Extending Diagnostics from Patients to Population

Cardiovascular disease (CVD) is the leading cause of death and ranks fourth in hospitalizations at Ministry of Health (MOH) hospitals in Malaysia(1). Patients with CVD in Malaysia are on average 10 years younger than those in developed countries(2). Increasing burden of CVD is primarily due to the rising prevalence rates of hypertension, diabetes, and high cholesterol(3,4). As of 2019, 3 out of every 10 adults in Malaysia had hypertension, 1 out of every 5 had diabetes, and 4 out of every 10 had high cholesterol(4).

Access to critical cardiology services at a public tertiary level in Sarawak is severely hampered by the fact that there is only one cardiology centre in Kuching, serving about 3 million people. This presents a major logistical obstacle due to the vast expanse of the state (Figure 1). The limited resources and geographical transportation challenges lead to delays in treatment, resulting in poorer outcomes and deaths. Given these factors, as well as the high burden of cardiovascular disease and prevalence of CVD risk factors in our population, it is crucial to leverage innovative digital health technologies to improve care for the population and prevent hospital admissions for CVDrelated issues.

Leveraging Digital Health Technologies for Cardiovascular Care

In 2017, cardiologists from the Sarawak Heart Centre, clinical researchers from the Clinical Research Centre Sarawak General Hospital, and neurologists from the Neurology Unit Sarawak General Hospital collaborated on the first digital health study –the SMART-AF study. We used a mobile ECG device to diagnose atrial fibrillation (AF) in post-stroke patients who had sinus rhythm in their 24-hour Holter screening(5). The SMARTAF trial (Figure 2) was also the first investigator-initiated, randomized controlled trial to evaluate the use of mobile digital health technology for patient-initiated cardiac monitoring at home. In this study, AF was detected in 9.5% of cases with a number needed to screen of 13 and an average time of 10 days from monitoring start to AF detection.

The compliance rate for such patient-initiated on-demand monitoring method, however was found to be 63.3%, which could be attributed to factors such as increased burden of monitoring, digital illiteracy, and smartphone compatibility issues(5). The findings of SMART-AF were published in ESC Europace journal in 2021 and cited by the Heart Rhythm Society’s white paper on clinical use of digital health technology that same year(6) .

With the success of the SMART-AF study and the promising potential of digital health technologies in cardiology diagnostics, there is a need for further exploration and implementation of digital health technologies in the healthcare system in Sarawak.

In 2020, we embarked on the PROVE-AF study, which aimed to compare the effectiveness of wireless cardiac patch devices for prolonged continuous cardiac monitoring with conventional 24-hour Holter monitoring in detecting atrial fibrillation in patients hospitalized for acute stroke (Figure 3). Our interim analysis showed a promising detection rate of 11.3% for AF, with a higher detection rate using the 7-day cardiac patch monitor compared to the 24-hour Holter monitor. Additionally, we were pleased to report a high compliance rate of 81.3% for the extended monitoring period, highlighting the feasibility and acceptability of this approach.

The impact of our work was further underscored by the recognition we received, including the National Heart Association of Malaysia Young Investigator Award (YIA) in 2021 and the ASEAN Federation of Cardiology YIA in 2022. These accolades affirmed the significance of our research in advancing cardiovascular care through digital health innovations.

In addition to our clinical research endeavours, we have also collaborated with international experts to address the challenges of detecting AF in Asian populations hospitalized for stroke(7). Our review paper (Figure 4) emphasized the need for improved methods and customized monitoring strategies to overcome the difficulties associated with diagnosing paroxysmal and silent AF in stroke patients. We advocated for the potential of digital health innovations and emerging technologies as promising alternatives, while acknowledging the need for further research to optimize their practical implementation.

Digital Health Techonologies Have the Potential to Revolutionise Cardiology Diagnostics by Extending Diagnostic Capabilities from Individual Patients to the Entire Population

Building on the successes of the SMART-AF and PROVE-AF studies, there is an opportunity to develop and implement more comprehensive digital cardiac monitoring programs that cater to a larger population. These programs could focus on utilizing wearable devices, telemedicine platforms, and data analytics to not only diagnose AF but also monitor other cardiac conditions such as arrhythmias, heart failure, and ischemic heart disease.

Furthermore, the COVID-19 pandemic outbreak in 2020 provided an impetus for the rapid integration of digital health interventions into healthcare systems. Our CRC SGH Human Physiology Laboratory collaboration with a diverse digital health team, which included medical experts from various specialties, experts in AI from the Swinburne University of Technology Sarawak Campus (led by Professor Patrick Then), and digital health solution/product development specialists from industry, led to the development of a software application for remote patient monitoring, equipped with an FDAapproved medical grade ECG sensor and accelerometer for falls detection (Figure 5). This initiative holds the promise of enhancing post-discharge care for patients with CVD on polypharmacy and addressing the needs of frail individuals residing in rural areas with limited access to healthcare facilities.

As we continue to push the boundaries of digital health in cardiology, our ongoing software application project signifies our commitment to leveraging technology for the benefit of patients and the population.

From mobile ECG devices and wireless cardiac patches used in our post-stroke research to multisensory remote monitoring patches for the elderly population and individuals on polypharmacy, we are consistently integrating digital tools to expand diagnostics from individual patients to entire populations.

