Atrial fibrillation: epidemiology, screening and digital health.

Atrial fibrillation (AF) is highly prevalent with a lifetime risk of about 1 in 3-5 individuals after the age of 45 years. Between 2010 and 2019, the global prevalence of AF has risen markedly from 33.5 million to 59 million individuals living with AF. Early detection of AF and implementation of appropriate treatment could reduce the frequency of complications associated with AF. International AF management guidelines recommend opportunistic and systematic screening for AF, but additional data are needed. Digital approaches and pathways have been proposed for early detection and for the transition to early AF management. Mobile health (mHealth) devices provide an opportunity for digital screening and should be part of novel models of care delivery based on integrated AF care pathways. For a broad implementation of mHealth-based, integrated care for patients with chronic diseases as AF, further high quality evidence is necessary. In this review, we present an overview of the present data on epidemiology, screening techniques, and the contribution of digital health solutions to the integrated management of AF. We also provide a systemic review on current data of digital and integrated AF management.

The impact of Twitter/X promotion on visibility of research articles: Results of the #TweetTheJournal study.

Aim: Social media (SoMe) are emerging as important tools for research dissemination. Twitter/X promotion has been shown to increase citation rates in well-established journals. We aimed to test the effect of a SoMe promotion strategy on the Mendeley reader counts, the Altmetric Attention Score and the number of citations in an upcoming open-access journal. Methods: The #TweetTheJournal study is a randomized, controlled study. Articles published in seven subsequent issues of the International Journal of Cardiology Heart & Vasculature (April 2021-April 2022) were randomized to a Twitter/X promotion arm (articles were posted four times) and to a control arm (without active posting). Articles with accompanied editorials were excluded. Primary endpoint of the study was Mendeley reader count, secondary endpoints were Altmetric Attention Score and number of citations. Follow-up was one year. Results: SoMe promotion of articles showed no statistically significant difference in Mendeley reader counts or number of citations at one year follow up. SoMe promotion resulted in a statistically significant higher Altmetric Attention Score in the intervention compared to the control group (RR 1.604, 95 % CI 1.024-2.511, p = 0.039). In the overall group, Altmetric Attention Score showed a correlation with Mendeley reader counts (Spearman's ρ = 0.202, p = 0.010) and Mendeley reader counts correlated significantly with number of citations (Spearman's ρ = 0.372, p < 0.001). Conclusion: A dedicated SoMe promotion strategy did not result in statistically significant differences in early impact indicators as the Mendeley reader count in a upcoming journal, but increased the Altmetric Attention Score.

[Characterization of atrial fibrillation burden using wearables]. / Charakterisierung der Vorhofflimmerlast mittels Wearables.

The characterization of atrial fibrillation (AF) according to current guidelines categorically refers to the differentiation between paroxysmal, persistent, and permanent AF. A more precise characterization of AF, including the evaluation of AF burden, is playing an increasingly significant role in both scientific research and clinical practice. Digital devices, especially those with the capability of passive (semi-)continuous recording, can contribute to a more accurate quantification of AF burden. Particularly in patients with an already established diagnosis of AF, the evaluation of AF burden can be used to monitor the success of antiarrhythmic therapy including antiarrhythmic drugs or pulmonary vein isolation. However, important questions remain unanswered: In addition to a uniform, evidence-based definition of AF burden, clinically relevant cut-offs for AF burden and resulting therapeutic consequences (e.g., subclinical AF) need to be elaborated. Furthermore, the establishment and evaluation of care structures for assessing and integrating AF burden in clinical care, especially by incorporating data from wearable medical devices, should take place.

Changes in healthcare utilisation during implementation of remote atrial fibrillation management: TeleCheck-AF project.

AIM: To evaluate changes in healthcare utilisation and comprehensive packages of care activities and procedures (referred in the Netherlands to as 'diagnose-behandelcombinatie (DBC) care products) during the implementation of the TeleCheck-AF approach (teleconsultation supported by app-based heart rate/rhythm monitoring) in a Dutch atrial fibrillation (AF) clinic. METHODS AND RESULTS: In the Maastricht University Medical Centre+ AF Clinic, data on healthcare utilisation and DBC care products for patients consulted by both a conventional approach in 2019 and the TeleCheck-AF approach in 2020 were analysed. A patient experience survey was performed. Thirty-seven patients (median age 68 years; 40% women) were analysed. With the conventional approach, 35 face-to-face consultations and 0 teleconsultations were conducted. After the implementation of TeleCheck-AF, the number of face-to-face consultations dropped by 80% (p < 0.001) and teleconsultations increased to 45 (p < 0.001). While 42 electrocardiograms (ECGs) and 25 Holter ECGs or echocardiograms were recorded when using the conventional approach, the number of ECGs decreased by 71% (p < 0.001) and Holter ECGs or echocardiograms by 72% (p < 0.001) with the TeleCheck-AF approach. The emergency department patient presentations showed no statistically significant change (p = 0.33). Overall, 57% of medium-weight DBC care products were changed to light-weight ones during implementation of the TeleCheck-AF approach. Patient satisfaction with the TeleCheck-AF approach was high. CONCLUSION: The implementation of TeleCheck-AF led to a change in healthcare utilisation, a change from medium-weight to light-weight DBC care products and a reduction in patient burden. These results created the basis for a new reimbursement code for the TeleCheck-AF approach in the Netherlands.

