World Heart Federation

Roadmap for Digital Health

in Cardiology WHF ROADMAP

JASPER TROMP* AWAD MOHAMED

DEVRAJ JINDAL* PABLO PEREL
JULIE REDFERN GONZALO EMANUEL PEREZ
AMI BHATT FAUSTO PINTO
TANIA SÉVERIN RAJESH VEDANTHAN
AMITAVA BANERJEE AXEL VERSTRAEL
JUNBO GE KHUNG KEONG YEO
DIPTI ITCHHAPORIA KIM ZULFIYA
TINY JAARSMA DORAIRAJ PRABHAKARAN CORRESPONDING AND
CO-FIRST AUTHORS:
FERNANDO LANAS CAROLYN S. P. LAM
Jasper Tromp
FRANCISCO LOPEZ-JIMENEZ MARTIN R. COWIE National University of
Singapore, SG
Author affiliations can be found in the back matter of this article
[email protected]
*Jasper Tromp and Devraj Jindal are co-first authors.
Devraj Jindal
Centre for Chronic Disease
Control, New Delhi, IN
[email protected]

ABSTRACT
KEYWORDS:
More than 500 million people worldwide live with cardiovascular disease (CVD). Health digital health interventions for
systems today face fundamental challenges in delivering optimal care due to ageing CVD; e-health; health system
populations, healthcare workforce constraints, financing, availability and affordability governance
of CVD medicine, and service delivery.
TO CITE THIS ARTICLE:
Digital health technologies can help address these challenges. They may be a tool
Tromp J, Jindal D, Redfern J,
to reach Sustainable Development Goal 3.4 and reduce premature mortality from Bhatt A, Séverin T, Banerjee A,
non-communicable diseases (NCDs) by a third by 2030. Yet, a range of fundamental Ge J, Itchhaporia D, Jaarsma
barriers prevents implementation and access to such technologies. Health system T, Lanas F, Lopez-Jimenez F,
governance, health provider, patient and technological factors can prevent or distort Mohamed A, Perel P, Perez
GE, Pinto F, Vedanthan R,
their implementation.
Verstrael A, Yeo KK, Zulfiya
World Heart Federation (WHF) roadmaps aim to identify essential roadblocks on the K, Prabhakaran D, Lam CSP,
pathway to effective prevention, detection, and treatment of CVD. Further, they aim Cowie MR. World Heart
Federation Roadmap for
to provide actionable solutions and implementation frameworks for local adaptation.
Digital Health in Cardiology.
This WHF Roadmap for digital health in cardiology identifies barriers to implementing Global Heart. 2022; 17(1): 59.
digital health technologies for CVD and provides recommendations for overcoming DOI: https://doi.org/10.5334/
them. gh.1141
BACKGROUND Tromp et al.
Global Heart
2

DOI: 10.5334/gh.1141
Cardiovascular disease (CVD) affects more than 500 million people worldwide if you wording
needs to be modified [1]. Global lifestyle changes, including worsening diets, reduced
physical activity and an increasing smoking prevalence, have led to a growing burden of non-
communicable diseases (NCDs) and risk factors for CVD [2, 3]. Health systems today face
fundamental challenges in delivering optimal care due to ageing populations, constraints
in their healthcare workforce, financing, availability and affordability of CVD medicine, and
service delivery [4–6]. Therefore, patient self-care and empowerment is becoming increasingly
important.

Digital health technologies, such as electronic decision support tools, telemonitoring, remote
monitoring, or mobile health (mHealth) apps, have the potential to help address health
system challenges which limit the achievement of optimal and universal health coverage
(UHC). These technologies can contribute to UHC by empowering patients [7] and providers
[8], promoting universal health services coverage [9], improving long-term patient outcomes
and care experience, and reducing healthcare costs (Figure 1) [10]. Therefore, Digital Health
Interventions (DHIs) may be a tool to reach Sustainable Development Goal 3.4 and reduce
premature mortality from NCDs by a third by 2030 [11].

Figure 1 The potential of

digital health interventions for
CVD. © World Heart Federation.

A range of fundamental barriers prevent implementation and access to digital health

technologies globally [12]. Health system governance (e.g., national privacy regulations and
internet access), health provider (e.g., digital literacy, perceived effectiveness), patient (e.g., age
[13], local sex/gender norms [14], socioeconomic factors [15], digital and health literacy [16]),
and technological factors (e.g., a context-specific adaptation of technology, interoperability
[16]) can prevent or distort the implementation of new digital health technologies. Digital
determinants of health and socioeconomic factors determining access and adoption of digital
technologies can create a ‘digital divide’: a chasm between those with and without access
to digital technologies due to economic factors, (digital and health) literacy, age, or sex. This
can cause inequity and inequality in access to digital technology and its potential benefits.
Unfortunately, similar inequalities often permeate across diseases and beyond health [17].
Furthermore, it is essential to acknowledge that not all DHIs to date have positively impacted
outcomes [18, 19]. Process evaluations have demonstrated that common barriers, such as
(poor) context-specific design of interventions or poor implementation, are often at the root of
an intervention’s effectiveness [20, 21]. Yet proper process evaluations for complex DHI are not
commonly performed, leaving many questions at the end of effectiveness studies about why
DHI were (not) effective. The World Heart Federation (WHF) Roadmaps have been published Tromp et al. 3
Global Heart
since 2014 to identify essential roadblocks on the pathway to effective prevention, detection, DOI: 10.5334/gh.1141
and treatment of cardiovascular disease [22–28]. The ultimate aim of the WHF Roadmap is
to provide implementation frameworks for local adaptation for prevention, detection and
treatment strategies for CVD. This WHF roadmap for digital health in cardiology aims to identify
barriers to implementing digital health technologies for CVD and provide recommendations for
overcoming them.

METHODOLOGY AND SELECTION OF THE EXPERT WRITING GROUP

In 2020, the WHF commissioned a writing group to develop a roadmap on digital health for
cardiology. WHF regional Members were invited to nominate an expert to the writing group
to ensure that the content of the roadmap has accurate global representation. In addition,
experts in digital health with clinical, public health or research backgrounds were selected. The
writing group also included representatives from allied health professions and people living
with CVD to ensure an inclusive perspective.

The roadmap is derived from a synthesis of peer-reviewed evidence on the barriers to and
benefits of using digital technologies, an online survey among WHF members and the public
and an iterative process of expert consultation involving eight writing committee members
and 12 reviewing committee members drawn from the global WHF membership network.
The Supplementary Appendix details the methodology of the survey. Inputs from surveys
and (patient) experts were supplemented with a narrative evidence synthesis on barriers and
solutions for implementing digital health solutions. The Writing Committee identified and
selected case studies based on their experience and relevance to the identified barriers and
solutions.

