Measurement and Data Transmission Validity of a Multi-Biosensor System for Real-Time Remote Exercise Monitoring Among Cardiac Patients

Background Remote telemonitoring holds great potential to augment management of patients with coronary heart disease (CHD) and atrial fibrillation (AF) by enabling regular physiological monitoring during physical activity. Remote physiological monitoring may improve home and community exercise-based cardiac rehabilitation (exCR) programs and could improve assessment of the impact and management of pharmacological interventions for heart rate control in individuals with AF. Objective Our aim was to evaluate the measurement validity and data transmission reliability of a remote telemonitoring system comprising a wireless multi-parameter physiological sensor, custom mobile app, and middleware platform, among individuals in sinus rhythm and AF. Methods Participants in sinus rhythm and with AF undertook simulated daily activities, low, moderate, and/or high intensity exercise. Remote monitoring system heart rate and respiratory rate were compared to reference measures (12-lead ECG and indirect calorimeter). Wireless data transmission loss was calculated between the sensor, mobile app, and remote Internet server. Results Median heart rate (-0.30 to 1.10 b∙min-1) and respiratory rate (-1.25 to 0.39 br∙min-1) measurement biases were small, yet statistically significant (all P≤.003) due to the large number of observations. Measurement reliability was generally excellent (rho=.87-.97, all P<.001; intraclass correlation coefficient [ICC]=.94-.98, all P<.001; coefficient of variation [CV]=2.24-7.94%), although respiratory rate measurement reliability was poor among AF participants (rho=.43, P<.001; ICC=.55, P<.001; CV=16.61%). Data loss was minimal (<5%) when all system components were active; however, instability of the network hosting the remote data capture server resulted in data loss at the remote Internet server during some trials. Conclusions System validity was sufficient for remote monitoring of heart and respiratory rates across a range of exercise intensities. Remote exercise monitoring has potential to augment current exCR and heart rate control management approaches by enabling the provision of individually tailored care to individuals outside traditional clinical environments.

[1]  P. Savage,et al.  Determinants of physical functioning in coronary patients: response to cardiac rehabilitation. , 1999, Archives of internal medicine.

[2]  Y. Wang,et al.  OdinTelehealth: A Mobile Service Platform for Telehealth , 2011, ANT/MobiWIS.

[3]  D. Mozaffarian,et al.  Heart disease and stroke statistics--2012 update: a report from the American Heart Association. , 2012, Circulation.

[4]  Lisa Hartling,et al.  Meta-Analysis: Secondary Prevention Programs for Patients with Coronary Artery Disease , 2005, Annals of Internal Medicine.

[5]  Andrew E. Kilding,et al.  Reliability and Validity of the Zephyr™ BioHarness™ to Measure Respiratory Responses to Exercise , 2011 .

[6]  Minsoo Kang,et al.  Validation of the Actiheart Monitor for the Measurement of Physical Activity , 2009, International Journal of Exercise Science.

[7]  Shah Ebrahim,et al.  European guidelines on cardiovascular disease prevention in clinical practice , 2004 .

[8]  Sharon-Lise T Normand,et al.  Use of Cardiac Rehabilitation by Medicare Beneficiaries After Myocardial Infarction or Coronary Bypass Surgery , 2007, Circulation.

[9]  A. Camm,et al.  Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). , 2010, European heart journal.

[10]  Nikolaos G. Bourbakis,et al.  A Survey on Wearable Sensor-Based Systems for Health Monitoring and Prognosis , 2010, IEEE Transactions on Systems, Man, and Cybernetics, Part C (Applications and Reviews).

[11]  Julie Redfern,et al.  Participating in cardiac rehabilitation: a systematic review and meta-synthesis of qualitative data , 2012, European journal of preventive cardiology.

[12]  David R Thompson,et al.  Exercise-based cardiac rehabilitation for coronary heart disease. , 2016, The Cochrane database of systematic reviews.

[13]  F. Martinez,et al.  American Thoracic Society/ American College of Chest Physicians ATS/ACCP Statement on Cardiopulmonary Exercise Testing , 2003 .

[14]  Ø. Rognmo,et al.  The higher the better? Interval training intensity in coronary heart disease. , 2014, Journal of science and medicine in sport.

[15]  E. W. Hancock,et al.  AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part III: intraventricular conduction disturbances: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American , 2009, Journal of the American College of Cardiology.

[16]  J. Doust,et al.  Assessment of the lactate and ventilatory thresholds by breathing frequency in runners , 1998 .

[17]  Shah Ebrahim,et al.  European Guidelines on Cardiovascular Disease Prevention in Clinical Practice (Version 2012) , 2012, International Journal of Behavioral Medicine.

[18]  Lippincott Williams Wilkins,et al.  Cardiac rehabilitation programs. A statement for healthcare professionals from the American Heart Association. , 1994, Circulation.

[19]  D. Altman,et al.  Measuring agreement in method comparison studies , 1999, Statistical methods in medical research.

[20]  C. Del Mar,et al.  Exercise for overweight or obesity. , 2006, The Cochrane database of systematic reviews.

[21]  A. Nevill,et al.  Validity and reliability of cardiorespiratory measurements recorded by the LifeShirt during exercise tests , 2009, Respiratory Physiology & Neurobiology.

[22]  J. Harvey-Berino,et al.  High-Calorie-Expenditure Exercise: A New Approach to Cardiac Rehabilitation for Overweight Coronary Patients , 2009, Circulation.

