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Perez MV, Mahaffey KW, Hedlin H, Rumsfeld JS, Garcia A, Ferris T, Balasubramanian V, Russo AM, Rajmane A, Cheung L, Hung G, Lee J, Kowey P, Talati N, Nag D, Gummidipundi SE, Beatty A, Hills MT, Desai S, Granger CB, Desai M, Turakhia MP. Large-Scale Assessment of a Smartwatch to Identify Atrial Fibrillation. N Engl J Med 2019; 381:1909-1917. [PMID: 31722151 PMCID: PMC8112605 DOI: 10.1056/nejmoa1901183] [Citation(s) in RCA: 869] [Impact Index Per Article: 173.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Optical sensors on wearable devices can detect irregular pulses. The ability of a smartwatch application (app) to identify atrial fibrillation during typical use is unknown. METHODS Participants without atrial fibrillation (as reported by the participants themselves) used a smartphone (Apple iPhone) app to consent to monitoring. If a smartwatch-based irregular pulse notification algorithm identified possible atrial fibrillation, a telemedicine visit was initiated and an electrocardiography (ECG) patch was mailed to the participant, to be worn for up to 7 days. Surveys were administered 90 days after notification of the irregular pulse and at the end of the study. The main objectives were to estimate the proportion of notified participants with atrial fibrillation shown on an ECG patch and the positive predictive value of irregular pulse intervals with a targeted confidence interval width of 0.10. RESULTS We recruited 419,297 participants over 8 months. Over a median of 117 days of monitoring, 2161 participants (0.52%) received notifications of irregular pulse. Among the 450 participants who returned ECG patches containing data that could be analyzed - which had been applied, on average, 13 days after notification - atrial fibrillation was present in 34% (97.5% confidence interval [CI], 29 to 39) overall and in 35% (97.5% CI, 27 to 43) of participants 65 years of age or older. Among participants who were notified of an irregular pulse, the positive predictive value was 0.84 (95% CI, 0.76 to 0.92) for observing atrial fibrillation on the ECG simultaneously with a subsequent irregular pulse notification and 0.71 (97.5% CI, 0.69 to 0.74) for observing atrial fibrillation on the ECG simultaneously with a subsequent irregular tachogram. Of 1376 notified participants who returned a 90-day survey, 57% contacted health care providers outside the study. There were no reports of serious app-related adverse events. CONCLUSIONS The probability of receiving an irregular pulse notification was low. Among participants who received notification of an irregular pulse, 34% had atrial fibrillation on subsequent ECG patch readings and 84% of notifications were concordant with atrial fibrillation. This siteless (no on-site visits were required for the participants), pragmatic study design provides a foundation for large-scale pragmatic studies in which outcomes or adherence can be reliably assessed with user-owned devices. (Funded by Apple; Apple Heart Study ClinicalTrials.gov number, NCT03335800.).
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Affiliation(s)
- Marco V Perez
- From the Division of Cardiovascular Medicine (M.V.P.), Stanford Center for Clinical Research (K.W.M., A.R., N.T.), the Quantitative Sciences Unit (H.H., A.G., V.B., J.L., S.E.G., M.D.), Information Resources and Technology (T.F., G.H.), Department of Medicine (S.D.), and the Center for Digital Health (M.P.T.), Stanford University, Stanford, Apple, Cupertino (L.C., D.N., A.B., S.D.), and the Veterans Affairs Palo Alto Health Care System, Palo Alto (M.P.T.) - all in California; the University of Colorado School of Medicine, Aurora (J.S.R.); the Division of Cardiovascular Disease, Cooper Medical School of Rowan University, Camden, NJ (A.M.R.); the Lankenau Heart Institute and Jefferson Medical College, Philadelphia (P.K.); StopAfib.org, American Foundation for Women's Health, Decatur, TX (M.T.H.); and the Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.)