TARGET AUDIENCE
The primary focus of this roadmap is to identify and provide solutions and tools for commonly
faced barriers in the development, implementation and scaling of DHIs for CVDs and their risk
factors. Solutions in this roadmap are intended to be practical and are directed at different
stakeholders within health systems, including people living with CVD and who might be active
in-patient organisations, health care practitioners and policy makers, helping them to come
together and drive meaningful change.

DEFINITION AND TYPE OF DIGITAL HEALTH INTERVENTIONS

In 2018, the World Health Organization (WHO) presented a classification of digital health
interventions (DHIs) [29]. This taxonomy classifies digital health solutions according to the
health system challenges they seek to address. In contrast, the United States Federal Drug
Administration (FDA) defined a digital health taxonomy based on the product or service to guide
legal regulations for each product [30]. Other existing classifications use the target group (e.g.
clients, healthcare providers, health system managers or data services) [31] for the purpose
of the intervention [32]. In the context of this roadmap, we used the WHO classification and
focused on client or provider-facing technologies and data services.

POTENTIAL OF DIGITAL HEALTH IN PREVENTING AND MANAGING

CARDIOVASCULAR DISEASE
Several DHIs have shown potential for CVD management [18, 33, 34–41, 42–44], including
text message programmes [34, 38–43], mobile (mHealth) apps [18, 33, 35, 36, 44], telehealth
consultations [45–47], wearable devices [48–50], and electronic decision support tools [37,
51, 52]. This section provides several non-exhaustive examples of DHIs to illustrate their
potential impact. Text message programmes can improve the management of single risk
factors, including tobacco smoking [33], high blood pressure [34], physical activity [38], weight
management [39], and medication adherence [40, 41]. For example, the TEXTME randomised
controlled trial (RCT) showed that four semi-personalised messages sent automatically on
random times and days of the week significantly improved blood pressure, body mass index, Tromp et al. 4
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smoking rates, physical activity and adherence to dietary guidelines [42]. A significant part of DOI: 10.5334/gh.1141
its success was the co-design of text content with patients and clinicians, using techniques
from behavioural psychology [43].

A 2018 systematic review found that mobile (mhealth) apps can reduce rehospitalisation, improve
patient knowledge, quality of life, and psychosocial well-being, and help manage CVD risk factors
[44]. Importantly, the success of mHealth interventions depended on simplicity, credible and
evidence-based information relying on behaviour change concepts, real-time data tracking,
virtual positive reinforcement, app personalisation, social elements, and ensuring privacy [53]. The
HERB Digital Hypertension 1 (HERB-DH1) RCT (390 patients from 12 sites in Japan) showed that
an interactive smartphone app retrieving home BP monitoring data to generate a personalised
programme of lifestyle modifications improved ambulatory, home and office SBP [35].

Physical activity trackers are an example of wearable devices that may be used to support
CVD management. A 2019 systematic review (28 RCTs including 3646 participants across nine
countries) investigated the effects of wearable activity trackers and found an average increase
of 627 daily steps (95% CI 417 to 862 steps) and energy expenditure among the intervention
groups compared to controls [50]. The mSToPS RCT demonstrated that a home-based wearable
continuous ECG monitoring patch could successfully identify patients with atrial fibrillation
[54]. The Apple Heart Study demonstrated moderate effectiveness of the Apple Watch in
identifying people with atrial fibrillation [55]. However, this study was not without criticism [56]:
An essential issue was the absence of a response by individuals notified by the Apple Watch of
possible health issues, highlighting the importance of considering how users interact with DHIs
to ensure effectiveness.

The EXPERT (Exercise Prescription in Everyday Practice & Rehabilitation Training) Tool is an
example of a clinical electronic decision support tool. The European Association for Preventive
Cardiology (EAPC) introduced EXPERT as an interactive decision aid enabling healthcare
professionals to compare their exercise prescriptions to predetermined patient cases using
an algorithm [57]. The recent PROMPT-HF trial showed that a tailored EHR-based alerting
system could improve the use of guideline-directed medication in heart failure [52]. Lastly,
artificial intelligence (AI) decision support tools can aid in interpreting medical imaging data
automatically [51, 58, 59].

REQUIREMENTS FOR SUCCESSFUL IMPLEMENTATION OF DIGITAL

HEALTH SOLUTIONS
The WHO recommendations on DHIs for health system strengthening laid out several conditions
necessary to implement digital health technologies successfully [60]. These include (1) The
health content, referring to the disease domain and associated treatment recommendations,
(2) a DHI that is technically aligned to achieve the proposed goal (3) digital applications such
as information and communications technology (ICT) systems and communication channels
to deliver the digital intervention — these include the ICT and software systems optimised
for its intended goal — and (4) an enabling environment consisting of a national strategy,
reimbursement policies, and a digital infrastructure. A recent European Society of Cardiology
(ESC) working paper emphasises the importance of DHIs for managing CVDs and provides
various practical recommendations [12].

ROADBLOCKS AND SOLUTIONS TO IMPLEMENT DIGITAL HEALTH

INTERVENTIONS
Unfortunately, in reality, many of the ideal conditions for implementing digital health
technologies are often not met. The WHO/ITU framework suggests that a national eHealth
environment requires good leadership and governance, high-quality legislation and policies,
a clear investment and reimbursement strategy, high-quality services and applications, a
supporting digital health infrastructure, clear interoperability and data standards and a tech-
savvy workforce [61]. Barriers and solutions were classified according to these components. In
addition, a category of patient-level barriers was added as it was not included in the WHO/ITU
framework (Figure 2).
 Tromp et al. 5
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DOI: 10.5334/gh.1141

Figure 2 Selected roadblocks

and solutions to implement
digital health interventions,
based on the WHO/ITU
framework. © World Heart
Federation.

Table 1 outlines common barriers to implementing digital health solutions based on a narrative
synthesis of existing literature and the online survey. The online survey was shared with WHF
membership organisations and social media channels between September 2, 2021 and
October 14, 2021. In total, 227 participants from 71 countries completed the survey. The survey
achieved global representation: 28.4% of the responses were collected in the WHO European
region; 25.3% in the Americas, 21.3% in South-East Asia, followed by 12% in the African Region,
9.8% in the western Pacific and 3.1% in the Eastern Mediterranean regions. Furthermore, 35%
were from high-income countries, 60% from middle-income countries and 15% from low-
income countries, according to 2019 World Bank Criteria. Solutions were identified based on
expert consensus and existing literature. In the next section, we discuss some of the most
reported barriers to implementing digital health solutions and provide solutions that might be
relevant to the local context.

