Advertisement

Advances in Tele-Cardiology

  • Jayashree Raikhelkar
  • Jayant K. Raikhelkar
Chapter

Abstract

Telemedicine has been a well-recognized entity for many years applying the use of modern information and communications technologies to the delivery of health services. Tele-cardiology has held an increasingly prominent place in the telemedicine domain. New advances in technology have allowed for real-time tele-consultation with cardiologists even in the most geographically isolated regions thereby improving patient care. Pre-hospital tele-cardiology has been proven to be effective in the management of acute coronary syndromes. Applications like tele-ECG and tele-echocardiography continue to be helpful for transmission of data and images from rural hospitals to tertiary care centers for attaining diagnoses or second opinions. Lastly, outpatient tele-cardiology has improved outcomes and readmissions in patients with chronic congestive heart failure and implanted devices.

Keywords

Telemedicine Cardiac care Heart failure Tele-cardiology Echocardiogram Electrocardiogram 

Notes

Disclosure Statement

The authors have nothing to disclose.

References

  1. 1.
    Strehle EM, Shabde N. One hundred years of telemedicine: does this technology have a place in paediatrics? Achiv Dis Child. 2006;91(12):956–9.CrossRefGoogle Scholar
  2. 2.
    Einthoven W. Le telecardiogramme (the telecardiogram). Arch Int Physiol. 1906;4:132–64.Google Scholar
  3. 3.
    Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Blaha MJ, Dai S, Ford ES, Fox CS, Franco S, Fullerton HJ, Gillespie C, Hailpern SM, Heit JA, Howard VJ, Huffman MD, Judd SE, Kissela BM, Kittner SJ, Lackland DT, Lichtman JH, Lisabeth LD, Mackey RH, Magid DJ, Marcus GM, Marelli A, Matchar DB, DK MG, Mohler ER 3rd, Moy CS, Mussolino ME, Neumar RW, Nichol G, Pandey DK, Paynter NP, Reeves MJ, Sorlie PD, Stein J, Towfighi A, Turan TN, Virani SS, Wong ND, Woo D, Turner MB. Executive summary: heart disease and stroke statistics--2014 update: a report from the American Heart Association. Circulation. 2014;129:399–410.CrossRefGoogle Scholar
  4. 4.
    Morrow DA, Fang JC, Fintel DJ, Granger CB, Katz JN, Kushner FG, Kuvin JT, Lopez-Sendon J, McAreavey D, Nallamothu B, Page RL 2nd, Parrillo JE, Peterson PN, Winkelman C. Evolution of critical care cardiology: transformation of the cardiovascular intensive care unit and the emerging need for new medical staffing and training models: a scientific statement from the American Heart Association. Circulation. 2012;126:1408–28.CrossRefGoogle Scholar
  5. 5.
    Yousef J, Lars A. Validation of a real-time wireless telemedicine system, using Bluetooth protocol and mobile phone, for remote monitoring patient in medical practice. Eur J Med Res. 2005;10:254–62.PubMedGoogle Scholar
  6. 6.
    Giannakakis G, Buliev I. ECG signal recording, processing and transmission using a mobile phone. Proceedings of the 1st international conference on pervasive technologies related to assistive environments; 2008 July 15–19; Athens, Greece. New York: ACM Digital Library; 2008.Google Scholar
  7. 7.
    Hsieh J, Li A, Yang C. Mobile, cloud, and big data computing: contributions, challenges, and new directions in tele-cardiology. Int J Environ Res Public Health. 2013;10:6131–615.CrossRefGoogle Scholar
  8. 8.
    Giovas P, Papadoyannis D, Thomakos D, et al. Transmission of electrocardiograms from a moving ambulance. J Telemed Telecare. 1998;4:S5–7.CrossRefGoogle Scholar
  9. 9.
