Application of telemedicine technology for cardiovascular diseases management during the COVID-19 pandemic: a scoping review

Background Recently, the use of telemedicine technology has increased due to the Covid-19 pandemic. Cardiovascular diseases management is one of the areas that has benefited from using this technology. This study aimed to identify the applications of telemedicine for cardiovascular diseases management during the Covid-19 pandemic. Methods This scoping study was conducted in 2023. Various databases, including PubMed, Web of Science, Scopus, the Cochrane Library, Ovid, CINAHL, ProQuest, and IEEE Xplore along with Google Scholar were searched and all related quantitative, qualitative, and mixed-method studies published in English between 2020 and 2022 were included. Finally, the required data were extracted, and the findings were reported narratively. Results A total of 17 articles were included in this study. The results showed that teleconsultation via telephone and videoconferencing were the most common used technologies. Telemedicine helped to improve clinical impacts such as patient health status and quality of care, and reduced hospitalizations and re-admission rates compared to in-person visits. The non-clinical impact included reducing waiting time, in-person visits, and healthcare costs during the Covid-19 pandemic. Conclusion The Covid-19 pandemic has led to an increased use of telemedicine technology, especially for patients with cardiovascular diseases. As teleconsultation and telemonitoring are useful for cardiovascular diseases management and regular examinations, future research should investigate how these technologies can be improved and used for a wider population.


Introduction
Cardiovascular diseases are one of the main causes of worldwide death (1,2).Nearly half of all deaths in high-income countries and about 28% of deaths in lowand middle-income countries are caused by cardiovascular diseases (3,4).According to the literature, approximately 23.6 million people will die due to cardiovascular diseases by 2030 (2, 5-7) Therefore, many interventions have been carried out to reduce the burden of diseases and the number of deaths, to provide the necessary training for better prevention and treatment, and to use new technologies such as telemedicine for better patient-provider interactions (6)(7)(8).
In late 2019, when the world faced with the Covid-19 pandemic (9), patients with cardiovascular diseases were more at risk of adverse consequences caused by infections and complications of the Covid-19 disease (10,11).Moreover, the pandemic caused significant cardiometabolic risk factors that could worsen the prognosis for cardiovascular patients.The cytokine storm and visceral obesity were among these risk factors.The cytokine storm, a hyperactive immune response triggered by Covid-19, coud lead to severe inflammation and multi-organ failure, particularly affecting the cardiovascular system.Visceral obesity, a condition characterized by excess fat around the internal organs, was identified as a major risk factor for severe Covid-19 outcomes, including heart failure and atherosclerosis (12).
Therefore, the application of telemedicine technology increased, as this technology helped with reducing the spread of the disease by decreasing patient attendance in the crowded places such as hospitals (13).In addition, the technology was easy to use and provided the patients with low-cost services (14).
The use of this technology for cardiovascular patients during the Covid-19 pandemic minimized the risk of disease transmission at primary care, provided optimal treatment, and prevented the deterioration of the clinical conditions.It also led to early signs monitoring of heart failure and reduced unnecessary hospitalizations (15)(16)(17).
Molinari et al.'s study showed that the use of telecardiography technology for cardiovascular patient management led to reduction in non-emergency and emergency visits by half and a quarter, respectively (18).In another study, Ajibade et al. found that the use of telemedicine services can be effective in pre-and post-operative care and for treating patients with cardiovascular diseases during the Covid-19 pandemic (9).
Although, several review studies have been conducted on the use of telemedicine technology for treating patients with cardiovascular diseases during the Covid-19 pandemic (9,(19)(20)(21)(22), few studies have investigated different types of technologies, services, and clinical and non-clinical impact of telemedicine on cardiovascular diseases management during the Covid-19 pandemic.Therefore, the present study aimed to identify the applications of telemedicine for cardiovascular diseases management during the Covid-19 pandemic.

