BACKGROUND
Current guidelines recommend at least 24 hours of electrocardiographic (ECG) monitoring after an ischemic stroke to rule out atrial fibrillation. However, the most effective duration and type of monitoring have not been established, and the cause of ischemic stroke remains uncertain despite a complete diagnostic evaluation in 20 to 40% of cases (cryptogenic stroke). Detection of atrial fibrillation after cryptogenic stroke has therapeutic implications.
METHODS
We conducted a randomized, controlled study of 441 patients to assess whether long-term monitoring with an insertable cardiac monitor (ICM) is more effective than conventional follow-up (control) for detecting atrial fibrillation in patients with cryptogenic stroke. Patients 40 years of age or older with no evidence of atrial fibrillation during at least 24 hours of ECG monitoring underwent randomization within 90 days after the index event. The primary end point was the time to first detection of atrial fibrillation (lasting >30 seconds) within 6 months. Among the secondary end points was the time to first detection of atrial fibrillation within 12 months. Data were analyzed according to the intention-to-treat principle.
RESULTS
By 6 months, atrial fibrillation had been detected in 8.9% of patients in the ICM group (19 patients) versus 1.4% of patients in the control group (3 patients) (hazard ratio, 6.4; 95% confidence interval [CI], 1.9 to 21.7; P<0.001). By 12 months, atrial fibrillation had been detected in 12.4% of patients in the ICM group (29 patients) versus 2.0% of patients in the control group (4 patients) (hazard ratio, 7.3; 95% CI, 2.6 to 20.8; P<0.001). CONCLUSIONS ECG monitoring with an ICM was superior to conventional follow-up for detecting atrial fibrillation after cryptogenic stroke. (Funded by Medtronic; CRYSTAL AF ClinicalTrials.gov number, NCT00924638.)

A national screening programme for atrial fibrillation is likely to represent a cost-effective use of resources, with systematic opportunistic screening more likely to be cost-effective than systematic population screening.

RESULTS:
Diagnostic test accuracy depended on the screening test and how it was interpreted. In general, the screening tests identified in our review had high sensitivity (> 0.9). Systematic population and systematic opportunistic screening strategies were found to be similarly effective, with an estimated 170 individuals needed to be screened to detect one additional AF case compared with no screening. Systematic opportunistic screening was more likely to be cost-effective than systematic population screening, as long as the uptake of opportunistic screening observed in randomised controlled trials translates to practice. Modified blood pressure monitors, photoplethysmography or nurse pulse palpation were more likely to be cost-effective than other screening tests. A screening strategy with an initial screening age of 65 years and repeated screens every 5 years until age 80 years was likely to be cost-effective, provided that compliance with treatment does not decline with increasing age.
CONCLUSIONS:
A national screening programme for AF is likely to represent a cost-effective use of resources. Systematic opportunistic screening is more likely to be cost-effective than systematic population screening. Nurse pulse palpation or modified blood pressure monitors would be appropriate screening tests, with confirmation by diagnostic 12-lead electrocardiography interpreted by a trained GP, with referral to a specialist in the case of an unclear diagnosis. Implementation strategies to operationalise uptake of systematic opportunistic screening in primary care should accompany any screening recommendations.

