Newer technologies for detection of atrial fibrillation

Novel Technologies in the Detection of Atrial Fibrillation: Review of Literature and Comparison of Different Novel Technologies for Screening of Atrial Fibrillation

Atrial fibrillation (AF) is globally the most common arrhythmia associated with significant morbidity and mortality. It impairs the quality of the patient's life, imposing a remarkable burden on public health, and the healthcare budget. The detection of AF is important in the decision to initiate anticoagulation therapy to prevent thromboembolic events. Nonetheless, AF detection is still a major clinical challenge as AF is often paroxysmal and asymptomatic. AF screening recommendations include opportunistic or systematic screening in patients ≥65 years of age or in those individuals with other characteristics pointing to an increased risk of stroke. The popularities of well-being and taking personal responsibility for one's own health are reflected in the continuous development and growth of mobile health technologies. These novel mobile health technologies could provide a cost-effective solution for AF screening and an additional opportunity to detect AF, particularly its paroxysmal and asymptomatic forms.

Handheld 6-Lead ECG for Early Detection of Acute Inferior Wall ST-T Segment Elevation Myocardial Infarction: HINT-MI Study Design and Rationale

Background: ST-T segment elevation myocardial infarction (STEMI) is a critical condition that requires rapid diagnosis and treatment. Recently, various ECG recording devices have been developed. In this study, we aim to determine the utility of a 6-lead handheld ECG recording device to shorten the time taken for the diagnosis of inferior wall STEMI. Methods and Design: HINT-MI is an investigator-derived, observational, prospective study that will evaluate the ability of a handheld 6-lead ECG device to diagnose acute inferior wall STEMI. Patients who have undergone coronary angiography for STEMI or for other reasons will be enrolled in the study. This study aims to evaluate sensitivity and specificity of a handheld 6-lead ECG device by the level of agreement with a standard 12-lead ECG for diagnosing inferior wall STEMI. Further, we will determine whether the use of the handheld device can reduce the time needed for reperfusion treatment through faster diagnosis. Conclusions: This study aims to investigate the feasibility of a handheld 6-lead ECG device for diagnosing inferior wall STEMI to reduce the time required to diagnose inferior wall STEMI and to allow timely treatment.

Automated Signal Quality Assessment of Single-Lead ECG Recordings for Early Detection of Silent Atrial Fibrillation

Atrial fibrillation (AF) is an arrhythmic cardiac disorder with a high and increasing prevalence in aging societies, which is associated with a risk for stroke and heart failure. However, early detection of onset AF can become cumbersome since it often manifests in an asymptomatic and paroxysmal nature, also known as silent AF. Large-scale screenings can help identifying silent AF and allow for early treatment to prevent more severe implications. In this work, we present a machine learning-based algorithm for assessing signal quality of hand-held diagnostic ECG devices to prevent misclassification due to insufficient signal quality. A large-scale community pharmacy-based screening study was conducted on 7295 older subjects to investigate the performance of a single-lead ECG device to detect silent AF. Classification (normal sinus rhythm or AF) of the ECG recordings was initially performed automatically by an internal on-chip algorithm. The signal quality of each recording was assessed by clinical experts and used as a reference for the training process. Signal processing stages were explicitly adapted to the individual electrode characteristics of the ECG device since its recordings differ from conventional ECG tracings. With respect to the clinical expert ratings, the artificial intelligence-based signal quality assessment (AISQA) index yielded strong correlation of 0.75 during validation and high correlation of 0.60 during testing. Our results suggest that large-scale screenings of older subjects would greatly benefit from an automated signal quality assessment to repeat measurements if applicable, suggest additional human overread and reduce automated misclassifications.

Early Diagnosis of Atrial Fibrillation and Stroke Incidence in Primary Care: Translating Measurements into Actions-A Retrospective Cohort Study

(1) Background: AF-related strokes will triple by 2060, are associated with an increased risk of cognitive decline, and alone or in combination, will be one of the main health and economic burdens on the European population. The main goal of this paper is to describe the incidence of new AF associated with stroke, cognitive decline and mortality among people at high risk for AF. (2) Methods: Multicenter, observational, retrospective, community-based studies were conducted from 1 January 2015 to 31 December 2021. The setting was primary care centers. A total of 40,297 people aged ≥65 years without previous AF or stroke were stratified by AFrisk at 5 years. The main measurements were the overall incidence density/1000 person-years (CI95%) of AF and stroke, prevalence of cognitive decline, and Kaplan-Meier curve. (3) Results: In total, 46.4% women, 77.65 ± 8.46 years old on average showed anAF incidence of 9.9/10³/year (CI95% 9.5-10.3), associated with a four-fold higher risk of stroke (CI95% 3.4-4.7), cognitive impairment(OR 1.34 (CI95% 1.1-1.5)), and all-cause mortality (OR 1.14 (CI95% 1.0-1.2)), but there was no significant difference in ischemic heart disease, chronic kidney disease, or peripheral arteriopathy. Unknown AF was diagnosed in 9.4% and of these patients, 21.1% were diagnosed with new stroke. (4) Conclusions: The patients at high AF risk (Q4th) already had an increased cardiovascular risk before they were diagnosed with AF.