| | - Kenneth W Mahaffey
- From the Division of Cardiovascular Medicine (M.V.P.), Stanford Center for Clinical Research (K.W.M., A.R., N.T.), the Quantitative Sciences Unit (H.H., A.G., V.B., J.L., S.E.G., M.D.), Information Resources and Technology (T.F., G.H.), Department of Medicine (S.D.), and the Center for Digital Health (M.P.T.), Stanford University, Stanford, Apple, Cupertino (L.C., D.N., A.B., S.D.), and the Veterans Affairs Palo Alto Health Care System, Palo Alto (M.P.T.) - all in California; the University of Colorado School of Medicine, Aurora (J.S.R.); the Division of Cardiovascular Disease, Cooper Medical School of Rowan University, Camden, NJ (A.M.R.); the Lankenau Heart Institute and Jefferson Medical College, Philadelphia (P.K.); StopAfib.org, American Foundation for Women's Health, Decatur, TX (M.T.H.); and the Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.)
| | - Haley Hedlin
- From the Division of Cardiovascular Medicine (M.V.P.), Stanford Center for Clinical Research (K.W.M., A.R., N.T.), the Quantitative Sciences Unit (H.H., A.G., V.B., J.L., S.E.G., M.D.), Information Resources and Technology (T.F., G.H.), Department of Medicine (S.D.), and the Center for Digital Health (M.P.T.), Stanford University, Stanford, Apple, Cupertino (L.C., D.N., A.B., S.D.), and the Veterans Affairs Palo Alto Health Care System, Palo Alto (M.P.T.) - all in California; the University of Colorado School of Medicine, Aurora (J.S.R.); the Division of Cardiovascular Disease, Cooper Medical School of Rowan University, Camden, NJ (A.M.R.); the Lankenau Heart Institute and Jefferson Medical College, Philadelphia (P.K.); StopAfib.org, American Foundation for Women's Health, Decatur, TX (M.T.H.); and the Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.)
| | - John S Rumsfeld
- From the Division of Cardiovascular Medicine (M.V.P.), Stanford Center for Clinical Research (K.W.M., A.R., N.T.), the Quantitative Sciences Unit (H.H., A.G., V.B., J.L., S.E.G., M.D.), Information Resources and Technology (T.F., G.H.), Department of Medicine (S.D.), and the Center for Digital Health (M.P.T.), Stanford University, Stanford, Apple, Cupertino (L.C., D.N., A.B., S.D.), and the Veterans Affairs Palo Alto Health Care System, Palo Alto (M.P.T.) - all in California; the University of Colorado School of Medicine, Aurora (J.S.R.); the Division of Cardiovascular Disease, Cooper Medical School of Rowan University, Camden, NJ (A.M.R.); the Lankenau Heart Institute and Jefferson Medical College, Philadelphia (P.K.); StopAfib.org, American Foundation for Women's Health, Decatur, TX (M.T.H.); and the Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.)
| | - Ariadna Garcia
- From the Division of Cardiovascular Medicine (M.V.P.), Stanford Center for Clinical Research (K.W.M., A.R., N.T.), the Quantitative Sciences Unit (H.H., A.G., V.B., J.L., S.E.G., M.D.), Information Resources and Technology (T.F., G.H.), Department of Medicine (S.D.), and the Center for Digital Health (M.P.T.), Stanford University, Stanford, Apple, Cupertino (L.C., D.N., A.B., S.D.), and the Veterans Affairs Palo Alto Health Care System, Palo Alto (M.P.T.) - all in California; the University of Colorado School of Medicine, Aurora (J.S.R.); the Division of Cardiovascular Disease, Cooper Medical School of Rowan University, Camden, NJ (A.M.R.); the Lankenau Heart Institute and Jefferson Medical College, Philadelphia (P.K.); StopAfib.org, American Foundation for Women's Health, Decatur, TX (M.T.H.); and the Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.)