BACKGROUND:
Device-detected atrial fibrillation (AF) is associated with increased risk of stroke; however, there are no clearly defined thresholds of AF burden at which to initiate oral anticoagulation (OAC). We sought to describe OAC prescription practice variation in response to new device-detected AF and the association with outcomes.
METHODS:
We performed a retrospective cohort study using data from the Veterans Health Administration linked to remote monitoring data that included day-level AF burden. We included patients with cardiac implantable electronic devices and remote monitoring from 2011 to 2014, CHA2DS2-VASc score ≥2, and no prior stroke or OAC receipt in the preceding 2 years. We determined the proportion of patients prescribed OAC within 90 days after new device-detected AF across a range of AF thresholds (≥6 minutes to >24 hours) and examined site variation in OAC prescription. We used multivariable Cox proportional hazards regressions to determine the association of OAC prescription with stroke by device-detected AF burden.
RESULTS:
Among 10 212 patients with cardiac implantable electronic devices, 4570 (45%), 3969 (39%), 3263 (32%), and 2469 (24%) had device-detected AF >6 minutes, >1 hour, >6 hours, and >24 hours, respectively. For device-detected AF >1 hour, 1712 patients met inclusion criteria (72±10 years; 1.5% female; CHA2DS2-VASc score 4.0±1.4; HAS-BLED score 2.6±1.1). The proportion receiving OAC varied based on device-detected AF burden (≥6 minutes: 272/2101 [13%]; >1 hour: 273/1712 [16%]; >6 hours: 263/1279 [21%]; >24 hours: 224/818 [27%]). Across 52 sites (N=1329 patients), there was substantial site-level variation in OAC prescription after device-detected AF >1 hour (median, 16%; range, 3%-67%; median odds ratio, 1.56 [95% credible interval, 1.49-1.71]). In adjusted models, OAC prescription after device-detected AF >24 hours was associated with reduced stroke risk (hazard ratio, 0.28; 95% CI, 0.10-0.81; P=0.02), although the propensity-adjusted model was significant when AF lasted at least 6 minutes.
CONCLUSIONS:
Among veterans with cardiac implantable electronic devices, device-detected AF is common. There is large practice variation in 90-day OAC initiation after new device-detected AF, with low rates of treatment overall, even for episodes that last >24 hours. The strongest association of OAC with reduction in stroke was observed after device-detected AF >24 hours. Randomized trials are needed to confirm these observational findings.

US-Studie 2011-2016: Die mittels Zio^XT ermittelte Flimmerlast (Dauer von VHF oder VoFla in % der 14-tägigen Monitoring-Periode) war bei 1.965 Erwachsenen im Alter von durchschnittlich 69 Jahren mit dem Schlaganfallrisiko korreliert. Das CHADS-VASc-adjustierte Risiko für einen Schlaganfall war bei einer Flimmerlast ≥11.4 % (oberes Tertial) mehr als 3-mal so hoch wie in den anderen Tertialen. Dieses Resultat war über alle demografischen und klinischen Subgruppen konsistent.

IMPORTANCE:
Atrial fibrillation is a potent risk factor for stroke, but whether the burden of atrial fibrillation in patients with paroxysmal atrial fibrillation independently influences the risk of thromboembolism remains controversial.
OBJECTIVE:
To determine if the burden of atrial fibrillation characterized using noninvasive, continuous ambulatory monitoring is associated with the risk of ischemic stroke or arterial thromboembolism in adults with paroxysmal atrial fibrillation.
DESIGN, SETTING, AND PARTICIPANTS:
This retrospective cohort study conducted from October 2011 and October 2016 at 2 large integrated health care delivery systems used an extended continuous cardiac monitoring system to identify adults who were found to have paroxysmal atrial fibrillation on 14-day continuous ambulatory electrocardiographic monitoring.
EXPOSURES:
The burden of atrial fibrillation was defined as the percentage of analyzable wear time in atrial fibrillation or flutter during the up to 14-day monitoring period.
MAIN OUTCOMES AND MEASURES:
Ischemic stroke and other arterial thromboembolic events occurring while patients were not taking anticoagulation were identified through November 2016 using electronic medical records and were validated by manual review. We evaluated the association of the burden of atrial fibrillation with thromboembolism while not taking anticoagulation after adjusting for the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) or CHA2DS2-VASc stroke risk scores.
RESULTS:
Among 1965 adults with paroxysmal atrial fibrillation, the mean (SD) age was 69 (11.8) years, 880 (45%) were women, 496 (25%) were persons of color, the median ATRIA stroke risk score was 4 (interquartile range [IQR], 2-7), and the median CHA2DS2-VASc score was 3 (IQR, 1-4). The median burden of atrial fibrillation was 4.4% (IQR ,1.1%-17.23%). Patients with a higher burden of atrial fibrillation were less likely to be women or of Hispanic ethnicity, but had more prior cardioversion attempts compared with those who had a lower burden. After adjusting for either ATRIA or CHA2DS2-VASc stroke risk scores, the highest tertile of atrial fibrillation burden (≥11.4%) was associated with a more than 3-fold higher adjusted rate of thromboembolism while not taking anticoagulants (adjusted hazard ratios, 3.13 [95% CI, 1.50-6.56] and 3.16 [95% CI, 1.51-6.62], respectively) compared with the combined lower 2 tertiles of atrial fibrillation burden. Results were consistent across demographic and clinical subgroups.
CONCLUSIONS AND RELEVANCE:
A greater burden of atrial fibrillation is associated with a higher risk of ischemic stroke independent of known stroke risk factors in adults with paroxysmal atrial fibrillation.

