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NEW ORLEANS – In the first study of this type involving more than 400,000 members of the population, the use of an Apple Watch to identify irregular heartbeats has been shown to be useful for the study. identification of atrial fibrillation (AF).
The watch identified an irregular rhythm in 0.5% of the total population of the study and in those who were followed later with an electrocardiogram (ECG) patch, it showed a positive predictive value for FA detection of 0.84.
"The positive predictive value of 84% reinforces the ability to correctly identify AF among people reporting an irregular rhythm through the watch," concluded co-principal investigator, Marco Perez, MD at the University of Toronto. Stanford, Calif., At its presentation today at the College of Cardiology, 68th Annual Scientific Session 2019 (ACC.19).
"Positive notification from the watch could therefore help to inform clinical badessment as well as clinical history and examination."
His co-principal, Mintu Turakhia, MD, Stanford School of Medicine, added, "This study helps us better understand how this portable technology and application work in the real world and how long it can detect long periods of time. from FA. "
Kenneth Mahaffey, MD, Stanford University, Head of Research, commented theheart.org | Medscape Cardiology: "I think the results confirm that the algorithm and accuracy around the measurements we have made are a proper basis for going forward and deepening this thinking on how to incorporate it into the clinical care. "
Delegates at the ACC.19 meeting expressed very divergent views on how this technology should be integrated into clinical practice.
Matthew Martinez, MD, chairman of the ACC Sports and Exercise Council and cardiologist at the Lehigh Valley Health Health Network, located in Allentown, Pennsylvania, has been enthusiastic about the new technology.
"This study shows that the use of an Apple Watch is an option to help detect autofocus.This technology is emerging, whether we like it or not. technology here is ahead of science, but we have to try to follow as best we can, "he said. theheart.org | Medscape Cardiology.
Martinez said he was "stunned and encouraged" by the rate of reporting irregular rhythms by 0.5% in the study. "It's far less than I expected and makes this approach workable in my opinion." On the positive predictive value of 85%, he said, "It's a good number, it's a good place to start."
But, in contrast, Ray Gibbons, MD, Mayo Clinic, Rochester, Minnesota, and former CCA president, was clearly unimpressed by the Apple study.
"It's very preliminary and not ready for prime time," he said. theheart.org | Medscape Cardiology. "Monitoring FA is a good idea only if a patient has a reasonable chance of having AF." The group of AF patients is made up of older people who do not wear an Apple watch. study were young, but is not a major health problem in young people.
"It's like ordering a coronary calcium score for a 35-year-old birthday gift," he said. "And for the older population, we have many alternative technologies to detect AF that have been better validated, so it's hard to know where this fits."
Gibbons believes that new Apple technology will increase health costs without improving public health. "It's a gift for hospital administrators. This will encourage young people who have a very low risk of developing serious health problems to consult their doctor and undergo several tests that are heavily reimbursed. "
He adds that this could overburden primary care physicians, who already have other problems with far more serious consequences for their health. "I would prefer that they devote their time and energy to treating high blood pressure and ensuring compliance with secondary prevention drugs for people with known coronary heart disease."
For the study, 419,297 US residents aged 22 years and older (mean age 40 years) enrolled for 8 months and wore the watch, which pbadively measured their heart rate with periodic point-in-time measurements.
The occurrence of an irregular rhythm in five out of six measures triggered a notification for the user to contact a telehealth doctor and send an ECG patch to the doctor. user, if any. The patch was worn for an additional week with the watch to detect AF.
The results showed that 2162 participants (0.5% of those enrolled) received an irregular pulse notification. It was, as expected, highly dependent on age. Of the 200,000 participants under the age of 40, the notification rate was 0.16%, compared to 3.2% for the 25,000 population aged 65 and over.
Turakhia called these numbers "very encouraging, as it shows that our understanding of AF is more common with age".
In total, an ECG patch was sent to 658 participants. 450 patches were returned and included in the badyzes.
When comparing pulse and simultaneous ECG patch recordings in 450 participants wearing both, the researchers found that the positive predictive value for an individual measure of irregular rhythm was 71% and the positive predictive value for the notification (triggered). irregular rhythms detected in five of the six measures) was 84%.
However, only 34% of those who had received an irregular pulse notification on their watch had an FA based on wearing an ECG patch more than a week later.
Turakhia said that it was not totally unexpected. "AF can appear and disappear, especially early in the course of the disease.It is not surprising that it is not detected during subsequent monitoring of the ECG patch," he said. -he declares.
"So while only 34% of people who still had atrial fibrillation on the outpatient ECG, that does not mean that the remaining 66% did not have atrial fibrillation." It simply means that fibrillation Auricular may not have been present at the time, "he said. I said. "These settings help us understand how, as clinicians, we should think about these notifications."
Of the patients diagnosed with AF, 89% had episodes lasting longer than 1 hour.
Of those who received an irregular pulse notification via the application, about half eventually established contact with the study physician, but the researchers said the others might have looked for care elsewhere. In subsequent investigations, 57% of those alerted said they consulted a doctor outside of the study, as they were seen virtually by a doctor in the study.
About one-third of those who received a notification had a CHADS-VASc score of 2 or greater.
The researchers in the study said the next obvious step was to study how this technology could be used in addition to other technologies, such as real-time ECG and other tools validated, to manage heart rhythm problems.
Martinez said the patients had already adopted this new technology. "I have been diagnosing in the last few weeks two AF patients who had entered because they had detected an abnormal rate on their Apple watches." If someone calls me out and tells me that his pace is abnormal, I ask him to e-mail a copy of the pulse control tape from the phone application, "he said.
"I would tell people that if you have an abnormal rhythm on the phone, go see a doctor.If you already have a cardiologist, go see them," said Martinez. "If you do not, a primary care physician is a good starting point because there's really no reason why they can not order the same tests, such as an ECG patch or Another type of surveillance – to primary care physicians – I would say, do not ignore it – I would say at least that it is worthwhile to continue the badessment for a short time. "
Mahaffey added, "My message to primary care physicians is to continue to evaluate patients with a good history, a physical examination, and an badessment of risk factors.The notification in the eve can be used as another data point in their badessment of whether to be done. "
At a more general discussion about the impact of digital technology on clinical practice, participants were generally extremely optimistic.
Turakhia pointed out that this study on Apple "really represents a paradigm shift in how clinical studies can be conducted.We do not have to get people to a physical clinic and to perform the intervention at the study ".
Paul Stoffels, MD, Scientific Director of Johnson & Johnson, has described a new randomized controlled trial starting this year comparing the Apple Watch to a control for the diagnosis of FA, which will also follow difficult clinical outcomes, such as infarction myocardium, stroke, and death.
"This study will examine whether digital health can have a real impact on events," said Stoffels.
Harlan Krumholz, MD, Yale School of Medicine, New Haven, Connecticut, said, "We are about to see a digital transformation, and there has never been such an exciting time in medicine."
John Rumsfeld, MD, director of innovation at VAC, concluded by stating, "I think we should all believe that in the future, digital health and medicine will simply call health and medicine ".
The Apple study was funded by Apple Inc. Turakhia announces fees and consulting fees from AliveCor and Cardiva Medical. Perez reports consultations and fees from Apple.
American College of Cardiology 68th Annual Scientific Session 2019 (ACC.19). Presented on March 16, 2019.
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