| | - Todd Ferris
- From the Division of Cardiovascular Medicine (M.V.P.), Stanford Center for Clinical Research (K.W.M., A.R., N.T.), the Quantitative Sciences Unit (H.H., A.G., V.B., J.L., S.E.G., M.D.), Information Resources and Technology (T.F., G.H.), Department of Medicine (S.D.), and the Center for Digital Health (M.P.T.), Stanford University, Stanford, Apple, Cupertino (L.C., D.N., A.B., S.D.), and the Veterans Affairs Palo Alto Health Care System, Palo Alto (M.P.T.) - all in California; the University of Colorado School of Medicine, Aurora (J.S.R.); the Division of Cardiovascular Disease, Cooper Medical School of Rowan University, Camden, NJ (A.M.R.); the Lankenau Heart Institute and Jefferson Medical College, Philadelphia (P.K.); StopAfib.org, American Foundation for Women's Health, Decatur, TX (M.T.H.); and the Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.)
| | - Vidhya Balasubramanian
- From the Division of Cardiovascular Medicine (M.V.P.), Stanford Center for Clinical Research (K.W.M., A.R., N.T.), the Quantitative Sciences Unit (H.H., A.G., V.B., J.L., S.E.G., M.D.), Information Resources and Technology (T.F., G.H.), Department of Medicine (S.D.), and the Center for Digital Health (M.P.T.), Stanford University, Stanford, Apple, Cupertino (L.C., D.N., A.B., S.D.), and the Veterans Affairs Palo Alto Health Care System, Palo Alto (M.P.T.) - all in California; the University of Colorado School of Medicine, Aurora (J.S.R.); the Division of Cardiovascular Disease, Cooper Medical School of Rowan University, Camden, NJ (A.M.R.); the Lankenau Heart Institute and Jefferson Medical College, Philadelphia (P.K.); StopAfib.org, American Foundation for Women's Health, Decatur, TX (M.T.H.); and the Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.)
| | - Andrea M Russo
- From the Division of Cardiovascular Medicine (M.V.P.), Stanford Center for Clinical Research (K.W.M., A.R., N.T.), the Quantitative Sciences Unit (H.H., A.G., V.B., J.L., S.E.G., M.D.), Information Resources and Technology (T.F., G.H.), Department of Medicine (S.D.), and the Center for Digital Health (M.P.T.), Stanford University, Stanford, Apple, Cupertino (L.C., D.N., A.B., S.D.), and the Veterans Affairs Palo Alto Health Care System, Palo Alto (M.P.T.) - all in California; the University of Colorado School of Medicine, Aurora (J.S.R.); the Division of Cardiovascular Disease, Cooper Medical School of Rowan University, Camden, NJ (A.M.R.); the Lankenau Heart Institute and Jefferson Medical College, Philadelphia (P.K.); StopAfib.org, American Foundation for Women's Health, Decatur, TX (M.T.H.); and the Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.)
| | - Amol Rajmane
- From the Division of Cardiovascular Medicine (M.V.P.), Stanford Center for Clinical Research (K.W.M., A.R., N.T.), the Quantitative Sciences Unit (H.H., A.G., V.B., J.L., S.E.G., M.D.), Information Resources and Technology (T.F., G.H.), Department of Medicine (S.D.), and the Center for Digital Health (M.P.T.), Stanford University, Stanford, Apple, Cupertino (L.C., D.N., A.B., S.D.), and the Veterans Affairs Palo Alto Health Care System, Palo Alto (M.P.T.) - all in California; the University of Colorado School of Medicine, Aurora (J.S.R.); the Division of Cardiovascular Disease, Cooper Medical School of Rowan University, Camden, NJ (A.M.R.); the Lankenau Heart Institute and Jefferson Medical College, Philadelphia (P.K.); StopAfib.org, American Foundation for Women's Health, Decatur, TX (M.T.H.); and the Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.)
| | - Lauren Cheung
- From the Division of Cardiovascular Medicine (M.V.P.), Stanford Center for Clinical Research (K.W.M., A.R., N.T.), the Quantitative Sciences Unit (H.H., A.G., V.B., J.L., S.E.G., M.D.), Information Resources and Technology (T.F., G.H.), Department of Medicine (S.D.), and the Center for Digital Health (M.P.T.), Stanford University, Stanford, Apple, Cupertino (L.C., D.N., A.B., S.D.), and the Veterans Affairs Palo Alto Health Care System, Palo Alto (M.P.T.) - all in California; the University of Colorado School of Medicine, Aurora (J.S.R.); the Division of Cardiovascular Disease, Cooper Medical School of Rowan University, Camden, NJ (A.M.R.); the Lankenau Heart Institute and Jefferson Medical College, Philadelphia (P.K.); StopAfib.org, American Foundation for Women's Health, Decatur, TX (M.T.H.); and the Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.)
