Digital Health and the Care of the Patient With Arrhythmia

Wearable Technologies and AI at the Far Edge for Chronic Heart Failure Prevention and Management: A Systematic Review and Prospects

Smart wearable devices enable personalized at-home healthcare by unobtrusively collecting patient health data and facilitating the development of intelligent platforms to support patient care and management. The accurate analysis of data obtained from wearable devices is crucial for interpreting and contextualizing health data and facilitating the reliable diagnosis and management of critical and chronic diseases. The combination of edge computing and artificial intelligence has provided real-time, time-critical, and privacy-preserving data analysis solutions. However, based on the envisioned service, evaluating the additive value of edge intelligence to the overall architecture is essential before implementation. This article aims to comprehensively analyze the current state of the art on smart health infrastructures implementing wearable and AI technologies at the far edge to support patients with chronic heart failure (CHF). In particular, we highlight the contribution of edge intelligence in supporting the integration of wearable devices into IoT-aware technology infrastructures that provide services for patient diagnosis and management. We also offer an in-depth analysis of open challenges and provide potential solutions to facilitate the integration of wearable devices with edge AI solutions to provide innovative technological infrastructures and interactive services for patients and doctors.

Reimbursement practices for use of digital devices in atrial fibrillation and other arrhythmias: a European Heart Rhythm Association survey

AIMS

Since digital devices are increasingly used in cardiology for assessing cardiac rhythm and detecting arrhythmias, especially atrial fibrillation (AF), our aim was to evaluate the expectations and opinions of healthcare professionals in Europe on reimbursement policies for the use of digital devices (including wearables) in AF and other arrhythmias.

METHODS AND RESULTS

An anonymous survey was proposed through announcements on the European Heart Rhythm Association website, social media channels, and mail newsletter. Two hundred and seventeen healthcare professionals participated in the survey: 32.7%, reported regular use of digital devices, 45.2% reported that they sometimes use these tools, 18.6% that they do not use but would like to. Only a minority (3.5%) reported a lack of trust in digital devices. The survey highlighted a general propensity to provide medical consultation for suspected AF or other arrhythmias detected by a consumer-initiated use of digital devices, even if time constraints and reimbursement availability emerged as important elements. More than 85% of respondents agreed that reimbursement should be applied for clinical use of digital devices, also in different settings such as post-stroke, post-cardioversion, post-ablation, and in patients with palpitations or syncope. Finally, 73.6% of respondents confirmed a lack of reimbursement fees in their country for physicians' consultations (tracings interpretation) related to digital devices.

CONCLUSIONS

Digital devices, including wearables, are increasingly and widely used for assessing cardiac rhythm and detecting AF, but a definition of reimbursement policies for physicians' consultations is needed.

Assessment of Apple Watch Series 6 pulse oximetry and electrocardiograms in a pediatric population

BACKGROUND

Recent technologic advances have resulted in increased development and utilization of direct-to-consumer cardiac wearable devices with various functionality. This study aimed to assess Apple Watch Series 6 (AW6) pulse oximetry and electrocardiography (ECG) in a cohort of pediatric patients.

METHODS

This single-center, prospective study enrolled pediatric patients ≥ 3kg and having an ECG and/or pulse oximetry (SpO2) as part of their planned evaluation. Exclusion criteria: 1) non-English speaking patients and 2) patients in state custody. Simultaneous tracings were obtained for SpO2 and ECG with concurrent standard pulse oximeter and 12-lead ECG. AW6 automated rhythm interpretations were compared to physician over-read and categorized as accurate, accurate with missed findings, inconclusive (automated interpretation: "inconclusive"), or inaccurate.

RESULTS

A total of 84 patients were enrolled over a 5-week period. 68 patients (81%) were placed into the SpO2 and ECG arm, with 16 patients (19%) placed into the SpO2 only arm. Pulse oximetry data was successfully collected in 71/84 (85%) patients and ECG data in 61/68 (90%). ΔSpO2 between modalities was 2.0±2.6% (r = 0.76). ΔRR was 43±44msec (r = 0.96), ΔPR 19±23msec (r = 0.79), ΔQRS 12±13msec (r = 0.78), and ΔQT 20±19msec (r = 0.9). The AW6 automated rhythm analysis yielded a 75% specificity and found: 1) 40/61 (65.6%) "accurate", 2) 6/61 (9.8%) "accurate with missed findings", 3) 14/61 (23%) "inconclusive", and 4) 1/61 (1.6%) incorrect.

