Combination of Tele-Cardiology Tools for Cardiovascular Risk Stratification in Primary Care: Data from the PROVAR+ Study

We aimed to evaluate the accuracy of tele-electrocardiography (ECG) to predict abnormalities in screening echocardiography (echo) in primary care (PC).

Methods:

In 17 months, 6 health providers at 16 PC units were trained on simplified handheld echo protocols. Tele-ECGs were recorded for final diagnosis by a cardiologist. Consented patients with major ECG abnormalities by the Minnesota code, and a 1:5 sample of normal individuals underwent clinical questionnaire and screening echo interpreted remotely. Major heart disease was defined as moderate/severe valve disease, ventricular dysfunction/hypertrophy, pericardial effusion, or wall-motion abnormalities. Association between major ECG and echo abnormalities was assessed by logistic regression as follows: 1) unadjusted model; 2) model 1 adjusted for age/sex; 3) model 2 plus risk factors (hypertension/diabetes); 4) model 3 plus history of cardiovascular disease (Chagas/rheumatic heart disease/ischemic heart disease/stroke/heart failure). P-values < 0.05 were considered significant.

Results:

A total 1,411 patients underwent echo; 1,149 (81%) had major ECG abnormalities. Median age was 67 (IQR 60 to 74) years, and 51.4% were male. Major ECG abnormalities were associated with a 2.4-fold chance of major heart disease on echo in bivariate analysis (OR = 2.42 [95% CI 1.76 to 3.39]), and remained significant after adjustments in models (p < 0.001) 2 (OR = 2.57 [95% CI 1.84 to 3.65]), model 3 (OR = 2.52 [95% CI 1.80 to3.58]), and model 4 (OR = 2.23 [95%CI 1.59 to 3.19]). Age, male sex, heart failure, and ischemic heart disease were also independent predictors of major heart disease on echo.

Conclusions:

Tele-ECG abnormalities increased the likelihood of major heart disease on screening echo, even after adjustments for demographic and clinical variables.

Keywords:
Cardiovascular Diseases; Mass Screening; Telemedicine; Electrocardiography; Risk Grade

Characteristic		N	Overall¹1 Brant LCC, Nascimento BR, Passos VMA, Duncan BB, Bensenõr IJM, Malta DC, et al. Variations and Particularities in Cardiovascular Disease Mortality in Brazil and Brazilian States in 1990 and 2015: Estimates from the Global Burden of Disease. Rev Bras Epidemiol. 2017;20(Suppl 1):116-28. doi: 10.1590/1980-5497201700050010. https://doi.org/10.1590/1980-54972017000...	Major echo abnormality (n=475)	Normal (n=936)	p value²2 Ribeiro ALP, Duncan BB, Brant LC, Lotufo PA, Mill JG, Barreto SM. Cardiovascular Health in Brazil: Trends and Perspectives. Circulation. 2016;133(4):422-33. doi: 10.1161/CIRCULATIONAHA.114.008727. https://doi.org/10.1161/CIRCULATIONAHA.1...
Sex		1,411				0,092
	Female		686 (48.6%)	216 (45.5%)	470 (50.2%)
	Male		725 (51.4%)	259 (54.5%)	466 (49.8%)
Age (years)		1,411	67.0 (59.5; 74.0)	73.0 (64.0; 80.0)	64.0 (58.0; 71.0)	<0.001
ECG		1,411				<0.001
	Major abnormality		1,149 (81.4%)	424 (89.3%)	725 (77.5%)
	Normal		262 (18.6%)	51 (10.7%)	211 (22.5%)
Follow-up echo promptly recommended		1,411	368 (26.1%)	334 (70.3%)	34 (3.6%)	<0.001
Hypertension		1,411	1,076 (76.3%)	397 (83.6%)	679 (72.5%)	<0.001
Diabetes		1,411	532 (37.7%)	197 (41.5%)	335 (35.8%)	0.037
Chagas disease		1,411	13 (0.9%)	6 (1.3%)	7 (0.7%)	0.381
Heart failure		1,411	38 (2.7%)	27 (5.7%)	11 (1.2%)	<0.001
AMI/coronary artery disease		1,411	314 (22.3%)	142 (29.9%)	172 (18.4%)	<0.001
Rheumatic heart disease		1,411	4 (0.3%)	1 (0.2%)	3 (0.3%)	>0.999
Stroke		1,411	78 (5.5%)	32 (6.7%)	46 (4.9%)	0.157

Variables/model		OR (95% CI)	p value
Model 1
	(Intercept)	0.24 (0.18-0.33)	< 0.001
	Major ECG abnormality	2.42 (1.76-3.39)	< 0.001
Model 2
	(Intercept)	0 (0-0)	< 0.001
	Major ECG abnormality	2.57 (1.84-3.65)	< 0.001
	Sex	1.37 (1.08-1.74)	0.009
	Age	1.07 (1.06-1.08)	< 0.001
Model 3
	(Intercept)	0 (0-0)	< 0.001
	Major ECG abnormality	2.52 (1.80-3.58)	< 0.001
	Sex	1.41 (1.11-1.79)	0.005
	Age	1.07 (1.06-1.08)	< 0.001
	Hypertension	1.46 (1.07-2.00)	0.017
	Diabetes	1.05 (0.82-1.35)	0.688
Model 4
	(Intercept)	0 (0-0)	< 0.001
	Major ECG abnormality	2.23 (1.59-3.19)	< 0.001
	Sex	1.35 (1.06-1.73)	0.015
	Age	1.07 (1.06-1.09)	< 0.001
	Hypertension	1.32 (0.97-1.81)	0.083
	Diabetes	1.03 (0.80-1.33)	0.825
	Chagas disease	1.09 (0.29-3.82)	0.897
	Heart failure	5.18 (2.43-11.87)	< 0.001
	AMI/coronary artery disease	1.56 (1.18-2.07)	0.002
	Rheumatic heart disease (known)	0.37 (0.01-6.16)	0.491
	Stroke	1.18 (0.72-1.93)	0.504

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[1] Mailing Address: Bruno Ramos Nascimento • Hospital das Clínicas da Universidade Federal de Minas Gerais – Serviço de Cardiologia e Cirurgia Carvdiovascular – Rua Professor Alfredo Balena, 110, 1° andar. Postal Code 30130-100, Belo Horizonte, MG – Brazil. E-mail: ramosnas@gmail.com