LEADERSHIP AND GOVERNANCE

Roadblock: Lack of national guidelines
National governments and policymakers are uniquely responsible for setting universally
applicable strategies and standards [61]. More than 70% of respondents to the survey noted
that a lack of national data privacy and sharing guidelines was a critical roadblock. The lack of
national guidelines was an essential barrier in a recent systematic scoping review [16], as it
can lead to the reluctance of providers to use DHIs. For example, the absence of clear national
guidelines on telehealth solutions in Bangladesh was a significant barrier for local healthcare
practitioners to adopt this technology [62].

Suggested solutions
The ITU/WHO national eHealth strategy toolkit guides the development of national eHealth
strategies [61]. National professional medical societies are uniquely positioned to advocate for
national guidelines on data sharing and universal data standards. Increasingly, digital health
data governance standards are emerging, involving regulations for ethics, data security, and
regulatory policies [63]. The development and deployment of digital health technologies are
dependent on the ability to collect, store, access and share medical data. Clear guidelines for
accessing these data can ensure their quality and availability [64]. A key aspect of development
includes rigorous stakeholder management with an emphasis on inclusive development [61].
Table 1 Barriers and possible solutions.

DESCRIPTION OF ROADBLOCK SOLUTION

Leadership and governance

National guidelines and Lack of national guidelines and eHealth Establish national or regional eHealth guidelines and strategy.
strategies strategy.

Stakeholder engagement Poor involvement of critical national Inclusive engagement with stakeholders by policymakers,
stakeholders. including representatives of patients, practitioners, payers,
industry and civil society.

Monitoring and evaluation Lack of clear monitoring and evaluation Clear national standards for monitoring and evaluation of DHIs.
standards. standards. No repeated monitoring Long-term monitoring of effectiveness and implications of digital
of effectiveness, reach and impact of health interventions. ‘unexpected effects’ registry.
interventions.

Legislation, policy and compliance

National legislation on data Lack of national guidelines on data security Explicit national guidelines on data access and security. Promote
security and access and access. Local institutional guidelines are harmonization of policies between institutions.
not harmonized.

Lack of regulatory approval or Lack of regulatory standards; poor health Improve HTA and regulatory standards.
guidance technology assessment (HTA) standards.

Strategy and investment

Reimbursement Unclear reimbursement pathways for digital Clear reimbursement strategy for DHI. Include economic
technologies. evaluations in the design phase.

Long-term investment Lack of long-term investment strategy for Include long-term investment strategy as part of national
strategy sustainability of digital technologies. guidelines.

Services and applications

Contextualisation Intervention not adapted to the local context. Perform a structured and holistic needs and context assessment
before designing and implementing interventions. Health system
assessment frameworks might be helpful tools.

Poor usability and design Non-user focused design. Employ user-centred and co-design principles. Include end-users
(practitioners/patients) early in the design phase.

Infrastructure

National or regional digital No clear investment in national or regional Investing in digital health infrastructure should be included as a
infrastructure digital infrastructure. national policy priority.

Healthcare provider systems Local infrastructure does not allow the Applications should be flexible and available in on- and offline
integration of new DHI. modes.

Standards and interoperability

Data structure standards National and international differences in data Promote collective definitions and data storage formats.
collection, storage and definitions standards. Emphasise implementation of open data platforms.

Health workforce

Poor needs assessment Poor understanding of the health workforce Include clear health system and needs assessment in the design
needs. phase of DHIs.

Data literacy Lack of understanding of DHI. Provider education on the use of digital technology.

Low acceptability Lack of perceived effectiveness and use of Inclusive technology design and education of use.
DHIs.

Patients

Poor digital literacy and skills Lack of understanding of DHI (literacy), or not Patient education on the use of digital technology, context
having physical capabilities to interact with specific adaptations of technology to match patients’ physical
DHI. abilities.

Low acceptability Lack of perceived effectiveness and use of Inclusive technology design, education of use and user
DHIs. acceptance, usefulness and engagement evaluation alongside
clinical trials and related research.
Roadblock: Lack of monitoring and evaluation standards Tromp et al. 7
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In the WHF digital health roadmap survey, low (perceived) quality was a moderate to DOI: 10.5334/gh.1141
significant barrier to more than 70% of respondents. The WHO reported that only 7% of DHIs
in LMICs are properly evaluated [65]. A systematic review confirmed these results and found
only the minority of DHIs are properly evaluated [66]. Similarly, few AI decision support tools
are evaluated prospectively [67]. On a policy level, few countries have dedicated frameworks
for evaluating DHIs [51]. The lack of perceived or proven effectiveness is a critical barrier to
the use of DHI by patients and clinicians [16]. The lack of proper evaluation standards has
prevented the uptake of DHIs in clinical guidelines, which has negatively influenced adoption.
Because they imply multiple interacting components that can target various behaviours and
require significant expertise to deliver or target numerous groups of people, many DHIs can be
considered complex interventions as defined by the British Medical Research Council [68]. This
means that the evaluation of DHIs in RCT settings is complex and not always possible when
deployed in a ‘real-world’ setting. Software-driven by AI algorithms poses a unique challenge.
These algorithms often undergo continuous training to improve their predictive capabilities.
However, there is a significant risk that ongoing training reinforces existing structural biases in
the data [69].

Suggested solutions
The WHO has highlighted the importance of robust evaluation and recommends using the
mHealth Evidence Reporting and Assessment (mERA) checklist, emphasising quantitative,
qualitative, and economic evaluation [70, 71]. The United Kingdom National Institute for Health
and Care Excellence (NICE) provides an Evidence Standards Framework for DHIs [72]. Cardiology
guidelines have a hierarchy of evidence that puts RCT at the top. Rarely are digital technologies
assessed this way – partly because of the small nature of many companies developing tech,
and the complex and rapid nature of DHIs. This requires a shift in the mindset of appreciating
DHI’s effectiveness. Many DHIs are considered complex interventions with multiple interacting
components. For example, the mWellcare Cluster-Randomized Controlled Trial randomised
community health centres and compared the use of electronic decision support tools versus
care as usual [73]. The nature of the intervention required healthcare practitioners (doctors,
nurses) to engage with the software effectively. A process evaluation can evaluate whether
the lack of benefit of mWellcare was due to poor staff engagement with the software or to
the software’s intrinsic capabilities. Frameworks for evaluating complex interventions, such
as the RE-AIM framework [74] can be used to assess complex DHIs with multiple interacting
components. Evaluation of AI-drive software requires specific frameworks [75]. The United
States Food and Drug Administration (FDA) outlined a framework in their AI action plan [76]. This
framework requires a predetermined change control plan with anticipated algorithm changes
by the developers and how this would impact safety and performance [76]. Subsequent
post-market access periodic updates are necessary to monitor real-world performance [76].
Professional medical associations play a role in advocating for the necessity for continuous
monitoring of AI-drive algorithms. In the same way that post-market monitoring of drug safety
and effectiveness is performed in phase IV trials, we require continuous monitoring of software
performance and safety when using rapidly changing algorithms.