Network analysis of the social media activities around the #TeleCheckAF project.

Aims: TeleCheck-AF is a novel remote on-demand mobile health infrastructure around teleconsultations for patients with atrial fibrillation. Social media (SoMe) communication on Twitter contributed to the dissemination of this healthcare innovation by using the hashtag #TeleCheckAF. This study aims to analyse the SoMe network behind #TeleCheckAF and determine the key opinion leaders. Methods and results: Publicly available data on actors and interactions around the hashtag #TeleCheckAF were collected by web scraping from the platform Twitter. With tools based on social network analysis, a social network was created, different communities were identified, and key opinion leaders were determined by their centrality in the network. The SoMe network consisted of 413 086 accounts with 636 502 ties in 22 different communities. A total of 287 accounts that diffused information and/or used the TeleCheck-AF infrastructure were analysed in depth. Those accounts involved users from >15 different countries and multidisciplinary professions. Further, 20 opinion leaders were identified, including four official accounts of societies and associated journals among key opinion leaders. Peaks in #TeleCheckAF tweets were seen after (virtual) conferences and other activities involving national and international cardiology societies. Social network analysis of the TeleCheck-AF Twitter hashtag revealed a wide, multidisciplinary potential reach for the diffusion of a healthcare innovation. Conclusion: Official society SoMe accounts can amplify the dissemination of research findings by featuring abstract presentations during conferences and published manuscripts. This underlines the synergistic effects between traditional and SoMe-based research dissemination strategies for novel healthcare approaches, such as the TeleCheck-AF project.

360° Virtual reality to improve patient education and reduce anxiety towards atrial fibrillation ablation.

AIMS: Evaluation of (i) the effects of a virtual reality (VR) preprocedural patient education video on information provision, procedure-related knowledge, satisfaction, and the level of worries in patients planned for atrial fibrillation (AF) ablation and (ii) the feasibility of a disposable cardboard VR viewer for home use in this setting. METHODS AND RESULTS: In this prospective observational cohort study, patients were alternatively assigned in a 1:1 ratio to the control or VR group. Controls received standard preprocedural information. VR group received standard information and a VR video (via in-hospital VR headset and disposable cardboard). The Amsterdam Preoperative Anxiety and Information Scale (APAIS) together with additional questions concerning procedural experience and satisfaction was completed pre- and post-ablation. Of 134 patients [38.1% female, aged 66 (58-72) years] included, 49.2% were assigned to the control and 50.7% to the VR group. The number of patients that worried about the ablation procedure was lower in VR than in control patients (19.1% vs. 40.9%, P = 0.006). More VR females than males had worries about the procedure (34.8% vs. 11.1%, P = 0.026). The number of VR patients that were satisfied with the preprocedural information provision was higher post-ablation than pre-ablation (83.3% vs. 60.4%, P = 0.007). In total, 59.4% reported that the disposable cardboard was easy to use and led to a discussion with relatives in 68.8%. CONCLUSION: In patients scheduled for AF ablation, a VR preprocedural educational video led to better information provision and procedure-related knowledge, higher satisfaction, and less worries regarding the procedure. The disposable cardboard was feasible for home use.

Atrial fibrillation-specific refinement of the STOP-Bang sleep apnoea screening questionnaire: insights from the Virtual-SAFARI study.