Validation of diagnostic accuracy of a handheld, smartphone-based rhythm recording device

AIM

Evaluation of the diagnostic accuracy of a rhythm recording device, for detection of atrial tachyarrhythmia (ATA) and atrial fibrillation (AF) compared to 12-lead-electrocardiogram (12-L-ECG).

RESEARCH DESIGN AND METHODS

Two hundred 12-L-ECGs (reference standard) and Coala Heart Monitor (CHM) recordings (index test) were collected from 189 patients. Two electrophysiologists independently performed manual analysis of all 12-L-ECGs and CHM recordings in random order. The CHM recordings were also analyzed by an automatic algorithm and compared to the results of the reference standard.

RESULTS

Manual analysis of CHM for ATA showed a sensitivity of 98.9% (95% confidence interval (CI): 94.0-100) and a specificity of 100% (CI: 96.6-100). Manual analysis for AF had a sensitivity of 100% (CI: 95.3-100) and a specificity of 97.5% (CI: 93.0-99.5). Automatic analysis for ATA showed a sensitivity of 93.5% (CI: 86.3-97.6) and a specificity of 92.6% (CI: 85.9-96.7). Automatic analysis for AF showed a sensitivity of 97.4% (CI: 91.0-99.7) and a specificity of 86.1% (CI: 78.6-91.7).

CONCLUSION

CHM has a very high accuracy for ATA and AF in manual analysis and a high accuracy for ATA and AF in automatic analysis, making the device suitable for screening.

Circulating exosome-derived miR-122-5p is a novel biomarker for prediction of postoperative atrial fibrillation

Postoperative atrial fibrillation (POAF) is a frequent complication associated with increased periprocedural mortality and morbidity after cardiac surgery. Our study aimed to identify the difference in exosomal miRNA and further explore its role in the diagnosis of POAF. First, the differentially expressed miRNAs (DEMs) were obtained by high-throughput RNA sequencing. Second, the DEMs target genes were put into gene ontology (GO) and KEGG pathway analysis. Third, real-time quantification PCR (RT-qPCR) was used to verify the DEMs. Finally, we revealed 23 DEMs in POAF patients. Furthermore, analysis of gene function revealed that DEMs may affect atrial structure through many signaling pathways. We also found that miR-122-5p was up-regulated in POAF patients, but there are no significant changes in miR-191-5p, miR-181a-5p, miR-155-5p and miR-151a-5p. Our study revealed that exosomal miRNAs exert enormous potential in evaluating the severity or prognostic of POAF.

Feasible approaches and implementation challenges to atrial fibrillation screening: a qualitative study of stakeholder views in 11 European countries

OBJECTIVES

Atrial fibrillation (AF) screening may increase early detection and reduce complications of AF. European, Australian and World Heart Federation guidelines recommend opportunistic screening, despite a current lack of clear evidence supporting a net benefit for systematic screening. Where screening is implemented, the most appropriate approaches are unknown. We explored the views of European stakeholders about opportunities and challenges of implementing four AF screening scenarios.

DESIGN

Telephone-based semi-structured interviews with results reported using Consolidated criteria for Reporting Qualitative research guidelines. Data were thematically analysed using the framework approach.

SETTING

AF screening stakeholders in 11 European countries.

PARTICIPANTS

Healthcare professionals and regulators (n=24) potentially involved in AF screening implementation.

INTERVENTION

Four AF screening scenarios: single time point opportunistic, opportunistic prolonged, systematic single time point/prolonged and patient-led screening.

PRIMARY OUTCOME MEASURES

Stakeholder views about the challenges and feasibility of implementing the screening scenarios in the respective national/regional healthcare system.

RESULTS

Three themes developed. (1) Current screening approaches: there are no national AF screening programmes, with most AF detected in symptomatic patients. Patient-led screening exists via personal devices, creating screening inequity. (2) Feasibility of screening: single time point opportunistic screening in primary care using single-lead ECG devices was considered the most feasible. Software algorithms may aid identification of suitable patients and telehealth services have potential to support diagnosis. (3) Implementation requirements: sufficient evidence of benefit is required. National screening processes are required due to different payment mechanisms and health service regulations. Concerns about data security, and inclusivity for those without primary care access or personal devices must be addressed.

CONCLUSIONS

There is an overall awareness of AF screening. Opportunistic screening appears the most feasible across Europe. Challenges are health inequalities, identification of best target groups for screening, streamlined processes, the need for evidence of benefit and a tailored approach adapted to national realities.

Continuous mHealth Patch Monitoring for the Algorithm-Based Detection of Atrial Fibrillation: Feasibility and Diagnostic Accuracy Study

Background

The detection of atrial fibrillation (AF) is a major clinical challenge as AF is often paroxysmal and asymptomatic. Novel mobile health (mHealth) technologies could provide a cost-effective and reliable solution for AF screening. However, many of these techniques have not been clinically validated.

