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2 TEMEO – The Principle TEMEO works in two modes – automatic mode and ECG mode. Automatic mode: This is the basic mode in which TEMEO works. 1. Sensors on the chest send signal on every heart contraction 2. A built-in accelerometer reports the physical activity 3. An electronic device receives the signals from the sensor and the accelerometer and forwards the information to the Telemedicine Center on every 5 minutes together with an ECG, representing the last 10 sec of the current 5-minute interval. ECG mode: There is a possibility for the patient to send a 10 sec ECG record to the Telemedicine Center anytime they feel some discomfort or worry. This is done by swithing TEMEO from automatic to ECG mode.

3 TEMEO device

4 GSM Network Internet Servers Medical Supervisors TEMEO Concept TEMEO Medical Expert TEMEO


6 At the telemedicine center are analyzed the pulse, variability of the heart rate, some heart rate and conduction disorders, physical activity of the patient, current cardiovascular risk. Also a call is generated from the telemedicine center to either the patient, their GP or an Emergency Center if there is such need. TEMEO - Telemedicine center

7 What type of information does TEMEO provide us? Supraventricular extrasystoles Ventricular extrasystoles Supraventricular extrasystoles in bigeminiya Ventricular extrasystoles in bigeminiya Atrial fibrilation Conduction disorders Bradycardia Supraventricular Tachycardia Ventricular Tachycardia ECG detailed visualization The results were verified through clinical investigations at MHAT Dr. Hristo Stambolski – Kazanlak and the National Cardiology Hospital.

8 RR – Physical activity For every 5-minute interval sent to the telemedicine center the system provides the following records: A record of the heart rate (in green) put together with the physical activity of the patient (in blue) An ECG record of the last 10 sec of this 5-minute interval (in yellow)

9 HRV analyses A variety of tolls for HRV analysis and processing

10 Report for a random period There is a possibility for generating a report for a random period of time about the following parameters: Heart rate Heart rate variability Heart rate disorders Conduction disorders

11 Normal night record - (Pulse rate and Physical activity) Respiratory Arrhythmia Normal day record - (Pulse rate and Physical activity)

12 Ventricular extrasystoles Supraventricular extrasystoles

13 Absolute Arrhythmia With patients with atrial fibrilation of basic interest are the leading, maximum and minimum heart rate during the different parts of the day, in rest and during physical activity. For all the patients the therapy was changed for better control of the heart rate and the effect of the changed dosages and the newly added drugs was immediately accounted. The system gave opportunity for registering the moments of paroxysmal atrial fibrilation of the patient with paroxysmal atrial fibrilation, as well as the heart rate during these moments.

14 Physical activity Supraventricular extrasystoles Physical activity Ventricular extrasystoles When working with patients with acute myocardial infarction during their early rehabilitation, it is essentially important to watch closely their heart rate, the heart rate dynamics during physical activity and the efficiency of their beta blocking. The results from the extended tracking of these factors were used for adapting the treatment of the patients concerned by titration of the dose of the beta blocker. With one of the patients with inferior myocardial infarction and RCA stent implementation, the system accounted a tendency for bradicardia up to 40-42 beats per minute at night and normal heart rates at day and during dosed physical activities. The system accounts the existence of ventricular extrasystole and shows its connection to the physical activity.

15 ECG EVENT In conclusion, the collected data together with our experience show a very good tolerance to the devices on the patients side, when the system is working absolutely autonomously. The system works fully in automatic mode, which is a precondition for a good compliance. The initial placement of the device, as well as the Internet based tracking, do not place any special requirements to the supervising doctors. The collected data was useful in specifying the status and adapting the therapy of the patients. The system can be used for seriously ill patients with cardiac diseases, at hospitals or at home. The system is also very useful for active cardiac patients because it gives opportunity for extended monitoring during physical activity.