| | - Grace Hung
- From the Division of Cardiovascular Medicine (M.V.P.), Stanford Center for Clinical Research (K.W.M., A.R., N.T.), the Quantitative Sciences Unit (H.H., A.G., V.B., J.L., S.E.G., M.D.), Information Resources and Technology (T.F., G.H.), Department of Medicine (S.D.), and the Center for Digital Health (M.P.T.), Stanford University, Stanford, Apple, Cupertino (L.C., D.N., A.B., S.D.), and the Veterans Affairs Palo Alto Health Care System, Palo Alto (M.P.T.) - all in California; the University of Colorado School of Medicine, Aurora (J.S.R.); the Division of Cardiovascular Disease, Cooper Medical School of Rowan University, Camden, NJ (A.M.R.); the Lankenau Heart Institute and Jefferson Medical College, Philadelphia (P.K.); StopAfib.org, American Foundation for Women's Health, Decatur, TX (M.T.H.); and the Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.)
| | - Justin Lee
- From the Division of Cardiovascular Medicine (M.V.P.), Stanford Center for Clinical Research (K.W.M., A.R., N.T.), the Quantitative Sciences Unit (H.H., A.G., V.B., J.L., S.E.G., M.D.), Information Resources and Technology (T.F., G.H.), Department of Medicine (S.D.), and the Center for Digital Health (M.P.T.), Stanford University, Stanford, Apple, Cupertino (L.C., D.N., A.B., S.D.), and the Veterans Affairs Palo Alto Health Care System, Palo Alto (M.P.T.) - all in California; the University of Colorado School of Medicine, Aurora (J.S.R.); the Division of Cardiovascular Disease, Cooper Medical School of Rowan University, Camden, NJ (A.M.R.); the Lankenau Heart Institute and Jefferson Medical College, Philadelphia (P.K.); StopAfib.org, American Foundation for Women's Health, Decatur, TX (M.T.H.); and the Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.)
| | - Peter Kowey
- From the Division of Cardiovascular Medicine (M.V.P.), Stanford Center for Clinical Research (K.W.M., A.R., N.T.), the Quantitative Sciences Unit (H.H., A.G., V.B., J.L., S.E.G., M.D.), Information Resources and Technology (T.F., G.H.), Department of Medicine (S.D.), and the Center for Digital Health (M.P.T.), Stanford University, Stanford, Apple, Cupertino (L.C., D.N., A.B., S.D.), and the Veterans Affairs Palo Alto Health Care System, Palo Alto (M.P.T.) - all in California; the University of Colorado School of Medicine, Aurora (J.S.R.); the Division of Cardiovascular Disease, Cooper Medical School of Rowan University, Camden, NJ (A.M.R.); the Lankenau Heart Institute and Jefferson Medical College, Philadelphia (P.K.); StopAfib.org, American Foundation for Women's Health, Decatur, TX (M.T.H.); and the Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.)
| | - Nisha Talati
- From the Division of Cardiovascular Medicine (M.V.P.), Stanford Center for Clinical Research (K.W.M., A.R., N.T.), the Quantitative Sciences Unit (H.H., A.G., V.B., J.L., S.E.G., M.D.), Information Resources and Technology (T.F., G.H.), Department of Medicine (S.D.), and the Center for Digital Health (M.P.T.), Stanford University, Stanford, Apple, Cupertino (L.C., D.N., A.B., S.D.), and the Veterans Affairs Palo Alto Health Care System, Palo Alto (M.P.T.) - all in California; the University of Colorado School of Medicine, Aurora (J.S.R.); the Division of Cardiovascular Disease, Cooper Medical School of Rowan University, Camden, NJ (A.M.R.); the Lankenau Heart Institute and Jefferson Medical College, Philadelphia (P.K.); StopAfib.org, American Foundation for Women's Health, Decatur, TX (M.T.H.); and the Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.)