    Carmody BJ. A novel approach to transmission of the out-of-hospital EKG in patients with ST segment elevation myocardial infarction. Ann Emerg Med. 2008;52:183–4.CrossRefGoogle Scholar
  10. 10.
    Brunetti ND, De Gennaro L, Amodio G, et al. Tele-cardiology improves quality of diagnosis and reduces delay to treatment in elderly patients with acute myocardial infarction and atypical presentation. Eur J Cardiovasc Prev Rehabil. 2010;17:615–20.CrossRefGoogle Scholar
  11. 11.
    Beygui F, Castren M, Brunetti ND, et al. ACCA Study Group on Pre-hospital Care. Pre-hospital management of patients with chest pain and/or dyspnoea of cardiac origin. A position paper of the Acute Cardiovascular Care Association (ACCA) of the ESC. Eur Heart J Acute Cardiovasc Care. Epub ahead of print 27 Aug 2015.Google Scholar
  12. 12.
    O'Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, Chung MK, de Lemos JA, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127(4):e362–425.PubMedGoogle Scholar
  13. 13.
    Ward MJ, Kripalani S, Zhu Y, Storrow AB, Dittus RS, Harrell FE Jr, et al. Incidence of emergency department visits for ST-elevation myocardial infarction in a recent six-year period in the United States. Am J Cardiol. 2015;115(2):167–70.CrossRefGoogle Scholar
  14. 14.
    McManus DD, Gore J, Yarzebski J, Spencer F, Lessard D, Goldberg RJ. Recent trends in the incidence, treatment, and outcomes of patients with STEMI and NSTEMI. Am J Med. 2011;124(1):40–7.CrossRefGoogle Scholar
  15. 15.
    Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018;39(2):119–77.CrossRefGoogle Scholar
  16. 16.
    Brunetti ND, Di Pietro G, Aquilino A, Bruno AI, et al. Pre-hospital electrocardiogram triage with tele-cardiology support is associated with shorter time-to-balloon and higher rates of timely reperfusion even in rural areas: data from the Bari-Barletta/Andria/Trani public emergency medical service 118 registry on primary angioplasty in ST-elevation myocardial infarction. Eur Heart J Acute Cardiovasc Care. 2014;3(3):204–13.CrossRefGoogle Scholar
  17. 17.
    Hutchison AW, Malaiapan Y, Jarvie I, et al. PreHospital and emergency department activation of the infarct team significantly improves door-to-door times: ambulance Vistoria and MonashHEART Acute Myocardial Infarction (MonAMI) 12-lead ECG project. Circ Cardiovasc Interv. 2009;2:528–34.CrossRefGoogle Scholar
  18. 18.
    Rasmussen MB, Frost L, Stengaard C, Brorholt-Petersen JU, et al. Diagnostic performance and system delay using telemedicine for prehospital diagnosis in triage and treatment of STEMI. Heart. 2014;100(9):711–5.CrossRefGoogle Scholar
  19. 19.
    Tanguay A, Brassard E, Lebon J, Begin F, Hebert D, Paradis JM. Effectiveness of a prehospital wireless 12-Lead electrocardiogram and cardiac catheterization laboratory activation for ST-elevation myocardial infarction. Am J Cardiol. 2017;119(4):553–9.CrossRefGoogle Scholar
  20. 20.
    Sivagangabalan G, Ong AT, Narayan A, Sadick N, et al. Effect of prehospital triage on revascularization times, left ventricular function, and survival in patients with ST-elevation myocardial infarction. Am J Cardiol. 2009;103(7):907–12.CrossRefGoogle Scholar
  21. 21.
    Chan AW, Kornder J, Elliott H, Brown RI, et al. Improved survival associated with pre-hospital strategy in a large regional ST-segment elevation myocardial infarction program. JACC Cardiovasc Interv. 2012;5(12):1239–46.CrossRefGoogle Scholar
  22. 22.
    Brunetti ND, Dellegrottaglie G, Lopriore C, Di Giuseppe G, et al. Prehospital telemedicine electrocardiogram triage for a regional public emergency medical service: is it worth it? a preliminary cost analysis. Clin Cardiol. 2014;37(3):140–5.CrossRefGoogle Scholar