LEGISLATION, POLICY AND COMPLIANCE

Roadblock: Lack of guidance on data security of digital health technologies
Privacy concerns and individuals’ willingness to disclose personal medical information
are essential barriers to adopting technologies [77]. The lack of national regulations and
inadequacy of legal requirements of DHIs was considered a significant barrier by more than
60% of respondents of the WHF survey. Multiple studies have shown that this is particularly
true for older individuals [78] and is essential in creating a ‘digital divide’. A study in Ireland
suggested that perceived trust and safety of digital (mHealth) technologies were important
adoption determinants, particularly in older individuals [79]. Similar studies performed in India
and China indicate that trust in the data security of digital health technologies contributes
to digital health adoption by patients across cultures and geographies [80, 81]. A recent
systematic review highlighted the importance of the lack of clarity of digital health regulations
as a significant barrier in LMICs [82]. Results of the online survey support these findings: lack of
national rules and issues surrounding data privacy for clients (patients) were among the most
significant barriers to implementing digital technologies. A recent scoping review highlighted Tromp et al. 8
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a lack of trust and issues with data privacy and security as a vital clinician-level barrier in DOI: 10.5334/gh.1141
7% of studies on barriers and enablers for digital health in CVD [16]. A recent study from the
United Kingdom suggested that a National Health Service (NHS) stamp of approval served as a
significant facilitator for digital health implementation [83].

Suggested solutions
Rigorous and transparent regulatory mechanisms and guidance on data security and privacy
are essential conduits to enhance trust by patients and clinicians in using digital health
technologies [61, 64]. An article by Tiffin and colleagues summarises components of data
governance. It includes guidelines on ethics and consent, data access, sustainability, and
legal frameworks on data security, third party access and a right to privacy [84]. The European
Union’s General Data Protection Regulation (GDPR) outlines vital data protection principles as
a global gold standard [85]. Importantly, patients are increasingly asking to be the owners of
their data. In this situation, the patient determines with whom their data is shared and in what
context, even after informed consent. While this is not commonplace, new technologies such
as blockchain might facilitate individual patient data ownership for research and development
purposes [86].

STRATEGY AND INVESTMENT

Roadblock: No strategy for reimbursement and long-term investment
Current policy guidelines in many countries require face-to-face consultation for reimbursement.
Therefore, the lack of proper reimbursement of DHIs is a significant barrier to adoption by
patients and providers. More than half of survey respondents considered limited reimbursement,
prohibitive costs of training staff and patients, and high out-of-pocket patient costs significant
barriers. Separate scoping and systematic reviews [16, 87, 88] on barriers and facilitators
highlighted that financial concerns were essential barriers for both patients and health care
providers. Unfortunately, many countries’ care facilities or suppliers’ costs are not reimbursed
[12]. Furthermore, the financing of DHIs often does not consider long-term sustainability. In
Africa, 85% of the funding for DHIs is targeted at research and early pilot programmes [89, 90].
For example, a national survey in Uganda found that most DHIs were pilot studies, operated
in silos, donor-funded, and lacked sustainability [91]. Unfortunately, donor-based funding in
LMICs often does not consider financial sustainability [92], and long-term public financing by
public healthcare systems in LMICs is often challenging [89].

Suggested solutions
Implementation of DHIs should consider funding mechanisms because they will impact the
(cost) evaluation and long-term sustainability. The COVID-19 pandemic has accelerated the
need for new funding mechanisms for telehealth solutions, for example, in the United States
[93] and Singapore [94]. Unfortunately, these funding mechanisms have primarily been ad-
hoc. Some of these funding mechanisms have been made permanent, as in Australia for
example [95]. Governments play a crucial role as conveners to guide the long-term financing
strategy, recognised by the WHO/ITU framework for developing a national eHealth strategy
[61]. National financing strategies should consider the national and local IT infrastructure as
fundamental perquisites for implementing individual DHIs. While many governments have
funded telehealth services with health professionals and electronic pharmacy scripts, this
does not extend to using DHIs such as apps and wearable devices [51]. Specific financing
instruments are beyond the scope of this roadmap. Examples relevant to the local context
can be found in the Broadband Commission for Sustainable Development Working Group on
Digital Health report [89]. Therefore, researchers/developers should consider the long-term
financial sustainability of DHIs during the design phase and cost-effectiveness analyses during
the testing phase [68].

SERVICES AND APPLICATIONS

Roadblock: No user- and context-specific adaptations
Common issues with DHIs are insufficient assessment of the patients’ and healthcare
providers’ actual needs, developing ‘one-off’ interventions without contextualisation within
national health systems, and lacking cultural and social adaptations [96]. Lack of contextual
adaptation was considered a barrier to DHIs among more than 60% of survey respondents Tromp et al. 9
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for this roadmap. The effectiveness of DHIs is dependent on the local context, which can also DOI: 10.5334/gh.1141
include the wider socioeconomic context. For example, a recent evaluation of a mobile text-
based support programme for people living with diabetes or hypertension in Cambodia found
that the intervention added little to an already effective peer-support network. Notably, the
intervention did not address the structural barriers determining access to care, such as patient
reimbursement and patient health literacy [20]. DHIs should also be designed with the user
in mind. The introduction of electronic medical records designed without considering the
clinician’s workflow is one of the prime examples of poor design standards [97]. Increased work
and responsibilities for clinicians were the most significant barrier to the uptake of digital health
technology by cardiovascular clinicians in a recent scoping review [16]. Similar to patients, poor
design and ability to interact with DHIs were significant barriers to adoption among healthcare
workers [16, 98].

