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Recently, HeartLogic emerged as a potent predictor of impending heart failure decompensation [ 6 — 11 ]. HeartLogic HL is a multiparametric algorithm that combines different device-based features first and third heart sounds, thoracic impedance, respiratory rate, tidal volume, tidal volume variation, heart rate, and physical activity into a single alert number. However, HL holds promise to be useful for the early detection of alternative diagnoses besides cardiac decompensation.
Here, we present a case in which a sudden and steep increase of HeartLogic with atypical features of heart failure decompensation increased the suspicion for an alternative diagnosis and helped in the early detection of a severe COVID pneumonia. We present the case of a year-old woman nonsmoker of African origin. Subsequent left and right heart catheterization revealed normal coronary arteries. The only known cardiovascular risk factor she had at the time of diagnosis was arterial hypertension which was treated accordingly.
Genetic analysis revealed no abnormalities. A two-chamber ICD was implanted in primary prevention.
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She also takes L-thyroxin 0. Concordant with the euvolemic state, the HeartLogic HL index was consistently under the threshold level for more than 6 months Figure 1.
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Seven days before admission, however, the HL index started to rise extremely fast, starting from a value of 9 till a HL index of 63 on the day of presentation at the emergency department. Figure 1 , Supplemental Figure available here. The parameters that contributed to the out of hospital alert were a decreased heart rate variability, a strongly increased third heart sound, a rapidly changing first heart sound i. Concomitantly, a decreased number of apneas and an average increased heart rate were observed.
This patient presented at the emergency department with severe dyspnea. The dyspnea symptoms started 36 hours before admission.
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A few days prior, the patient suffered from a dry cough. She could not recall to having experienced fever; no fever was measured upon admission Clinical exam revealed the known mitral insufficiency murmur as well as a normal pulmonary auscultation without wheezes or rhonchi. The CT scan revealed bilateral multifocal subpleural ground glass opacities, with peribronchovascular distribution and partial consolidation, and thin pleural strands in both lower lobes. No pulmonary edema and no pleural effusion were observed Figure 2.
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This is a timely case report wherein device-based telemonitoring delivered a warning signal that was atypical for heart failure alone, holding the promise to help in the early diagnosis of other health problems such as a viral pneumonia, here caused by SARS-CoV Device-based telemonitoring is rapidly emerging as an interesting tool for remote follow-up in heart failure patients with a pacemaker, ICD, or CRT device [ 3 ]. Also, in other branches of medicine wireless follow-up of glycaemia in diabetic patients, follow-up of therapeutic adherence to continuous positive airway pressure therapy in obstructive sleep apnea [ 12 , 13 ] , remote patient follow-up allows for faster processing of specific patient data to control larger patient cohorts.
The HeartLogic device helps in the early detection of heart failure. Based on the validation study [ 6 ], the median time between the rise-above-threshold of HL and the clinical event was more than 30 days, allowing for corrective measures in order to prevent heart failure hospitalizations. This case report supports this idea and hints at the possibility to make a differential diagnosis of dyspnea in heart failure patients using the HL device during the current SARS-CoV-2 pandemic. The rapidly increasing respiratory frequency together with an increasing thoracic impedance pleads against a pure cardiac decompensation with subsequent fluid overload and hints towards an important alternative diagnosis, a hypothesis that was corroborated by the CT scan findings and finally by showing SARS-CoV-2 in the nasopharyngeal swab.
Indeed, the parameters that contributed significantly to the alert helped to differentiate COVID from heart failure exacerbation. We observed an increased thoracic impedance, whereas normally a lower impedance would be expected for severe HF decompensation [ 14 ], as well as an out-of-proportion increase in respiratory frequency Figure 1. If lung alveoli are progressively filled up with water pulmonary edema due to decompensation , resistance decreases as the conductivity for electric current is higher for water than for air [ 15 ]. Therefore, an increased thoracic impedance is very atypical for cardiac decompensation.
In this case, the increase in thoracic impedance might be explained by multiple factors, e. Also, in many cases with established heart failure, an increased heart rate is explained by atrial fibrillation whereas here a sinus tachycardia was noted.