  23. 23.
    Davis DP, Graydon C, Stein R, Wilson S, Buesch B, Berthiaume S, Lee DM, Rivas J, Vilke GM, Leahy DR. The positive predictive value of paramedic versus emergency physician interpretation of the prehospital 12-lead electrocardiogram. Prehosp Emerg Care. 2007;11:399–402.CrossRefGoogle Scholar
  24. 24.
    Aufderheide TP, Kereiakes DJ, Weaver WD, Gibler WB, Simoons ML. Planning, implementation, and process monitoring for prehospital 12-lead ECG diagnostic programs. Prehosp Disaster Med. 1996;11:162–71.CrossRefGoogle Scholar
  25. 25.
    Lilly CM, Cody S, Zhao H, Landry K, Baker SP, et al. Hospital mortality, length of stay and preventable complications among critically ill patients before and after tele-ICU reengineering of critical care processes. JAMA. 2011;305(21):2175–83.CrossRefGoogle Scholar
  26. 26.
    Sadaka F, Palagiri A, Trottier S, Deibert W, et al. Telemedicine intervention improves ICU outcomes. Crit Care Res Pract. 2013;2013:456389.PubMedPubMedCentralGoogle Scholar
  27. 27.
  28. 28.
    Nikus K, Lahteenmaki J, Lehto P, Eskola M. The role of continuous monitoring in a 24/7 tele-cardiology consultation service- a feasibility study. J Electrocardiol. 2009;42(6):473–80.CrossRefGoogle Scholar
  29. 29.
    Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet. 2003;361:13–20.CrossRefGoogle Scholar
  30. 30.
    Dalby M, Bouzamondo A, Lechat P, Montalescot G. Transfer for primary angioplasty versus immediate thrombolysis in acute myocardial infarction: a meta-analysis. Circulation. 2003;108:1809–14.CrossRefGoogle Scholar
  31. 31.
    O’Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX, Anderson JL, Jacobs AK, Halperin JL, Albert NM, Brindis RG, Creager MA, DeMets D, Guyton RA, Hochman JS, Kovacs RJ, Kushner FG, Ohman EM, Stevenson WG, Yancy CW. 2013 accf/aha guideline for the management of st-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines. Circulation. 2013;127:e362–425.CrossRefGoogle Scholar
  32. 32.
    Danchin A, Durand E, Blanchard D. Pre-hospital thrombolysis in perspective. Eur Heart J. 2008;29(23):2835–42.CrossRefGoogle Scholar
  33. 33.
    Danchin N, Blanchard P, Steg PG, et al. Impact of prehospital thrombolysis for acute myocardial infarction on 1 year outcome: results from the French nationwide USIC 2000 registry. Circulation. 2004;110(14):1909–15.CrossRefGoogle Scholar
  34. 34.
    McLean S, Wild S, Connor P, Flapan AD. Treating ST elevation myocardial infarction by primary percutaneous coronary intervention, in-hospital thrombolysis and prehospital thrombolysis. An observational study of timelines and outcomes in 625 patients. Emerg Med J. 2011;28(3):230–6.CrossRefGoogle Scholar
  35. 35.
    Correa BS, Goncalves B, Teixeira IM, Gomes AT, Ziviani A. AToMS: a Ubiquitous teleconsultation system for supporting AMI patients with prehospital thrombolysis. Int J Telemed Appl. 2011;2011:560209.PubMedPubMedCentralGoogle Scholar
  36. 36.
    Bilgi M, Erol T, Gullu H, Sezgin AT, Hamad S, Bilgel ZG, Muderrisoglu H. Teleconsultation of coronary angiograms using smartphones and an audio/video conferencing application. Technol Health Care. 2013;21(4):407–14.PubMedGoogle Scholar
  37. 37.
    Finley JP, Sharratt GP, Nanton MA, Chen RP, et al. Paediatric echocardiography by telemedicine—nine years’ experience. J Telemed Telecare. 1997;3(4):200–4.CrossRefGoogle Scholar
  38. 38.