Suggested Solutions
There is a need to focus on unmet population needs and promote thoroughly researched
and adequately contextualised technologies. Contextualising DHIs starts by recognising that
many are often considered complex interventions [68]. DHIs involve various components that
interact within the health system and broader sociopolitical context. For example, mobile
app interventions in rural areas with poor reception and internet connectivity will likely not
enable community health workers to provide better care. Therefore, contextualisation requires
a system thinking approach to recognise the complex interacting parts in determining access
to and quality of care in the local context [99]. This should translate to a broad needs and
contextual assessment, considering the local (ICT) context, workflow, and sociopolitical barriers
to accessing high-quality care. Health system assessment tools and frameworks can help
structure the review of the current obstacles and facilitators surrounding CVD prevention and
care [100, 101], which often require a mixed-methods approach. User-centred and co-design
principles are necessary to contextualise interventions and make them more effective [102,
103]. The World Wide Web Consortium summarised the user-centred design process [104],
which outlines clear steps in the (co)-design of applications. The International Organization
for Standardization (ISO) provides further guidance on human-centred design for interactive
systems [105].

INFRASTRUCTURE
Roadblock: Limited national and institutional ICT infrastructure
Limited national and institutional ICT and digital infrastructure are essential barriers to
implementing DHIs [61, 106]. In 2020, almost 40% of the global population did not have
access to the internet [107]. Lack of internet access and institutional support were moderately
or very important barriers according to more than 50% of survey respondents in determining
access to DHIs. Poor internet connection remains a significant barrier in many LMICs [16, 108].
Institutional support and existing infrastructure were critical enablers [16]. ICT infrastructure
is also a key barrier on an institutional level. Many LMICs still have paper-based records and
limited existing ICT infrastructure [109, 110]. The 2016 WHO atlas on eHealth Country Profiles
demonstrated that only 10% of 125 countries used EHRs [110]. A national assessment of barriers
to implementing digital technology interventions to improve hypertension management
in India found that IT infrastructure was available in less than half of mid-tier primary and
community health centres [111].

Suggested Solutions
DHIs require sufficient and efficient information and communications infrastructure, including
software, hardware, internet connectivity, maintenance support, data storage and security.
National governments should consider national infrastructure in their eHealth and finance
strategy, for which the ITU/WHO guidance is a valuable tool [61]. In addition, the WHO and ITU
have developed a ‘digital Health Platform Implementation Handbook’, which can serve as a
guide to implementing digital health platforms [112]. On an institutional level, national society
guidelines might help guide implementation. The American Medical Association developed
a playbook for implementing telehealth, which provides a practical guideline for healthcare
systems to implement telehealth consultations [113]. Almost all the public system innovations
meant to be adopted require long-term support and maintenance planning to ensure the
product’s sustainability after the initial implementation phase. Researchers/innovators Tromp et al. 10
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working on digital health solutions should try to align their products with national policies and DOI: 10.5334/gh.1141
infrastructure. During the design phase of a DHI, researchers and producers should consider
local infrastructure requirements. This requires flexibility of the application. In many LMICs,
applications should be able to function as stand-alone services and in offline settings.

STANDARDS AND INTEROPERABILITY

Roadblock: Limited interoperability of digital health interventions
Lack of integration with the existing (ICT) workflow was a moderate to significant barrier for
most respondents. These results were in line with published studies and meta-analyses [91, 92].
Institutional data is often saved digitally or in paper format and, depending on the institution,
usually uses proprietary software solutions. Cardiac imaging analyses are stored in Digital
Imaging and Communications in Medicine (DICOM) format in some institutions but as OpenCV
or MP4s in others. Lack of technical interoperability can prevent data exchange between two
technologies, such as electronic medical records and a new AI application. The Global System
for Mobile Communications Association (GSMA) emphasised that legacy ICT infrastructure and
commercial software packages using non-open data standards commonly cause a lack of
interoperability [89]. Enhancing interoperability is critical to enabling training and deployment
of algorithms and a substantial barrier to scaling DHI nationally [92]. The lack of high-quality
data in LMICs can perpetuate healthcare disparities [114]. Without access to high-quality large
volumes of data, it is challenging to develop effective algorithms for populations in LMICs.

Suggested Solutions
The Health Data Collaborative Digital Health & Interoperability working group, currently co-
chaired by USAID and WHO, has developed several toolkits relevant to developing and
implementing national data interoperability standards [115]. Many data platforms are
available, which can also function as (national) medical record platforms. Examples include
OpenDataKit [116], OpenMRS [117], and CommCare [118]. In 2014, a randomised study in
South Africa demonstrated that CommCare had no errors compared to 3.8% errors in the
paper-based arm for assessing CVD risk [119]. The broadband commission working group
on digital health highlighted that LMICs without legacy systems are uniquely positioned to
leapfrog high-income countries by adopting new solutions faster [89]. Professional societies
can help promote the importance of interoperability standards. For example, the European
Society of Cardiology (ESC) launched the Cardiology Audit and Registration Data Standard in
2015 to promote the collection of shared data definitions in health information systems [120].

HEALTH WORKFORCE
Roadblock: Acceptability and feasibility for health workers
DHIs have the potential to empower and educate health workers, reduce their workload and
save travelling time [60]. A recent scoping review identified the most common barriers health
workers face in CVD [16]. These included increased workload and responsibilities, commonly
due to poor integration with existing ICT systems, unreliable technologies and/or lack of
evidence supporting using the technology, financial concerns with using the technology, and
data privacy and security concerns. Similar reviews studying barriers and facilitators for DHIs
for hypertension management highlighted identical obstacles, including lack of technology
usability and support, lack of validation of technology and concerns over data privacy and
security [87, 88]. One of the most significant barriers to implementing DHIs is interventions not
working within existing clinical workflows and poor usability. Reimbursement of digital health
technologies impacts adoption by healthcare workers. A recent McKinsey survey highlighted
that many patients embraced telehealth visits, but physicians still had significant reservations
[121]. Particularly, a minority of physicians felt that telehealth visits were more convenient than
most patients [121]. Finally, healthcare workers’ digital literacy and confidence in using newer
digital health technologies might be a significant barrier. A recent survey on e-health knowledge
and usage in general cardiology by the European Society of Cardiology (ESC) Practice and Digital
Health Committee suggested that more than 25% of cardiologists rated their knowledge of
eHealth as low [122].
Suggested solutions Tromp et al. 11
Global Heart
User-focused design and a solid evidence base regarding effectiveness are vital in enabling DOI: 10.5334/gh.1141
clinicians to use digital health technologies [60]. As a rule, digital technologies should reduce
the burden on clinicians or significantly improve patient outcomes to be acceptable. Involving
healthcare workers in the design phase of DHIs can prevent poor usability and integration with
existing clinical workflows. Most DHIs are not evaluated in randomised controlled trials [66].
Therefore, the design of DHIs should be accompanied by rigorous testing in randomised clinical
trials. Digital literacy of health workers is vital. Therefore, targeted health worker education on
using digital health technologies is essential. Notably, costs of (continued) training of healthcare
workers in digital technologies should be considered when estimating cost-effectiveness.
Professional medical organisations, such as ESC, AHA or the Asia Pacific Society of Cardiology,
have a unique opportunity to educate their members on the benefits and limitations of DHIs
and their evaluation. Specifically, they could offer training during professional meetings on
digital solutions and develop specific eLearnings for their members.