Methods
In this scoping review, Arksey and O'Malley's framework was used (23).A scoping review can help to provide a comprehensive overview of the research topic and to combine the results of different study types.In addition, conducting a scoping review allows for faster and more cost-effective resolution of the gaps in the existing knowledge and the extraction of essential data elements from different studies.

Stage 1: identify the research question
The starting point for developing a search strategy in review studies is identifying the research question.Therefore, the research question for the present study was generated as follows: What were the applications of telemedicine technology for cardiovascular diseases management during the COVID-19 pandemic?

Stage 2: identifying of relevant studies
To identify relevant studies, search strategies were developed and eight databases including PubMed, Web of Science, Scopus, the Cochrane Library, Ovid, IEEE Xplore, ProQuest, CINAHL, and the Google Scholar search engine were searched for studies that were published in English between 1st June 2020 and 31th December 2022.The search strategy consisted of the three main terms "Covid-19", "telemedicine", and "cardiovascular diseases" which were combined using AND/OR logical operators (Appendix I).To increase reliability, the reference list of the included studies and their citations were also examined.

Stage 3: selection of the studies
To select the relevant studies, specific inclusion and exclusion criteria were set.All original articles published in English that used different types of research methodologies including quantitative, qualitative, and mixed-methods approaches to evaluate the use of telemedicine interventions for cardiovascular diseases management during the Covid-19 pandemic were included in this study.
Review articles, letters to the editor, protocols, and studies that did not reported the use of telemedicine technology for cardiovascular diseases management as an intervention were excluded from the current study.In addition, studies that were not published in English, did not report clinical or non-clinical impacts, and their full-texts were not available were all excluded from the review.

Stage 4: data charting
After searching articles, the retrieved studies were entered into the EndNote software.Then, duplicates were removed, and the remaining articles were evaluated based on the relevance of their titles and abstracts to the objective of the present study.Subsequently, the full texts of the eligible studies was obtained and examined.Both authors (HA and ET) independently screened the articles and resolved any disagreements through discussion.Any disagreements were discussed and solved with the help of the third author (HA).The screening process of articles was undertaken based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (24).
Having read the full texts of the included studies, the required data were extracted using a data extraction form.The data included the name/s of the author/s, year of publication, country, study objective, research methodology, type of telemedicine services, type of telemedicine technology, the impact of technology, and a summary of the main results.

Stage 5: collecting, summarizing, and reporting the results
The extracted data were tabulated, summarized, and reported narratively.Results were reported by categorizing studies according to the type of telemedicine services, type of technology, and clinical and non-clinical impact.

The impact of using telemedicine services
The impact of using telemedicine services on cardiovascular diseases management were divided into two categories: clinical impact (e.g., reducing re-admissions rates, improving patient condition, etc.), and non-clinical impact (e.g., reducing waiting times and increasing satisfaction, awareness, etc.).The details of these categories are presented in the below sections.

Clinical impact
Patients with cardiovascular diseases benefited from using telemedicine services during the Covid-19 pandemic.It improved clinical symptoms (27,29), low-density lipoprotein cholesterol (29), shortness of breath (28,37), palpitations (28), and limb edema (28).The use of telemedicine also enhanced the timeliness of respiratory infection diagnosis (37).Batalik et al. reported that telerehabilitation improved cardiac and respiratory functions and reduced walking test times in patients with coronary artery diseases (16).Teleconsultation also aided cardiac rehabilitation for patients with acute myocardial infarction (31).Hospitalization rates were reduced using telemedicine services compared to in-person visits (7,15,26,33).

Non-clinical impact
Several studies demonstrated that the implementation of teleconsultation services has resulted in increasing satisfaction among physicians, nurses (31, 33), and patients (33).In addition, teleconsultation services can efficiently decrease waiting times (29), and the time required for in-person visits (7,18,31).Some studies showed that using telemedicine services during the Covid-19 pandemic had some advantages over in-person consultations.These included reducing the workload of physicians (29,31), saving travel costs (31), preventing readmissions (26, 34), and improving healthcare quality (16).