„Real-Life“-Studie aus Dänemark zum Screening auf Vorhofflimmern (VHF) bei über 65-Jährigen. 970 Patienten wurden mittels Pulspalpation und (bei unregelmäßigem Puls) anschließendem 12-Kanal-EKG untersucht. Unregelmäßiger Puls war bei 4.4 % (65-74 Jahre) bzw. 10.5 % (75-84 Jahre) bzw. 22.9 % (≥85 Jahre) vorhanden, VHF wurde bei 0.83 bzw. 0.54 bzw. 3.39 % bestätigt. Allgemeinmediziner vermuteten bei 13 EKG VHF, welches von Kardiologen bei 10 EKG bestätigt wurde.

Atrial fibrillation (AF) is a chronic disease with an incidence increasing steeply by age and affecting more than 11 million patients in Europe and the United States. Diagnosing AF is essential for the prevention of stroke by oral anticoagulation. Opportunistic screening for AF in patients ≥65 years of age is recommended by the European and Danish Societies of Cardiology. The study aim was to examine the detection rate of AF in consecutively screened patients in the primary care setting in Denmark. In an open, non-interventional, cluster, multicenter, cross-sectional, observational study patients ≥65 years of age entering consecutively into general practice clinics were invited to nurse-assisted opportunistic screening for AF. The General Practice (GP) clinics participating were randomized to patient inclusion in three age groups: 65-74, 75-84, and ≥85 years respectively. All patients underwent pulse palpation followed by 12-led electrocardiogram in case of irregular pulse. Two cardiologists validated all electrocardiogram examinations. Forty-nine general practice clinics recruited in total 970 patients split into three age groups; 480 patients (65-74 years), 372 (75-84 years), and 118 patients ≥85 years of age. Co-morbidities increased by age with hypertension being most frequent. Eighty-seven patients (9%) were detected with an irregular pulse, representing 4.4%, 10.5% and 22.9%, respectively in the three age groups. Assessment of electrocardiograms by the GP showed suspicion of AF in 13 patients with final verification of electrocardiograms by cardiologists revealing 10 AF-patients. The highest detection rate of AF was found in the ≥85 age group (3.39%) followed by the 65-74 age group (0.83%) and the 75-84 age group (0.54%). Opportunistic screening of AF in primary care is feasible and do result in the detection of new AF-patients. Close collaboration with cardiologists is advisable to avoid false positive screening results.

Von 205 Finnen im Alter ≥75 Jahren erlernten 139 (68%) die Puls-Selbstkontrolle. Signifikante Prädiktoren für den Lernerfolg waren ein hoher Mini-Mental State Examination score (>24) (OR 7.5, 95% CI 1.5-37.3, p = 0.014), PC-Benutzung zu Hause (OR 4.7, 95% CI 1.9-11.5, p = 0.001), Unabhängigkeit bei alltäglichen Aktivitäten (OR 4.2, 95% CI 1.4-13.6, p = 0.013) und niedrige Herzfrequenz (OR 1.04, 95% CI 1.0-1.08, p = 0.037). Die Puls-Selbstkontrolle führte nicht zur vermehrten Inanspruchnahme örtlicher Einrichtungen des Gesundheitswesens und beeinträchtigte die Lebensqualität nicht. Innerhalb eines Monats entdeckten vier Teilnehmer neues asymptomatisches Vorhhofflimmern.