| | - Divya Nag
- From the Division of Cardiovascular Medicine (M.V.P.), Stanford Center for Clinical Research (K.W.M., A.R., N.T.), the Quantitative Sciences Unit (H.H., A.G., V.B., J.L., S.E.G., M.D.), Information Resources and Technology (T.F., G.H.), Department of Medicine (S.D.), and the Center for Digital Health (M.P.T.), Stanford University, Stanford, Apple, Cupertino (L.C., D.N., A.B., S.D.), and the Veterans Affairs Palo Alto Health Care System, Palo Alto (M.P.T.) - all in California; the University of Colorado School of Medicine, Aurora (J.S.R.); the Division of Cardiovascular Disease, Cooper Medical School of Rowan University, Camden, NJ (A.M.R.); the Lankenau Heart Institute and Jefferson Medical College, Philadelphia (P.K.); StopAfib.org, American Foundation for Women's Health, Decatur, TX (M.T.H.); and the Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.)
| | - Santosh E Gummidipundi
- From the Division of Cardiovascular Medicine (M.V.P.), Stanford Center for Clinical Research (K.W.M., A.R., N.T.), the Quantitative Sciences Unit (H.H., A.G., V.B., J.L., S.E.G., M.D.), Information Resources and Technology (T.F., G.H.), Department of Medicine (S.D.), and the Center for Digital Health (M.P.T.), Stanford University, Stanford, Apple, Cupertino (L.C., D.N., A.B., S.D.), and the Veterans Affairs Palo Alto Health Care System, Palo Alto (M.P.T.) - all in California; the University of Colorado School of Medicine, Aurora (J.S.R.); the Division of Cardiovascular Disease, Cooper Medical School of Rowan University, Camden, NJ (A.M.R.); the Lankenau Heart Institute and Jefferson Medical College, Philadelphia (P.K.); StopAfib.org, American Foundation for Women's Health, Decatur, TX (M.T.H.); and the Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.)
| | - Alexis Beatty
- From the Division of Cardiovascular Medicine (M.V.P.), Stanford Center for Clinical Research (K.W.M., A.R., N.T.), the Quantitative Sciences Unit (H.H., A.G., V.B., J.L., S.E.G., M.D.), Information Resources and Technology (T.F., G.H.), Department of Medicine (S.D.), and the Center for Digital Health (M.P.T.), Stanford University, Stanford, Apple, Cupertino (L.C., D.N., A.B., S.D.), and the Veterans Affairs Palo Alto Health Care System, Palo Alto (M.P.T.) - all in California; the University of Colorado School of Medicine, Aurora (J.S.R.); the Division of Cardiovascular Disease, Cooper Medical School of Rowan University, Camden, NJ (A.M.R.); the Lankenau Heart Institute and Jefferson Medical College, Philadelphia (P.K.); StopAfib.org, American Foundation for Women's Health, Decatur, TX (M.T.H.); and the Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.)
| | - Mellanie True Hills
- From the Division of Cardiovascular Medicine (M.V.P.), Stanford Center for Clinical Research (K.W.M., A.R., N.T.), the Quantitative Sciences Unit (H.H., A.G., V.B., J.L., S.E.G., M.D.), Information Resources and Technology (T.F., G.H.), Department of Medicine (S.D.), and the Center for Digital Health (M.P.T.), Stanford University, Stanford, Apple, Cupertino (L.C., D.N., A.B., S.D.), and the Veterans Affairs Palo Alto Health Care System, Palo Alto (M.P.T.) - all in California; the University of Colorado School of Medicine, Aurora (J.S.R.); the Division of Cardiovascular Disease, Cooper Medical School of Rowan University, Camden, NJ (A.M.R.); the Lankenau Heart Institute and Jefferson Medical College, Philadelphia (P.K.); StopAfib.org, American Foundation for Women's Health, Decatur, TX (M.T.H.); and the Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.)