Synthesis
Overall, the results of this study indicated that telephone consultation (n = 9, 53%) and videoconferencing (n = 7, 41.1%) were the most common tools for providing telemedicine services.CardioClick, Heartbeat Health, and Zoom were the most commonly used platforms for videoconferencing.The findings also indicated that the primary non-clinical impacts of telemedicine services for patients with cardiovascular diseases during the Covid-19 pandemic included the reduction of in-person visits and healthcare providers' workload.The clinical impacts included decreasing re-admission rates, improving vital signs, and quality of care.

Discussion
The present study examined the applications of telemedicine for cardiovascular diseases management during the Covid-19 Teleconsultation significantly improved medication adherence (P < 0.02), smoking cessation (P = 0.001), and cardiac rehabilitation (P = 0.001).About 87% of patients were satisfied with the telemedicine services, and many patients were satisfied with the virtual visits even after they were discharged.About 61% of patients believed that the teleconsultation was as effective as visiting the clinic.
(Continued) pandemic.According to the results, teleconsultations and televisits were the most used services and the main tools were telephone and videoconferencing.The use of telemedicine had some clinical and non-clinical impacts which could improve quality of care and cardiac rehabilitation, and reduce waiting times and healthcare costs.Similar to the findings of this study, other studies have demonstrated that offering teleconsultation services, particularly for cardiovascular patients, has resulted in reducing the risk of Covid-19 infection (38).Furthermore, several studies showed that teleconsultation services have significantly improved clinical symptoms compared to the in-person consulattions (39,40).This was an effective approach for reducing in-person visits, readmissions, and referrals.Better medication adherence, improving clinical symptoms, and easier patient follow-up during the Covid-19 pandemic were among other benefits of teleconsultations.
The results showed that televisit services during Covid-19 pandemic had a number of benefits, such as reducing the physician's workload and saving their time.Similarly, Gorodeski et al. showed that televisit services might be helpful for patients with heart failure to reduce re-hospitalization rates and to improve clinical outcomes (41).Brunettiet al. showed that using televisits and electrocardiograms reduced the duration of emergency care for patients with cardiovascular diseases (19,42).
Regarding the technology and communication tools, telephone and videoconferencing were the most commonly used technologies for the provision of telemedicine services to the patients with cardiovascular diseases during the Covid-19 pandemic.The results of several studies showed that the use of telephone consultation was effective in providing ongoing support for maintaining and promoting behavioral health changes, medication adherence, and controlling risk factors for cardiovascular diseases (43,44).
Moreover, telephone counseling can effectively reduce healthcare costs for cardiovascular patients (42).This type of services led to a reduction in hospital length of stay, number of referrals, and number of hospitalizations, surgeries, and emergency surgeries during the Covid-19 era (43).Similarly, the use of videoconferencing led to diagnose symptoms and treat patients as early as possible, reduce re-hospitalizations, decrease emergency care visits, and save healthcare costs (42,44,45).Idris et al. showed that videoconferencing can be effective for patients with heart failure in scheduling weekly visits (46).
The use of mobile-based applications was another approach to manage cardiovascular diseases.For instance, Sua et al. demonstrated that self-management interventions using mobilebased applications were correlated with a decrease in blood pressure among individuals with cardiovascular conditions (47).Similarly, Rawstorn et al. found that telemedicine and telecardiac rehabilitation were effective in controlling diastolic blood pressure, reducing low-density lipoprotein cholesterol, and improving respiratory capacity (48).
However, the findings of Huang et al.'s research indicated that the implementation of telemedicine interventions did not yield a statistically significant correlation with enhanced cardiac The findings demonstrated that telemedicine and mobile phone applications were effective in reducing the hospitalization rates of patients with cardiovascular diseases during the Covid-19 pandemic.Similarly, several studies showed that telemedicine interventions effectively decreased the rate of re-admission among patients with cardiovascular diseases compared to the standard care (50)(51)(52)(53)(54).In contrast, some researchers reported that the implementation of telemonitoring did not have an impact on the re-admission rate of patients with heart failure (55, 56).
Improving clinical care, quality of life, and psychological wellbeing for patients with heart failure were other benefits of using telemedicine services during the Covid-19 pandemic.Marra et al. found that using telephone consultation and videoconferencing services was significantly effective in improving nutritional wellbeing in patients with cardiovascular diseases (57).
Several studies reported that using telemedicine in the management of patients with heart failure has resulted in a reduction in mortality rate (52,(58)(59)(60).Similarly, the study conducted by Gallagher et al. revealed that providing postdischarge telephone consultations can improve treatment adherence in patients with heart failure (44,61).The results of several studies demonstrated that telephone consultation is especially helpful for the early diagnosis of cardiovascular diseases and reduces diagnostic costs (42,52,62).Van Dyck et al. found that using telemonitoring services decreased the number of emergency department visits and reduced 15% healthcare costs (63).Other studies reported that using telemedicine significantly improves physical activity and quality of life in patients with coronary heart disease (59,64).
It is notable that during the Covid-19 pandemic, managing heart failure in patients with dilated cardiomyopathy (DCM) posed significant challenges that were effectively mitigated through telemedicine technologies.DCM is characterized by the heart's diminished ability to pump blood effectively, and requires continuous and comprehensive management to prevent exacerbations and hospitalizations (65).Telemedicine enabled remote management by providing tools for regular teleconsultations, which allowed healthcare providers to assess DCM symptoms, adjust treatments, and offer immediate medical advice without necessitating in-person visits (66, 67).
Telemonitoring technologies, such as wearable devices and mobile health applications, played a crucial role by continuously tracking vital signs like blood pressure, heart rate, and weight (68).These technologies facilitated early detection of worsening conditions, prompting timely medical interventions for DCM patients that prevented hospital admissions.In addition, virtual cardiac rehabilitation programs supported DCM patients in maintaining their physical activity and managing their condition during lockdowns (69,70).
Studies showed that these telehealth interventions led to reduced hospital readmissions, improved medication adherence, and better management of heart failure symptoms.
The ability to provide real-time, patient-specific care remotely proved invaluable in maintaining the health and safety of DCM patients, minimizing their exposure to Covid-19, and ensuring continuous, effective disease management (32).This approach not only addressed the immediate needs during the pandemic but also highlighted the potential for ongoing telemedicine integration in managing chronic cardiovascular diseases (71).

