title: Cardiovascular screening in low-income settings using a novel 4-lead smartphone-based electrocardiograph (D-Heart®).
abstract: BACKGROUND
  MHealth technologies are revolutionizing cardiovascular medicine. However, a low-cost, user-friendly smartphone-based electrocardiograph is still lacking. D-Heart® is a portable device that enables the acquisition of the ECG on multiple leads which streams via Bluetooth to any smartphone. Because of the potential impact of this technology in low-income settings, we determined the accuracy of D-Heart® tracings in the stratification of ECG morphological abnormalities, compared with 12-lead ECGs.
  
  
  METHODS
  Consecutive African patients referred to the Ziguinchor Regional Hospital (Senegal) were enrolled (n=117; 69 males, age 39±11years). D-Heart® recordings (3 peripheral leads plus V5) were obtained immediately followed by 12 lead ECGs and were assessed blindly by 2 independent observers. Global burden of ECG abnormalities was defined by a semi-quantitative score based on the sum of 9 criteria, identifying four classes of increasing severity.
  
  
  RESULTS
  D-Heart® and 12-lead ECG tracings were respectively classified as: normal: 72 (61%) vs 69 (59%); mildly abnormal: 42 (36%) vs 45 (38%); moderately abnormal: 3 (3%) vs 3 (3%). None had markedly abnormal tracings. Cohen's weighted kappa (kw) test demonstrated a concordance of 0,952 (p<0,001, agreement 98,72%). Concordance was high as well for the Romhilt-Estes score (kw=0,893; p<0,001 agreement 97,35%). PR and QRS intervals comparison with Bland-Altman method showed good accuracy for D-Heart® measurements (95% limit of agreement ±20ms for PR and ±10ms for QRS).
  
  
  CONCLUSIONS
  D-Heart® proved effective and accurate stratification of ECG abnormalities comparable to the 12-lead electrocardiographs, thereby opening new perspectives for low-cost community cardiovascular screening programs in low-income settings.
authors.affiliation: Referral Center for Cardiomyopathies, Careggi University Hospital, Florence, Italy. Electronic address: niccolo.maurizi@gmail.com.
authors.forename: Niccolo'
authors.initials: N
authors.lastname: Maurizi
authors.affiliation: Center for International Cooperation, University of Pavia, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Faragli
authors.affiliation: Center for International Cooperation, University of Pavia, Italy.
authors.forename: Jacopo
authors.initials: J
authors.lastname: Imberti
authors.affiliation: Center for International Cooperation, University of Pavia, Italy.
authors.forename: Nicolò
authors.initials: N
authors.lastname: Briante
authors.affiliation: Referral Center for Cardiomyopathies, Careggi University Hospital, Florence, Italy.
authors.forename: Mattia
authors.initials: M
authors.lastname: Targetti
authors.affiliation: Referral Center for Cardiomyopathies, Careggi University Hospital, Florence, Italy.
authors.forename: Katia
authors.initials: K
authors.lastname: Baldini
authors.affiliation: Dept. of Cardiology, Regional Hospital of Ziguinchor, Senegal.
authors.forename: Amadou
authors.initials: A
authors.lastname: Sall
authors.affiliation: Regional Hospital of Ziguinchor, Senegal.
authors.forename: Abibou
authors.initials: A
authors.lastname: Cisse
authors.affiliation: Biostastic and Clinical Epidemiology Unit, Dept. of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy.
authors.forename: Francesca Gigli
authors.initials: FG
authors.lastname: Berzolari
authors.affiliation: Biostastic and Clinical Epidemiology Unit, Dept. of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy.
authors.forename: Paola
authors.initials: P
authors.lastname: Borrelli
authors.affiliation: Dept. of Radiology, IRCCS San Matteo, Pavia, Italy.
authors.forename: Fulvio
authors.initials: F
authors.lastname: Avvantaggiato
authors.affiliation: Internal Medicine Unit, Cardiovascular and Metabolic Diseases, IRCCS San Matteo, Pavia, Italy.
authors.forename: Stefano
authors.initials: S
authors.lastname: Perlini
authors.affiliation: Dept. of Clinical and Experimental Medicine, University of Florence, Italy.
authors.forename: Niccolo'
authors.initials: N
authors.lastname: Marchionni
authors.affiliation: Dept. of Clinical and Experimental Medicine, University of Florence, Italy.
authors.forename: Franco
authors.initials: F
authors.lastname: Cecchi
authors.affiliation: Center for International Cooperation, University of Pavia, Italy.
authors.forename: Gianbattista
authors.initials: G
authors.lastname: Parigi
authors.affiliation: Referral Center for Cardiomyopathies, Careggi University Hospital, Florence, Italy.
authors.forename: Iacopo
authors.initials: I
authors.lastname: Olivotto
mesh_terms: D000328:Adult; D002318:Cardiovascular Diseases / Q000175:diagnosis* / Q000191:economics / Q000453:epidemiology; D015331:Cohort Studies; D004562:Electrocardiography / Q000191:economics / Q000295:instrumentation / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000191:economics / Q000295:instrumentation / Q000379:methods*; D008875:Middle Aged; D011203:Poverty / Q000191:economics; D012675:Senegal / Q000453:epidemiology; D000068997:Smartphone / Q000191:economics / Q000706:statistics & numerical data*; D017216:Telemedicine / Q000191:economics / Q000295:instrumentation / Q000379:methods*
keywords: Low-income settings; Portable electrocardiograph; Telemedicine; mHealth