CONCLUSION

The AW6 can accurately measure oxygen saturation when compared to hospital pulse oximeters in pediatric patients and provide good quality single lead ECGs that allow for accurate measurement of RR, PR, QRS, and QT intervals with manual interpretation. The AW6-automated rhythm interpretation algorithm has limitations for smaller pediatric patients and patients with abnormal ECGs.

At the Crossroads! Time to Start Taking Smartwatches Seriously

Patients have demonstrated a growing interest in using wearable devices, particularly smartwatches, to monitor and improve their cardiovascular wellness. Wearable devices are now one of the fastest growing sectors of the technology industry, and big technology companies, such as Apple (Apple Watch), Google (Fitbit), and Samsung (Galaxy), have engineered smartwatch features that are capable of monitoring biometrics, such as heart rhythm, heart rate, blood pressure, and sleep. These devices hold significant potential to impact the relation between cardiologists and their patients, but concerns exist about device trustworthiness to detect pertinent data points and deliver alerts with accuracy. How these devices' features will interplay with cardiologists' workflow has also yet to be defined and requires thoughtful implementation. Furthermore, the success of smartwatches as medical devices is dependent on patients' continuous use. Keeping patients engaged with their devices through leveraging behavioral factors may lead to achieving and optimizing healthcare goals. Socioeconomic disparities and privacy concerns are other barriers in the path forward. Cardiovascular professional societies are uniquely poised to help impact how these devices are eventually accepted and used in everyday practice. In conclusion, engagement and collaboration with big tech companies will help guide how this market grows.

Implementation and Early Experience of a Pediatric Electrophysiology Telehealth Program

Background

Telehealth (TH) visits have been growing with exponential increased utilization during the COVID-19 pandemic. The aim of this manuscript is to describe the implementation and early experience of a pediatric electrophysiology (EP) TH program implemented during the pandemic, assessing patient satisfaction, patient equity and inclusion (measured by geographical outreach), and sustainability.

Methods

A retrospective chart review study was performed and data were collected from the medical record, including demographic, testing, and billing data from scheduled TH encounters between March and August 2020 of a single pediatric EP group in the Midwest. Patients were called to complete satisfaction surveys.

Results

Patients with diverse pathologies were seen in TH, with supraventricular/atrial tachycardias (n = 41, 35%) and inherited arrhythmia syndromes (n = 23, 20%) being most common. The mean distance from clinic was 95 miles (range 2.8–320 miles), with 43% of patients living more than 100 miles away from clinic. A total of 172 tests were performed previsit (n = 102, 59%), during the visit (n = 17, 10%), or postvisit (n = 53, 31%), including 15 EP studies. Time-based Current Procedural Terminology codes were predominantly used for billing purposes (n = 92, 78%). There was generation of work relative value units (wRVU) for visits (220.5 wRVU) and testing (325.1 wRVU). Survey data demonstrated that 98% of patients were satisfied with their telehealth appointment and 99% had a clear understanding of their diagnosis.

Conclusion

Pediatric EP TH clinics can provide care for a geographically and pathologically heterogeneous group of patients who had positive attitudes toward TH. Our study shows significant downstream testing and subsequent wRVU generation, suggesting financial sustainability.

