Mobile Health Tools Create Home for Hearts

September 2012Andrew Schwartz

Managing and monitoring patients with heart disease remains an enormous challenge. Together, the various forms of heart disease remain the nation’s most prolific killer; as of 2008, the Centers for Disease Control and Prevention associated heart disease with almost one in four deaths in the United States.

Of course, the term heart disease embraces numerous heart-related conditions. There are patients who have received a heart transplant, who are at real risk for rejection; the clinical challenge with them is monitoring them closely enough to catch the signs of rejection early enough to improve the chance of survival. There are the comorbid heart failure patients, who are not transplant candidates. Health care teams must carefully monitor these patients’ status and constantly adapt treatment plans to optimize their quality of life. And there are many other patients who suffer from various forms of heart disease.

For many of these patients, nurses are often frontline providers. That’s why nurse scientists like UCSF School of Nursing’s Barbara Drew and Jill Howie-Esquivel are ideally positioned to explore ways to manage heart disease more efficiently and effectively. Mobile technology offers one intriguing option.

Early Detection of Allograft Rejection to Improve Heart Transplant Outcomes

Barbara Drew Within the first six months of heart transplantation, acute rejection is common. At present, reversing the process depends on clinical teams conducting biopsies often enough to catch rejection in the early stages. The problem, says Drew, is that such procedures are both costly and invasive.

After reading about a small Stanford study that indicated patients experiencing severe rejection consistently showed a lengthening of their QT interval – a measure of the heart’s electrical depolarization and repolarization that can be seen on an electrocardiogram (ECG) – Drew decided to design a study to determine whether an increase in the QT interval is, indeed, a specific and sensitive biomarker for rejection and if the QT interval criteria correspond to the proven biopsy-based measures. A secondary aim of the study is to find out if remote monitoring of the QT intervals can effectively give clinicians the diagnostic information they need.

Drew is an innovative nurse scientist, with numerous heart treatment studies under her belt; her project aims to remotely monitor 325 heart transplant recipients who have undergone procedures at medical centers in New York and Los Angeles. Post-procedure, from their homes, patients record a 10-second ECG every day using a device that automatically transmits the results for analysis to UCSF; patients also undergo regular biopsies. The five-year study began in 2011.

“About 75 percent of what nurses do is monitor people to figure out if they are moving toward recovery or going in the other direction,” says Drew. “If this pans out as I hope it will, clinicians could have a more timely, less invasive and less costly way to detect and reverse rejection and reduce mortality post-transplant.”

Helping Heart Failure/COPD Patients Get Regular Exercise

Even when patients suffer simultaneously from heart failure and chronic obstructive pulmonary disease (COPD), they can enjoy a reasonable quality of life if their conditions are managed properly. Exercise is critically important.

Yet patients with these conditions struggle to move their bodies much at all. Howie-Esquivel, a heart failure expert, and her collaborator Doranne Donesky, an expert in COPD, have worked together before to show that yoga can be a safe and effective form of exercise for these patients because it is low-impact and emphasizes movement coordinated with breathing. But in their prior study, Howie-Esquivel and Donesky also uncovered a significant barrier: getting back and forth to a class often stops these typically frail, older adults from participating.

Jill Howie-Esquivel “We hope we’ve found a way to overcome that barrier through the use of multipoint, interactive videoconferencing technologies,” says Howie-Esquivel. They have begun a pilot study in which patients use this technology to engage in yoga classes from the comfort of their own home.

Nurses set up the videoconferencing technology and then conduct a baseline physical assessment. Then, before each session, to ensure they are okay to begin, patients take their own vitals and call them in to the nurse.

When the class begins, patients, the instructor and the nurse can all see the instructor and other class participants on their TV screens. The instructor conducts the class much as she would in person, providing encouragement and correction both to the group and to individuals.

At the end of the biweekly, eight-week course, Howie-Esquivel and Donesky will assess not just the safety feasibility and adherence rate of the intervention versus a control group, but also its effect on physical function (endurance, balance, strength and activity) and symptoms (dyspnea, sleep and fatigue).

“We’re in the middle of the pilot,” says Howie-Esquivel. “The setup can take longer than expected, and I’m not sure patients connect as quickly to the class as they would if they could be there in person, but they’re starting to talk with each other and talk about themselves within the group. I feel confident we’ll be able to show physical and psychological benefit, and it’s important to remember that the idea here is that many of these patients would not be participating at all without this technology.”