BACKGROUND: Sleep-disordered breathing (SDB) is prevalent in up to 50% of patients referred for atrial fibrillation (AF) catheter ablation (CA). Currently, it remains unclear how to improve pre-selection for SDB screening in patients with AF. AIM: We aimed to (1) assess the accuracy of the STOP-Bang screening questionnaire for detection of SDB within an AF population referred for CA; (2) derive a refined, AF-specific SDB score to improve pre-selection. METHODS: Consecutive AF patients referred for CA without a history of SDB and/or SDB screening were included. Patients were digitally referred to the previously implemented Virtual-SAFARI SDB screening and management pathway including a home sleep test. An apnoea-hypopnoea index (AHI) of  ≥ 15 was interpreted as moderate-to-severe SDB. Logistic regression analysis was used to assess characteristics associated with moderate-to-severe SDB to refine pre-selection for SDB screening. RESULTS: Of 206 included patients, 51% were diagnosed with moderate-to-severe SDB. The STOP-Bang questionnaire performed poorly in detecting SDB, with an area under the receiver operating characteristic curve (AUROC) of 0.647 (95% Confidence-Interval (CI) 0.573-0.721). AF-specific refinement resulted in the BOSS-GAP score. Therein, BMI with cut-off point ≥ 27 kg/m2 and previous stroke or transient ischaemic attack (TIA) were added, while tiredness and neck circumference were removed. The BOSS-GAP score performed better with an AUROC of 0.738 (95% CI 0.672-0.805) in the overall population. CONCLUSION: AF-specific refinement of the STOP-Bang questionnaire moderately improved detection of SDB in AF patients referred for CA. Whether questionnaires bring benefits for pre-selection of SDB compared to structural screening in patients with AF requires further studies. TRIAL REGISTRATION NUMBER: ISOLATION was registered NCT04342312, 13-04-2020.

[How to: clinical use of antiarrhythmic drugs]. / How to: Antiarrhythmika in der klinischen Anwendung.

Antiarrhythmic drugs are important for the noninvasive rhythm control therapy of heart rhythm disorders. Antiarrhythmic drugs, which can be categorized into subgroups based on their different effects on ion channels, are clinically used for various types of arrhythmias. Knowledge about these specific electrophysiological effects contributes to a better understanding in order to select the correct drug for each specific arrhythmia. This review summarizes mechanisms, indications, contraindications, and side effects of the different antiarrhythmic drugs and, thus, supports their adequate use in daily clinical routine.

Patient motivation and adherence to an on-demand app-based heart rate and rhythm monitoring for atrial fibrillation management: data from the TeleCheck-AF project.

AIMS: The aim of this TeleCheck-AF sub-analysis was to evaluate motivation and adherence to on-demand heart rate/rhythm monitoring app in patients with atrial fibrillation (AF). METHODS AND RESULTS: Patients were instructed to perform 60 s app-based heart rate/rhythm recordings 3 times daily and in case of symptoms for 7 consecutive days prior to teleconsultation. Motivation was defined as number of days in which the expected number of measurements (≥3/day) were performed per number of days over the entire prescription period. Adherence was defined as number of performed measurements per number of expected measurements over the entire prescription period.Data from 990 consecutive patients with diagnosed AF [median age 64 (57-71) years, 39% female] from 10 centres were analyzed. Patients with both optimal motivation (100%) and adherence (≥100%) constituted 28% of the study population and had a lower percentage of recordings in sinus rhythm [90 (53-100%) vs. 100 (64-100%), P < 0.001] compared with others. Older age and absence of diabetes were predictors of both optimal motivation and adherence [odds ratio (OR) 1.02, 95% coincidence interval (95% CI): 1.01-1.04, P < 0.001 and OR: 0.49, 95% CI: 0.28-0.86, P = 0.013, respectively]. Patients with 100% motivation also had ≥100% adherence. Independent predictors for optimal adherence alone were older age (OR: 1.02, 95% CI: 1.00-1.04, P = 0.014), female sex (OR: 1.70, 95% CI: 1.29-2.23, P < 0.001), previous AF ablation (OR: 1.35, 95% CI: 1.03-1.07, P = 0.028). CONCLUSION: In the TeleCheck-AF project, more than one-fourth of patients had optimal motivation and adherence to app-based heart rate/rhythm monitoring. Older age and absence of diabetes were predictors of optimal motivation/adherence.

Mobile app-based symptom-rhythm correlation assessment in patients with persistent atrial fibrillation.

