Gender Differences in Guideline-Directed Medical Therapy for Cardiovascular Disease Among Young Veterans.

BACKGROUND: There is an increasing burden of cardiovascular disease, including coronary artery disease (CAD) and heart failure (HF), among women Veterans. Clinical practice guidelines recommend multiple pharmacotherapies that can reduce risk of mortality and adverse cardiovascular outcomes. OBJECTIVE: To determine if there are disparities in the use of guideline-directed medical therapy by gender among Veterans with incident CAD and HF. DESIGN: Retrospective. PARTICIPANTS: Veterans (934,504; 87.8% men and 129,469; 12.2% women) returning from Operations Enduring Freedom, Iraqi Freedom, and New Dawn. MAIN MEASURES: Differences by gender in the prescription of Class 1, Level of Evidence A guideline-directed medical therapy among patients who developed incident CAD and HF at 30 days, 90 days, and 12 months after diagnosis. For CAD, medications included statins and antiplatelet therapy. For HF, medications included beta-blockers and renin-angiotensin-aldosterone system inhibitors. KEY RESULTS: Overall, women developed CAD and HF at a younger average age than men (mean 45.8 vs. 47.7 years, p<0.001; and 43.7 vs. 45.4 years, p<0.02, respectively). In the 12 months following a diagnosis of incident CAD, the odds of a woman receiving a prescription for at least one CAD drug was 0.85 (95% confidence interval [CI], 0.68-1.08) compared to men. In the 12 months following a diagnosis of incident HF, the odds of a woman receiving at least one HF medication was 0.54 (95% CI, 0.37-0.79) compared to men. CONCLUSIONS: Despite guideline recommendations, young women Veterans have approximately half the odds of being prescribed guideline-directed medical therapy within 1-year after a diagnosis of HF. These results highlight the need to develop targeted strategies to minimize gender disparities in CVD care to prevent adverse outcomes in this young and growing population.

Immediate and long-term effects of the COVID-19 pandemic and lockdown on physical activity in patients with implanted cardiac devices.

BACKGROUND: Physical activity (PA) is an important determinant of cardiovascular health that may be affected the COVID-19 pandemic. Therefore, we examined the immediate and long-term effects of the pandemic and lockdown on PA in patients with established cardiovascular risk. METHODS: Objectively-measured daily PA data was obtained from cardiovascular implantable electronic devices (CIEDs) from 3453 U.S patients (mean and standard deviations [SD] age, 72.65 [13.24] years; 42% women). Adjusted mixed-effects models stratified by device type were used to compare daily PA from periods in 2020: pre-lockdown (March 1-14), lockdown (March 15 to May 8), and the reopening phase of the pandemic (May 9 to December 31) versus 2019. Patient characteristics and events associated with inactivity during lockdown and the proportion of patients who returned to their 2019 PA-level by the end of reopening phase (December 31, 2020) were examined. RESULTS: Daily PA was significantly lower during the lockdown compared to the same period in 2019 (-15%; p < .0001), especially for pacemaker patients, adults aged <65, and patients more active prior to lockdown. Non-COVID hospitalization and ICD shock were similarly associated with low PA during lockdown (p = .0001). In the reopening phase of the pandemic, PA remained 14.4% lower in the overall sample and only 23% of patients returned to their 2019 PA level by the end of follow-up. CONCLUSIONS: In this large cohort of patients with CIEDs, PA was markedly lower during the lockdown and remained lower for months after restrictions were lifted. Strategies to maintain PA during a national emergency are urgently needed.

Posttraumatic Stress Disorder, Antidepressant Use, and Hemorrhagic Stroke in Young Men and Women: A 13-Year Cohort Study.

BACKGROUND AND PURPOSE: Antidepressants are commonly prescribed for posttraumatic stress disorder (PTSD) and may increase the risk of bleeding, including hemorrhagic stroke. METHODS: We prospectively examined independent effects of PTSD, selective serotonin and norepinephrine reuptake inhibitors (SSRI and SNRI) on the risk of incident hemorrhagic stroke in a nationwide sample of 1.1 million young and middle-aged veterans. Time-varying multivariate Cox models were used to examine hemorrhagic stroke risk by PTSD status and use of SSRI or SNRI while adjusting for demographics, lifestyle factors, stroke, and psychiatric comorbidities. Sensitivity analyses controlled for health care utilization. RESULTS: During 13 years of follow-up (2.14 years on average), 507 patients (12% women) suffered a hemorrhagic stroke. The overall incidence rate was 1.70 events per 10 000-person years. In unadjusted models, PTSD was associated with an 82% greater risk of new-onset hemorrhagic stroke (hazard ratio [HR], 1.82 [95% CI, 1.48-2.24]), SSRI use was associated with a >2-fold risk (HR, 2.02 [95% CI, 1.66-2.57]), and SNRI use was associated with a 52% greater risk (HR, 1.52 [95% CI, 1.08-2.16]). In fully adjusted models, effects of PTSD and SNRI were attenuated (adjusted HR, 1.03 [95% CI, 0.81-1.34]; adjusted HR, 1.19 [95% CI, 0.83-1.71]), but SSRI use remained associated with a 45% greater risk of hemorrhagic stroke (adjusted HR, 1.45 [95% CI, 1.13-1.85]). Hypertension, drug abuse, and alcohol abuse were also associated with increased stroke risk. Nonobesity and being non-Hispanic were protective factors. In sensitivity analyses, health care utilization was a small but significant predictor of stroke. CONCLUSIONS: In the largest known investigation of PTSD and antidepressant-associated risk for hemorrhagic stroke in young adults, use of SSRIs, but neither PTSD nor SNRIs were independently associated with incident stroke. SNRIs may be preferable for treating PTSD and comorbid conditions, although pursuing other modifiable risk factors and non-pharmacological treatments for PTSD also remains essential.