Objective

The purpose of this study is to evaluate the feasibility and reliability of artificial intelligence (AI) arrhythmia analysis for AF detection with an mHealth patch device designed for personal well-being.

Methods

Patients (N=178) with an AF (n=79, 44%) or sinus rhythm (n=99, 56%) were recruited from the emergency care department. A single-lead, 24-hour, electrocardiogram-based heart rate variability (HRV) measurement was recorded with the mHealth patch device and analyzed with a novel AI arrhythmia analysis software. Simultaneously registered 3-lead electrocardiograms (Holter) served as the gold standard for the final rhythm diagnostics.

Results

Of the HRV data produced by the single-lead mHealth patch, 81.5% (3099/3802 hours) were interpretable, and the subject-based median for interpretable HRV data was 99% (25th percentile=77% and 75th percentile=100%). The AI arrhythmia detection algorithm detected AF correctly in all patients in the AF group and suggested the presence of AF in 5 patients in the control group, resulting in a subject-based AF detection accuracy of 97.2%, a sensitivity of 100%, and a specificity of 94.9%. The time-based AF detection accuracy, sensitivity, and specificity of the AI arrhythmia detection algorithm were 98.7%, 99.6%, and 98.0%, respectively.

Conclusions

The 24-hour HRV monitoring by the mHealth patch device enabled accurate automatic AF detection. Thus, the wearable mHealth patch device with AI arrhythmia analysis is a novel method for AF screening.

Trial Registration

ClinicalTrials.gov NCT03507335; https://clinicaltrials.gov/ct2/show/NCT03507335

End-to-end sensor fusion and classification of atrial fibrillation using deep neural networks and smartphone mechanocardiography

OBJECTIVE

The purpose of this research is to develop a new deep learning framework for detecting atrial fibrillation (AFib), one of the most common heart arrhythmias, by analyzing the heart's mechanical functioning as reflected in seismocardiography (SCG) and gyrocardiography (GCG) signals. Jointly, SCG and GCG constitute the concept of mechanocardiography (MCG), a method used to measure precordial vibrations with the built-in inertial sensors of smartphones.

APPROACH

We present a modified deep residual neural network model for the classification of sinus rhythm (SR), AFib, and Noise categories from tri-axial SCG and GCG data derived from smartphones. In the model presented, pre-processing including automated early sensor fusion and spatial feature extraction are carried out using attention-based convolutional and residual blocks. Additionally, we use bidirectional long short-term memory layers on top of fully-connected layers to extract both spatial and spatiotemporal features of the multidimensional SCG and GCG signals. The dataset consisted of 728 short measurements recorded from 300 patients. Further, the measurements were divided into disjoint training, validation, and test sets, respectively, of 481 measurements, 140 measurements, and 107 measurements. Prior to ingestion by the model, measurements were split into 10-second segments with 75 percent overlap, pre-processed, and augmented.

MAIN RESULTS

On the unseen test set, the model delivered average micro- and macro-F1-score of 0.88 (0.87-0.89; 95% CI) and 0.83 (0.83-0.84; 95% CI) for the segment-wise classification as well as 0.95 (0.94-0.96; 95% CI) and 0.95 (0.94-0.96; 95% CI) for the measurement-wise classification, respectively.

SIGNIFICANCE

Our method not only can effectively fuse SCG and GCG signals but also can identify heart rhythms and abnormalities in the MCG signals with remarkable accuracy.

Clinical Implications of Atrial Fibrillation Detection Using Wearable Devices in Patients With Cryptogenic Stroke (CANDLE-AF) Trial: Design and Rationale

Background

Although many electrocardiography wearable devices have been released recently for the detection of atrial fibrillation (AF), there are few studies reporting prospective data for wearable devices compared to the strategy of the existing guidelines in the detection of atrial fibrillation (AF) after cryptogenic stroke. A tiny single-patch monitor is more convenient than a conventional Holter monitor recording device and, therefore, longer duration of monitoring may be acceptable.

Methods and Design

The CANDLE-AF study is a multicenter, prospective, randomized controlled trial. Patients with transient ischemic attack or ischemic stroke without any history of AF will be enrolled. The superiority of the 72-h single-patch monitor to standard strategy and non-inferiority of the 72-h single-patch monitor to an event-recorder-type device will be investigated. Single-patch monitor arm will repeat monitoring at 1, 3, 6, and 12 months, event-recorder-type arm will repeat monitoring twice daily for 12 months. The enrollment goal is a total of 600 patients, and the primary outcome is the detection of AF which continues at least 30 s during study period. The secondary outcome is the rate of changes from antiplatelet to anticoagulant and major adverse cardiac and cerebrovascular events within 1 year.

Conclusions

The results of CANDLE-AF will clarify the role of a single-lead patch ECG for the early detection of AF in patients with acute ischemic stroke. In addition, the secondary outcome will be analyzed to determine whether more sensitive AF detection can affect the prognosis and if further device development is meaningful. (cris.nih.go.kr KCT0005592).

