People who have recently suffered a heart-attack or have had a heart surgery, or been admitted for heart failure, need to be inducted into a cardiac rehabilitation program to assist them to gradually return to a normal life in due course of time. The hope and intention is also to prevent a recurrence or worsening of the problem (called Secondary Prevention).
The process of achieving the above objectives is called Cardiac Rehabilitation (CR).
CR is a specialized area and involves a wide range of activities such as:
Till a few decades ago, CR was a complex process that involved innumerable doctors, specialists, nurses and the family members of the patient. Compliance with secondary prevention measures and proactive participation, by the patient, were low. Then came Tele-rehabilitation and Tele-Medicine in the early 2000s. These aimed at remote consultation with the patient, however they have not been found to be effective in CR.
In the last decade- and-a-half, advances in sensor technology and mobile applications have been able to automate many of the above activities. This has led to a plethora of wearable devices and cardiac implantable electronic devices (CIEDs) that capture real-time data and relay it to concerned specialists who will then suggest the required intervention.
The sensors can be invasive or non-invasive and can be used to monitor parameters such as heart rate, pulmonary artery pressure, blood pressure, thoracic wall impedance, weight and physical activity. They can also monitor behavioural aspects such as adherence to medication and movements that reflect active smoking. Smart tools then make sure that data capture is automatic in order to increase patient comfort. Further, many of these devices and platforms are interoperable (able to exchange and make use of information) which ensures that the healthcare provider (such as the hospital managing the CR) finds the system user-friendly.
Further, all these data are being integrated into an Artificial Intelligence based software system.
AI-driven algorithms can simplify decision making regarding physical activities to be undertaken by the person, and medication, and can be as autonomous as possible. Secondary prevention is achieved through a partially-automated, personalized, AI-based VHC or Virtual Health Coach that is basically a smartphone application but is also integrated to all hardware worn by the person. All these are then integrated in to a system that is supervised by a team of healthcare professionals involved in the CR.
The sum-total of all this is – a highly personalized CR program, which goes a long way in reducing the burden on the healthcare system. Further, it has moved the playing field from clinics and hospitals to the patient’s home. This increases patient comfort, reduces the hassles associated with CR and improves CR outcomes.
There is a plethora of tools, technologies, devices and sensors in use today or under active research. It’s not possible to cover all of them here, so for the purpose of this article, we will cover only the most popular and widely used ones.
Hypertension / High BP: The manual sphygmomanometer used by doctors and clinics is now being replaced by digital, upper-arm sphygmomanometer or BP monitor that can be used at home. The data from it can be integrated with smartphone applications.
Physical activity: The ubiquitous Fitbit and smartphone apps that monitor or measure physical activity are first generation options. Today, CIEDs (cardiac implantable electronic devices) are fitted inside the heart and these use an array of sensors such as accelerometers, pulmonary impedance sensors, ventilation sensors, cardiac contractility sensors and blood temperature sensors.
Weight Management: There are various surgical and non-surgical options available today for weight-loss and weight-management. These are being complemented by smartphone apps that approve or disapprove food purchases by bar-code scanning, remembering recent food inputs (both purchase and consumption), photographs of food consumed or purchased, auto-completion of text and recognizing food items from uploaded photos.
Diabetes Management: The capillary prick method for glucose monitoring will become a thing of the past. Chronic diabetics can have subcutaneous glucose sensors implanted. Along with smart insulin pens, automatic pumps and decision support-systems, they achieve better diabetes management.
Smoking Cessation: Exhaled Carbon Monooxide sensors are used in conjunction with smartphone applications that monitor the person’s changes in behavior. Inputs from these two are fed to an AI-based program that predicts Smoking Cessation treatment outcomes. An AI-based chat-bot then follows up with counselling for behavioral change.
Medication Adherence: Smart pillboxes are smartphone apps that remind and monitor the patient’s adherence to prescriptions. Digital pills (still under research) are a drug-device combination that relay a signal when the pill comes in contact with gastric acids.
Sensors in Heart Failure: A Patient Management Intervention System under research captures and transmits daily information on heart rate, body weight, heart rhythm, blood pressure, peripheral capillary oxygen saturation, and self-rated health status. It engages a tele-monitoring system that consists of a three-channel electrocardiogram (ECG), a blood pressure measuring device and weighing scales that provide their inputs to a smartphone application. Studies are underway that use disposable, multi-sensor patches to measure ECG, skin impedance, temperature, and accelerometry in order to derive information about heart rate and variations, arrhythmia burden, body posture, gross activity, respiratory rate, body tilt, walking and sleep.
Tele-monitoring using CIEDs: Cardiac Implantable Electronic Devices such as cardioverter-defibrillators (ICDs) and cardiac resynchronization defibrillators (CRT-Ds) are improving clinical outcomes for patients with heart failure.
Sensors in Arrhythmia Detection and Monitoring: Photo-plethysmo-graphy (PPG) and Electro-cardio-graphy (ECG)-based smartwatches, smart-cameras and smartphone-based apps are being used to monitor and/or diagnose Atrial Fibrillation (AF) and malignant arrhythmias.
Internet of People: This is in the early stage of research. Biochemical sensors fitted into smart mirrors, smart contact-lenses, smart vehicles and smart sanitation can monitor health parameters of CR (or any heart) patients and trigger alarms or alerts when threshold values are crossed. Voice recordings are being analyzed to detect Coronary Artery Disease (CAD) or heart-failure decompensation.
Digital Twin: The above technology will soon evolve in such a way as to create a digital twin for the patient. One can simulate various structural and physiological characteristics of the patient and create a digital copy of him/her. This way, the heart function, exercise capacity and medication tolerance can all be simulated and analyzed, without harming or hassling the patient in any way.
Reviewed by Dr Suresh S Venkita, Group Medical Director, Kauvery Hospitals
Kauvery Hospital is globally known for its multidisciplinary services at all its Centers of Excellence, and for its comprehensive, Avant-Grade technology, especially in diagnostics and remedial care in heart diseases, transplantation, vascular and neurosciences medicine. Located in the heart of Trichy (Tennur, Royal Road and Alexandria Road (Cantonment), Chennai, Hosur, Salem, Tirunelveli and Bengaluru, the hospital also renders adult and pediatric trauma care.
Chennai – 044 4000 6000 • Trichy – Cantonment – 0431 4077777 • Trichy – Heartcity – 0431 4003500 • Trichy – Tennur – 0431 4022555 • Hosur – 04344 272727 • Salem – 0427 2677777 • Tirunelveli – 0462 4006000 • Bengaluru – 080 6801 6801
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