BACKGROUND: The assessment of symptom-rhythm correlation (SRC) in patients with persistent atrial fibrillation (AF) is challenging. Therefore, we performed a novel mobile app-based approach to assess SRC in persistent AF. METHODS: Consecutive persistent AF patients planned for electrical cardioversion (ECV) used a mobile app to record a 60-s photoplethysmogram (PPG) and report symptoms once daily and in case of symptoms for four weeks prior and three weeks after ECV. Within each patient, SRC was quantified by the SRC-index defined as the sum of symptomatic AF recordings and asymptomatic non-AF recordings divided by the sum of all recordings. RESULTS: Of 88 patients (33% women, age 68 ± 9 years) included, 78% reported any symptoms during recordings. The overall SRC-index was 0.61 (0.44-0.79). The study population was divided into SRC-index tertiles: low (<0.47), medium (0.47-0.73) and high (≥0.73). Patients within the low (vs high) SRC-index tertile had more often heart failure and diabetes mellitus (both 24.1% vs 6.9%). Extrasystoles occurred in 19% of all symptomatic non-AF PPG recordings. Within each patient, PPG recordings with the highest (vs lowest) tertile of pulse rates conferred an increased risk for symptomatic AF recordings (odds ratio [OR] 1.26, 95% coincidence interval [CI] 1.04-1.52) and symptomatic non-AF recordings (OR 2.93, 95% CI 2.16-3.97). Pulse variability was not associated with reported symptoms. CONCLUSIONS: In patients with persistent AF, SRC is relatively low. Pulse rate is the main determinant of reported symptoms. Further studies are required to verify whether integrating mobile app-based SRC assessment in current workflows can improve AF management.

Researchers in cardiology - Why and how to get on Twitter?

Social media (SoMe) for professional use has gained importance for scientific impact. In cardiology, Twitter is among the preferred SoMe platforms for scientific dissemination. We are in the middle of a paradigm shift within scientific dissemination as more scientific content is presented on Twitter, and it is crucial to embrace it. Therefore, this paper includes a description and discussion of the existing literature reporting the impact of Twitter on research dissemination, as well as a guide on how to get started. In addition, we describe a case of the Danish Cardiovascular Academy Summer Meeting 2021 as an example of a scientific event that was promoted on Twitter before, during and after the event and present a survey showing that participants were inspired to increase the use of SoMe professionally. Finally, the paper addresses limitations of Twitter and SoMe for scientific use and discuss a need for an increased evidence base.

Mobile health solutions for atrial fibrillation detection and management: a systematic review.

AIM: We aimed to systematically review the available literature on mobile Health (mHealth) solutions, including handheld and wearable devices, implantable loop recorders (ILRs), as well as mobile platforms and support systems in atrial fibrillation (AF) detection and management. METHODS: This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The electronic databases PubMed (NCBI), Embase (Ovid), and Cochrane were searched for articles published until 10 February 2021, inclusive. Given that the included studies varied widely in their design, interventions, comparators, and outcomes, no synthesis was undertaken, and we undertook a narrative review. RESULTS: We found 208 studies, which were deemed potentially relevant. Of these studies included, 82, 46, and 49 studies aimed at validating handheld devices, wearables, and ILRs for AF detection and/or management, respectively, while 34 studies assessed mobile platforms/support systems. The diagnostic accuracy of mHealth solutions differs with respect to the type (handheld devices vs wearables vs ILRs) and technology used (electrocardiography vs photoplethysmography), as well as application setting (intermittent vs continuous, spot vs longitudinal assessment), and study population. CONCLUSION: While the use of mHealth solutions in the detection and management of AF is becoming increasingly popular, its clinical implications merit further investigation and several barriers to widespread mHealth adaption in healthcare systems need to be overcome. Mobile health solutions for atrial fibrillation detection and management: a systematic review.

A VIRTUAL Sleep Apnoea management pathway For the work-up of Atrial fibrillation patients in a digital Remote Infrastructure: VIRTUAL-SAFARI.

AIMS: In atrial fibrillation (AF) patients, untreated sleep-disordered breathing (SDB) is associated with lower success rates of rhythm control strategies and as such structured SDB testing is recommended. Herein, we describe the implementation of a virtual SDB management pathway in an AF outpatient clinic and examine the utility and feasibility of this new approach. METHODS AND RESULTS: Prospectively, consecutive AF patients accepted for AF catheter ablation procedures without previous diagnosis of SDB were digitally referred to a virtual SDB management pathway and instructed to use WatchPAT-ONE (ITAMAR) for one night. Results were automatically transferred to a virtual sleep laboratory, upon which a teleconsultation with a sleep physician was planned. Patient experience was measured using surveys. SDB testing was performed in 119 consecutive patients scheduled for AF catheter ablation procedures. The median time from digital referral to finalization of the sleep study report was 18 [11-24] days. In total, 65 patients (55%) were diagnosed with moderate-to-severe SDB. Patients with SDB were prescribed more cardiovascular drugs and had higher body mass indices (BMI, 29 ± 3.3 vs. 27 ± 4.4kg/m2, P < 0.01). Patients agreed that WatchPAT-ONE was easy to use (91%) and recommended future use of this virtual pathway in AF outpatient clinics (86%). Based on this remote SDB testing, SDB treatment was recommended in the majority of patients. CONCLUSION: This novel virtual AF management pathway allowed remote SDB testing in AF outpatient clinics with a short time to diagnosis and high patient satisfaction. Structured SDB testing results in a high detection of previously unknown SDB in AF patients scheduled for AF ablation.

