Diagnostic yield of asymptomatic arrhythmias detected by mobile cardiac outpatient telemetry and autotrigger looping event cardiac monitors

Diagnosis and Management of Atrial Fibrillation in Acute Ischemic Stroke in the Setting of Reperfusion Therapy: Insights and Strategies for Optimized Care

Reperfusion therapy in the form of intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT) has revolutionised the field of stroke medicine. Atrial fibrillation (AF) patients constitute a major portion of the overall stroke population; however, the prevalence of AF amongst acute ischemic stroke (AIS) patients receiving reperfusion therapy remains unclear. Limitations in our understanding of prevalence in this group of patients are exacerbated by difficulties in appropriately diagnosing AF. Additionally, the benefits of reperfusion therapy are not consistent across all subgroups of AIS patients. More specifically, AIS patients with AF often tend to have poor prognoses despite treatment relative to those without AF. This article aims to present an overview of the diagnostic and therapeutic management of AF and how it mediates outcomes following stroke, most specifically in AIS patients treated with reperfusion therapy. We provide unique insights into AF prevalence and outcomes that could allow healthcare professionals to optimise the treatment and prognosis for AIS patients with AF. Specific indications on acute neurovascular management and secondary stroke prevention in AIS patients with AF are also discussed.

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.

Review of the Requirements for a Wearable, Low-Cost External Cardiac Loop Recorder with WBAN in Resource-Constrained Settings

Cardiovascular disease (CVD) has become the most serious health concern in India and globally. The cost of treatment for CVD is very high and in a country like India, where most of the population belongs to rural area, affording treatment is not possible. Diagnosis and treatment are further hampered due to shortage of medical expertise as well as the unavailability of the wearable device. This makes the condition worst in rural areas. As a result of delay in diagnosis, patients do not receive appropriate treatment on time, thus risking lives. Hence, early detection of physiological abnormalities in patients is the best solution to avoid sudden death. In India, the majority of ECG diagnosis is done using a standard ECG machine or Holter monitor, which are not adequate to detect transient or infrequent arrhythmia as the window of detection is 30 s or up to 48 h. So, for arrhythmia diagnosis or syncope and palpitation, external cardiac loop recorder (ECLR) is preferred. ECLR is a monitoring device which records cardiac activities and detects infrequent arrhythmias with syncope and palpitation of a subject for longer period continuously. Due to recent improvements in technology, such as flexible electronics and wireless body area network (WBAN), wearable medical devices are progressively assisting people to monitor their health status while doing their day-to-day activities and furnishing more information to clinicians for early diagnosis and treatment. Flexible electronics allows to develop an electronic circuit on a flexible substrate hence making the device bendable and stretchable. WBAN is a wireless communication between different nodes like sensors and processors that are located at different points on the body. By incorporating technologies such as miniaturization of electronics, making flexible electronics and WBAN concept in ECLR, the device can be made wearable so as to not interfere with the patient's day-to-day activities. This review paper discusses the limitations of existing standard ECG machines as well as how to make the existing ECLR devices more robust, more advanced, more comfortable and also affordable.

Costs and outcomes of mobile cardiac outpatient telemetry monitoring post-transcatheter aortic valve replacement

Aim: To estimate the costs and outcomes of transcatheter aortic valve replacement (TAVR) recipients based on the use of mobile cardiac outpatient telemetry (MCOT) monitoring. Materials & methods: A retrospective database study was conducted to estimate costs, contribution margins (CMs), pacemaker insertions, and other outcomes for patients undergoing TAVR procedures with MCOT monitoring post-procedure versus non-MCOT monitoring. Results: A total of 4164 patients were identified (283 MCOT monitoring and 3881 non-MCOT monitoring). The rate of pacemaker insertion following hospital discharge was higher in the MCOT cohort (6.6 MCOT vs 2.1% non-MCOT; p = 0.007). MCOT use was associated with lower costs and improved CMs of the index TAVR admission (costs: US$40,569 MCOT vs $43,289 non-MCOT; p = 0.003; CMs: US$7087 MCOT vs $5177 non-MCOT; p = 0.047) with no difference through the subsequent 60-day period following discharge. Conclusion: MCOT for ambulatory cardiac monitoring post-TAVR discharge is associated with higher rates of pacemaker insertion, at no overall greater costs.

Remote Cardiac Rhythm Monitoring in the Era of Smart Wearables: Present Assets and Future Perspectives

Remote monitoring and control of heart function are of primary importance for patient evaluation and management, especially in the modern era of precision medicine and personalized approach. Breaking technological developments have brought to the frontline a variety of smart wearable devices, such as smartwatches, chest patches/straps, or sensors integrated into clothing and footwear, which allow continuous and real-time recording of heart rate, facilitating the detection of cardiac arrhythmias. However, there is great diversity and significant differences in the type and quality of the information they provide, thus impairing their integration into daily clinical practice and the relevant familiarization of practicing physicians. This review will summarize the different types and dominant functions of cardiac smart wearables available in the market. Furthermore, we report the devices certified by official American and/or European authorities and the respective sources of evidence. Finally, we comment pertinent limitations and caveats as well as the potential answers that flow from the latest technological achievements and future perspectives.