Limitations
This study had some limitations.The first limitation was related to the number of databases and the inclusion criteria set for the selecting the articles.In this study, certain databases were searched and only studies published in English were included.There might be other articles indexed in different databases and published in non-English languages that were not included in this study.However, the researchers believed that the main databases were searched in this study to include as many relevant articles as possible.The second limitation might be related to the type of the study which was a scoping review.Although this study helped to provide an overview of the applications of telemedicine for cardiovascular diseases management during the Covid-19 pandemic, the impact of this intervention was not measured quantitatively.Future research can focus on conducting systematic reviews and meta-analysis to identify the clinical and non-clinical impact of telemedicine using quantitative approaches.

Conclusion
This study investigated the application of telemedicine for cardiovascular diseases management during the Covid-19 pandemic.The findings showed the efficacy of using telemedicine for cardiovascular diseases management, especially in terms of clinical and non-clinical impacts.The results suggested the potentials of telemedicine technology for managing patients with cardiovascular diseases even in the post-Covid-19 era.Future research should concentrate on identifying practical strategies for using telemedicine in cardiovascular diseases management, considering patients' and healthcare providers' perspectives.In addition, future studies should investigate new solutions to improve the accessibility, affordability, and privacy of telemedicine services.

TABLE 1
Summary of the studies.

TABLE 1 Continued
(49)hermore, it failed to induce improvements in clinical symptoms such as weight loss, blood pressure, cholesterol levels, smoking cessation, and quality of life(49).