The onset of paroxysmal atrial fibrillation does not occur randomly. The large patient population in the present study suggests that the circadian rhythm of paroxysmal atrial fibrillation is similar to that described for other cardiovascular diseases, with clustering of events in the morning and (to a lesser degree) late in the evening. Weekly and yearly circadian patterns are also prominent.

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SummaryBackground: The rising cost of services provided by hospital emergency departments is of major concern. Attempts to reduce the costs of emergency cardiac care have thus far focused primarily on medical and administrative management in the hospital. The role of the patient in appropriate prehospital decision-making has been generally ignored.Hypothesis: Membership in "Shahal" (an integrative telemedicine system) may have beneficial effects on patient decision-making and national health costs.Methods: During a 6-month period, a random group of subscribers who had called for medical assistance during the previous 24 h were asked what action they would have taken had they not been Shahal subscribers. All study patients were followed for at least 7 days.Results: In all, 1,608 subscribers (age 7 1 k 13 years) were included. Of these, 5 14 replied that they "would have waited," 363 "would have contacted their physicians," and 73 1 "would have sought emergency department care." Of the presenting medical problems, 86% were resolved without utilizing hospital facilities. A mobile intensive care unit was dispatched in 412 (26%) cases. A cost estimate of abuse indicated that the service resulted in a savings to the national economy of approximately $830,000 per 10,000 members per year.Conclusions: This study demonstrated that Shahal membership can reduce costs of medical care and the number of hospital emergency department visits.

Background:One disadvantage of current loop recorders is the long interval between recording an electrocardiogram (ECG), establishing a diagnosis, and taking appropriate medical measures. The Cardio R loop recorder transmits cardiac recordings by cellular communication at the push of a button. Users can concomitantly relay symptoms, thereby providing a symptom/cardio‐rhythm correlation.Hypothesis:The Cardio R is capable of early detection of cardio‐electrical events that could account for patients' symptoms.Methods:This observational study was designed to evaluate patients who were referred from community physicians/cardiologists for evaluation of various cardiac symptoms that were not observed by regular office ECGs or traditional 24‐hour Holter cardiac monitoring. Transmitted recordings were instantly displayed on a monitor for immediate diagnosis by the on‐duty medical team at SHL‐Telemedicine's call center. Abnormal tracings, especially when accompanied by symptoms selected from the prepared list, enabled the staff to instruct the subscriber, notify their physician, and/or dispatch a mobile intensive care unit to the scene.Results:Between January 2009 and August 2010, there were 17 622 ECG transmissions received from 604 patients (age range, 10–95 years) who completed a 1‐month trial with the Cardio R device. Palpitation, presyncope, and chest pain were the leading complaints. A disturbance in rhythm that could account for symptoms occurred during recording in 49% cases and was displayed within 7 minutes in 93% of them. No longer than 2 days elapsed from recording onset to diagnosis.Conclusions:The Cardio R device enables prompt ECG confirmation/exclusion of a probable arrhythmic cause of symptoms, enabling rapid intervention for cardiac‐relevant complaints. © 2011 Wiley Periodicals, Inc.Dr. Arie Roth is a medical consultant for SHL‐Telemedicine.The authors have no other funding, financial relationships, or conflicts of interest to disclose.

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"SHL" Telemedicine (established 1987 in Israel) provides professional care to subscribers who use cardiobeepers and contact its medical call center via telecommunication networks. The extended 6-month Acute Coronary Syndrome Israel Survey (ACSIS) 2004 involved all 26 intensive cardiac care units in Israeli hospitals. We compared the 1-year survival rates of the "SHL" Telemedicine subscribers and ACSIS participants who survived hospitalization after sustaining an acute myocardial infarction. The myocardial infarction data for the ACSIS cohort (3,899 patients) and the SHL Telemedicine cohort (699 subscribers) were provided for this study by the ACSIS executive and SHL's files, respectively. One-year mortality was ascertained by telephone contacts with patients or their relatives. Mortality at 1 year was 4.4% for the "SHL" patients and 9.7% for the ACSIS patients (p < 0.0001). The "SHL" cohort was significantly older (p < 0.0001) than the ACSIS cohort (mean age [+/-SD] 69 +/- 11 versus 63 +/- 13 years), had significantly more past myocardial infarctions (p < 0.001), more past strokes (p < 0.0032), more heart failure (p < 0.0001), more hypertension (p = 0.002), and more hyperlipidemia (p < 0.0001). Gender distribution and diabetes status were similar for both groups. In spite of having more risk factors than the ACSIS subjects, the "SHL" Telemedicine subscribers had significantly higher survival rates at 1 year compared to the ACSIS patients, whose outcome is consistent with that of the Western world. Availability of medical call centers in the out-of-hospital setting for patients with suspected cardiac symptoms improves their motivation to seek timely and appropriate medical assistance.

The absence of randomized studies on sufficiently large patient cohorts precludes the drawing of any firm conclusions on the comparative performance between nurses and physicians in transtelephonic triage and consultations and in diagnostic and management decision-making. We conducted such a comparative study at the SHL telemedicine facility. This facility also provides face-to-face medical management for its subscribers by means of mobile intensive care units (MICUs) staffed by physicians. The outcome of calls that came between 7:00 AM and 11:00 PM throughout the study year and that were handled at random by specially trained physicians (n = 15) or nurses (n = 35) were analyzed. Of 48,707 subscribers who fulfilled the study entry criteria 25,106 used the service at least once, producing 88,103 calls (81,817 handled by nurses and 6,286 by physicians). Teleconsultations were sufficient for most of the cases (80.13%). There were no significant differences between the performance of nurses and physicians regarding demographics (age, gender) and medical diagnoses of the applicants. The nurses' performance and decisions were comparable to those of physicians with respect to teleconsultations, medically justified dispatches of an MICU, repeated calls to the center and mortality during the week after the index call, although the duration of the physicians' telephone consultations was longer. Delegation of equal authority to nurses and physicians in triage and consultation in telecardiology results in equivalent and highly satisfactory medical care in a system in which subscribers receive service orchestrated from a single center of telecommunications.

Telemedicine technology shows considerable promise for reducing 30-day readmission rates of post-AMI patients.