Atrial Fibrillation Population Screening

Atrial fibrillation (AF) is associated with adverse outcomes. Screening may lead to earlier recognition and treatment of asymptomatic AF. However, most evidence regarding AF applies to clinical AF, with symptoms or electrocardiographic diagnosis. Whether this evidence can be translated toward subclinical AF, without symptoms and detected by novel, more continuous screening devices is uncertain. The diagnostic yield of screening is determined by the screening population, tool, duration and frequency. Longer and more frequent screening in a higher risk population leads to more effective screening. New devices based on photoplethysmography and single-lead electrocardiography increase convenience and the likelihood of cost-effectiveness.

The Role of Exosomes and Their Cargos in the Mechanism, Diagnosis, and Treatment of Atrial Fibrillation

Atrial fibrillation (AF) is the most common persistent arrhythmia, but the mechanism of AF has not been fully elucidated, and existing approaches to diagnosis and treatment face limitations. Recently, exosomes have attracted considerable interest in AF research due to their high stability, specificity and cell-targeting ability. The aim of this review is to summarize recent literature, analyze the advantages and limitations of exosomes, and to provide new ideas for their use in understanding the mechanism and improving the diagnosis and treatment of AF.

2021 ISHNE/HRS/EHRA/APHRS collaborative statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals: From the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society

This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society describes the current status of mobile health ("mHealth") technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self-management are novel aspects of mHealth. The promises of predictive analytics but also operational challenges in embedding mHealth into routine clinical care are explored.

Large-scale screening studies for atrial fibrillation - is it worth the effort?

Atrial fibrillation (AF) is a common disease with increasing prevalence, approximately 3.2% in the adult population. In addition, about one third of AF cases are considered asymptomatic. Due to increased longevity, increased detection and increased prevalence of risk factors, the prevalence of AF is expected to at least double by the year 2060. Patients with AF have an increased risk for ischaemic stroke, heart failure, death and cognitive decline. Treatment with oral anticoagulation reduces the risk of ischaemic stroke and mortality, and the effect on cognitive decline is being studied. Based on the increasing prevalence of AF, its often asymptomatic and paroxysmal presentation and the efficacy of oral anticoagulation treatment, screening for AF has been proposed. AF seems to fulfil most of the Wilson-Jungner criteria for screening issued by the World Health Organization, but some knowledge gaps remain, gaps that will be addressed by several ongoing studies. The knowledge gaps in AF screening consist of the magnitude of the net benefit or net harm inflicted by AF screening because the oral anticoagulation treatment will also increase the risk of bleeding, and the psychological effects of AF screening are not very well studied. So far, the AF screening recommendations issued by the European Society of Cardiology have had limited impact on national and regional AF screening activities. Several large-scale AF screening studies will report results on hard endpoints within the next few years, and these results will hopefully manifest AF as a cardiovascular disease which we need to pay more attention to.

Performance of pulse palpation compared to one-lead ECG in atrial fibrillation screening

Background

The 2020 European Society of Cardiology atrial fibrillation guidelines recommend opportunistic screening for atrial fibrillation by pulse taking or ECG rhythm strip in those aged over 65 years.

Hypothesis

We aimed to compare the diagnostic accuracy of pulse palpation to ECG rhythm strip when screening for atrial fibrillation. A secondary aim was to investigate whether participants with palpitations were more likely to be diagnosed with new atrial fibrillation.

Methods

The study population were 75/76 year old individuals that participated in the STROKESTOP II study, a Swedish screening study for atrial fibrillation. Pulse palpation of the radial pulse for 30 sec was performed by healthcare professionals and recorded as regular or irregular. Thereafter a 30‐sec single‐lead ECG was registered. Patients were asked also if they had a history of palpitations.

Results

Of the 6159 participants included in the study, 461 (7.5%) had irregular pulse. Twenty‐two (4.8%) of those with irregular pulse were diagnosed with atrial fibrillation on single‐lead ECG rhythm strip. Among those with regular pulse, 6 (0.1%) cases of new atrial fibrillation were found. The sensitivity of the pulse palpation test was 78.6% and positive predictive value 4.8%. The proportion of newly diagnosed atrial fibrillation was not different between those with and without history of palpitations.

Conclusion

Pulse palpation was inferior to single‐lead ECG when screening for atrial fibrillation. We therefore advocate the use of single‐lead ECG rather than pulse palpation when screening for atrial fibrillation. Palpitations did not predict atrial fibrillation.

2021 ISHNE/ HRS/ EHRA/ APHRS collaborative statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals: From the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society

This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology/ Heart Rhythm Society/ European Heart Rhythm Association/ Asia Pacific Heart Rhythm Society describes the current status of mobile health ("mHealth") technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self-management are novel aspects of mHealth. The promises of predictive analytics but also operational challenges in embedding mHealth into routine clinical care are explored.

