HRS White Paper on Clinical Utilization of Digital Health Technology

Are Wearable ECG Devices Ready for Hospital at Home Application?

The increasing focus on improving care for high-cost patients has highlighted the potential of Hospital at Home (HaH) and remote patient monitoring (RPM) programs to optimize patient outcomes while reducing healthcare costs. This paper examines the role of wearable devices with electrocardiogram (ECG) capabilities for continuous cardiac monitoring, a crucial aspect for the timely detection and management of various cardiac conditions. The functionality of current wearable technology is scrutinized to determine its effectiveness in meeting clinical needs, employing a proposed ABCD guide (accuracy, benefit, compatibility, and data governance) for evaluation. While smartwatches show promise in detecting arrhythmias like atrial fibrillation, their broader diagnostic capabilities, including the potential for monitoring corrected QT (QTc) intervals during pharmacological interventions and approximating multi-lead ECG information for improved myocardial infarction detection, are also explored. Recent advancements in machine learning and deep learning for cardiac health monitoring are highlighted, alongside persistent challenges, particularly concerning signal quality and the need for further validation for widespread adoption in older adults and Hospital at Home settings. Ongoing improvements are necessary to overcome current limitations and fully realize the potential of wearable ECG technology in providing optimal care for high-risk patients.

Cardiac Contributions to Brain Health: A Scientific Statement From the American Heart Association

The burden of neurologic diseases, including stroke and dementia, is expected to grow substantially in the coming decades. Thus, achieving optimal brain health has been identified as a public health priority and a major challenge. Cardiovascular diseases are the leading cause of death and disability in the United States and around the world. Emerging evidence shows that the heart and the brain, once considered unrelated organ systems, are interdependent and linked through shared risk factors. More recently, studies designed to unravel the intricate pathogenic mechanisms underpinning this association show that people with various cardiac conditions may have covert brain microstructural changes and cognitive impairment. These findings have given rise to the idea that by addressing cardiovascular health earlier in life, it may be possible to reduce the risk of stroke and deter the onset or progression of cognitive impairment later in life. Previous scientific statements have addressed the association between cardiac diseases and stroke. This scientific statement discusses the pathogenic mechanisms that link 3 prevalent cardiac diseases of adults (heart failure, atrial fibrillation, and coronary heart disease) to cognitive impairment.

Cardiac Arrhythmias and Autonomic Dysfunction Associated With COVID-19: A Scientific Statement From the American Heart Association

Cardiac arrhythmias are commonly noted in patients during infections with and recovery from COVID-19. Arrhythmic manifestations span the spectrum of innocuous and benign to life-threatening and deadly. Various pathophysiological mechanisms have been proposed. Debate continues on the impact of incident and exacerbated arrhythmias on the acute and chronic (recovery) phase of the illness. COVID-19 and COVID-19 vaccine-associated myocardial inflammation and autonomic disruption remain concerns. As the pandemic has transformed to an endemic, with discovery of new SARS-CoV-2 variants, updated vaccines, and potent antiviral drugs, vigilance for COVID-19-associated arrhythmic and dysautonomic manifestations remains. The objective of this American Heart Association scientific statement is to review the available evidence on the epidemiology, pathophysiology, clinical presentation, and management of cardiac arrhythmias and autonomic dysfunction in patients infected with and recovering from COVID-19 and to provide evidence-based guidance. The writing committee's consensus on implications for clinical practice, gaps in knowledge, and directions for future research are highlighted.

State of the art of mobile health technologies use in clinical arrhythmia care

The rapid growth in consumer-facing mobile and sensor technologies has created tremendous opportunities for patient-driven personalized health management. The diagnosis and management of cardiac arrhythmias are particularly well suited to benefit from these easily accessible consumer health technologies. In particular, smartphone-based and wrist-worn wearable electrocardiogram (ECG) and photoplethysmography (PPG) technology can facilitate relatively inexpensive, long-term rhythm monitoring. Here we review the practical utility of the currently available and emerging mobile health technologies relevant to cardiac arrhythmia care. We discuss the applications of these tools, which vary with respect to diagnostic performance, target populations, and indications. We also highlight that requirements for successful integration into clinical practice require adaptations to regulatory approval, data management, electronic medical record integration, quality oversight, and efforts to minimize the additional burden to health care professionals.

