Dr Ronan G Ali
Cardiovascular disease (CVD) is the leading cause of global mortality. Whilst CVD encompasses a wide variety of heart conditions, in Trinidad, coronary heart disease (CHD) is responsible for most death and disability that we see from CVD in general. CHD describes what happens when your heart’s blood supply is blocked or interrupted by a buildup of fatty substances in the coronary arteries.
CHD is influenced by a combination of behavioural and metabolic risk factors. Behavioural risk factors include smoking, physical inactivity, and an unhealthy diet. Metabolic risk factors are influenced by the behavioural risk factors and include high blood pressure, diabetes, high cholesterol, and obesity. Other non-modifiable risk factors include age, gender, and a family history of CHD.
Digital Health Technologies prioritised by WHO
Digital health is defined as the use of digital, mobile, and wireless technologies to support the achievement of health objectives. In 2018, the World Health Organization (WHO) urged health organisations to prioritise digital health technologies to close the gap of health access inequities and improve and strengthen health systems. With the advent of the COVID-19 pandemic, digital health has become even more relevant in attempting to follow mandates of social isolation and continuing to be able to access the needed CVD care.
Digital Health Interventions
One of the earliest studied digital health interventions to improve CVD care was text-messaging. Text messages are an inexpensive, convenient means of communication and can be sent to many people simultaneously with automated software. Smoking cessation was shown to be almost twice as likely when patients were enrolled in a text messaging program than not. Physical activity levels were better in patients receiving text messaging reminders with a significant increase in step counts per day. Similar improvements in weight loss in overweight participants has also been noted with text messaging programs. Medication adherence is a critical component of CHD care and most studies have reported improvement in sticking to a medication regimen when aided by text messages.
Smartphones and tablets have ushered in a new era of sophisticated digital health interventions. Apps can educate and inform, provide reminders, and track medications among other functionalities. Attempts at clinical trials to show improvement (or harm) to patients have been difficult because of the vast numbers of apps involved, small sample sizes and short follow up times. An important point to remember is that most of these apps are not developed by doctors and have little input from health professionals. The apps also may not follow evidence-based guidelines. The guidelines also change quite frequently, and apps may not be adequately updated.
Wearables – Do they improve our Health?
Wearable electronic devices can capture patient data such as step counts, distance walked, energy expenditure and heart rate. Many such devices connect to smartphone apps and provide a virtual incentive for increasing activity levels. Groups of friends can also engage in a virtual competition for daily step counts and physical activity levels. When these wearable devices were studied, they did show a significant increase in the number of steps per day as well as an increase in the amount of time spent performing moderate-to-vigorous physical activity. A newer type of wearable device, the smartwatch, was studied in 2019 to determine its ability to detect a type of abnormal heart rhythm called atrial fibrillation. Atrial fibrillation is an important heart rhythm abnormality as it can potentially cause a stroke. The smartwatch was found to be very accurate at detecting atrial fibrillation. This led to more recently the development of a home mobile cardiac monitor using a system of wearable sensors and a smartphone app which can accurately generate an ECG, detect atrial fibrillation, and transmit the information to your doctor for confirmation.
COVID-19 and Telemedicine
Specifically with regard to the COVID-19 pandemic, telephone and video remote consultations can minimise the need for in-person clinic visits. Remote data analysis including lab result analysis, home electrocardiograms and image transmission are all useful tools that can assist with risk mitigation for COVID-19. The success of these interventions may not apply to high-risk or unstable patients who still may require in-hospital care. Potential drawbacks of digital health interventions include that both the patient and the physician must be familiar with the digital tools for them to work. Many patients and physicians are not tech-savvy enough to have an effective telemedicine experience. The elderly and those with learning disabilities may also find telehealth complex. Complex CVD patients will also often need a face-to-face consultation to be given the proper level of care.
Charles Lowe of ACTIVAGE project shared, “Technical experts therefore need to be aware of these complexities when designing and creating new digital health interventions, especially those designed for older people who typically have greater difficulty mastering the new. Most importantly they need to produce technology that is intuitive to use.”
Dr Ronan G Ali is a graduate of the University of The West Indies (UWI) St Augustine campus. He specialised in Internal Medicine at Yale New Haven Hospital, Connecticut and then Cardiovascular Disease and Interventional Cardiology at Baystate Medical Center, Massachusetts. He has held faculty positions at Yale University, Tufts University, and his alma mater the UWI. He is a fellow of the American College of Physicians, the American College of Cardiology, the Society for Cardiovascular Angiography and Interventions and the Royal College of Physicians Edinburgh. Currently he is a Consultant Cardiologist at Medical Associates Hospital.