2021 ISHNE/HRS/EHRA/APHRS Expert Collaborative Statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals: From the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia-Pacific Heart Rhythm Society

This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia-Pacific Heart Rhythm Society describes the current status of mobile health technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self-management are novel aspects of mobile health. The promises of predictive analytics but also operational challenges in embedding mobile health into routine clinical care are explored.

2021 ISHNE/HRS/EHRA/APHRS Collaborative Statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals: From the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society

This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society describes the current status of mobile health ("mHealth") technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self-management are novel aspects of mHealth. The promises of predictive analytics but also operational challenges in embedding mHealth into routine clinical care are explored.

2021 ISHNE / HRS / EHRA / APHRS Collaborative Statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals: From the International Society for Holter and Noninvasive Electrocardiology / Heart Rhythm Society / European Heart Rhythm Association / Asia Pacific Heart Rhythm Society

This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology / Heart Rhythm Society / European Heart Rhythm Association / Asia Pacific Heart Rhythm Society describes the current status of mobile health ("mHealth") technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self-management are novel aspects of mHealth. The promises of predictive analytics but also operational challenges in embedding mHealth into routine clinical care are explored.

Risk of Atrial Fibrillation, Ischemic Stroke and Cognitive Impairment: Study of a Population Cohort ≥65 Years of Age

PURPOSE

To evaluate a model for calculating the risk of AF and its relationship with the incidence of ischemic stroke and prevalence of cognitive decline.

MATERIALS AND METHODS

It was a multicenter, observational, retrospective, community-based study of a cohort of general population ≥6ct 35 years, between 01/01/2016 and 31/12/2018. Setting: Primary Care. Participants: 46,706 people ≥65 years with an active medical history in any of the primary care teams of the territory, information accessible through shared history and without previous known AF. Interventions: The model to stratify the risk of AF (PI) has been previously published and included the variables sex, age, mean heart rate, mean weight and CHA2DS2VASc score. Main measurements: For each risk group, the incidence density/1000 person/years of AF and stroke, number of cases required to detect a new AF, the prevalence of cognitive decline, Kendall correlation, and ROC curve were calculated.

RESULTS

The prognostic index was obtained in 37,731 cases (80.8%) from lowest (Q1) to highest risk (Q4). A total of 1244 new AFs and 234 stroke episodes were diagnosed. Q3-4 included 53.8% of all AF and 69.5% of strokes in men; 84.2% of all AF and 85.4% of strokes in women; and 77.4% of cases of cognitive impairment. There was a significant linear correlation between the risk-AF score and the Rankin score (p < 0.001), the Pfeiffer score (p < 0.001), but not NIHSS score (p 0.150). The overall NNS was 1/19.

CONCLUSION

Risk stratification allows identifying high-risk individuals in whom to intervene on modifiable risk factors, prioritizing the diagnosis of AF and investigating cognitive status.

Effectiveness of a single lead AliveCor electrocardiogram application for the screening of atrial fibrillation: A systematic review

BACKGROUND

Increasing prevalence of atrial fibrillation has a significant impact on health, society, and healthcare resource utilization, due to increased morbidity, mortality, risk of stroke, and reduction in quality of life. Early diagnosis allows for treatment initiation, a reduction in complications and associated costs, and so innovation to improve screening and enable easy access are needed Developments in digital technology have significantly contributed to the availability of screening tools. The single-lead electrocardiogram AliveCor (Mountainview, CA) device offers the opportunity to provide heart rhythm screening and has been used extensively in clinical practice and research studies.

METHODS

This review investigates the feasibility, validity, and utility of the AliveCor device as a tool for atrial fibrillation detection in clinical practice and in wider research. Databases searched included PUBMED, CINAHL, MEDLINE, and World of Science, plus grey literature search. Search terms related to atrial fibrillation, screening, and AliveCor with adults >18 years. Feasibility metrics were applied including process, resource, management, and scientific outcomes. Studies not written in the English language were excluded. Validity of AliveCor was explored by extracting sensitivity and specificity data from eligible studies and overall effectiveness analyzed by incorporating the above, with wider issues surrounding screening approaches, cost effectiveness and appropriateness of AliveCor as a screening tool.

RESULTS

The AliveCor device screening was reviewed in 11 studies matching inclusion criteria. Atrial fibrillation detection rates ranged from 0.8% to 36% and this largely correlated to the study population, where wider age inclusion and mass/population screening represented lower atrial fibrillation detection. Recruitment from higher-risk groups (older age, targeted localities, chronic disease) identified higher numbers with atrial fibrillation. Feasibility metrics demonstrated AliveCor as an effective tool of choice in terms of process, resources, and management. Duration of screening time had an impact on rates of atrial fibrillation detection. There was however significant heterogeneity between studies reviewed.

CONCLUSION

The AliveCor device offers a convenient, valid, and feasible means of monitoring for atrial fibrillation. Further analysis of electrocardiograms produced by AliveCor may be necessary in some circumstances. The AliveCor electrocardiogram device can be successfully implemented into both opportunistic and systematic screening strategies for atrial fibrillation.

Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: A cross-sectional feasibility study

BACKGROUND

Growing prevalence of atrial fibrillation (AF) in the ageing population and its associated life-changing health and resource implications have led to a need to improve its early detection. Primary care is an ideal place to screen for AF; however, this is limited by shortages in general practitioner (GP) resources. Recent increases in the number of clinical pharmacists within primary care makes them ideally placed to conduct AF screening. This study aimed to determine the feasibility of GP practice-based clinical pharmacists to screen the over-65s for AF, using digital technology and pulse palpation during the influenza vaccination season.

METHODS AND FINDINGS

Screening was conducted over two influenza vaccination seasons, 2017-2018 and 2018-2019, in four GP practices in Kent, United Kingdom. Pharmacists were trained by a cardiologist to pulse palpate, record, and interpret a single-lead ECG (SLECG). Eligible persons aged ≥65 years (y) attending an influenza vaccination clinic were offered a free heart rhythm check. Six hundred four participants were screened (median age 73 y, 42.7% male). Total prevalence of AF was 4.3%. All participants with AF qualified for anticoagulation and were more likely to be male (57.7%); be older; have an increased body mass index (BMI); and have a CHA2DS2-VASc (Congestive heart failure, Hypertension, Age ≥ 75 years, Diabetes, previous Stroke, Vascular disease, Age 65-74 years, Sex category) score ≥ 3. The sensitivity and specificity of clinical pharmacists diagnosing AF using pulse palpation was 76.9% (95% confidence interval [CI] 56.4-91.0) and 92.2% (95% CI 89.7-94.3), respectively. This rose to 88.5% (95% CI 69.9-97.6) and 97.2% (95% CI 95.5-98.4) with an SLECG. At follow-up, four participants (0.7%) were diagnosed with new AF and three (0.5%) were initiated on anticoagulation. Screening with SLECG also helped identify new non-AF cardiovascular diagnoses, such as left ventricular hypertrophy, in 28 participants (4.6%). The screening strategy was cost-effective in 71.8% and 64.3% of the estimates for SLECG or pulse palpation, respectively. Feedback from participants (422/604) was generally positive. Key limitations of the study were that the intervention did not reach individuals who did not attend the practice for an influenza vaccination and there was a limited representation of UK ethnic minority groups in the study cohort.

CONCLUSIONS

This study demonstrates that AF screening performed by GP practice-based pharmacists was feasible, economically viable, and positively endorsed by participants. Furthermore, diagnosis of AF by the clinical pharmacist using an SLECG was more sensitive and more specific than the use of pulse palpation alone. Future research should explore the key barriers preventing the adoption of national screening programmes.

Time trends and patient selection in the use of continuous electrocardiography for detecting atrial fibrillation after stroke: a nationwide cohort study

BACKGROUND AND PURPOSE

Clinical use of continuous electrocardiography (cECG) for detecting atrial fibrillation (AF) after stroke is unclear. In a Danish nationwide cohort, we described post-stroke time trends in outpatient cECG usage and AF incidence and characterized factors associated with cECG use.

METHODS

Patients without AF discharged after their first ischaemic stroke between 2010 and 2016 were identified from Danish nationwide registries. cECG included Holter or event recording within 120 days from discharge. Cumulative incidence analysis and multivariable adjusted logistic regression were used to assess time trends and factors associated with cECG usage and AF.

RESULTS

The study population comprised 39 641 patients. Cumulative use of cECG increased threefold from 3.3% [95% confidence intervals (CI), 2.8-3.8] in 2010 to 10.5% (95% CI, 9.7-11.3) in 2016. Correspondingly, cumulative incidence of post-stroke AF increased from 1.9% (95% CI, 1.5-2.3) to 2.8% (95% CI, 2.4-3.2). Of all cECG-evaluated patients, 6.3% received an AF diagnosis versus 2.2% of the unevaluated. Receiving cECG was associated with increased odds of AF (odds ratio, 3.4; 95% CI, 2.8-4.0). Lower age, milder strokes and less comorbidity were associated with increased odds of receiving cECG. In contrast, risk factors for AF were increasing age and more comorbidity.

CONCLUSIONS

Post-stroke outpatient cECG use and AF incidence have increased over time, but screening rates were low. cECG use was associated with tripled odds of detecting AF. There was a disparity between factors associated with cECG use and risk factors of AF. This raise questions as to the appropriateness of the current clinical approach to post-stoke AF detection.