BACKGROUND:
Early detection of atrial fibrillation (AF) in older people is important because AF is often asymptomatic and its first manifestation may be a disabling stroke. The objective of the LietoAF Study is to assess the motivation and capability of older people to learn pulse palpation and continue regular pulse measurements, and whether this self-assessment is helpful in the detection of new AF.
DESIGN AND METHOD:
The LietoAF Study is an intervention study. A total of 205 people aged ≥75 years were randomly selected to participate in the programme where a trained nurse gave individual education on pulse palpation. At 1 month, the eligible participants came to the first follow-up visit to assess the success of pulse self-monitoring.
RESULTS:
A total of 139 participants (68%) learned pulse palpation and performed regular measurements during the early follow-up period. The significant independent predictors for learning and motivation were high Mini-Mental State Examination score (>24) (OR 7.5, 95% CI 1.5-37.3, p = 0.014), computer use at home (OR 4.7, 95% CI 1.9-11.5, p = 0.001), independence at daily activities (OR 4.2, 95% CI 1.4-13.6, p = 0.013) and low heart rate (OR 1.04, 95% CI 1.0-1.08, p = 0.037). Education did not cause extra visits to local healthcare centres and did not affect quality of life. Four participants observed a new asymptomatic AF during the 1-month follow-up.
CONCLUSION:
Active older people are motivated and seem to learn pulse palpation. Our early experience suggests that simple nurse-based education is effective and useful in the early detection of asymptomatic AF.

Nach kurzer Anleitung durch eine Pflegefachkraft und 1-monatiger Puls-Selbstkontrolle konnten 173 finnische ≥75-Jährige mit vergleichbarer Zuverlässigkeit wie 57 Profis (10 Pflegefachkräfte, 17 Paramedic-Studenten im letzten Ausbilungsjahr, 15 Pflege-Studenten im letzten Ausbildungsjahr und 15 Paramedic-Studentens im vorletzten Ausbildungsjahr) zwischen Sinusrhythmus (SR), Sinusrhythmus mit Extrasystolen (SR+ES) und Vorhofflimmern (VHF) unterscheiden. 25 von ihnen (14.5 %) mussten allerdings ausgeschlossen werden, weil sie den Puls nicht tasten konnten. Bzgl. der Detektion von SR (97.3% vs. 96.5%) und SR+ES (74.3% vs. 71.4%) bestanden keine signifikanten Unterschiede, langsames VHF (81.8% vs. 56.1%) und schnelles VHF (91.9% vs. 80.7%) wurde von den älteren Menschen aber zuverlässiger detektiert als von den Profis.

PURPOSE:
Atrial fibrillation (AF) may first present as an ischemic stroke. Pulse palpation is a potential screening method for asymptomatic AF. We aimed to assess the reliability of pulse palpation by the elderly in detecting AF.
MATERIALS AND METHODS:
After brief information and training session conducted by a nurse, 173 subjects aged ≥75 years were instructed to palpate their pulse regularly for a month. After this, their ability to distinguish sinus rhythm (SR), SR with premature ventricular contractions (PVC) and AF by pulse palpation was assessed using an anatomic human arm model programmable with various rhythms. A control group of 57 healthcare professionals received the same information but not the training. Subjects unable to find the pulse were excluded (25 (14.5%) of the elderly and none in the healthcare group).
RESULTS:
The median age of the elderly subjects was 78.4 [3.9] years and 98 (56.6%) were women. There were no differences between the elderly and healthcare groups in detecting SR (97.3% vs. 96.5%) or SR with PVCs (74.3% vs. 71.4%), but the elderly subjects identified slow (81.8% vs. 56.1%) and fast AF (91.9% vs. 80.7%) significantly better than the healthcare group. The ability to recognize SR with PVCs by the elderly was independently predicted by previous pulse palpation experience, secondary or higher level of education and one-point increase in MMSE score, while identifying the other rhythms had no predictors.
CONCLUSIONS:
The elderly can learn to reliably distinguish a normal rhythm after education. Pulse self-palpation may be a useful low-cost method to screen for asymptomatic AF.