PATIENTS
Roadblock: Acceptability and feasibility for patients
Similar to providers, DHIs have the potential to empower and educate patients, reduce their
workload and save travelling time. Various patient-level barriers impact DHI adoption and
acceptability. Patients with CVD are commonly older and have several comorbidities leading
to impaired physical and mental functioning [82]. The disease progression of various subtypes
of CVD, such as heart failure, can lead to progressive cognitive impairment, which can reduce
patients’ ability to engage with DHIs. This barrier is shared across countries of different economic
levels [16, 82, 88, 91]. Cultural, and socioeconomic factors might influence the acceptability
of digital health technologies. Well-known user characteristics associated with lower digital
health use are sex [62], older age, low (health) literacy [62] and low socioeconomic status
[123–125]. These characteristics, in part, are related to lower digital literacy, especially in
the use of mobile apps and telehealth solutions [123–125]. For example, patients might feel
uncomfortable with home visits or telemedicine visits with video calls in some cultures due
to privacy concerns regarding their home situation. Economic barriers remain a significant
challenge for patients but have been extensively discussed in previous sections. Finally, a lack
of perceived effectiveness experienced by patients and a potential overload of DHIs might
hinder adoption. Because patients with CVD often have multiple comorbidities, there is an
inherent risk of being confronted with different unrelated DHIs for individual comorbidities (e.g.,
hyperlipidaemia, hypertension). Patients with a lower education level are at a higher risk of not
being able to engage with digital health technologies, especially at an older age [126].

Suggested solutions
As is the case for health care workers, digital health technologies require significant investments
in patient education. Active involvement of caregivers and assisting patients in using DHIs might
improve utilisation [82]. Deployment of DHIs requires a rigorous context and needs assessment.
Patient factors such as socioeconomic status, gender role influencing access to technology,
cultural factors, practical ability, and digital literacy should be considered. Involving patients
in co-designing DHIs is necessary to mitigate these risks and has been demonstrated to be
impactful [43]. Further, it is essential to evaluate user perspectives and engagement alongside
clinical trials to fully understand how to optimise usefulness and engagement beyond the trial
[36].

CONCLUSIONS AND RECOMMENDATIONS

DHIs can fill critical health system gaps in CVD management and prevention, empower patients,
and enable healthcare practitioners to provide higher quality and more efficient care. There is
a substantial unmet need for collective action involving patients, healthcare providers, industry
members, regulators and reimbursement authorities, and policy makers to identify and
help solve context-specific barriers. This roadmap provided potential solutions for frequently
encountered obstacles to scaling up digital health solutions to improve the management and
prevention of CVD and the support and experience of care for those living with those conditions
globally.
CASE STUDIES Tromp et al.
Global Heart
12

MPOWER HEALTH A CLINICAL DECISION SUPPORT SYSTEM FOR EVIDENCE- DOI: 10.5334/gh.1141
BASED CARE
Health system challenge
Empower non-physician healthcare workers through the use of a digital platform (evidence-
based Clinical Decision Support System).

Intervention
mPower Health is a digital platform designed to deliver integrated, comprehensive, and
continuous care to patients through innovative technology-driven tools that support healthcare
professionals.

In 2010, the Government of India initiated the National Programme for Prevention and Control
of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) to respond to the challenges
related to the high burden of NCDs in India. The mPower Health platform was designed to
complement the NPCDCS programme.

The mPower Heart works on two core principles: Technology (a knowledge-based Clinical
Decision Support System-CDSS) and task-shifting (empowering non-physician healthcare
providers) (Figure 3).

Figure 3 NCD nurse using

mPower Health CDSS in a
government health facility,
reproduced with permission
from the Centre for Chronic
Disease Control (CCDC), New
Delhi, India.

mPower Health’s major capabilities/features are:

• A mobile app for healthcare providers and a web-based dashboard/server for healthcare
administration.
• Clinical Decision Support System generates ersonalized management plans for patients
with hypertension and diabetes by computing complex clinical management algorithms
and suggesting the diagnosis, optimal drugs, dosage, warning contra-indications, etc.
• Computing clinical risk scores to identify high-risk individuals and initiate preventive
measures.
• Maintaining longitudinal health records of the patient and assisting in scheduling follow-
up visits based on clinical parameters (avoid unnecessary travel and visits of the patients).
• Task Shifting: empowering the non-physician workforce to deliver quality care by using
technology.
• Generating lifestyle recommendations tailored to individual patients.
• Ability to work in offline mode (without internet connectivity).
• Real-time monitoring and profile visualiser for trending and quick decision making.

Link with barriers and solutions

Acceptability and feasibility for health workers, ICT infrastructure
Piloting of the mPower platform has shown impressive results and significantly impacted clinical
outcomes of patients with hypertension and diabetes [127]. Two states (Tripura and Mizoram)
governments in India adopted the mPower Health system for state-wide implementation.
It was successfully implemented in forty health facilities in the state of Tripura [128] and Tromp et al. 13
Global Heart
sixteen health facilities in Mizoram in India with the support of key stakeholders by providing an DOI: 10.5334/gh.1141
enabling environment (healthcare workforce, digital infrastructure, change management, etc.).
The mPower Health met all the important conditions recommended by WHO for a successful
DHI such as health content (mPower Health provided standardised evidence-based care for
NCDs), alignment of the intervention with the national goal, digital infrastructure (support
provided the state health department) and enabling environment. In Tripura and Mizoram,
around 207, 000 people have benefited from this technology-enabled NCD care.