[Interpretation of photoplethysmography: a step-by-step guide]. / Interpretation der Photoplethysmographie: Schritt für Schritt.

By applying photoplethysmography (PPG), the camera of the mobile phone can be used to remotely assess heart rate and rhythm, which was widely used in conjunction with teleconsultations within the TeleCheck-AF project during the coronavirus disease 2019 (COVID-19) pandemic. Herein, we provide an educational, structured, stepwise practical guide on how to interpret PPG signals. A better understanding of PPG recordings is critical for the implementation of this widely available technology into clinical practice.

Self-Reported Mobile Health-Based Risk Factor and CHA2DS2-VASc-Score Assessment in Patients With Atrial Fibrillation: TeleCheck-AF Results.

INTRODUCTION: The TeleCheck-AF approach is an on-demand mobile health (mHealth) infrastructure incorporating mobile app-based heart rate and rhythm monitoring through teleconsultation. We evaluated feasibility and accuracy of self-reported mHealth-based AF risk factors and CHA2DS2-VASc-score in atrial fibrillation (AF) patients managed within this approach. MATERIALS AND METHODS: Consecutive patients from eight international TeleCheck-AF centers were asked to complete an app-based 10-item questionnaire related to risk factors, associated conditions and CHA2DS2-VASc-score components. Patient's medical history was retrieved from electronic health records (EHR). RESULTS: Among 994 patients, 954 (96%) patients (38% female, median age 65 years) completed the questionnaire and were included in this analysis. The accuracy of self-reported assessment was highest for pacemaker and anticoagulation treatment and lowest for heart failure and arrhythmias. Patients who knew that AF increases the stroke risk, more often had a 100% or ≥80% correlation between EHR- and app-based results compared to those who did not know (27 vs. 14% or 84 vs. 77%, P = 0.001). Thromboembolic events were more often reported in app (vs. EHR) in all countries, whereas higher self-reported hypertension and anticoagulant treatment were observed in Germany and heart failure in the Netherlands. If the app-based questionnaire alone was used for clinical decision-making on anticoagulation initiation, 26% of patients would have been undertreated and 6.1%-overtreated. CONCLUSION: Self-reported mHealth-based assessment of AF risk factors is feasible. It shows high accuracy of pacemaker and anticoagulation treatment, nevertheless, displays limited accuracy for some of the CHA2DS2-VASc-score components. Direct health care professional assessment of risk factors remains indispensable to ensure high quality clinical-decision making.

The photoplethysmography dictionary: practical guidance on signal interpretation and clinical scenarios from TeleCheck-AF.

Aims: Within the TeleCheck-AF project, numerous centres in Europe used on-demand photoplethysmography (PPG) technology to remotely assess heart rate and rhythm in conjunction with teleconsultations. Based on the TeleCheck-AF investigator experiences, we aimed to develop an educational structured stepwise practical guide on how to interpret PPG signals and to introduce typical clinical scenarios how on-demand PPG was used. Methods and results: During an online conference, the structured stepwise practical guide on how to interpret PPG signals was discussed and further refined during an internal review process. We provide the number of respective PPG recordings (FibriCheck®) and number of patients managed within a clinical scenario during the TeleCheck-AF project. To interpret PPG recordings, we introduce a structured stepwise practical guide and provide representative PPG recordings. In the TeleCheck-AF project, 2522 subjects collected 90 616 recordings in total. The majority of these recordings were classified by the PPG algorithm as sinus rhythm (57.6%), followed by AF (23.6%). In 9.7% of recordings, the quality was too low to interpret. The most frequent clinical scenarios where PPG technology was used in the TeleCheck-AF project was a follow-up after AF ablation (1110 patients) followed by heart rate and rhythm assessment around (tele)consultation (966 patients). Conclusion: We introduce a newly developed structured stepwise practical guide on PPG signal interpretation developed based on presented experiences from TeleCheck-AF. The present clinical scenarios for the use of on-demand PPG technology derived from the TeleCheck-AF project will help to implement PPG technology in the management of AF patients.