Validation and user experience of a dry electrode based Health Patch for heart rate and respiration rate monitoring

Successful implementation of remote monitoring of vital signs outside of the hospital setting hinges on addressing three crucial unmet needs: longer-term wear, skin comfort and signal quality. Earlier, we developed a Health Patch research platform that uses self-adhesive dry electrodes to measure vital digital biomarkers. Here, we report on the analytical validation for heart rate, heart rate variability and respiration rate. Study design included n = 25 adult participants with data acquisition during a 30-minute exercise protocol involving rest, squats, slow, and fast cycling. The Shimmer3 ECG Unit and Cosmed K5, were reference devices. Data analysis showed good agreement in heart rate and marginal agreement in respiratory rate, with lower agreement towards higher respiratory rates. The Lin's concordance coefficient was 0.98 for heart rate and 0.56 for respiratory rate. Heart rate variability (RMSSD) had a coefficient of 0.85. Participants generally expressed a positive experience with the technology, with some minor irritation from the medical adhesive. The results highlighted potential of this technology for short-to-medium term clinical use for cardiorespiratory health, due to its reliability, accuracy, and compact design. Such technology could become instrumental for remote monitoring providing healthcare professionals with continuous data, remote assessment and enhancing patient outcomes in cardiorespiratory health management.

Evaluating the impacts of digital ECG denoising on the interpretive capabilities of healthcare professionals

Aims

Electrocardiogram (ECG) interpretation is an essential skill across multiple medical disciplines; yet, studies have consistently identified deficiencies in the interpretive performance of healthcare professionals linked to a variety of educational and technological factors. Despite the established correlation between noise interference and erroneous diagnoses, research evaluating the impacts of digital denoising software on clinical ECG interpretation proficiency is lacking.

Methods and results

Forty-eight participants from a variety of medical professions and experience levels were prospectively recruited for this study. Participants' capabilities in classifying common cardiac rhythms were evaluated using a sequential blinded and semi-blinded interpretation protocol on a challenging set of single-lead ECG signals (42 × 10 s) pre- and post-denoising with robust, cloud-based ECG processing software. Participants' ECG rhythm interpretation performance was greatest when raw and denoised signals were viewed in a combined format that enabled comparative evaluation. The combined view resulted in a 4.9% increase in mean rhythm classification accuracy (raw: 75.7% ± 14.5% vs. combined: 80.6% ± 12.5%, P = 0.0087), a 6.2% improvement in mean five-point graded confidence score (raw: 4.05 ± 0.58 vs. combined: 4.30 ± 0.48, P < 0.001), and 9.7% reduction in the mean proportion of undiagnosable data (raw: 14.2% ± 8.2% vs. combined: 4.5% ± 2.4%, P < 0.001), relative to raw signals alone. Participants also had a predominantly positive perception of denoising as it related to revealing previously unseen pathologies, improving ECG readability, and reducing time to diagnosis.

Conclusion

Our findings have demonstrated that digital denoising software improves the efficacy of rhythm interpretation on single-lead ECGs, particularly when raw and denoised signals are provided in a combined viewing format, warranting further investigation into the impact of such technology on clinical decision-making and patient outcomes.

The Use of Electrocardiogram Smartwatches in Patients with Cardiac Implantable Electrical Devices

Unlimited access to ECGs using an over-the-counter smartwatch constitutes a real revolution for our discipline, and the application is rapidly expanding to include patients with cardiac implantable electronic devices (CIEDs) such as pacemakers (PMs) and implantable cardioverter defibrillators (ICDs). CIEDs require periodic evaluation and adjustment by healthcare professionals. In addition, implanted patients often present with symptoms that may be related to their PMs or ICDs. An ECG smartwatch could reveal information about device functioning, confirm normal device function, or aid in the case of device troubleshooting. In this review, we delve into the available evidence surrounding smartwatches with ECG registration and their integration into the care of patients with implanted pacemakers and ICDs. We explore safety considerations and the benefits and limitations associated with these wearables, drawing on relevant studies and case series from our own experience. By analyzing the current landscape of this emerging technology, we aim to provide a comprehensive overview that facilitates informed decision-making for both healthcare professionals and patients.

Characterizing Real-World Implementation of Consumer Wearables for the Detection of Undiagnosed Atrial Fibrillation in Clinical Practice: Targeted Literature Review

BACKGROUND

Atrial fibrillation (AF), the most common cardiac arrhythmia, is often undiagnosed because of lack of awareness and frequent asymptomatic presentation. As AF is associated with increased risk of stroke, early detection is clinically relevant. Several consumer wearable devices (CWDs) have been cleared by the US Food and Drug Administration for irregular heart rhythm detection suggestive of AF. However, recommendations for the use of CWDs for AF detection in clinical practice, especially with regard to pathways for workflows and clinical decisions, remain lacking.