National guidelines and clear strategy for long-term investment

The lack of national guidelines and strategies for the DHI at the time of implementation of
the mPower Health and no strategies for long-term investment impacted the uptake and
sustainability of mPower Health. As a result, the Government of India recently initiated the
Ayushman Bharat Digital Mission (ABDM) which aims to provide the necessary framework and
infrastructure [129]. The learnings from the states of Tripura and Mizoram and the support
provided by national agencies led to integrating the CDSS module of the mPower Health with
the Government of India’s Comprehensive Primary Health Care -NCD system under the I-TREC
[130]. Furthermore, the World Health Organization (WHO) adopted the mPower platform
to develop the mPEN App for promoting the use of the WHO PEN Package in the clinical
management of non-communicable diseases.

CONNECT: A CONSUMER-FOCUSED, RESPONSIVE AND PRIMARY CARE-

INTEGRATED WEB-APPLICATION
Health system challenge
To integrate data and communication directly between patients and their health care providers.

Intervention
Consumer Navigation of Electronic Cardiovascular Tools (CONNECT) is a consumer-focused,
responsive web application that is interactive and integrated with data from the patient’s
primary care electronic health record. It was co-designed with consumers, clinicians and
software developers and supported CVD risk management and decision-making. CONNECT
(Figure 4) includes digital reminders and access to (1) medical conditions, medicines and
interactive absolute risk awareness (red tiles); (2) goal-setting, progress tracking and virtual
rewards (green tiles); polling for interactivity and social interaction (blue tiles). In the words of
a patient, ‘It was a nice way of seeing the graph of the cholesterol thing coming down, so that
was great–that’s a bonus…visual feedback…I better keep walking, riding, whatever because it’s
working.’ [131].

Figure 4 CONNECT
smartphone application.
Reproduced from NPJ Digit
Med. 2020; 3. Redfern J,
Coorey G, Mulley J, et al., A
digital health intervention
for cardiovascular disease
management in primary
care (CONNECT) randomized
controlled trial.
Links with barriers and solutions Tromp et al. 14
Global Heart
User- and context-specific adaptations DOI: 10.5334/gh.1141
Patients have electronic access to auto-populated information about their medical conditions
and prescribed medicines with links to more detailed information to enhance knowledge.
CONNECT also has smartphone and website access to an interactive and personalised CVD
risk system where individual patients can use interactive functions and receive visual feedback
about the relationships between their risk factors and absolute cardiovascular risk. Interactive
goal-setting (including virtual rewards) based on healthier eating, physical activity, smoking
cessation and emotional well-being, and goal achievement tracking with virtual rewards to
facilitate and motivate lifestyle changes.

Interoperability of digital health interventions

CONNECT is integrated with each patient’s primary care electronic record. Progress tracking
combines data imported from electronic medical records with patient logs such as blood
pressure control and weight management with calendar links for tests such as cholesterol
measurement requirements.

Acceptability and feasibility for healthcare works and patients

The intervention was co-designed, validated and beta-tested via a four-phase iterative
process that involved consumers, multidisciplinary clinicians, software developers and graphic
designers [132]. Through this process, researchers understood the complexity of end-user
needs and preferences, thereby improving and enriching the increasingly detailed system
designs and prototypes for a mobile responsive web application. The CONNECT intervention was
subsequently tested in a randomised clinical trial (n=934 patients with or at high risk of CVD) in
the Australian primary care environment with an average follow-up of 12. The study found no
significant difference between groups for medication adherence, modest (but not significant)
improvements in risk but significant improvements in attainment of physical activity targets and
e-health literacy [18]. However, in qualitative analysis, patients, reported benefiting from the
cardiovascular risk score, goal tracking, risk factor self-monitoring and receipt of motivational
health tips. In contrast, general practitioners reported increased patient attendance and
engagement with care [131]. CONNECT has also been found to be accessible, well utilised, and
supported [121, 123]. It includes social interaction and an optional messaging service (email
or text). Patients can receive semi-personalised cardiovascular disease prevention tips and
motivational messages related to diet, medications and lifestyle. Further work is underway to
be iterative in implementation and revision of CONNECT and related DHIs that enable delivery
of tools that are useful for patients and beneficial for health outcomes.

RURAL EMERGENCY TELEMEDICINE SUPPORT

Health system challenge
Deliver emergency care in underserved areas and remote settings.

Intervention
Providing emergency care in rural areas continues to be a global challenge. The pandemic
amplified the disparity in the care of underserved populations in the United States, notably the
20% of the people living in rural areas. With the closure of many rural hospitals, the emergency
medical response system faced longer response and transport times, delaying hospital-level
medical care. The Emory rural Tele-Emergency Medical Services (Tele-EMS) network underwent
a significant innovative change with the work of Drs. Monique Smith and Michael Carr and their
team bring the clinical understanding of the hospital to the point of emergency contact and
automate data communication, allowing earlier patient-focused clinical care in the community
[133]. The digital strategy needed to accomplish this network in a rural area was an impressive
and globally relevant challenge to overcome. It involved three key pillars: clinical expertise,
the coordinated transmission of medical information and investment in communication
infrastructure.

In this programme, an emergency physician provides a video televisit to rural Grady Hospital
EMS crews to evaluate and suggest management of initial patient care. Patient data is
uploaded to a streaming cloud if specialised care is needed. The receiving facility is notified of
the patient’s arrival and the treatment plans that have been started. This allows emergency
medical personnel to focus their attention on the patient’s care while the communication is Tromp et al. 15
Global Heart
automated. DOI: 10.5334/gh.1141

Links with barriers and solutions

User- and context-specific adaptations, ICT infrastructure
In contrast to usual telemedicine programmes, rural platforms require the ability to work in low
bandwidth settings and inside and outside the hospital. After evaluating solutions from multiple
companies, Emory chose SWYMED [134], which allows telemedicine visits to be conducted with
transmission as low as 60 kb per second. This significantly increased the geographic reach of
telemedicine utilisation for emergency services. In addition, Emory worked with the primary
cellular provider for their region, Verizon, to identify the Airlink MG 90 router (Sierra wireless[R]
Vancouver Canada [135]) and installed it in their hospital system and affiliated ambulances.
This allowed rapid downlink and uplink speeds, Wi-Fi and ethernet access.

Interoperability of digital health interventions

Notably, the platform can integrate into EMS and hospital technology to enable rapid
cardiovascular data transmission. In this instance, the product integrated explicitly with Zoll,
the X series monitor defibrillator used on Grady ambulances and the Emory electronic medical
record.

In conclusion, this case underscores the complex human capital, data standardisation,
integration, transmission and communications infrastructure needed to achieve scalable and
sustainable rural telemedicine. It also highlights the importance of multi-industry collaboration
to create meaningful change in rural health by creating new systems for high-quality access to
high-quality care.

