationship between changes in the voltage of the ECG QRS complexes, with

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perturbations in the edematous state of patients with sepsis, the

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ones undergoing hemodialysis, and with HF. It is proposed herein to employ serially SPT-based 3-lead ECG recording/transmission for the monitoring and management of patients with HF in their

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ambient environment. The proposed method will enable patients

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with HF to acquire/transmit their 3-lead ECG to the caring HF

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team, using only their smart phone and it takes into consideration the advanced degrees of physical incapacitation and age-related

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infirmities inherent to the HF population.

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Fig. 4

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