Reliability of pulse palpation in the detection of atrial fibrillation in an elderly population

Diagnostic performance of a wearing dynamic ECG recorder for atrial fibrillation screening: the HUAMI heart study

BACKGROUND

Atrial fibrillation (AF) is the most prevalent cardiac dysrhythmia with high morbidity and mortality rate. Evidence shows that in every three patients with AF, one is asymptomatic. The asymptomatic and paroxysmal nature of AF is the reason for unsatisfactory and delayed detection using traditional instruments. Research indicates that wearing a dynamic electrocardiogram (ECG) recorder can guide accurate and safe analysis, interpretation, and distinction of AF from normal sinus rhythm. This is also achievable in an upright position and after exercises, assisted by an artificial intelligence (AI) algorithm.

METHODS

This study enrolled 114 participants from the outpatient registry of our institution from June 24, 2020 to July 24, 2020. Participants were tested with a wearable dynamic ECG recorder and 12-lead ECG in a supine, an upright position and after exercises for 60 s.

RESULTS

Of the 114 subjects enrolled in the study, 61 had normal sinus rhythm and 53 had AF. The number of cases that could not be determined by the wristband of dynamic ECG recorder was two, one and one respectively. Case results that were not clinically objective were defined as false-negative or false-positive. Results for diagnostic accuracy, sensitivity, and specificity tested by wearable dynamic ECG recorders in a supine position were 94.74% (95% CI% 88.76-97.80%), 88.68% (95% CI 77.06-95.07%), and 100% (95% CI 92.91-100%), respectively. Meanwhile, the diagnostic accuracy, sensitivity and specificity in an upright position were 97.37% (95% CI 92.21-99.44%), 94.34% (95% CI 84.03-98.65%), and 100% (95% CI 92.91-100%), respectively. Similar results as those of the upright position were obtained after exercise.

CONCLUSION

The widely accessible wearable dynamic ECG recorder integrated with an AI algorithm can efficiently detect AF in different postures and after exercises. As such, this tool holds great promise as a useful and user-friendly screening method for timely AF diagnosis in at-risk individuals.

Atrial fibrillation: a geriatric perspective on the 2020 ESC guidelines

BACKGROUND

The Task Force for the diagnosis and management of atrial fibrillation (AF) of the European Society of Cardiology (ESC) published in 2020 the updated Guidelines for the Diagnosis and Management of Atrial Fibrillation with the contribution of the European Heart Rhythm Association (EHRA) of the ESC and the European Association for Cardiothoracic Surgery (EACTS).

METHODS AND RESULTS

In this narrative viewpoint, we approach AF from the perspective of aging medicine and try to provide the readers with information usually neglected in clinical routine, mainly due to the fact that while the large majority of AF patients in real life are older, frail and cognitively impaired, these are mostly excluded from clinical trials, and physicians' attitudes often prevail over standardized algorithms.

CONCLUSIONS

On the basis of existing evidence, (1) opportunistic AF screening by pulse palpation or ECG rhythm strip is cost-effective, and (2) whereas advanced chronological age by itself is not a contraindication to AF treatment, a Comprehensive Geriatric Assessment (CGA) including frailty, cognitive impairment, falls and bleeding risk may assist in clinical decision making to provide the best individualized treatment.

Education of Self-Radial Pulse Palpation and Atrial Fibrillation Signs and Symptoms

The purpose of this evidence-based education initiative was to increase A Fib detection in a cardiovascular diseased population in which participants were taught radial pulse palpation and signs/symptoms of A Fib. Participants were evaluated after initial education on performance of radial pulse palpation and teach back of signs/symptoms of the arrhythmia and again at three weeks on adherence to daily self-screening and recall of signs/symptoms of A Fib. Post initial education, 88% of eligible participants learned pulse-palpation and 93% could verbalize at minimum one sign/symptom. After three weeks, 94.7% reported daily self-screening, but only 44.7% could verbalize at minimum one sign/symptom. This indicated that participants were continuing to self-screen, but in need of booster education sessions. Educating individuals on self-screening and signs/symptoms of A Fib is clinically feasible.

Risk prediction for new-onset atrial fibrillation using the Minnesota code electrocardiography classification system

Background

Few risk models are available to predict future onset of atrial fibrillation (AF) in workers. We aimed to develop risk prediction models for new-onset AF, using annual health checkup (HC) data with electrocardiogram findings.