    Trippi JA, Lee KS, Kopp G, et al. Emergency echocardiography telemedicine: an efficient method to provide 24-hour consultative echocardiography. J Am Coll Cardiol. 1996;27:1748–52.CrossRefGoogle Scholar
  39. 39.
    Trippi JA, Kopp A, Lee KS, Morrison H, Risk G, et al. The feasibility of dobutamine stress echocardiography in the emergency department with telemedicine interpretation. J Am Soc Echocardiogr. 1996;9(2):113–8.CrossRefGoogle Scholar
  40. 40.
    Trippi JA, Lee KS, Kopp G, et al. Dobutamine stress tele-cardiography for evaluation of emergency department patients with chest pain. J Am Coll Cardiol. 1997;30:627–32.CrossRefGoogle Scholar
  41. 41.
    Franchi D, Cini D, Arpesella G, et al. Second-opinion stress tele-echocardiography for the Adonhers (aged donor heart rescue by stress echo) project. Cardiovasc Ultrasound. 2010;1:20.CrossRefGoogle Scholar
  42. 42.
    Krishnan A, Fuska M, Dixon R, et al. The evolution of pediatric tele-echocardiography: 15-year experience of over 10,000 transmissions. Telemed J E Health. 2014;20:681–6.CrossRefGoogle Scholar
  43. 43.
    Grant B, Morgan GJ, McCrossan BA, Crealey GE, Sands AJ, et al. Remote diagnosis of congenital heart disease: the impact of telemedicine. Arch Dis Child. 2010;95:270–80.CrossRefGoogle Scholar
  44. 44.
    Dowie R, Mistry H, Yound TA, Franklin RC, Gardiner HM. Cost implications of introducing a tele-cardiology service to support fetal ultrasound screening. J Telemed Telecare. 2008;14:412–22.CrossRefGoogle Scholar
  45. 45.
    Haley JE, Klewer SE, Barber BJ, Meaney FJ, Donnerstein RL, et al. Remote diagnosis of congenital heart disease in southern Arizona: comparison between tele-cardiography and videotapes. Telemed J E Health. 2012;18(10):736–42.CrossRefGoogle Scholar
  46. 46.
    Fabien C, Vieyres P, Istepanian R, Arbeille P, Bru C. Clinical trials and evaluation of a mobile, robotic tele-ultrasound system. J Telemed Telecare. 2005;11(Suppl. 1):46–9.Google Scholar
  47. 47.
  48. 48.
    Otto CA, Shemenski R, Drudi L. Real-time tele-echocardiography: diagnosis and management of a pericardial effusion secondary to pericarditis at Antarctic research station. Telemed J E Health. 2012 Sep;18(7):521–4.CrossRefGoogle Scholar
  49. 49.
    Hamilton DR, Sargsyyan AE, Martin DS, Garcia KM, Melton SL, et al. On-orbit prospective echocardiography on International Space Station crew. Echocardiography. 2011;28(5):491–501.CrossRefGoogle Scholar
  50. 50.
    Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62:e147–239.CrossRefGoogle Scholar
  51. 51.
    Benjamin EJ, Virani SS, Callaway CW, Chamberlain AM, Chang AR, Cheng S, et al. Heart disease and stroke statistics-2018 update: a report from the American Heart Association. Circulation. 2018;137(12):e67–e492.CrossRefGoogle Scholar
  52. 52.
    Vigen R, Maddox TM, Allen LA. Aging of the United States population: impact on heart failure. Curr Heart Fail Rep. 2012;9:369–74.CrossRefGoogle Scholar
  53. 53.
    Desai AS, Stevenson LW. Rehospitalization for heart failure: predict or prevent? Circulation. 2012;126:501–6.CrossRefGoogle Scholar
  54. 54.
  55. 55.
    van Diepen S, Podder M, Hernandez AF, Westerhout CM, Armstong PW, McMurray JJ, et al. Acute decompensated heart failure patients admitted to critical care units: insights from ASCEND-HF. Int J Cardiol. 2014;177(3):840–6.CrossRefGoogle Scholar
  56. 56.
    Riley JP, Cowie MR. Telemonitoring in heart failure. Heart. 2009;95:1964–8.CrossRefGoogle Scholar
  57. 57.
    Rich MW, Beckham V, Wittenberg C, Leven CL, Freeland KE, Carney RM. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med. 1995;333:1190–5.CrossRefGoogle Scholar