OBJECTIVE

We conducted a targeted literature review to identify articles on CWDs characterizing the current state of wearable technology for AF detection, identifying approaches to implementing CWDs into the clinical workflow, and characterizing provider and patient perspectives on CWDs for patients at risk of AF.

METHODS

PubMed, ClinicalTrials.gov, UpToDate Clinical Reference, and DynaMed were searched for articles in English published between January 2016 and July 2023. The searches used predefined Medical Subject Headings (MeSH) terms, keywords, and search strings. Articles of interest were specifically on CWDs; articles on ambulatory monitoring tools, tools available by prescription, or handheld devices were excluded. Search results were reviewed for relevancy and discussed among the authors for inclusion. A qualitative analysis was conducted and themes relevant to our study objectives were identified.

RESULTS

A total of 31 articles met inclusion criteria: 7 (23%) medical society reports or guidelines, 4 (13%) general reviews, 5 (16%) systematic reviews, 5 (16%) health care provider surveys, 7 (23%) consumer or patient surveys or interviews, and 3 (10%) analytical reports. Despite recognition of CWDs by medical societies, detailed guidelines regarding CWDs for AF detection were limited, as was the availability of clinical tools. A main theme was the lack of pragmatic studies assessing real-world implementation of CWDs for AF detection. Clinicians expressed concerns about data overload; potential for false positives; reimbursement issues; and the need for clinical tools such as care pathways and guidelines, preferably developed or endorsed by professional organizations. Patient-facing challenges included device costs and variability in digital literacy or technology acceptance.

CONCLUSIONS

This targeted literature review highlights the lack of a comprehensive body of literature guiding real-world implementation of CWDs for AF detection and provides insights for informing additional research and developing appropriate tools and resources for incorporating these devices into clinical practice. The results should also provide an impetus for the active involvement of medical societies and other health care stakeholders in developing appropriate tools and resources for guiding the real-world use of CWDs for AF detection. These resources should target clinicians, patients, and health care systems with the goal of facilitating clinician or patient engagement and using an evidence-based approach for establishing guidelines or frameworks for administrative workflows and patient care pathways.

Improved 1-year outcomes after active cooling during left atrial radiofrequency ablation

BACKGROUND

Active esophageal cooling during pulmonary vein isolation (PVI) with radiofrequency (RF) ablation for the treatment of atrial fibrillation (AF) is increasingly being utilized to reduce esophageal injury and atrioesophageal fistula formation. Randomized controlled data also show trends towards increased freedom from AF when using active cooling. This study aimed to compare 1-year arrhythmia recurrence rates between patients treated with luminal esophageal temperature (LET) monitoring versus active esophageal cooling during left atrial ablation.

METHOD

Data from two healthcare systems (including 3 hospitals and 4 electrophysiologists) were reviewed for patient rhythm status at 1-year follow-up after receiving PVI for the treatment of AF. Results were compared between patients receiving active esophageal cooling (ensoETM, Attune Medical, Chicago, IL) and those treated with traditional LET monitoring using Kaplan-Meier estimates.

RESULTS

A total of 513 patients were reviewed; 253 received LET monitoring using either single or multi-sensor temperature probes; and 260 received active cooling. The mean age was 66.8 (SD ± 10) years, and 36.8% were female. Arrhythmias were 60.1% paroxysmal AF, 34.3% persistent AF, and 5.6% long-standing persistent AF, with no significant difference between groups. At 1-year follow-up, KM estimates for freedom from AF were 58.2% for LET-monitored patients and 72.2% for actively cooled patients, for an absolute increase in freedom from AF of 14% with active esophageal cooling (p = .03). Adjustment for the confounders of patient age, gender, type of AF, and operator with an inverse probability of treatment weighted Cox proportional hazards model yielded a hazard ratio of 0.6 for the effect of cooling on AF recurrence (p = 0.045).

CONCLUSIONS

In this first study to date of the association between esophageal protection strategy and long-term efficacy of left atrial RF ablation, a clinically and statistically significant improvement in freedom from atrial arrhythmia at 1 year was found in patients treated with active esophageal cooling when compared to patients who received LET monitoring. More rigorous prospective studies or randomized studies are required to validate the findings of the current study.

Review of current ECG consumer electronics (pros and cons)

BACKGROUND

Several wearable, medical-grade consumer ECG devices are now available and integrated into consumer electronics like multi sensor fitness watches and scales. Specific consumer ECGs can also come in the form of patches or thin sensor plates in credit card or other shapes. Watches with ECG capabilities are often multi vital sign sensor devices. The majority of these devices are usually connected to a mobile smartphone. However, there are pros and cons to their use.

METHODS

We review here an exemplary selection of modern consumer ECG devices based on device type, recording method and the number of standard ECG channels derived.