[23]  Tiny Jaarsma,et al.  Compliance in heart failure patients: the importance of knowledge and beliefs. , 2006, European heart journal.

[24]  Gerwyn Hughes,et al.  Bioharness(™) multivariable monitoring device: part. I: validity. , 2012, Journal of sports science & medicine.

[25]  T. Watson,et al.  Field based reliability and validity of the bioharness™ multivariable monitoring device. , 2012, Journal of sports science & medicine.

[26]  T. Watson,et al.  Bioharness(™) Multivariable Monitoring Device: Part. II: Reliability. , 2012, Journal of sports science & medicine.

[27]  U. Ekelund,et al.  Reliability and validity of the combined heart rate and movement sensor Actiheart , 2005, European Journal of Clinical Nutrition.

[28]  M. Clark,et al.  Predictors of exercise adherence following participation in a cardiac rehabilitation program , 1997, International journal of behavioral medicine.

[29]  E. W. Hancock,et al.  Recommendations for the standardization and interpretation of the electrocardiogram: part I: the electrocardiogram and its technology a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Card , 2007, Journal of the American College of Cardiology.

[30]  R. Arena,et al.  Cardiovascular fitness and mortality after contemporary cardiac rehabilitation. , 2013, Mayo Clinic proceedings.

[31]  G. Parati,et al.  Evaluation of a textile-based wearable system for the electrocardiogram monitoring in cardiac patients. , 2013, Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology.

[32]  K. Jolly,et al.  Home based versus centre based cardiac rehabilitation: Cochrane systematic review and meta-analysis , 2010, BMJ : British Medical Journal.

[33]  S. Ebrahim,et al.  Exercise-based cardiac rehabilitation for coronary heart disease. , 2016, The Cochrane database of systematic reviews.

[34]  S. Ebrahim,et al.  Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. , 2004, The American journal of medicine.

[35]  N. Pride,et al.  Sex and age differences in pulmonary mechanics in normal nonsmoking subjects. , 1976, Journal of applied physiology.

[36]  N. Pride,et al.  Pulmonary mechanics in patients with respiratory muscle weakness. , 2015, The American review of respiratory disease.

[37]  C. Worringham,et al.  Development and Feasibility of a Smartphone, ECG and GPS Based System for Remotely Monitoring Exercise in Cardiac Rehabilitation , 2011, PloS one.

[38]  H. Bethell,et al.  The rise and fall of cardiac rehabilitation in the United Kingdom since 1998. , 2007, Journal of public health.

[39]  D. Chew,et al.  Variations in the application of cardiac care in Australia , 2008, The Medical journal of Australia.

[40]  K. Schulman,et al.  Relationship Between Cardiac Rehabilitation and Long-Term Risks of Death and Myocardial Infarction Among Elderly Medicare Beneficiaries , 2010, Circulation.

[41]  G Atkinson,et al.  Statistical Methods For Assessing Measurement Error (Reliability) in Variables Relevant to Sports Medicine , 1998, Sports medicine.

[42]  Leo Smith,et al.  American Association of Cardiovascular and Pulmonary Rehabilitation , 1986 .

[43]  Vera Bittner,et al.  Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Pr , 2007, Journal of cardiopulmonary rehabilitation and prevention.

[44]  Jeffrey B. Powell,et al.  Measurement Accuracy of Heart Rate and Respiratory Rate during Graded Exercise and Sustained Exercise in the Heat Using the Zephyr BioHarnessTM , 2012, International Journal of Sports Medicine.

[45]  Yan Liu,et al.  Validity and Reliability of Multiparameter Physiological Measurements Recorded by the Equivital Lifemonitor During Activities of Various Intensities , 2013, Journal of occupational and environmental hygiene.

[46]  K. Filion,et al.  Efficacy of exercise-based cardiac rehabilitation post-myocardial infarction: a systematic review and meta-analysis of randomized controlled trials. , 2011, American heart journal.

[47]  R. Ross,et al.  ATS/ACCP statement on cardiopulmonary exercise testing. , 2003, American journal of respiratory and critical care medicine.

[48]  A. Sheel,et al.  Measurement of exercise ventilation by a portable respiratory inductive plethysmograph , 2006, Respiratory Physiology & Neurobiology.

[49]  G A Naughton,et al.  Exercise for type 2 diabetes mellitus. , 2006, The Cochrane database of systematic reviews.

[50]  Rehabilitation after cardiovascular diseases, with special emphasis on developing countries. Report of a WHO Expert Committee. , 1993, World Health Organization technical report series.

[51]  E. Piotrowicz,et al.  Cardiac telerehabilitation: current situation and future challenges , 2013, European journal of preventive cardiology.

[52]  A. Terzis,et al.  378 Revitalizing a Vital Sign: Measurement of Respiratory Rate With a Thoracic Belt Improves Detection of Tachypnea at Primary Triage , 2011 .

[53]  Jeroen J. Bax,et al.  Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). , 2010, Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology.

[54]  R. W. Jones.  The International Telecommunication Union , 1997 .

[55]  T. Astorino,et al.  Recommendations for Improved Data Processing from Expired Gas Analysis Indirect Calorimetry , 2010, Sports medicine.

[56]  C. Worringham,et al.  Exercise-Based Cardiac Rehabilitation for the 21st Century , 2013, Current Cardiovascular Risk Reports.