Incidence and Risk Assessment for Atrial Fibrillation at 5 Years: Hypertensive Diabetic Retrospective Cohort

(1) Background: The link between diabetes and hypertension is mutual and reciprocal, increasing the risks for the development of atrial fibrillation (AF). The main objective was to develop a prediction model for AF in a population with both diabetes and hypertension at five years of follow-up. (2) Methods: A multicenter and community-based cohort study was undertaken of 8237 hypertensive diabetic patients without AF between 1 January 2103 and 31 December 2017. Multivariate Cox proportional-hazards regression models were used to identify predictors AF and to stratify risk scores by quartiles. (3) Results: AF incidence was 10.5/1000 people/years (95% confidence interval (CI) 9.5-11.5), higher in men. The independent prognostic factors identified: age (hazard ratio (HR) 1.07 95% CI 1.05-1.09, p < 0.001), weight (HR 1.03 95% CI 1.02-1.04, p < 0.001), CHA2DS2VASc score (HR 1.57 95% CI 1.16-2.13, p = 0.003) and female gender (HR 0.55 95% CI 0.37-0.82, p = 0.004). Q4 (highest-risk group for AF) had the highest AF incidence, stroke and mortality, and the smallest number needed to screen to detect one case of AF. (4) Conclusions: Risk-based screening for AF should be used in high cardiovascular risk patients as the hypertensive diabetics, for treatment of modifiable cardiovascular risk, and monitoring AF detection.

Intermittent vs continuous electrocardiogram event recording for detection of atrial fibrillation-Compliance and ease of use in an ambulatory elderly population

BACKGROUND

There are many atrial fibrillation (AF) screening devices available. Validation studies have mainly been performed in optimal settings in the young population.

HYPOTHESIS

We aim to compare the yield of AF detection, compliance, and patient-based experience in an ambulatory elderly population by using intermittent electrocardiogram (ECG) recordings and continuous event recording simultaneously.

METHODS

The study participants were part of the STROKESTOP II study, a Swedish screening study for AF. All participants were 75/76 years of age, were clinically free of AF, and had N-terminal pro b-type natriuretic peptides levels ≥125 ng/L. AF screening was performed in parallel during a 2-week period, using a continuous event recording device (R-test 4; Novacor) and 30-second intermittent recordings using a handheld ECG device (Zenicor II) four times daily. Participants were asked to fill out a questionnaire with regard to compliance and ease of use of the devices.

RESULTS

During continuous event recording, 6% (n = 15/269) were diagnosed with AF and intermittent ECG detected AF in 2% (n = 5/269) of the participants (P = .002). No new cases of AF were detected using intermittent ECG monitoring only, but some episodes were detected in parallel for patients. On a graded ordinal scale of 1 to 5, with 1 reflecting "very easy to use", continuous monitoring was graded 2 (interquartile range [IQR]: 1-3) compared to intermittent 1 (IQR: 1-1) (P < .001).

CONCLUSION

Continuous event recording detected three times more AF compared to intermittent ECG in an elderly ambulatory population. Compliance and user-friendliness were rated higher for the intermittent ECG device.

Asystole in an older patient with recurrent falls. Case report

Introduction: Recurrent falls are a usual problema in older patients. It is therefore important to learn how to differentiate a pathological or syncopal episode from a simple stumbling fall, especially in patients who have limitations for communicating clearly and are poorly understood, in general terms, during the medical consultation. Implantable loop recorders (ILR) have been used as an investigation tool in selected cases of recurrent falls in older patients. Consequently, this case report aims to describe its usefulness in this type of patients.Case presentation: An 87-year-old female patient, hypertensive, with a history of recent stroke and frequent falls —referred to as stumbling—, received an implantable loop recorder due to atrial fibrillation. During one follow-up appointment, a 36-second pause related to a fall was documented, so a bicameral pacemaker was implanted.Conclusions: Evaluating repeated falls in older patients is complex; it must be done in detail to rule out syncopal episodes. Implantable devices to diagnose arrhythmic causes are useful and allow achieving accurate diagnoses and establish specific behaviors aimed at improving the quality of life of patients.

Searching for Atrial Fibrillation Poststroke: A White Paper of the AF-SCREEN International Collaboration

Cardiac thromboembolism attributed to atrial fibrillation (AF) is responsible for up to one-third of ischemic strokes. Stroke may be the first manifestation of previously undetected AF. Given the efficacy of oral anticoagulants in preventing AF-related ischemic strokes, strategies of searching for AF after a stroke using ECG monitoring followed by oral anticoagulation (OAC) treatment have been proposed to prevent recurrent cardioembolic strokes. This white paper by experts from the AF-SCREEN International Collaboration summarizes existing evidence and knowledge gaps on searching for AF after a stroke by using ECG monitoring. New AF can be detected by routine plus intensive ECG monitoring in approximately one-quarter of patients with ischemic stroke. It may be causal, a bystander, or neurogenically induced by the stroke. AF after a stroke is a risk factor for thromboembolism and a strong marker for atrial myopathy. After acute ischemic stroke, patients should undergo 72 hours of electrocardiographic monitoring to detect AF. The diagnosis requires an ECG of sufficient quality for confirmation by a health professional with ECG rhythm expertise. AF detection rate is a function of monitoring duration and quality of analysis, AF episode definition, interval from stroke to monitoring commencement, and patient characteristics including old age, certain ECG alterations, and stroke type. Markers of atrial myopathy (eg, imaging, atrial ectopy, natriuretic peptides) may increase AF yield from monitoring and could be used to guide patient selection for more intensive/prolonged poststroke ECG monitoring. Atrial myopathy without detected AF is not currently sufficient to initiate OAC. The concept of embolic stroke of unknown source is not proven to identify patients who have had a stroke benefitting from empiric OAC treatment. However, some embolic stroke of unknown source subgroups (eg, advanced age, atrial enlargement) might benefit more from non-vitamin K-dependent OAC therapy than aspirin. Fulfilling embolic stroke of unknown source criteria is an indication neither for empiric non-vitamin K-dependent OAC treatment nor for withholding prolonged ECG monitoring for AF. Clinically diagnosed AF after a stroke or a transient ischemic attack is associated with significantly increased risk of recurrent stroke or systemic embolism, in particular, with additional stroke risk factors, and requires OAC rather than antiplatelet therapy. The minimum subclinical AF duration required on ECG monitoring poststroke/transient ischemic attack to recommend OAC therapy is debated.