In Malaysia, heart failure patients are typically younger than Caucasians, yet they often experience more severe illness and have a higher prevalence of diabetes(8,9). Our recent collaboration with an international organization based in Singapore involved the ANCHOR-DM study (Figure 6). We utilized AI automated handheld echo to screen individuals with diabetes in primary care settings (Figure 6). This clinical validation project compared AI-enhanced handheld echo devices against conventional manual cart-based echo systems. The results revealed that AI echo with point-of-care ultrasound (POCUS) demonstrated very good diagnostic accuracy in detecting diastolic dysfunction and matched well with manual echo irrespective of image quality. Furthermore, AI echo addressed diagnostic challenges associated with sub-clinical HFpEF, enabling echo screening at the community level—especially among populations at high risk of developing heart failure.

The impact of ANCHOR-DM was recognized internationally when the project received the Grand Prize YIA at the Asia Pacific Society of Cardiology Congress 2023.

Figure 6a-b. ANCHOR-DM study and AI-echo with POCUS

Building a Connected Future

Through the integration of AI automated handheld echo devices, we are extending diagnostics from individual patients to entire population, enabling widespread screening and early detection of cardiovascular conditions in a more accessible and cost-effective manner. The shift towards population-wide screening by novices in echo which will be implemented in our coming Heart2Miss initiative has the potential to significantly impact public health by identifying at-risk individuals and implementing timely interventions to prevent the progression of heart failure that could result in hospitalizations, longer hospital stays, poor quality of life, and increases burden to the families.

As a clinician researcher who interfaces between tertiary and primary settings, I have the unique opportunity to understand the pivotal role that primary CVD prevention plays – by not only in reducing hospital admissions and decongesting hospitals, but also in improving cardiovascular health and quality of life. In line with our commitment to extending diagnostics from individual patients to the broader population for CVD prevention, we are continuing our partnership with Centre of Digital Futures at Swinburne University of Technology Sarawak Campus and actively seeking opportunities to establish more partnerships with local organizations in digital economy and innovations, particularly in scaling up remote monitoring applications development. By harnessing the capabilities of telemedicine and remote monitoring, our goal is to provide personalized care plans that cater to each patient’s unique needs while ensuring continuous support for managing their cardiovascular health.

Digital Health in Cardiovascular Research:
Extending Diagnostics from Patients to Population for CVD Prevention in Sarawak

Considering the challenges in access to cardiology services in Sarawak, digital health technologies can bridge the gap by enabling real-time remote monitoring, diagnosis and consultations. This approach can provide timely expert advice to healthcare providers in remote areas and improve overall cardiac care management.

Furthermore, the integration of AI-powered digital health technologies streamline work processes, reduces human error, and increases efficiency and diagnostic accuracy. This technology, such as the AI-powered POCUS, provides opportunities for taskshifting (addresses challenges with limited resources in human capacity and infrastructure), and thus, allows for screening at community level to detect early signs of CVD so that early intervention personalized treatment adjustments can be constituted for at-risk individuals identified. This innovative approach has the potential to improve outcomes and reduce the healthcare burden associated with cardiovascular conditions.

With our current and future projects, we are extending digital health in diagnostics from patients to population. This will allow for widespread screening and early detection of cardiovascular conditions in a more accessible and cost-effective way. Our commitment to innovative digital health solutions enables us not only to improve individual patient care, but also to contribute to the larger goal of improving cardiovascular health at a population level.

References

1 Health Facts 2021 [Internet]. Health Informatics Centre Planning Division, Ministry of Health Malaysia; 2021 [cited 2024 Jan 17]. Available from: https://iptk.moh.gov.my/images/technical_report/2020/4_ Infographic_ Booklet_NHMS_2019_-_English.pdf

2 Alan Fong, Wan Azman Wan Ahmad AR, Feizul Mustapha, Zanariah Hussein, Sri Wahyu Taher, Asrul Akmal Shafie, et al. Heart Matters: The Rising Burden of Cardiovascular Disease in Malaysia and Potential Touchpoints for Interventions [Internet]. IQVIA; 2023 [cited 2024 Jan 17]. Available from: https://www.iqvia.com/locations/asia-pacific/library/white-papers/heart-matters-the-rising-burden-of-cardiovascular-disease

3 Ministry of Health Malaysia. National Health and Morbidity Survey 2011 NHMS 2011. National Health and Morbidity Survey. 2011;

4 National Health Morbidity Survey (NHMS). National Health Morbidity Survey (NHMS 2019). National Institute of Health Malaysia. 2019;1.

5 Koh KT, Law WC, Zaw WM, Foo DHP, Tan CT, Steven A, et al. Smartphone electrocardiogram for detecting atrial fibrillation after a cerebral ischaemic event: a multicentre randomized controlled trial. EP Europace. 2021 Jul 18;23(7):1016–23.

6 Wan EY, Ghanbari H, Akoum N, Itzhak Attia Z, Asirvatham SJ, Chung EH, et al. HRS White Paper on Clinical Utilization of Digital Health Technology. Cardiovasc Digit Health J. 2021 Aug;2(4):196–211.

7 Foo DHP, Fong AYY, Almahmeed W. Detection of Atrial Fibrillation in Patients Admitted with Ischaemic Stroke: A Non-systematic Review of the Asian Population. Journal of Asian Pacific Society of Cardiology. 2023 Mar 21;2.

8 Wan Ahmad WA, Abdul Ghapar AK, Zainal Abidin HA, Karthikesan D, Ross NT, S.K. Abdul Kader MA, et al. Characteristics of patients admitted with heart failure: Insights from the first Malaysian Heart Failure Registry. ESC Heart Fail. 2023 Dec 22;

9 Tromp J, Tay WT, Ouwerkerk W, Teng THK, Yap J, MacDonald MR, et al. Multimorbidity in patients with heart
failure from 11 Asian regions: A prospective cohort study using the ASIAN-HF registry. PLoS Med. 2018 Mar 27;15(3):e1002541.