Methods and Results

We retrospectively included 56,288 factory or office workers (mean age = 51.5 years, 33.0% women) who underwent a HC at a medical center and fulfilled the following criteria; age ≥ 40 years, no history of AF, and greater than 1 annual follow-up HC in 2013–2016. Using Cox models with the Akaike information criterion, we developed and compared prediction models for new-onset AF with and without the Minnesota code information. We externally validated the discrimination accuracy of the models in a general Japanese population cohort, the Hisayama cohort. During the median 3.0-year follow-up, 209 (0.37%) workers developed AF. Age, sex, waist circumference, blood pressure, LDL cholesterol, and γ-GTP were associated with new-onset of AF. Using the Minnesota code information, the AUC significantly improved from 0.82 to 0.84 in the derivation cohort and numerically improved from 0.78 to 0.79 in the validation cohort, and from 0.77 to 0.79 in the Hisayama cohort. The NRI and IDI significantly improved in all and male subjects in both the derivation and validation cohorts, and in female subjects in both the validation and the Hisayama cohorts.

Conclusions

We developed useful risk model with Minnesota code information for predicting new-onset AF from large worker population validated in the original and external cohorts, although study interpretation is limited by small improvement of AUC.

Sociodemographic, behavioral, and clinical factors associated with low atrial fibrillation knowledge among older adults with atrial fibrillation: The SAGE-AF study

BACKGROUND

Management of AF requires patient engagement in disease management which requires adequate knowledge about AF.

OBJECTIVE

To identify the patient characteristics associated with low AF knowledge among older adults with AF.

METHODS

The SAGE-AF cohort enrolled adults aged ≥65 diagnosed with AF in 2016-2018. Patient characteristics associated with low AF knowledge (<6/8 JAKQ items correct) were examined using multivariable adjusted logistic regression models.

RESULTS

Participants (N = 950) were on average 74 years old (SD: 6.7), 50 % female, and 87 % non-Hispanic white. The average JAKQ score was 68.7 (SD: 17.1), and 78 % had low AF knowledge. Participants aged ≥ 75 (OR: 1.55, 95 % CI: 1.03, 2.33), without a college degree (OR: 0.46, 95 % CI: 0.32, 0.65), cognitively impaired (OR: 1.72, 95 % CI: 1.15, 2.58), with a history of anxiety (OR: 1.76, 95 % CI: 1.09, 2.83), myocardial infarction (OR: 1.82, 95 % CI: 1.08, 3.07), and heart failure (OR: 1.84, 95 % CI: 1.16, 2.91) were more likely to have low AF knowledge.

PRACTICE IMPLICATIONS

Characteristics available in the electronic medical record may identify patients at risk for low AF knowledge. Formal assessment of AF knowledge may identify areas of weakness and allow for targeted education.

A self-management support intervention for patients with atrial fibrillation: a randomized controlled pilot trial

BACKGROUND

Atrial fibrillation (AF) is the most common arrhythmia worldwide. Despite effective treatment, it is characterized by frequent recurrences. Optimal therapeutic management of AF requires active participation and self-management from patients. Two major components of self-management are self-monitoring and sign-and-symptom management. Pulse self-palpation (PSP) is a method of self-monitoring; however, not all AF patients are capable of successfully performing PSP. Due to a lack of interventions on this topic, a nurse-led intervention for patients with AF (PSPAF intervention) was developed to foster self-monitoring and to enhance self-management through PSP. The purpose of this pilot study was to test the acceptability, feasibility, and potential effects of this intervention on the capability of patients' PSP and sign-and-symptom management. Moreover, we aimed at gathering data on the feasibility of applied research methods to aid in the design of future studies.

METHODS

The pilot trial involved 20 adult patients with AF, randomized to an intervention or usual care group. At baseline and during a home visit 3-5 weeks later, we collected data using questionnaires, checklists, field notes, a mobile ECG device, and a diary. Acceptability and feasibility measures were validated through predefined cut-off points. Effect size estimates were expressed as relative risks (RR) and the number needed to treat (NNT).

RESULTS

The PSPAF intervention seemed feasible, but only partly acceptable. There were limitations in terms of potential effectiveness, suitability, addressing participants' willingness to implement its content in daily life, and adherence. Estimations of effect sizes suggest a large effect of the intervention on patients' PSP capability (RR = 6.0; 95% CI = [0.83, 43.3]; NNT = 2.4), but almost no effect on sign-and-symptom management (RR = 1.5; 95% CI = [0.7, 3.1]; NNT = 4.0). The feasibility of applied research methods showed minor limitations on recruitment and participant burden.

CONCLUSIONS

Despite some limitations, the intervention seemed to be applicable and promising. Taking into account the suggestions and amendments we have made, we recommend conducting a full-scale trial to examine the efficacy of the PSPAF intervention.

TRIAL REGISTRATION

This pilot study was registered in the German Clinical Trials Register at September 4, 2017 (Main ID: DRKS00012808).

Validity of daily self-pulse palpation for atrial fibrillation screening in patients 65 years and older: A cross-sectional study

BACKGROUND

The European Society of Cardiology guidelines recommend (Class IA) single-time-point screening for atrial fibrillation (AF) using pulse palpation. The role of pulse palpation for AF detection has not been validated against electrocardiogram (ECG) recordings. We aimed to study the validity of AF screening using self-pulse palpation compared with an ECG recording conducted at the same time using a handheld ECG 3 times a day for 2 weeks.