ACKNOWLEDGEMENTS
We would like to thank World Heart Federation members and partners who provided feedback
through the roadmap development.

We also thank Astra Zeneca for their sponsorship of the WHF Digital Health Roadmap, as well
as Aktiia for their support of the initiative.

COMPETING INTERESTS
Dr Jasper Tromp is supported by the National University of Singapore Start-up grant, the tier 1
grant from the ministry of education and the CS-IRG New Investigator Grant from the National
Medical Research Council; has received consulting or speaker fees from Daiichi-Sankyo,
Boehringer Ingelheim, Roche diagnostics and Us2.ai, owns patent US-10702247-B2 related to
artificial intelligence and echocardiography.

Dr Devraj Jindal holds a copyright for the CARDIOMETCARE-M software which is a clinical
decision support system.

Dr Julie Redfern owns a portion of the IP for the TEXTCARE software that was developed
following the TEXTME study. She is also funded by a NHMRC Investigator Grant Leadership Level
2 [GNT2007946].

Dr Khung Keong Yeo has received research funding from Amgen, Astra Zeneca, Abbott Vascular,
Bayer, Boston Scientific, Shockwave Medical, Nestle, Novartis (all significant, via institution);
Consulting or honoraria feeds (all modest) from Abbott Vascular, Boston Scientific, Medtronic,
Amgen, Bayer, Novartis, Astra Zeneca, Peijia Medical; Speaker or Proctor fees from Shockwave
Medical, Abbott Vascular, Boston Scientific, Medtronic, Philips, Alvimedica, Bayer, Biotronik,
Orbus Neich, Shockwave Medical, Amgen, Novartis, Astra Zeneca, Microport, Terumo.

Dr. Lopez-Jimenez is co-inventor of several AI algorithms that have been licensed to digital
health companies and may receive financial compensation in the future. He is member of the
advisory board for Anumana, an AI-based technology company. He has co-developed digital
health technology to use 3D volumes to assess cardiometabolic risk with Selected Research
Inc, and may receive financial benefit in the future.
Dr Dorairaj Prabhakaran holds a copyright for the CARDIOMETCARE-M software which is a Tromp et al. 16
Global Heart
clinical decision support system. DOI: 10.5334/gh.1141

Prof Carolyn SP Lam is supported by a Clinician Scientist Award from the National Medical
Research Council of Singapore; has received research support from Bayer and Roche Diagnostics;
has served as consultant or on the Advisory Board/Steering Committee/ Executive Committee
for Abbott, Actelion, Alleviant Medical, Allysta Pharma, Amgen, AnaCardio AB, Applied
Therapeutics, AstraZeneca, Bayer, Boehringer Ingelheim, Boston Scientific, Cytokinetics, Darma
Inc., EchoNous Inc, Impulse Dynamics, Ionis Pharmaceutical, Janssen Research & Development
LLC, Medscape/WebMD Global LLC, Merck, Novartis, Novo Nordisk, Prosciento Inc, Radcliffe
Group Ltd., Roche Diagnostics, Sanofi, Siemens Healthcare Diagnostics and Us2.ai; and serves
as co-founder & non-executive director of Us2.ai.

Dr Martin R Cowie has provided consultancy advice to Medtronic, Boston Scientific, Abbott and
AstraZeneca, related to aspects of digital health. As from 1 August 2022 he has been employed
by AstraZeneca as Clinical Vice-President in Late Stage Research (Biopharmaceuticals).

AUTHOR CONTRIBUTIONS
Dorairaj Prabhakaran, Carolyn S.P. Lam and Martin R. Cowie are co-Chairs of the Roadmap
and contributed equally to this manuscript.

AUTHOR AFFILIATIONS
Jasper Tromp orcid.org/0000-0001-6043-0713
Saw Swee Hock School of Public Health, National University of Singapore, The National University Health
System Singapore, and Duke-NUS Medical school, Singapore
Devraj Jindal orcid.org/0000-0003-2384-7354
Centre for Chronic Disease Control, New Delhi, IN
Julie Redfern
School of Health Sciences, Faculty of Medicine and Health, University of Sydney, AU
Ami B. Bhatt
Massachusetts General Hospital, Boston, US
Tania Séverin
World Heart Federation, Geneva, CH
Amitava Banerjee
Institute of Health Informatics, University College London, London, GB
Junbo Ge
Fudan University Zhongshan Hospital, CN
Dipti Itchhaporia
Hoag Hospital, University of California, Irvine, Newport Beach, US
Tiny Jaarsma
Dpt of Medicine, Health and Caring Sciences, Linköping University, Linköping, SE
Fernando Lanas
Universidad de La Frontera, Temuco, CL
Francisco Lopez-Jimenez
Dpt of cardiovascular medicine, Mayo Clinic, Rochester, US
Awad Mohamed
Dpt of Medicine, University of Khartoum, Khartoum, SD
Pablo Perel
London School of Hygiene & Tropical Medicine, London, UK; World Heart Federation, Geneva, CH
Gonzalo Emanuel Perez
Dpt of Cardiology, Clínica Olivos, Buenos Aires, AR
Fausto J. Pinto
University Hospital CHULN, CAML, CCUL@RISE, Faculty of Medicine of the University of Lisbon, Lisbon, PT
Rajesh Vedanthan
Department of Population Health/Institute for Excellence in Health Equity, New York University Grossman
School of Medicine, New York, US
Axel Verstrael
Hasselt University, Antwerp, BE
Khung Keong Yeo Tromp et al. 17
Dpt of cardiology, National Heart Centre Singapore, SG Global Heart
DOI: 10.5334/gh.1141
Kim Zulfiya
Dpt of internal medicine, City Clinical Hospital No. 7, Kazan medical state university, Kazan, RU
Dorairaj Prabhakaran orcid.org/0000-0002-3172-834X
Centre for Chronic Disease Control, New Delhi, IN; Public Health Foundation of India, Gurugram, IN;
London School of Hygiene & Tropical Medicine, London, UK
Carolyn S.P. Lam
National Heart Centre Singapore, Duke-National University of Singapore, SG
Martin R. Cowie orcid.org/0000-0001-7457-2552
Royal Brompton Hospital & School of Cardiovascular Medicine, Faculty of Life-sciences and Medicine,
King’s College London, London, GB

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Submitted: 14 July 2022

Accepted: 20 July 2022
Published: 26 August 2022

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