Background: Many patients report symptoms of palpitations or dizziness/presyncope. These patients are often referred for 24-hour Holter ECG, although the sensitivity for detecting relevant arrhythmias is comparatively low. Intermittent short ECG recording over a longer time period might be a convenient and more sensitive alternative. The objective of this study is to compare the efficacy of 24-hour Holter ECG with intermittent short ECG recording over four weeks to detect relevant arrhythmias in patients with palpitations or dizziness/presyncope.
Methods: Design: prospective, observational, cross-sectional study. Setting: Clinical Physiology, University Hospital. Patients: 108 consecutive patients referred for ambiguous palpitations or dizziness/presyncope. Interventions: All individuals underwent a 24-hour Holter ECG and additionally registered 30-second handheld ECG (Zenicor EKG® thumb) recordings at home, twice daily and when having cardiac symptoms, during 28 days. Main outcome measures: Significant arrhythmias: atrial fibrillation (AF), paroxysmal supraventricular tachycardia (PSVT), atrioventricular (AV) block II–III, sinus arrest (SA), wide complex tachycardia (WCT).
Results: 95 patients, 42 men and 53 women with a mean age of 54.1 years, completed registrations. Analysis of Holter registrations showed atrial fibrillation (AF) in two patients and atrioventricular (AV) block II in one patient
(= 3.2% relevant arrhythmias [95% CI 1.1–8.9]). Intermittent handheld ECG detected nine patients with AF, three with paroxysmal supraventricular tachycardia (PSVT) and one with AV-block-II (= 13.7% relevant arrhythmias [95% CI 8.2–22.0]). There was a significant difference between the two methods in favour of intermittent ECG with regard to the ability to detect relevant arrhythmias (P = 0.0094). With Holter ECG, no symptoms were registered during any of the detected arrhythmias. With intermittent ECG, symptoms were registered during half of the arrhythmia episodes.
Conclusions: Intermittent short ECG recording during four weeks is more effective in detecting AF and PSVT in patients with ambiguous symptoms arousing suspicions of arrhythmia than 24-hour Holter ECG.

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. opens in new tab.)

Background
Low detection and nonadherence are major problems in current management approaches for patients with suspected atrial fibrillation (AF). Mobile health devices may enable earlier AF detection and improved AF management.

Objectives
This study sought to investigate the effectiveness of AF screening in a large population-based cohort using smart device–based photoplethysmography (PPG) technology, combined with a clinical care AF management pathway using a mobile health approach.

Methods
AF screening was performed with smart devices using PPG technology, which were made available for the population ≥18 years of age across China. Monitoring for at least 14 days with a wristband (Honor Band 4) or wristwatch (Huawei Watch GT, Honor Watch, Huawei Technologies Co., Ltd., Shenzhen, China) was allowed. The patients with “possible AF” episodes using the PPG algorithm were further confirmed by health providers among the MAFA (mobile AF app) Telecare center and network hospitals, with clinical evaluation, electrocardiogram, or 24-h Holter monitoring.

Results
There were 246,541 individuals who downloaded the PPG screening app, and 187,912 individuals used smart devices to monitor their pulse rhythm between October 26, 2018, and May 20, 2019. Among those with PPG monitoring (mean age 35 years, 86.7% male), 424 (of 187,912, 0.23%) (mean age 54 years, 87.0% male) received a “suspected AF” notification. Of those effectively followed up, 227 individuals (of 262, 87.0%) were confirmed as having AF, with the positive predictive value of PPG signals being 91.6% (95% confidential interval [CI]: 91.5% to 91.8%). Both suspected AF and identified AF markedly increased with age (p for trend <0.001), and individuals in Northeast China had the highest proportion of detected AF of 0.28% (95% CI: 0.20% to 0.39%). Of the individuals with identified AF, 216 (of 227, 95.1%) subsequently entered a program of integrated AF management using a mobile AF application; approximately 80% of high-risk patients were successfully anticoagulated. Conclusions
Based on the present study, continuous home monitoring with smart device–based PPG technology could be a feasible approach for AF screening. This would help efforts at screening and detection of AF, as well as early interventions to reduce stroke and other AF-related complications. (Mobile Health [mHealth] Technology for Improved Screening, Patient Involvement and Optimizing Integrated Care in Atrial Fibrillation [MAFA II]; ChiCTR-OOC-17014138)

Aims

To study the prevalence of unknown atrial fibrillation (AF) in a high-risk, 75/76-year-old, population using N-terminal B-type natriuretic peptide (NT-proBNP) and handheld electrocardiogram (ECG) recordings in a stepwise screening procedure.