RESULTS

Single-channel consumer ECG devices such as Smart Watches can be useful for detecting and monitoring atrial fibrillation and flutter and other arrhythmias, as well as ectopic complexes. However, they are currently limited with respect to recording duration and information content (a single-channel or limb‑lead ECG having less diagnostic information than a 12‑lead ECG). While some non watch-based consumer ECG devices can now record all 6 limb leads to yield increased information, no consumer ECG devices can currently reliably detect ST-segment deviations, potentially indicating myocardial infarction or ischemic episodes. Moreover, barriers to use still exist for at-risk elderly people. Finally, there currently is no universal data exchange format.

CONCLUSION

Consumer ECG devices, whether in fitness or fashionable design, allow for reliable detection of atrial fibrillation. Timely detection of atrial fibrillation and subsequent treatment might protect against stroke, especially in high-risk groups, yet prospective evidence is still lacking. Six-channel consumer ECG and longer data collection capabilities extend potential functionality, including for the monitoring of ST-segments and QT intervals. However, no currently available devices are sufficiently suitable for the detection of myocardial infarction or ischemia, which is why portable 12-channel technologies are desirable. For the reliable detection of a myocardial infarction, the determination of specific myocardial infarction blood markers and evaluation of patient medical history still is indispensable in addition to the 12 lead ECG.

Wearables in Sports Cardiology

The expanding array and adoption of consumer health wearables is creating a new dynamic to the patient-health-care provider relationship. Providers are increasingly tasked with integrating the biometric data collected from their patients into clinical care. Further, a growing body of evidence is supporting the provider-driven utility of wearables in the screening, diagnosis, and monitoring of cardiovascular disease. Here we highlight existing and emerging wearable health technologies and the potential applications for use within sports cardiology. We additionally highlight how wearables can advance the remote cardiovascular care of patients within the context of the COVID-19 pandemic. Finally, despite these promising advances, we acknowledge some of the significant challenges that remain before wearables can be routinely incorporated into clinical care.

Clinical Care of Hyperthyroidism Using Wearable Medical Devices in a Medical IoT Scenario

This paper presents an in-depth study and analysis of clinical care of patients with hyperthyroidism using wearable medical devices in the context of medical IoT scenarios. According to the use scenario of the gateway and the connectivity of the equipment, the hardware architecture, hardware interfaces, functionality, and performance of the gateway were briefly designed, so as to monitor patients with hyperthyroidism more comprehensively and save labor costs. The gateway can provide access to different devices and adaptation functions to different hardware interfaces and provide hardware support for the subsequent deployment of the proposed new medical communication protocols and related information systems. A medical data convergence information system based on multidevice management and multiprotocol parsing was designed and implemented. The system enables the management and configuration of different medical devices and access to data through the targeted parsing of the underlying medical device communication protocols. The system also provides the automatic adaptation of multiple types of underlying medical device communication protocols and automatic parsing of multiple versions and can provide multiple devices to process fused data streams or device information and data from a single device. The use of event-driven asynchronous communication eliminates the tight dependency on service invocation in the synchronous communication approach. The use of a metadata-based data model structure enables model extensions to accommodate the impact of iterative business requirements on the database structure. Real-time patient physiological data transmission for intraoperative monitoring based on the MQTT protocol and video transmission for intraoperative patient monitoring based on the RTMP protocol were implemented. The development of the intelligent medical monitoring service system was completed, and the system was tested, optimized, and deployed. The functionality and performance of the system were tested, the performance issue of slow query speed was optimized, and the deployment of the project using Docker containers was automated.

Recent Updates and Technological Developments in Evaluating Cardiac Syncope in the Emergency Department

Syncope is a commonly encountered problem in the emergency department (ED), accounting for approximately 3% of presenting complaints. Clinical assessment of syncope can be challenging due to the diverse range of conditions that can precipitate the symptom. Annual mortality for patients presenting with syncope ranges from 0-12%, and if the syncope is secondary to a cardiac cause, then this figure rises to 18-33%. In ED, it is paramount to accurately identify those presenting with syncope, especially patients with an underlying cardiac aetiology, initiate appropriate management, and refer them for further investigations. In 2018, the European Society of Cardiology (ESC) updated its guidelines with regard to diagnosing and managing patients with syncope. We highlight recent developments and considerations in various components of the workup, such as history, physical examination, investigations, risk stratification, and novel biomarkers, since the establishment of the 2018 ESC guidelines. We further discuss the emerging role of artificial intelligence in diagnosing cardiac syncope and postulate how wearable technology may transform evaluating cardiac syncope in ED.