Key Points:
- TELE-ACS evaluates the use of telemedicine strategies to reduce hospital readmission rates in patients with a recent history of acute coronary syndrome
- There was a 76% reduction in hospital readmission in the first six months for patients with a history of ACS who received the telemedicine intervention compared to controls (HR: 0.24, 95% CI: 0.13-0.44, p < 0.00)
- The use of a telemedicine intervention resulted in a 41% reduction in emergency department visits (HR: 0.59, 95% CI HR: 0.40-0.89, p < 0.001)
TELE-ACS is a United Kingdom-based randomized control trial that evaluates the use of telemedicine to help with the clinical management of patients with a history of acute coronary syndrome (ACS). In our current healthcare system, presentation to the emergency room is the most expedited way for patients with a recent history of ACS to be evaluated for new or recurrent symptoms. The primary question asked in TELE-ACS is whether the use of telemedicine strategies could help support a reduction in hospital readmission rates after a patient’s initial presentation with ACS. To be enrolled in the trial, patients had to have a history of at least one cardiovascular risk factor and have presented with ACS requiring intervention. The primary outcome was time to hospital readmission over the first 6 months and the trial was conducted at a large tertiary care center in London.
Of the 337 patients that were randomized between January 2022 and April 2023, half were randomized to the interventional arm and received a telemonitoring package including a user-applied 12-lead ECG belt and pulse oximeter and training prior to their hospital discharge from a large tertiary hospital in London, United Kingdom. These patients also underwent training calls at 2, 4, and 8 weeks after hospital discharge. Of note, patients who did not have access to a smartphone/smart device and patients unable to use telemonitoring equipment were excluded, likely leading to some inherent selection bias. If a patient in the intervention arm developed possible cardiovascular symptoms, he/she was instructed to use the telemonitoring equipment. The patient would then receive a call from the trial team to collect details followed by a cardiologist to offer advice. The primary role of the cardiologist was to triage the patient for primary care, emergency care, or clinical follow-up as previously planned.
The mean patient age was 58.1 years and 86.1% of patients were male. There were 169 telemedicine calls in the intervention arm of the trial of which 55% led to provision of reassurance, 27% led to a recommendation to seek primary care and 19% led to a recommendation to seek emergency care. In the first six months. There was a reduced rate of readmission over 6 months in the telemedicine arm compared to the standard therapy arm, leading to a hazard ratio of 0.24 (95% CI HR: 0.13-0.44, p < 0.001). There was also a significant reduction in emergency department attendance in the interventional arm with a hazard ratio of 0.59 (95% CI HR: 0.40-0.89, p < 0.001) compared to the standard care arm. With regard to patient-reported symptoms, only 7% of patients in the intervention arm reported chest pain compared to 22% of patients in the control arm (difference -15%, 95% CI -22% to -7%, P= 0.003). Interestingly, there was also a reduction in unplanned coronary interventions with a rate of 3% in the intervention group compared to 9% in the control group (difference -7%, 95% CI -12% to -2%, P= 0.01).
In conclusion, this trial highlights the potential benefit of integrating telemedicine in the clinical care of patients with a recent history of ACS. Some limitations of this study include the predominantly male patient population and potential for recall bias for patients. Future studies will be necessary to evaluate the practical feasibility of incorporating this resource-intensive strategy in diverse health systems.