16 ECG TEMEO provides tools for filtering, processing and analysis of ECG.

17 Parameter Holter ECGTemeo Holter ECGp value Monitoring time72 778 min61 389 min Registered QRS complexes83 505 ± 1480678 912 ± 14 736р = 0.8 Average frequency73 ± 14 bpm74 ± 16 bpm(р = 0.16) Maximal frequency133 ± 33 bpm 121 ± 19 bpm(р = 0.007) Minimal frequency54 ± 14 bpm47 ± 12 bpm(р < 0.001) % Time in tachycardia11.4 ± 18.3%9 ± 15.1%(р = 0.24) Single premature ventricular contractions 2897 ± 8388363 ± 722(р = 0.02) Double premature ventricular contractions 456 ± 70875 ± 195(р < 0.001) Triple premature ventricular contractions 0.3 ± 10(р = 0.15) Clinical research statistics:

18 ECG - Extrasystole


20 Ventricular extrasystole episodes of bigeminy type

21 Patient: M. S. K., 72 years old Entered the hospital on: 24.09.2009 Discharged from hospital on: 25.09.2009 Diagnosis: coronary artery disease. Stable angina FC II-III. PCI with stent implantation in SVG-DCA and stenting of SVG-OM1. Post-myocardial infarction-1989. Condition after ACB x 3-1999 (SVG-Ladd, CAD-PA, OM1). Atrial fibrillation. Hypertension III degree dyslipidemia. Electrocardiographically verified atrial fibrillation

22 Venticular exstrasystoles of trigeminy type

23 Interpolated venticular extrasystole

24 Venticular extrasystoles followed by a venticular tachycardia

25 Atrial flutter episode

26 Significant horizontal depression of the ST segment episode

27 Atrial fibrilation episode

28 Patient: T. I. T., 61 years old Complaints: episodes of tachycardia, not registered with ECG by the moment. TEMEO is placed. Initial record – normal rhythm.

29 On the third day of the medical supervision, during physical activity atrial fibrilation episode was registered with high heart rate. A voice contact with the patient was created and an emergency team was sent to him. The patient was brought to the ICD of MHAT Dr. Hristo Stambolski – Kazanlak, for treatment. After and hour the normal heart rate was restored.

30 Patient S.D.M., 55 years old, hospitalized in Neurology Department, diagnosed with ischemic stroke. In connection with atrial fibrillation suspicion, the patient is put a TEMEO. At the beginning – sinus rhythm.

31 On the forth day of the supervision an atrial fibrillation episode was detected. The patient was prescribed anticoagulation therapy for embolism prevention.

32 Patient D.I.I. – 65 years old. When hospitalized the patient was diagnosed with acute myocardial infarction of the LV. A coronarography was made in emergency and a stent was placed in the proximal segment of LAD. Due to the existence of frequent ventricular extrasystoles an ECG was made to register VLP. 3 positive signs of VLP were revealed (according to Davis criteria ). At discharge of hospital the patient was put a TEMEO for prolonged telemedical supervision. At the beginning – sinus rhythm.

33 On the third day of the supervision a paroxysmal ventricular tachycardia episode was registered. The patient was sent an emergency team and taken in Cardiac Department, where the tachycardia was taken under control by electrical cardioversion.

34 Patient living and working in Blackburn, England, watched over in the telemedicine center in Kazanlak, Bulgaria. The system works flawlessly with patients, situated outside Bulgaria, the quality of the ECG and the automatic analysis remaining with excellent at the same time.

35 TEMEO C5 – two-channel record; Channel 1 – modified II standard lead. On this channel arrhythmias are observed. Channel 2 – modified V5 lead. On this channel depression and elevation of the ST segment are observed.

36 The philosophy of TEMEO products consists in the idea that we want to know about the diseases and their complications right now, at present, not tomorrow when it will be late. We have arrived at this conclusion as a result of our experience. For less than a year in the telemedicine center at the town 1300 patients have been looked after.

37 TEMEO - The FUTURE Best wishes!!! SSI together with ICD MHAT Dr.H.S. Kazanlak


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