Diagnostic accuracy of an algorithm for detecting atrial fibrillation in a wrist-type pulse wave monitor

We evaluated the diagnostic value of atrial fibrillation (AF) measured by a wrist-type pulse wave monitor in this case-control study. Six serial pulse wave values (three in the left and three in the right wrist) were measured using a wrist-type monitor in 29 AF patients and 30 subjects with sinus rhythm. We defined "monitor AF in irregular pulse peak (IPP) 15/20/25" as follows: (a) IPP: |interval of pulse peak - the average of the interval of the pulse peak| ≥ the average of the interval of the pulse peak × 15/20/25%; (b) irregular heartbeat (IHB): beats of IPP ≥ total pulse × 20%; and (c) monitor AF: ≥4 IHBs of the six pulse wave measurements. In IPP 15, the sensitivity and specificity were 0.97 and 1.00, respectively. Pulse wave analysis by a wrist-type monitor was shown to have high sensitivity and specificity for the diagnosis of AF.

CHA2DS2-VASc score can guide the screening of atrial fibrillation - cross-sectional study in a geriatric ward

Purpose: Atrial fibrillation (AF) is an increasingly common rhythm disorder and an important risk factor of ischemic stroke, heart failure, hospitalization, and cardiovascular mortality. Its diagnosis, however, is often delayed because of silent character of the arrhythmia. The aim of the study was to identify independent determinants of AF in patients of the geriatric ward, so as to be able to propose a strategy for screening of this arrhythmia. Methods: Cross-sectional cohort study of patients admitted to the department of geriatrics was conducted. The prevalence of AF and its health correlates (including AF recognized risk factors) was assessed. Relative risks were calculated and multivariable logistic regression analysis model was built. The predictive performance was evaluated using receiver-operating characteristic (ROC) curve analysis. Results: There were 416 patients hospitalized in the study period and 98 (23.6%) presented with AF. The independent predictors with top 3 strongest association with AF were congestive heart failure (OR 5.43; 95%CI 3.14-9.39; P<0.001), age of 75+years (OR 4.0; 95% CI 1.43-11.2; P=0.008), and previous history of stroke or transient ischemic attack (OR 2.1; 95% CI 1.06-4.13; P=0.03). ROC analysis showed CHA2DS2-VASc scale significance as a screening tool for AF (ROC-AUC 0.75; 0.7-0.8; P<0.001), with the value of 4 or more as the best cut-off point. Conclusions: Based on CHA2DS2-VASc score the intensity of surveillance for AF at a primary prevention population level could be probably guided, but it requires further research.

Long-term rhythm monitoring with an implantable loop recorder in patients after the first clinical atrial fibrillation episode. Towards an individualized management

Although atrial fibrillation (AF) is an arrhythmia with a variable clinical profile (symptomatic and asymptomatic episodes), the first symptomatic episode leads to its initial diagnosis in most cases. Nowadays, continuous and remote long-term cardiac rhythm monitoring is feasible by the use of implantable loop recorders. The data concerning the AF recurrences and progression after the first electrocardiographic-documented clinical AF episode demonstrates that a high percentage of patients may not suffer any other AF recurrence, or may present a low recurrence rate of the arrhythmia in the future. The AF burden may play a key role in the management of the arrhythmia as far as the decision-making for anticoagulation, rate and/or rhythm control therapy is concerned. There is evidence that a higher AF burden is associated with a higher risk of ischemic stroke. Non-vitamin K antagonists (NOACs) anticoagulants are increasingly used in the management of AF, providing a more predictable effect with rapid onset and offset of their action. The use of these agents in combination with devices that provide a continuous remote rhythm monitoring capability has encouraged anticoagulation strategies based on the AF burden. Data from tailored anticoagulation studies in AF are in favor of the long-term rhythm monitoring, ensuring a patient-centered approach with a better evaluation and more individualized management of AF, especially in patients with intermediate thromboembolic risk and high bleeding risk. Further large randomized trials are needed, not only to evaluate such strategies but also to elucidate the long-term cardiac rhythm monitoring in the AF management.