Electrophysiology Telemedicine has been used for years for simple transmission of electrophysiologic data through transtelephonic event recorders and pacemaker evaluations Remote monitoring of rhythm data from bedside monitors is also commonplace Leveraging applications for smart phones and tablets for rhythm analysis makes monitoring of cardiac electrical activity detection of arrhythmias and myocardial infarction feasible The SEARCH-AF trial from Australia evaluated nearly 1000 patients with a single-lead ECG device built into an iPhone case The technology was accurate and cost effective and has the potential to prevent stroke.88,89 A modification of the existing single-lead device was used in a recent study for assessment of ST elevation myocardial infarction (STEMI) There was agreement in six patients (four with STEMI and two with non-STEMI) when comparing the smart phone tracing to 12-lead ECG.85 This technology can generate tracings of diagnostic quality in children with positive user satisfaction and could be used to manage children with supraventricular tachycardia and atrial fibrillation.90 New “biomedical shirt” technology that enables even more practical remote ECG monitoring for children and adults is currently under investigation.91 Take the example of J.K., who is a savvy teenager with a history of intermittent palpitations He has recently started to use a wearable device to track his heart rate and rhythm in addition to an event monitor prescribed by his cardiologist for suspected pathologic tachycardia While watching a video on his cell-phone, suddenly he feels a pounding sensation in his chest Using his new cell-phone technology he notices that his heart rate is 180 beats/min He informs his mom, who starts driving him to the nearest emergency department 10 minutes away On the way, he transfers his heart rate information to his cardiologist office, which gives the local emergency room a heads-up In the emergency department, he is quickly triaged and connected to a cardiorespiratory monitor and confirmed to be in supraventricular tachycardia A peripheral intravenous catheter is started while vagal maneuvers are attempted In the next minute a bolus of adenosine converts him back to normal sinus rhythm with a heart rate of 70 beats/min, bringing relief to the patient and his mother While the details of the above event were slightly different in real life, smartphone- and smartwatch-based tele heart rhythm monitoring is on the rise and is predicted to soon be ubiquitous Mobile device–mediated telemedicine is likely to transform direct-toconsumer telemedicine Kardia Mobile by Alivecor is a medical device for home telemonitoring that is Food and Drug Administration cleared and has received European Conformity marking, indicating it conforms with health, safety, and environmental protection standards for products sold within the European Economic Area Kardia uses a single-lead ECG tracing that is acquired for 30 seconds with placement of two fingers from each hand on the device electrodes The ECG recordings are transmitted to a compatible device running Google android or Apple iOS mobile operating systems It has been clinically validated for the recording of single-channel lead I ECGs in clinical and community-based trials.92,93 At the Heart Rhythm Society 2016 scientific sessions, Begg and colleagues presented a comparative study of AliveCor monitor and found it to be superior to conventional Holter monitoring in patients with palpitations, providing a higher diagnostic yield, more detected arrhythmias, with a similar workload Using mobile telemedicine devices enables prompt ECG confirmation/exclusion of a probable arrhythmic cause of symptoms, enabling rapid intervention for cardiac-relevant complaints.94 AliveCor monitoring has the potential to enhance evaluation of symptomatic college athletes by allowing trainers and team physicians to make diagnosis in real time.95 Events of lifethreatening wide-complex tachycardia have been reportedly recorded by patients96 and complete heart block by bystanders97 using this technology This has the potential of being more widely available and accessible than defibrillators in public places Halcox and colleagues showed that telemedicine screening with twice-weekly single-lead iECG in ambulatory patients aged 65 years or older at increased risk of stroke is significantly more likely to identify incident atrial fibrillation than routine care over a 12-month period.98 There are randomized clinical trials underway to investigate the utility of a mobile telemedicine intervention in a “real world” setting Participants are being randomized 1 : 1 to receive the iHEART intervention, receiving an iPhone equipped with an AliveCor mobile ECG and accompanying Kardia application and behavioral altering motivational text messages or usual cardiac care for 6 months.99 In the adult population, postablation of arrhythmias, monitoring using a mobile-based platform, is preferable compared to traditional telemedicine monitoring.100 In the increasing technology savvy pediatric population and the young parents, one can imagine more widespread acceptance of cell-phone– based telemedicine portal There is FDA approval for using mobile ECG monitor: Kardia and Kardia Mobile for adult patients Medical providers are embracing mobile-based diagnostic tools LeshamRubinow and colleagues set up a telemedicine call center where transmitted three-lead ECG recordings were instantly displayed on a monitor for immediate diagnosis by the on-duty medical team.94 Telemedicine allows transmission of cardiac recordings by cellular communication at the push of a button Users can concomitantly relay symptoms by cellphone, thereby providing a symptom/cardio rhythm correlation Their set-up allowed for prompt response to abnormal tracings, especially when accompanied by symptoms selected from the prepared list It enabled their staff to instruct the subscriber, notify their physician, and/or dispatch a mobile intensive care unit to the scene in a matter of minutes Photoplethysmography (PPG), is an optical method available on a smartphone or tablet, for consumer-based telemedicine, without any additional peripheral devices like Kardia It measures changes in tissue blood volume caused by the pulse.101 A PPG waveform is acquired from a finger illuminated by LED smartphone flash and while that finger is also in contact with the phone camera A software application (Cardiio Rhythm) then measures pulsatile changes in light intensity reflected and classifies rhythm as “regular” or “irregular.” While the sensitivity and specificity of optical PPG is less than ECG-based detection, it is also quite high.92 On Apple's App store and Google's Play store, applications such as “iCare Health Monitor,” “Cardiograph,” “Heart Rate Monitor,” and a few others that use PPG for heart-rate measurement have had millions of downloads Wrist-wearable devices like smartwatches are less well validated than smartphone-based devices, but that is likely related to the fact that they are newer technologies Wang and colleagues evaluated four wrist-worn, optically based heart-rate monitors and found that two of the four had suboptimal accuracy during exercise.102 Health care teams are working with device manufacturers to improve their precision and accuracy.103,104 There have been anecdotal case reports of the Apple Watch used for continuous heart-rate monitoring in premature infants.105 However, at this point these wearable smartwatches are primarily helpful in setting safe and appropriate fitness goals, counseling on other lifestyle changes, and providing overall feedback and encouragement In their recent commentary published in Canadian Medical ... a mobile-based platform, is preferable compared to traditional telemedicine monitoring.100 In the increasing technology savvy pediatric population and the young parents, one can imagine more widespread acceptance of cell-phone–