  58. 58.
    Riegel B, Carlson B, Kopp Z, LePetri B, Glaser D, Unger A. Effect of a standardized nurse case-management telephone intervention on resource use in patients with chronic heart failure. Arch Intern Med. 2002;162(6):705–12.CrossRefGoogle Scholar
  59. 59.
    DeBusk RF, Miller NH, Parker KM, Bandura A, et al. Care management for low-risk patients with heart failure, a randomized, control trial. Ann Intern Med. 2004;141:606–13.CrossRefGoogle Scholar
  60. 60.
    GESICA Inventigators. Randomised trial of telephone intervention in chronic heart failure: DIAL trial. BMJ. 2005;331(7514):425.Google Scholar
  61. 61.
    Dunagan WC, Littenberg B, Ewald GA, Jones CA, et al. Randomized trial of a nurse-administered, telephone-based disease management for patients with heart failure. J Card Fail. 2005;11(5):358–65.Google Scholar
  62. 62.
    Chaudhry SI, Mattera JA, Curtis JP, Spertus JA, Herrin J, Lin Z, et al. Telemonitoring in patients with heart failure. N Engl J Med. 2010;363(24):2301–9.CrossRefGoogle Scholar
  63. 63.
    Ong MK, Romano PS, Edgington S, Aronow HU, Auerbach AD, Black JT, et al. Effectiveness of remote patient monitoring after discharge of hospitalized patients with heart failure: the better effectiveness after transition – heart failure (BEAT-HF) randomized clinical trial. JAMA Intern Med. 2016;176(3):310–8.CrossRefGoogle Scholar
  64. 64.
    Conway A, Inglis SC, Clark RA. Effective technologies for noninvasive remote monitoring in heart failure. Telemed J E Health. 2014;20:531–8.CrossRefGoogle Scholar
  65. 65.
    Inglis SC, Clack RA, McAlister FA, Stewart S, Cleland JG. Which components of heart failure programmes are effective? a systematic review and meta-analysis of the outcome of structures telephone support or telemonitoring as the primary component of chronic heart failure management in 8323 patients: abridged cochrane review. Eur J Heart Fail. 2011;13(9):1028–40.CrossRefGoogle Scholar
  66. 66.
    Schmidt S, Schuchert A, Krieg T, Oeff M. Home telemonitoring in patients with chronic heart failure: a chance to improve care? Dtsch Arztebl Int. 2010;107(8):131–8.PubMedPubMedCentralGoogle Scholar
  67. 67.
    Koehler F, Winkler S, Scheiber M, Sechtem U, Stangl K, et al. Impact of remote telemedicine management on mortality and hospitalizations in ambulatory patients with chronic heart failure. Circulation. 2011;123:1873–80.CrossRefGoogle Scholar
  68. 68.
    Kotooka N, Kitakaze M, Nagashima K, Asaka M, et al. The first multicenter, randomized, controlled trial of home telemonitoring for Japanese patients with heart failure: home telemonitoring study for patients with heart failure [HOMES-HF]. Heart Vessels. 2018;33(8):866–76.CrossRefGoogle Scholar
  69. 69.
    van Veldhuisen DJ, Braunschweig F, Conraads V, Ford I, Cowie MR, Jondeau G, et al. Intrathoracic impedance monitoring, audible patient alerts, and outcome in patients with heart failure. Circulation. 2011;124(16):1719–26.CrossRefGoogle Scholar
  70. 70.
    Morgan JM, Dimitrov BD, Gill J, Kitt S, Ng GA, McComb JM, et al. Rationale and study design of the REM-HF study: remote management of heart failure using implanted devices and formalized follow-up procedures. Eur J Heart Fail. 2014;16(9):1039–45.CrossRefGoogle Scholar
  71. 71.
    Abraham WT, Adamson PB, Bourge RC, Aaron MF, Costanzo MR, Stevenson LW, et al. Wireless pulmonary artery haemodynamic monitoring in chronic heart failure: a randomised controlled trial. Lancet (London, England). 2011;377(9766):658–66.CrossRefGoogle Scholar
