Predictive validity of automated oscillometric blood pressure monitors for screening atrial fibrillation: a systematic review and meta-analysis

Atrial Fibrillation and Early Vascular Aging: Clinical Implications, Methodology Issues and Open Questions-A Review from the VascAgeNet COST Action

Atrial fibrillation (AF), the most common cardiac arrhythmia, is associated with adverse CV outcomes. Vascular aging (VA), which is defined as the progressive deterioration of arterial function and structure over a lifetime, is an independent predictor of both AF development and CV events. A timing identification and treatment of early VA has therefore the potential to reduce the risk of AF incidence and related CV events. A network of scientists and clinicians from the COST Action VascAgeNet identified five clinically and methodologically relevant questions regarding the relationship between AF and VA and conducted a narrative review of the literature to find potential answers. These are: (1) Are VA biomarkers associated with AF? (2) Does early VA predict AF occurrence better than chronological aging? (3) Is early VA a risk enhancer for the occurrence of CV events in AF patients? (4) Are devices measuring VA suitable to perform subclinical AF detection? (5) Does atrial-fibrillation-related rhythm irregularity have a negative impact on the measurement of vascular age? Results showed that VA is a powerful and independent predictor of AF incidence, however, its role as risk modifier for the occurrence of CV events in patients with AF is debatable. Limited and inconclusive data exist regarding the reliability of VA measurement in the presence of rhythm irregularities associated with AF. To date, no device is equipped with tools capable of detecting AF during VA measurements. This represents a missed opportunity to effectively perform CV prevention in people at high risk. Further advances are needed to fill knowledge gaps in this field.

Evaluation of atrial fibrillation using wearable device signals and home blood pressure data in the Michigan Predictive Activity & Clinical Trajectories in Health (MIPACT) Study: A Subgroup Analysis (MIPACT-AFib)

Background

The rising adoption of wearable technology increases the potential to identify arrhythmias. However, specificity of these notifications is poorly defined and may cause anxiety and unnecessary resource utilization. Herein, we report results of a follow-up screening protocol for incident atrial fibrillation/flutter (AF) within a large observational digital health study.

Methods

The MIPACT Study enrolled 6,765 adult patients who were provided an Apple Watch and blood pressure (BP) monitors. From March to July 2019, participants were asked to contact the study team for any irregular heart rate (HR) notification. They were assessed using structured questionnaires and asked to provide 6 Apple Watch EKGs. Those with arrhythmias or non-diagnostic EKGs were sent 7-day monitors. The EHR was reviewed after 3 years to determine if participants developed arrhythmias.

Results

86 participants received notifications and met inclusion criteria. Mean age was 50.5 (SD 16.9) years, and 46 (53.3%) were female. Of 76 participants assessed by the study team, 32 (42.1%) reported anxiety surrounding notifications. Of 59 participants who sent at least 1 EKG, 52 (88.1%) were in sinus rhythm, 3 (5.1%) AF, 2 (3.4%) indeterminate, and 2 (3.4%) sinus bradycardia. Cardiac monitor demonstrated AF in 2 of 3 participants with AF on Apple Watch EKGs. 2 contacted their PCPs and were diagnosed with AF. In total, 5 cases of AF were diagnosed with 1 additional case identified during EHR review.

Conclusion

Wearable devices produce alarms that can frequently be anxiety provoking. Research is needed to determine the implications of these alarms and appropriate follow-up.

Sensitivity and specificity of automated blood pressure devices to detect atrial fibrillation: A systematic review and meta-analysis of diagnostic accuracy

Background

Atrial fibrillation (AF) is a prevalent and preventable cause of stroke and mortality.

Aim

This systematic review and meta-analysis aimed to investigate the sensitivity and specificity of office and out-of-office automated blood pressure (BP) devices to detect AF.

Methods

Diagnostic studies, extracted from databases such as Ovid Medline and Embase, on AF detection by BP device(s), electrocardiography, and reported sensitivity and specificity, were included. Screening of abstracts and full texts, data extraction, and quality assessment were conducted independently by two investigators using Covidence software. The sensitivity and specificity of the BP devices were pooled using a random-effects model.

Results

Sixteen studies including 10,158 participants were included. Only a few studies were conducted in primary care (n = 3) or with a low risk of bias (n = 5). Office BP devices, which utilised different algorithms to detect AF, had a sensitivity and specificity of 96.2 and 94%, respectively. Specificity was reduced when only one positive result was considered among consecutive BP measurements. Only a few studies (n = 3) investigated out-of-office BP. Only one study (n = 100) suggested the use of ≥79 and ≥26% of positive readings on 24-h ambulatory BP measurements to detect AF and paroxysmal AF, respectively.

Conclusions

Office BP devices can be used clinically to screen for AF in high-risk populations. Clinical trials are needed to determine the effect of AF screening using office BP devices in reducing stroke risk and mortality. Further studies are also required to guide out-of-office use of BP devices for detecting paroxysmal AF or AF.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022319541, PROSPERO CRD42022319541.

Home blood pressure monitoring: methodology, clinical relevance and practical application: a 2021 position paper by the Working Group on Blood Pressure Monitoring and Cardiovascular Variability of the European Society of Hypertension

The present paper provides an update of previous recommendations on Home Blood Pressure Monitoring from the European Society of Hypertension (ESH) Working Group on Blood Pressure Monitoring and Cardiovascular Variability sequentially published in years 2000, 2008 and 2010. This update has taken into account new evidence in this field, including a recent statement by the American Heart association, as well as technological developments, which have occurred over the past 20 years. The present document has been developed by the same ESH Working Group with inputs from an international team of experts, and has been endorsed by the ESH.