Matt Reed is Honorary Professor of Emergency Medicine at Edinburgh University and the RCEM Professor.

Professor Reed is also a Consultant and NRS Fellow at the Royal Infirmary of Edinburgh (RIE) where he leads EMERGE, a multidisciplinary clinical research group that aims to ensure that research is part of everyday clinical care.

In this article Professor Reed explores the vital role that remote monitoring devices can play in the identification of cardiac arrhythmias, and in the prevention of ischemic stroke.

What inspired you to specialise in emergency medicine, and to research emergency cardiac problems?

Each year, across the United Kingdom (UK) around 300,000 patients present to the emergency department (ED) with heart palpitations and this figure is rising.

A heart palpitation is when an individual becomes aware of their heartbeat pounding or beating more quickly than usual.

The clinical concern here, is that these palpitations could be the result of a cardiac arrhythmia, which can
be caused by an abnormal electrical rhythm of the heart.

There are multiple causes for arrhythmias, however in some more serious incidences they can be a sign of problems with the heart.

Upon hospital admission a patient’s cardiac symptoms can often subside; it is therefore challenging for emergency clinicians to build a complete picture of their overall cardiac health.

Emergency clinicians can perform a 12-lead electrocardiogram (ECG) in the ED, but this does not typically reveal the cardiac arrhythmia. The treating clinician therefore, often has very little option but to discharge patient without any conclusive diagnosis, advising them to return should further symptoms occur.

This dilemma inspired my interest and research into the role of medical technologies that could remotely record an ECG over a prolonged period of time, without the need for hospital attendance or admission.

Why did you develop a new care pathway using a personal ECG device at the Royal Infirmary of Edinburgh?

As a result of us establishing EMERGE in 2008, the RIE was able to offer potential cardiac patients the opportunity to take part in the Investigation of Palpitations in the Emergency Department (IPED) trial using AliveCor’s medical-grade, personal ECG device KardiaMobile®.

This device enabled us to selectively screen patients, rather than continuously monitor them for a prolonged period, which can be expensive and would overwhelm current inpatient ECG monitoring resources.

The IPED intervention enabled the hospital to randomise suitable potential cardiac patients after assessment in the ED; opting them into either the KardiaMobile® monitoring pathway or the traditional cardiac care pathway. Once discharged, patients selected for the IPED intervention were given and educated on the KardiaMobile® device, which they took away with them.

Patients then kept the device on their person for the next three months. If they felt an episode of palpitation occurring, they recorded an ECG using the KardiaMobile® device along with the Kardia app on their smartphone.

The clinical and research teams then followed up with the patient to see if any cardiac arrhythmia was recorded. The IPED intervention resulted in 55% of patients receiving a diagnosis within 90 days of discharge from the RIE, compared with just nine and a half percent of patients using the traditional care pathway. Of the eleven patients that had cardiac arrhythmia at the RIE, two thirds were diagnosed with Atrial Fibrillation (AF).

The IPED intervention’s overwhelming success, resulted in the development of a new cardiac palpitations pathway at the RIE; whereby, if a patient attended the ED with cardiac symptoms, specifically palpitations, they were referred directly to the smartphone ambulatory palpitations clinic.

The ambulatory palpitations clinic refers to a next day outpatient clinic where patients can be reviewed thereby saving admission to hospital. In the ambulatory clinic, if appropriate, patients are fitted with the KardiaMobile® device, and then discharged home.

How could remote monitoring play a vital role in ischemic stroke prevention in Scotland?

Many patients that I see at the RIE ED, unfortunately suffer from an acute, often ischemic stroke, commonly caused by AF. Despite ongoing research, existing stroke treatments still remain relatively limited.

Those who successfully seek treatment within a four-and-a-half-hour window often experience improved patient outcomes, and are administered a lysis drug that breaks down blood clots.

Delivering the right care in a timely manner can be incredibly challenging in some rural areas of Scotland.

If patients have a stroke in the Highlands or in other rural areas, it is difficult to get to a facility that enables them to receive optimal evidence-based treatment within the required timeframe.

Remote monitoring can play a vital role in the identification of AF, accelerating it’s diagnosis and treatment, and thus reducing the risk and prevalence of ischemic stroke.

How were you able to justify the creation of a new clinical pathway?

To justify a new clinical pathway for the RIE, I alongside my colleagues identified the number of hospital readmissions with continued undiagnosed palpitations, combined with how much was being spent on standard care, per diagnosis, per patient.

These were both key metrics for the Scottish Health Technologies Group (SHTG) and the National Institute for Health and Care Excellence (NICE).

The IPED study demonstrated that patients could be monitored remotely using event recorder technology in the comfort of their own homes, which has the ability to reduce the number of patients visiting hospital and therefore potentially the number of ED attendances for those who could be monitored from their own home.

How can medical technology deliver value to the NHS and HSE?

There has been a lot of discussion within the NHS and HSE about how they can best adopt new technologies within their existing infrastructures.

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Examples of this occurred during the pandemic, with the creation of COVID wards that highlighted the potential value of discharging patients home with oxygen saturation monitors that allowed continual remote observation.

Medical technology can play a vital role in delivering value not only in Scotland, but around the world. It has the potential to transform patient experiences and outcomes, whilst relieving pressure on strained healthcare services if used in an evidence based and cost-effective way.

By working to prevent cardiac episodes through early identification, the HSE will be better equipped to save lives across Scotland, particularly in rural areas.