  72. 72.
    Givertz MM, Stevenson LW, Costanzo MR, Bourge RC, Bauman JG, Ginn G, et al. Pulmonary artery pressure-guided management of patients with heart failure and reduced ejection fraction. J Am Coll Cardiol. 2017;70(15):1875–86.CrossRefGoogle Scholar
  73. 73.
    Desai AS, Bhimaraj A, Bharmi R, Jermyn R, Bhatt K, Shavelle D, et al. Ambulatory hemodynamic monitoring reduces heart failure hospitalizations in “real-world” clinical practice. J Am Coll Cardiol. 2017;69(19):2357–65.CrossRefGoogle Scholar
  74. 74.
    Abraham WT, Perl L. Implantable hemodynamic monitoring for heart failure patients. J Am Coll Cardiol. 2017;70(3):389–98.CrossRefGoogle Scholar
  75. 75.
    Brunetti ND, Lanzone S, Dellegrottaglie G, Di Giuseppe G, De Gennaro L, Novielli V, Straziota E, Loiacone T, Di Biase M. The CAPITAL study {CArdiovascular prevention with tele-cardiology in ApuLia}: preliminary results. J Cardiovasc Med(Hagerstown). 2016;17(7):455–61.CrossRefGoogle Scholar
  76. 76.
    Scalvini S, Zanelli E, Comini L, Dalla Tomba M, Troise G, Febo O, Giordano A. Home-based versus in-hospital cardiac rehabilitation after cardiac surgery: a nonrandomized controlled study. Phys Ther. 2013;93(8):1073–83.CrossRefGoogle Scholar
  77. 77.
    Scalvini S, Zanelli E, Comini L, et al. Home-based exercise rehabilitation with telemedicine following cardiac surgery. J Telemed Telecare. 2009;15:297–301.CrossRefGoogle Scholar
  78. 78.
    Roth A, Malov N, Steinberg DM, et al. Telemedicine for post-myocardial infarction patients: an observational study. Telemed J E Health. 2009;15:24–30.CrossRefGoogle Scholar
  79. 79.
    Dalleck LC, Schmidt LK, Lueker R. Cardiac rehabilitation outcomes in a conventional versus telemedicine-based programme. J Telemed Telecare. 2011;17:217–21.CrossRefGoogle Scholar
  80. 80.
    Rao A, Kardouh Y, Darda S, Desai D, Devireddy L, Lalonde T, Rosman H, David S. Impact of the pre-hospital ECG on door-to-balloon time in STEMI. Catheter Cardiovasc Interv. 2010;75(2):174–8.CrossRefGoogle Scholar
  81. 81.
    Abraham WT, Stough WG, Pina IL, Linde C, Borer JS, De Ferrari GM, Mehran R, Stein KM, Vincent A, Yadav JS, Anker SD, Zannad F. Trials of implantable monitoring devices in heart failure: which design is optimal? Nat Rev Cardiol. 2014;11(10):576–85.CrossRefGoogle Scholar
  82. 82.
    Ting HH, Krumholz HM, Bradley EH, Cone DC, Curtis JP, Drew BJ, Field JM, French WJ, Gibler WB, Goff DC, Jacobs AK, Nallamothu BK, O’Connor RE, Schuur JD, American Heart Association Interdisciplinary Council on Quality of Care and Outcomes Research, Emergency Cardiovascular Care Committee; American Heart Association Council on Cardiovascular Nursing; American Heart Association Council on Clinical Cardiology. Implementation and integration of prehospital ECGs into systems of care for acute coronary syndrome: a scientific statement from the American Heart Association Interdisciplinary Council on Quality of Care and Outcomes Research, Emergency Cardiovascular Care Committee, Council on Cardiovascular Nursing, and Council on Clinical Cardiology. Circulation. 2008;118(10):1066–79. https://doi.org/10.1161/CIRCULATIONAHA.108.190402. Epub 2008 Aug 13.

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Jayashree Raikhelkar
    • 1
  • Jayant K. Raikhelkar
    • 2
  1. 1.Emory University School of MedicineAtlantaUSA
  2. 2.Department of Medicine, Division of Cardiovascular MedicineUniversity of Chicago School of MedicineChicagoUSA

Personalised recommendations