Cardiovascular Rounds

From risk factors to Apple apps: 4 major trends in the arrhythmia world

by Megan Tooley and Julie Bass

Patients with atrial fibrillation (AF) and other cardiac arrhythmias are particularly complex to manage due to the chronic, often comorbid nature of these patient populations. Heart rhythm disorders affect patients both within and outside the CV service line—in fact, 17% of all admitted patients in the United States have some type of arrhythmia.

But that's not the most concerning point: The prevalence of atrial fibrillation (AF) is expected to grow to 12.1 million by 2030, more than double the 5.1 million cases in 2010.

With a growing patient population to manage, the health care market is doubling down on efforts to improve care and treatment for arrhythmias, as evidenced by the range of exciting development showcased at the recent 2017 Heart Rhythm Society (HRS) Scientific Sessions. Here's an overview of four major trends from these sessions and across the arrhythmia world.

1. New research focuses on risk factor management

  • Lean body mass and AF: Research in the past two decades has demonstrated that obesity is a well-established risk factor for AF. However, a new study in the Journal of the American College of Cardiology concluded lean body mass to be the primary anthropometric risk factor for AF—not obesity. The authors researched almost 4,000 patients with AF to analyze the association between various risk factors and development of the disease, and found that none of the obesity-related measures had significant independent influence with development of an arrhythmia.

  • Alcohol consumption and arrhythmias: While alcohol is known to be risk factor for cardiac arrhythmias, a recent study in the European Heart Journal aimed to prospectively link alcohol consumption with arrhythmias. Set during 2015's Munich Octoberfest, the aptly abbreviated “MunichBREW” trial studied over 3,000 participants using smartphone-based ECGs and breath alcohol concentration measurements. The authors concluded that acute alcohol consumption is in fact associated with cardiac arrhythmias—sinus tachycardia in particular.

  • Delayed treatment and dementia risk: Researchers from Intermountain Healthcare presented new research at HRS 2017 suggesting that delayed use of anticoagulants for AF patients could increase risk of dementia. The study followed more than 76,000 AF patients with no history of dementia from time of AF diagnosis to start of therapy—one group received immediate treatment within 30 days and the other received delayed treatment starting after one year. The study found that risk of dementia in the delayed treatment group was 30% higher for low-risk patients and 136% higher for high-risk patients.

  • Regional variation in CV mortality: If you're interested in geographic variation in AF mortality, see the Journal of the American Medical Association's new study on regional variation in CV mortality across the US. Among the 314,988 deaths due to AF between 1980-2014, counties with the highest age-standardized AF mortality rate were highest in the Northwest/Mountain region (Oregon, northern California, Utah, Idaho, northeastern Montana). Counties with the lowest mortality rates were in South Dakota, Iowa, along the Mississippi River from Illinois to the Gulf of Mexico, and along the border of the United States and Mexico.

2. Wearable monitors: The future of ECG monitoring?

  • The Zio monitor: In a recent study, iRhythm's Zio monitor demonstrated superiority in detecting AF over traditional Holter monitoring. The Zio monitor is a wearable patch that patients can wear throughout normal daily activities for a longer period of time compared to Holter. Researchers compared Holter monitor results (wearable for 24 hours) to Zio monitor results (wearable for up to 14 days) in 116 patients with history of prior stroke or transient ischemic attack (TIA). Paroxysmal AF was detected in 16.3% of patients with a Zio monitor compared to 2.1% of patients using the Holter monitor.

  • Cardea Solo: FDA recently approved Cardea Solo, a wearable ECG sensor from Cardiac Insight. The ECG is leadless, water-resistant, and wearable up to seven days. The sensor records ECG data and patient symptoms, and once removed the recorded cardiac data can be analyze via software in a physician's office

  • An Apple Watch app: The wave has even hit Apple Watches: New Health eHeart results announced at HRS 2017 found that artificial intelligence analyzing data from Cardiogram (a heart rate monitoring app) successfully detects AF in the Apple Watch wearer. The study enrolled more than 6,000 participants and collected more than 139 million heart rate measurements to train a deep neural network (artificial intelligence) to detect AF from normal heart rhythm.

3. Implantable devices are still essential for long-term monitoring

  • Abbott's Confirm Rx ICM device: The smartphone-compatible cardiac monitor recently gained CE mark. Several countries in Europe are implanting the device, and it's currently waiting for FDA approval. The device continuously transmits data through the MyMerlin application and allows patients and physicians to remotely monitor heart rhythm activity. This eliminates the burden on patients to actively transmit their own data and could potentially reduce physician follow-up frequency in the future.

  • Older patients can use apps, too: A recent Medtronic study evaluated 15,595 patients with Medtronic pacemakers assigned to use a MyCareLink app-based remote monitor. The study concluded that 88% of patients of all ages successfully activated the app, and almost 90% were adherent by transmitting data to Medtronic's CareLink network within one year. Interestingly, age was not a significant factor in adherence: levels of adherence ranged from 89.7% among patients 71+, 86.7% in patients 18-50, and 91% in patients 51-70 years of age. This is important data for many providers that may misperceive older patients as less able to adapt to new technologies.

4. New guideline updates for 2017 support evidence-based practice for arrhythmias

Three new guidelines in the past few months provide updates on evidence-based treatment for arrhythmias, primarily catheter and surgical ablation:

  • 2017 Heart Rhythm Society expert consensus statement on catheter and surgical ablation of AF (an update to the society's 2014 guidelines);
  • 2017 Society for Thoracic Surgeons (STS) guidelines for the surgical treatment of AF; and
  • 2017 American Association for Thoracic Surgery (AATS) expert consensus guidelines for surgical ablation for AF.

All societies conclude that catheter and surgical ablation of AF are important treatment options for patients with AF and some other arrhythmias.

Notably, many of the guidelines indicate that while there have been many advancements in the field of surgical ablation—still a relatively new treatment within the past three decades—there is currently no consensus on optimal technique or outcome expectation. However, both surgical societies note that based on comprehensive literature reviews, surgical ablation can reduce AF burden and improve quality of life, particularly for persistent AF patients for whom catheter ablation has failed. Further indications for both catheter and surgical ablations are included in depth in the guidelines.

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