Remote and Wearable ECG Devices with Diagnostic Abilities in Adults: A State-of-the-Science Scoping Review

The electrocardiogram (ECG) records the electrical activity in the heart in real-time, providing an important opportunity to detecting various cardiac pathologies. The 12-lead ECG currently serves as the "standard" ECG acquisition technique for diagnostic purposes for many cardiac pathologies other than arrhythmias. However, the technical aspects of acquiring a 12-lead ECG are not easy and its usage is currently restricted to trained medical personnel, limiting the scope of its usefulness. Remote and wearable ECG devices have attempted to bridge this gap by enabling patients to take their own ECG using a simplified method at the expense of a reduced number of leads, usually a single-lead ECG. In this review article, we summarize the studies which investigate the use of remote ECG devices and their clinical utility in diagnosing cardiac pathologies. Eligible studies discussed FDA-cleared, commercially available devices that were validated on an adult population. We summarize technical logistics of signal quality and device reliability, dimensional and functional features, and diagnostic value. In summary, our synthesis shows that reduced-set ECG wearables have huge potential for long-term monitoring, particularly if paired with real-time notification techniques. Such capabilities make them primarily useful for abnormal rhythm detection and there is sufficient evidence that a remote ECG device can be more superior to traditional 12-lead ECG in diagnosing specific arrhythmias such as atrial fibrillation. However, this review identifies important challenges faced by this technology, highlighting the limited availability of clinical research examining their usefulness.

Subclinical and Device-Detected Atrial Fibrillation: Pondering the Knowledge Gap: A Scientific Statement From the American Heart Association

The widespread use of cardiac implantable electronic devices and wearable monitors has led to the detection of subclinical atrial fibrillation in a substantial proportion of patients. There is evidence that these asymptomatic arrhythmias are associated with increased risk of stroke. Thus, detection of subclinical atrial fibrillation may offer an opportunity to reduce stroke risk by initiating anticoagulation. However, it is unknown whether long-term anticoagulation is warranted and in what populations. This scientific statement explores the existing data on the prevalence, clinical significance, and management of subclinical atrial fibrillation and identifies current gaps in knowledge and areas of controversy and consensus.

Ambulatory cardiac bio-signals: From mirage to clinical reality through a decade of progress

BACKGROUND

Health monitoring is shifting towards continuous, ambulatory and clinically comparable wearable devices. Telemedicine and remote diagnosis could harness the capability of mobile cardiac health information, as the technology on bio-physical signal monitoring has improved significantly.

OBJECTIVES

The purpose of this review article is (1) to systematically assess the viability of ambulatory electrocardiography (ECG), (2) to provide a systems level understanding of a broad spectrum of wearable heart signal monitoring approaches and (3) to identify areas of improvement in the existing technology needed to attain clinical grade diagnosis.

RESULTS

Based on the included literature, we have identified (1) that the developments in ECG monitoring through wearable devices are reaching feasibility, and are capable of delivering diagnostic and prognostic information, (2) that reliable sensing is the major bottleneck in the entire process of ambulatory monitoring, (3) that there is a strong need for artificial intelligence and machine learning techniques to parse and infer the biosignals and (4) that aspects of wearer comfort has largely been ignored in the prevailing developments, which can become a key factor for consumer acceptance.

CONCLUSIONS

Cardiac health information is crucial for diagnosis and prevention of several disease onsets. Mobile and continuous monitoring can aid avoiding risks involved with acute symptoms. The health information obtained through continuous monitoring can serve as the BigData of heart signals, and can facilitate new treatment methods and devise effective health policies.

Newer technologies for detection of atrial fibrillation

Atrial fibrillation is a common arrhythmia that is associated with increased risk of stroke, which can be reduced with appropriate anticoagulation treatment. However, it remains underdiagnosed in contemporary clinical practice using conventional detection methods, resulting in missed opportunities to implement appropriate treatment. Newer technologies developed in recent years can potentially enhance the detection of atrial fibrillation and overcome certain limitations of the conventional methods. However, uncertainties remain about their use and the significance of atrial fibrillation detected by some of these newer technologies. This review examines the evidence supporting the use of some of these technologies and evaluates their applications in certain clinical scenarios.

Heart Rate Variability: An Old Metric with New Meaning in the Era of using mHealth Technologies for Health and Exercise Training Guidance. Part One: Physiology and Methods

The autonomic nervous system plays a major role in optimising function of the cardiovascular (CV) system, which in turn has important implications for CV health. Heart rate variability (HRV) is a measurable reflection of this balance between sympathetic and parasympathetic tone and has been used as a marker for cardiac status and predicting CV outcomes. Recently, the availability of commercially available heart rate (HR) monitoring systems has had important CV health implications and permits ambulatory CV monitoring on a scale not achievable with traditional cardiac diagnostics. The focus of the first part of this two-part review is to summarise the physiology of HRV and to describe available technologies for HRV monitoring. Part two will present HRV measures for assessing CV prognosis and athletic training.