Methods and results

The STROKESTOP II study is a population-based cohort study in which all 75/76-year-old in the Stockholm region (n = 28 712) were randomized 1:1 to be invited to an AF screening programme or to serve as the control group. Participants without known AF had NT-proBNP analysed and were stratified into low-risk (NT-proBNP <125 ng/L) and high-risk (NT-proBNP ≥125 ng/L) groups. The high-risk group was offered extended ECG-screening, whereas the low-risk group performed only one single-lead ECG recording. In total, 6868 individuals accepted the screening invitation of which 6315 (91.9%) did not have previously known AF. New AF was detected in 2.6% [95% confidence interval (CI) 2.2–3.0] of all participants without previous AF. In the high-risk group (n = 3766/6315, 59.6%), AF was diagnosed in 4.4% (95% CI 3.7–5.1) of the participants. Out of these, 18% had AF on their index-ECG. In the low-risk group, one participant was diagnosed with AF on index-ECG. The screening procedure resulted in an increase in known prevalence from 8.1% to 10.5% among participants. Oral anticoagulant treatment was initiated in 94.5% of the participants with newly diagnosed AF.

Conclusion

N-terminal B-type natriuretic peptide-stratified systematic screening for AF identified 4.4% of the high-risk participants with new AF. Oral anticoagulant treatment initiation was well accepted in the group diagnosed with new AF.

Atrial fibrillation (AF) causes a third of all strokes, but often goes undetected before stroke. Identification of unknown AF in the community and subsequent anti-thrombotic treatment could reduce stroke burden. We investigated community screening for unknown AF using an iPhone electrocardiogram (iECG) in pharmacies, and determined the cost-effectiveness of this strategy. Pharmacists performed pulse palpation and iECG recordings, with cardiologist iECG over-reading. General practitioner review/12-lead ECG was facilitated for suspected new AF. An automated AF algorithm was retrospectively applied to collected iECGs. Cost-effectiveness analysis incorporated costs of iECG screening, and treatment/outcome data from a United Kingdom cohort of 5,555 patients with incidentally detected asymptomatic AF. A total of 1,000 pharmacy customers aged ≥65 years (mean 76 ± 7 years; 44% male) were screened. Newly identified AF was found in 1.5% (95% CI, 0.8–2.5%); mean age 79 ± 6 years; all had CHA2DS2-VASc score ≥2. AF prevalence was 6.7% (67/1,000). The automated iECG algorithm showed 98.5% (CI, 92–100%) sensitivity for AF detection and 91.4% (CI, 89–93%) specificity. The incremental cost-effectiveness ratio of extending iECG screening into the community, based on 55% warfarin prescription adherence, would be $AUD5,988 (€3,142; $USD4,066) per Quality Adjusted Life Year gained and $AUD30,481 (€15,993; $USD20,695) for preventing one stroke. Sensitivity analysis indicated cost-effectiveness improved with increased treatment adherence. Screening with iECG in pharmacies with an automated algorithm is both feasible and cost-effective. The high and largely preventable stroke/thromboembolism risk of those with newly identified AF highlights the likely benefits of community AF screening. Guideline recommendation of community iECG AF screening should be considered.