In addition, the overall speed of changes increased the suspicion of an alternative diagnosis. It is however important to emphasize that the infection with SARS-CoV-2 will have contributed to worsening heart failure. Indeed, respiratory infections are often sufficient to flip a euvolemic HF patient towards decompensation and fluid overload. Of course, the HL algorithm cannot replace the regular clinical evaluation but should be seen as an interesting help to raise a timely suspicion for the presence of an alternative diagnosis for heart failure or at least a diagnosis that can trigger cardiac decompensation.
Especially during this SARS-CoV-2 pandemic, hospital services are being reorganized for a full focus on the control of this infection. Device-based telemonitoring of heart failure patients can help to detect noncardiac diseases that significantly alter overall homeostasis.
Moreover, detailed analysis of the HeartLogic algorithm can help to shed light on the diagnosis. To prepare for the practical test, you have the choice between doing practical driver training at an accredited driving school or driver training undertaken privately.
To be admitted for the practical test, you must have passed the theory test within the past 3 years or be exempt and have passed the risk perception test. This test, conducted by computer before the beginning of your test, consists of determining your level of skill after your driver training. A list of skills is displayed on the screen. For each statement, you have to score yourself, from 1 to 5 very good , for the level that you believe you have reached at the end of learning to drive. This assessment does not in any way affect the result of your test.
The examiner will look at your results on completion of the test. It will help make the final debriefing objective. New manoeuvres. During your test, you will be required to perform two manoeuvres on public roads. The first, which is mandatory, is stopping on the left or right of the roadway. The second is drawn at random from the following manoeuvres:. Three-point turn; Reversing in a straight line; Perpendicular parking on the roadway going forward; Perpendicular parking on the roadway in reverse.
You will be required to drive on public roads for 10 minutes, in control alone and without any directions from the examiner, using traffic signs and signals. The examiner will tell you when this part of the test starts and finishes. All documents must be the originals and be valid. Identity card out of date?
The test will take place on condition that if you have the out-of-date identity card with you and can present a receipt issued by your local council offices proving you have applied for renewal. Without the receipt, the test will not take place. Identity card Provisional driving licence Pass certificate for the risk perception test Follow-up certificate for the learning appointment private training Completed roadbook at least 1, km for applicants holding a provisional 18 or month driving licence. Identity card Driving licence Follow-up certificate for the learning appointment private training.
Registration certificate Insurance card Green technical inspection certificate if submitted L plate. You will be issued with a request for a driving licence that will enable you to obtain your driving licence from your local council within a period of 3 years following the time you pass the practical test.
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After failing the practical test on 2 occasions, you will only be able to take the test again after attending at least 6 hours of practical driving lessons at an accredited driving school. Category B A category B driving licence is required for drivers of motor vehicles with a maximum authorised mass not in excess of 3, kg and which are designed and built to carry a maximum of 8 passengers in addition to the driver.
Motor-driven quadricycles also come into this category. Want to attach a trailer to your vehicle? Type of vehicle Motor vehicles 8 places maximum kg. Did you know? Holders of a category B licence can also drive a category AM moped or scooter? Theory test If you wish to obtain your driving licence, you will first have to pass a theory test.
Minimum age to take the theory test. Risk perception test RPT Passing the risk perception test is necessary in order to take the practical test. The Radschnellege Fast cycle route in German links a series of towns in the largest urban agglomeration in Germany: the Ruhr in North-Rhine Westphalia region.
The km fast cycling route will connect 10 major cities of the region, including Dortmund, Essen and Duisburg which have all more than , inhabitants.
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This linear fast cycling route is expected to attract daily between 1, and 4,o cyclists on each section. The future network of fast cycling routes will be composed of 3 concentric circular cycle routes and 9 radials connecting the heart of the city to the surrounding towns. It will also integrate the local sections of EuroVelo 5 and EuroVelo 15 into the network.
Public lightning, winter service and regular maintenance will be provided on the entire network.
The construction of a fast cycling route is therefore appropriate between the two cities. Have we missed a fast cycling route project? Use the boxes below to subscribe to the ECF newsletter or this link for press releases. Skip to main content.