Digital Technology Application for Improved Responses to Health Care Challenges: Lessons Learned From COVID-19

While COVID-19 is still ongoing and associated with more than 5 million deaths, the scope and speed of advances over the past year in terms of scientific discovery, data dissemination, and technology have been staggering. It is not a matter of “if” but “when” we will face the next pandemic, and how we leverage technology and data management effectively to create flexible ecosystems that facilitate collaboration, equitable care, and innovation will determine its severity and scale. The aim of this review is to address emerging challenges that came to light during the pandemic in health care and innovations that enabled us to adapt and continue to care for patients. The pandemic highlighted the need for seismic shifts in care paradigms and technology with considerations related to the digital divide and health literacy for digital health interventions to reach full potential and improve health outcomes. We discuss advances in telemedicine, remote patient monitoring, and emerging wearable technologies. Despite the promise of digital health, we emphasise the importance of addressing its limitations, including interpretation challenges, accuracy of findings, and artificial intelligence–driven algorithms. We summarise the most recent recommendation of the Virtual Care Task Force to scaling virtual medical services in Canada. Finally, we propose a model for optimal implementation of health digital innovations with 5 tenets including data management, data security, digital biomarkers, useful artificial intelligence, and clinical integration.

HRS White Paper on Clinical Utilization of Digital Health Technology

This collaborative statement from the Digital Health Committee of the Heart Rhythm Society provides everyday clinical scenarios in which wearables may be utilized by patients for cardiovascular health and arrhythmia management. We describe herein the spectrum of wearables that are commercially available for patients, and their benefits, shortcomings and areas for technological improvement. Although wearables for rhythm diagnosis and management have not been examined in large randomized clinical trials, undoubtedly the usage of wearables has quickly escalated in clinical practice. This document is the first of a planned series in which we will update information on wearables as they are revised and released to consumers.

The Role of Artificial Intelligence in Arrhythmia Monitoring

Arrhythmia management has been revolutionized by the ability to monitor the cardiac rhythm in a patient's home environment in real-time using high-fidelity prescription-grade and commercially available wearable electrodes. The vast amount of digitally acquired electrophysiological signals has generated the need for scalable and efficient data processing with actionable output that can be provided directly to clinicians and patients. In this setting, artificial intelligence applications are increasingly important in arrhythmia monitoring, ranging from conventional algorithmic analysis for rhythm determination to more complex deep machine learning methods that have led to the realization of fully automated humanlike rhythm determination in real-time.

Use of Smartphones and Wearables for Arrhythmia Monitoring

Smartphones and other wearable electronic devices increasingly are used for ambulatory cardiac rhythm assessment. These consumer technologies have been evaluated in several studies for diagnosis and management of atrial fibrillation. Diverse mobile health applications, including management of other arrhythmias and medical conditions, are expanding alongside advances in technology. Electronic devices owned by millions of consumers have the potential to alter health care delivery as well as research design and implementation. This review provides an up-to-date discussion of the available mobile health technologies, specific applications and limitations for arrhythmia evaluation, their impact on health care systems, and key areas for future investigation.

Optimizing indices of AF susceptibility and burden to evaluate AF severity, risk and outcomes

Atrial fibrillation (AF) has heterogeneous patterns of presentation concerning symptoms, duration of episodes, AF burden, and the tendency to progress towards the terminal step of permanent AF. AF is associated with a risk of stroke/thromboembolism traditionally considered dependent on patient-level risk factors rather than AF type, AF burden, or other characterizations. However, the time spent in AF appears related to an incremental risk of stroke, as suggested by the higher risk of stroke in patients with clinical AF vs. subclinical episodes and in patients with non-paroxysmal AF vs. paroxysmal AF. In patients with device-detected atrial tachyarrhythmias, AF burden is a dynamic process with potential transitions from a lower to a higher maximum daily arrhythmia burden, thus justifying monitoring its temporal evolution. In clinical terms, the appearance of the first episode of AF, the characterization of the arrhythmia in a specific AF type, the progression of AF, and the response to rhythm control therapies, as well as the clinical outcomes, are all conditioned by underlying heart disease, risk factors, and comorbidities. Improved understanding is needed on how to monitor and modulate the effect of factors that condition AF susceptibility and modulate AF-associated outcomes. The increasing use of wearables and apps in practice and clinical research may be useful to predict and quantify AF burden and assess AF susceptibility at the individual patient level. This may help us reveal why AF stops and starts again, or why AF episodes, or burden, cluster. Additionally, whether the distribution of burden is associated with variations in the propensity to thrombosis or other clinical adverse events. Combining the improved methods for data analysis, clinical and translational science could be the basis for the early identification of the subset of patients at risk of progressing to a longer duration/higher burden of AF and the associated adverse outcomes.