DOI: 10.1160/TH14-03-0231

A paucity of data exists on the accuracy of primary care physicians’ (PCP) interpretation of KardiaMobile ECGs compared with the device’s automated diagnosis. Using 408 ECGs in 51 patients, before and after elective cardioversion, this study demonstrated variable accuracy in clinician interpretation, with a mean accuracy of 91% for the review by cardiologists, and 85% accuracy for the review by PCPs. With exclusion of Unclassified ECGs, the algorithm accuracy had a sensitivity and specificity of 100% and 95%, respectively. Accurate diagnosis of a KardiaMobile Unclassified ECG was established in 10⁄12 when assessed by a cardiologist, and 9⁄12 on review by a primary care physician. Combining the automated algorithm with cardiologist interpretation of only Unclassified traces yielded excellent results and provides an efficient, cost-effective workflow for the utilization of a smartphone-based ECG in clinical practice.

doi: 10.1016/j.ahj.2018.08.001

Hintergrund

Patienten mit Palpitationen und Beinahe-Synkope stellen sich häufig in der Notaufnahme vor, ohne dass der den Symptomen zugrundeliegende Herzrhythmus bei der ersten Vorstellung identifiziert werden kann. Diese Studie vergleicht die Erkennungsrate für den symptombegleitenden Rhythmus eines Smartphone-basierten Eventrecorders (AliveCor) in Kombination mit Standarddiagnostik versus alleiniger Standarddiagnostik für Patienten, die sich wegen Palpitationen oder Präsynkope in einer Notaufnahme vorstellen, ohne dass bei der Erstkonsultation dafür ein offensichtlicher Grund gefunden wurde.

Methoden

Multizentrische randomisierte kontrollierte Open-Label-Studie. Patienten im Alter ≥16 Jahren, die sich in einer der Notaufnahmen von zehn britischen Krankenhäusern vorstellten, wurden eingeschlossen. Die Teilnehmer wurden randomisiert entweder (a) der Interventionsgruppe; Standarddiagnostik plus Einsatz eines Smartphone-basierten Eventrecorders oder (b) der Kontrollgruppe; nur Standarddiagnostik zugeteilt. Primärer Endpunkt war die Detektion des symptomatischen Rhythmus nach 90 Tagen. Trial registration number NCT02783898 (ClinicalTrials.gov).

Ergebnisse

Von 1.635 Patienten zwischen Juli 2016 und Januar 2018 wurden 1.392 ausgeschlossen, am häufigsten wegen vorheriger diagnostischer EKG-Befunde (n=403) oder Konsultation außerhalb der Öffnungszeiten (n=509). 242 Patienten im Alter von durchschnittlich 39.6 Jahren wurden randomisiert der Interventionsgruppe (n=125) oder Kontrollgruppe (n=117) zugeteilt. Eine symptomatische Herzrhythmusstörung wurde innerhalb von 90 Tagen bei 69 (55.6%; 95% CI 46.9–64.4%) Studienteilnehmern in der Interventionsgruppe versus 11 (n = 116; 9.5%; 95% CI 4.2–14.8) in der Kontrollgruppe gefunden (RR 5.9, 95% CI 3.3–10.5; p < 0.0001). Die mittlere Zeit bis zur Dokumentation betrug in der Interventionsgruppe 9.5 Tage (SD 16.1, range 0–83) versus 42.9 Tage (SD 16.0, range 12–66; p < 0.0001) in der Kontrollgruppe. Die am häufigsten dokumentierten Rhythmen bei Symptomatik waren Sinusrhythmus, Sinustachykardie und Extrasystolen. Eine symptomatische Arrythmie wurde innerhalb von 90 Tagen bei 11 (n = 124; 8.9%; 95% CI 3.9–13.9%) Teilnehmern in der Interventionsgruppe versus 1 (n = 116; 0.9%; 95% CI 0.0–2.5%) in der Kontrollgruppe (RR 10.3, 95% CI 1.3–78.5; p = 0.006) dokumentiert.

Interpretation

Die Anwendung eines Smartphone-basierten Eventrecorders erhöht die Anzahl von Patienten, bei denen während ihrer Symptomatik ein EKG dokumentiert werden kann um mehr als das 5-fache auf mehr als 55 % innerhalb von 90 Tagen. Dieses sichere, nicht-invasive and einfach zu benutzende Device sollte als Bestandteil der Diagnostik für alle Patienten erwogen werden, die sich akut wegen unerklärte Palpitationen oder Präsynkope vorstellen.

The psychology of patient interaction with ‘smart’ personal medical devices is an emerging field, and better understanding of patient/device interaction is likely to be important in realising the potential benefits of new technologies.