HRS/EHRA/APHRS/LAHRS/ACC/AHA Worldwide Practice Update for Telehealth and Arrhythmia Monitoring During and After a Pandemic

Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), started in the city of Wuhan late in 2019. Within a few months, the disease spread toward all parts of the world and was declared a pandemic on March 11, 2020. The current health care dilemma worldwide is how to sustain the capacity for quality services not only for those suffering from COVID-19 but also for non-COVID-19 patients, all while protecting physicians, nurses, and other allied health care workers.

. There have also been several case reports of atrioventricular block in hospitalized patients, which is otherwise rarely described during viral illness (4,5).
Although the residual left ventricular dysfunction and arrhythmic risk are currently unknown, preliminary pathophysiological (6), histological (7), and imaging (8) data suggest that SARS-CoV-2 infection holds the potential to induce durable myocardial changes predisposing to arrhythmias or heart failure.
Electrocardiographic monitoring and inpatient monitoring services may become necessary but face the potential hurdles of limited telemetry wards, contamination of equipment and infection of health care personnel, and shortage of personal protective equipment (9,10). In parallel, there is a continued responsibility to maintain care of COVID-19-negative patients with arrhythmias. These pressures have led to inventive utilization and adaptation of existing telemedicine technologies as alternative options.
This document discusses how digital health may facilitate electrophysiology practice for patients with arrhythmia, whether hospitalized for COVID-19 or not.
The representation of authors from some of the most severely affected countries, such as China, Spain, Italy, and the United States, is a tribute from our worldwide community to those colleagues who have worked on the front lines of the pandemic.

MONITORING STRATEGIES DURING A PANDEMIC: HERE TO STAY
In light of the current pandemic, monitoring strategies should focus on selecting high-risk patients in need of close surveillance and using alternative remote recording devices to preserve personal protective equipment and protect health care workers from potential contagious harm.

Inpatient
For inpatient monitoring, telemetry is reasonable when there is concern for clinical deterioration (as may be indicated by acute illness, vital signs, or sinus tachycardia), or in patients with cardiovascular risk factors and/ or receiving essential QT-prolonging medications.
Telemetry is generally not necessary for persons under investigation without concern for arrhythmias or clinical deterioration and in those not receiving QT-prolonging drug therapy. In situations in which a hospital's existing telemetry capacity has been exceeded by patient numbers or when conventional telemetry monitoring is not feasible, such as off-site or nontraditional hospital units, mobile devices may be used, for example, mobile cardiac outpatient telemetry (MCT) as an adjunctive approach to support inpatient care (11)(12)(13)(14)(15). The majority of MCT devices can provide continuous arrhythmia monitoring using a single-lead electrocardiogram (ECG) and allow for real-time and offline analysis of long-term ECG data.
Telemetry can be extended using patch monitoring (16,17). Smartphone ECG monitors are wireless and have also been utilized during the current pandemic. Information is limited, however, on how parameters such as QTc measured on a single-(or limited number) lead ECG can reliably substitute for 12-lead ECG information (18,19).
In one study, QT was underestimated by smartphone single-lead ECG (20).

THERAPY FOR COVID-19 AND POTENTIAL ELECTRICAL EFFECTS
No specific cure exists for COVID-19 (28-30). Potential COVID-19 therapies, especially hydroxychloroquine and azithromycin, are being investigated in ongoing trials but also have been used off label in many parts of the world.
These may exert QT-prolonging effects (31) ( Table 3) and, since recent observational data have questioned their efficacy, require a careful risk-benefit adjudication (32).
Combination therapy (eg, hydroxychloroquine and azithromycin) may have synergistic effects on QT prolongation (33,34). In a retrospective cohort study of 1,438

COVID-19 patients hospitalized in metropolitan New
York (ie, a disease epicenter), cardiac arrest was more frequent in patients who received hydroxychloroquine with azithromycin compared with patients who received neither drug (35). The adjusted hazard ratio for inhospital mortality for treatment with hydroxychloroquine alone was 1.08, for azithromycin alone was 0.56, and for combined hydroxychloroquine and azithromycin was 1.35. However, none of these hazard ratios were statistically significant. The observational design of this study may limit interpretation of these findings. In    Varma et al. and outpatient care will be increasingly served by digital medicine tools.  (12). Wearable and smartphone-based devices allow convenient real-time monitoring for arrhythmias on a long-term basis due to the comfort associated with their small size and ease of use while reducing patient and health care worker exposure. Remote CIED monitoring has existed for decades (24). It is strongly endorsed by professional societies, but in practice only a fraction of its diagnostic and therapeutic capabilities has been utilizeduntil now (59). Since the start of the pandemic, utilization of wireless communication with CIEDs has grown exponentially, permanently altering the future of device follow-up. Patient outcomes may be improved with intensive device-based monitoring compared with traditional in-clinic evaluations at regular intervals (60).
Recent data indicate that in-person CIED evaluation can be extended safely to at least biennially when daily digital connectivity is maintained (61). Remote monitoring has the potential advantage of detecting and alerting caregivers (and in the future-patients directly) about important parameter changes, enabling earlier patient hospitalization, even during a presymptomatic phase (62).
Connectivity permits longitudinal follow-up, with advantages ranging from individual disease management to assessment of penetration of recommended therapies In summary, the crisis precipitated by the pandemic has catalyzed the adoption of remote patient management across many specialties and for heart rhythm professionals, in particular. This practice is here to stay-it will persist even if other less arrhythmogenic treatment strategies evolve for COVID-19 and after the pandemic has passed. This is an opportunity to embed and grow remote services in everyday medical practice worldwide.