| | - Sumbul Desai
- From the Division of Cardiovascular Medicine (M.V.P.), Stanford Center for Clinical Research (K.W.M., A.R., N.T.), the Quantitative Sciences Unit (H.H., A.G., V.B., J.L., S.E.G., M.D.), Information Resources and Technology (T.F., G.H.), Department of Medicine (S.D.), and the Center for Digital Health (M.P.T.), Stanford University, Stanford, Apple, Cupertino (L.C., D.N., A.B., S.D.), and the Veterans Affairs Palo Alto Health Care System, Palo Alto (M.P.T.) - all in California; the University of Colorado School of Medicine, Aurora (J.S.R.); the Division of Cardiovascular Disease, Cooper Medical School of Rowan University, Camden, NJ (A.M.R.); the Lankenau Heart Institute and Jefferson Medical College, Philadelphia (P.K.); StopAfib.org, American Foundation for Women's Health, Decatur, TX (M.T.H.); and the Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.)
| | - Christopher B Granger
- From the Division of Cardiovascular Medicine (M.V.P.), Stanford Center for Clinical Research (K.W.M., A.R., N.T.), the Quantitative Sciences Unit (H.H., A.G., V.B., J.L., S.E.G., M.D.), Information Resources and Technology (T.F., G.H.), Department of Medicine (S.D.), and the Center for Digital Health (M.P.T.), Stanford University, Stanford, Apple, Cupertino (L.C., D.N., A.B., S.D.), and the Veterans Affairs Palo Alto Health Care System, Palo Alto (M.P.T.) - all in California; the University of Colorado School of Medicine, Aurora (J.S.R.); the Division of Cardiovascular Disease, Cooper Medical School of Rowan University, Camden, NJ (A.M.R.); the Lankenau Heart Institute and Jefferson Medical College, Philadelphia (P.K.); StopAfib.org, American Foundation for Women's Health, Decatur, TX (M.T.H.); and the Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.)
| | - Manisha Desai
- From the Division of Cardiovascular Medicine (M.V.P.), Stanford Center for Clinical Research (K.W.M., A.R., N.T.), the Quantitative Sciences Unit (H.H., A.G., V.B., J.L., S.E.G., M.D.), Information Resources and Technology (T.F., G.H.), Department of Medicine (S.D.), and the Center for Digital Health (M.P.T.), Stanford University, Stanford, Apple, Cupertino (L.C., D.N., A.B., S.D.), and the Veterans Affairs Palo Alto Health Care System, Palo Alto (M.P.T.) - all in California; the University of Colorado School of Medicine, Aurora (J.S.R.); the Division of Cardiovascular Disease, Cooper Medical School of Rowan University, Camden, NJ (A.M.R.); the Lankenau Heart Institute and Jefferson Medical College, Philadelphia (P.K.); StopAfib.org, American Foundation for Women's Health, Decatur, TX (M.T.H.); and the Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.)
| | - Mintu P Turakhia
- From the Division of Cardiovascular Medicine (M.V.P.), Stanford Center for Clinical Research (K.W.M., A.R., N.T.), the Quantitative Sciences Unit (H.H., A.G., V.B., J.L., S.E.G., M.D.), Information Resources and Technology (T.F., G.H.), Department of Medicine (S.D.), and the Center for Digital Health (M.P.T.), Stanford University, Stanford, Apple, Cupertino (L.C., D.N., A.B., S.D.), and the Veterans Affairs Palo Alto Health Care System, Palo Alto (M.P.T.) - all in California; the University of Colorado School of Medicine, Aurora (J.S.R.); the Division of Cardiovascular Disease, Cooper Medical School of Rowan University, Camden, NJ (A.M.R.); the Lankenau Heart Institute and Jefferson Medical College, Philadelphia (P.K.); StopAfib.org, American Foundation for Women's Health, Decatur, TX (M.T.H.); and the Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.)
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