METHODS AND FINDINGS

In this cross-sectional screening study, patients 65 years of age and older attending 4 primary care centers (PCCs) outside Stockholm County were invited to take part in AF screening from July 2017 to December 2018. Patients were included irrespective of their reason for visiting the PCC. Handheld intermittent ECGs 3 times per day were offered to patients without AF for a period of 2 weeks, and patients were instructed in how to take their own pulse at the same time. A total of 1,010 patients (mean age 73 years, 61% female, with an average CHA2DS2-VASc score 2.9) participated in the study, and 27 (2.7%, 95% CI 1.8%-3.9%) new cases of AF were detected. Anticoagulants (ACs) could be initiated in 26 (96%, 95% CI 81%-100%) of these cases. A total of 53,782 simultaneous ECG recordings and pulse measurements were registered. AF was verified in 311 ECG recordings, of which the pulse was palpated as irregular in 77 recordings (25%, 95% CI 20%-30% sensitivity per measurement occasion). Of the 27 AF cases, 15 cases felt an irregular pulse on at least one occasion (56%, 95% CI 35%-75% sensitivity per individual). 187 individuals without AF felt an irregular pulse on at least one occasion. The specificity per measurement occasion and per individual was (98%, 95% CI 98%-98%) and (81%, 95% CI 78%-83%), respectively.

CONCLUSIONS

AF screening using self-pulse palpation 3 times daily for 2 weeks has lower sensitivity compared with simultaneous intermittent ECG. Thus, it may be better to screen for AF using intermittent ECG without stepwise screening using pulse palpation. A limitation of this model could be the reduced availability of handheld ECG recorders in primary care centers.

Effects of acute-phase multidisciplinary rehabilitation on unplanned readmissions after cardiac surgery

OBJECTIVES

The provision of inpatient programs that reduce the incidence of readmission after cardiac surgery remains challenging. Investigators have focused on multidisciplinary cardiac rehabilitation (CR) because it reduces the postoperative readmission rate; however, most previous studies used outpatient models (phase II CR). We retrospectively investigated the effect of comprehensive multidisciplinary interventions in the acute inpatient phase (phase I CR) on unplanned hospital readmission.

METHODS

In a retrospective cohort study, we compared consecutive patients after cardiac surgery. We divided them into the multidisciplinary CR (multi-CR) group or conventional exercise-based CR (conv-CR) group according to their postoperative intervention during phase I CR. Multi-CR included psychological and educational intervention and individualized counseling in addition to conv-CR. The primary outcome was unplanned readmission rates between the groups. A propensity score-matching analysis was performed to minimize selection biases and the differences in clinical characteristics.

RESULTS

In our cohort (n = 341), 56 (18.3%) patients had unplanned readmission during the follow-up period (median, 419 days). Compared with the conv-CR group, the multi-CR group had a significantly lower unplanned readmission rate (multivariable regression analysis; hazard ratio, 0.520; 95% confidence interval, 0.28-0.95; P = .024). A Kaplan-Meier analysis of our propensity score-matched cohort showed that, compared with the conv-CR group, the multi-CR group had a significantly lower incidence of readmission (stratified log-rank test, P = .041).

CONCLUSIONS

In phase I, compared to conv-CR alone, multi-CR reduced the incidence of unplanned readmission. Early multidisciplinary CR can reduce hospitalizations and improve long-term prognosis after cardiac surgery.

Detection of atrial fibrillation using a wrist-worn device

OBJECTIVE

This study proposes an algorithm for the detection of atrial fibrillation (AF), designed to operate on extended photoplethysmographic (PPG) signals recorded using a wrist-worn device of own design.

APPROACH

Robustness against false alarms is achieved by means of signal quality assessment and different techniques for suppression of ectopic beats, bigeminy, and respiratory sinus arrhythmia. The decision logic is based on our previously proposed RR interval-based AF detector, but modified to account for differences between interbeat intervals in the ECG and the PPG. The detector is evaluated on simulated PPG signals as well as on clinical PPG signals recorded during cardiac rehabilitation after myocardial infarction.

MAIN RESULTS

Analysis of the clinical signals showed that 1.5 false alarms were on average produced per day with a sensitivity of 72.0% and a specificity of 99.7% when 89.2% of the database was available for analysis, whereas as many as 15 when the RR interval-based AF detector, boosted by accelerometer information for signal quality assessment, was used. However, a sensitivity of 97.2% and a specificity of 99.6% were achieved when increasing the demands on signal quality so that 50% was available for analysis.

SIGNIFICANCE

The proposed detector offers promising performance and is particularly well-suited for implementation in low-power wearable devices, e.g. wrist-worn devices, with significance in mass screening applications.