Measurement of patient confidence in self-management of atrial fibrillation: Initial validation of the Confidence in Atrial fibriLlation Management (CALM) Scale.

BACKGROUND: The patient experience of atrial fibrillation (AF) involves several daily self-care behaviors and ongoing confidence to manage their condition. Currently, no standardized self-report measure of AF patient confidence exists. The purpose of this study is to provide preliminary support for the reliability and validity of a newly developed confidence in AF management measure. METHODS: This study provides preliminary analysis of the Confidence in Atrial FibriLlation Management (CALM) scale, which was rationally developed to measure patient confidence related to self-management of AF. The scale was provided to a sample of AF patients N = 120, (59% male) electronically through a patient education platform. Principal component analysis (PCA) and Cronbach's α were employed to provide preliminary assessment of the validity and reliability of the measure. RESULTS: PCA identified a four-factor solution. Internal consistency of the CALM was considered excellent with Cronbach's α = .910. Additional PCA confirmed the value of a single factor solution to produce a total confidence score for improved utility and ease of clinical interpretation. CONCLUSIONS: Initial assessment of a novel scale measuring patient confidence in managing AF provided promising reliability and validity. Patient confidence in self-management of AF may prove useful as a key marker and endpoint of the patient experience beyond QOL.

Effect of a virtual self-management intervention for atrial fibrillation during the outbreak of COVID-19.

BACKGROUND: As the pandemic continues to unfold, effective, technology-based solutions are needed to help patients with atrial fibrillation (AF) maintain their health and well-being during the outbreak of COVID-19. METHODS: This single-center, pilot study investigated the effects of a 4-week (eight sessions) virtual AF self-management program. Questionnaires were completed at baseline and 1 week after the intervention, and assessed AF knowledge, adherence to self-management behaviors, mental health, physical function, and disease-specific quality of life in patients with AF. Secondary outcomes included knowledge of COVID-19, intervention, acceptability, and satisfaction. RESULTS: Of 68 patients who completed baseline questionnaires, 57 participated in the intervention and were included in the analysis (mean age of 73.4 ± 10.0 years, 60% male). Adherence to AF self-monitoring behaviors, including monitoring their heart rate (p < .001), heart rhythm (p = .003), and blood pressure (p = .013) were significantly improved at the end of the intervention compared with baseline. Symptom identification (p = .007) and management (p < .001) also improved. Reductions in sleep disturbance (p < .001), anxiety (p = .014), and depression (p = .046) were also observed. Misinformation and inaccurate beliefs about COVID-19 were significantly reduced at the end of the intervention compared with baseline. CONCLUSIONS: This pilot study suggests that a virtual patient education program could have beneficial effects on adherence to guideline-recommend self-care of AF, emotional wellbeing, physical function, and knowledge of COVID-19 in patients with AF. Future randomized studies in larger samples are needed to determine the clinical benefits of the intervention.

Facility Variation in Troponin Ordering Within the Veterans Health Administration.

BACKGROUND: Current United States guidelines recommend troponin as the preferred biomarker in assessing for acute coronary syndrome, but recommendations are limited about which patients to test. Variations in troponin ordering may influence downstream health care utilization. METHODS: We performed a cross-sectional analysis of 3,308,131 emergency department (ED) visits in all 121 acute care facilities within the Veterans Health Administration from 2015 to 2017. We quantified the degree to which case mix and facility characteristics accounted for variations in facility rates in troponin ordering. We then assessed the association between facility quartiles of risk-adjusted troponin ordering and downstream resource utilization [inpatient admissions, noninvasive testing (stress tests, echocardiograms), and invasive procedures (coronary angiograms, percutaneous coronary interventions, and coronary artery bypass grafting surgeries)]. RESULTS: The proportion of ED visits with troponin orders ranged from 2.2% to 64.5%, with a median of 37.1%. Case mix accounted for 9.5% of the variation in troponin orders; case mix and differences in facility characteristics accounted for 34.6%. Facilities in the highest quartile of troponin ordering, as compared with those in the lowest quartile, had significantly higher rates of inpatient admissions, stress tests, echocardiograms, coronary angiograms, and percutaneous coronary intervention. CONCLUSIONS: Significant variation in troponin utilization exists across Veterans Health Administration facilities and that variation is not well explained by case mix alone. Facilities with higher rates of troponin ordering were associated with more downstream resource utilization.

Patient and Partner Sexual Concerns During the First Year After an Implantable Cardioverter Defibrillator: A Secondary Analysis of the P+P Randomized Clinical Trial.

BACKGROUND: Sexual concerns and changes in sexual activity are common among patients and their intimate partners after an implantable cardioverter defibrillator (ICD). AIMS: Our aims were to (i) describe patient and partner sexual activity and related concerns from the time of an initial ICD implant through 12-month follow-up and (ii) identify factors predictive of return to sexual activity and fears associated with sexual activity. METHODS: This secondary descriptive analysis was conducted with data from a randomized controlled trial (2009-2015) designed to compare 2 interventions for patients (Patient-Only) and for patients and their partners (Patient+Partner) after implant of an initial ICD. The sample included 105 patients and their intimate partners who reported sexual activity during the 24 months before ICD implant. OUTCOMES: The Sexual Concerns Inventory was used to assess sexual activity and related concerns. RESULTS: Study participants comprised 72% male and were of mean age 65.6 ± 10.6 years; partners comprised 64% female and were of mean age 63 ± 11.6 years. Sexual activity increased after ICD: 73% of patients reported no sexual intercourse during 2 months before study enrollment, whereas only 46% reported no sexual intercourse during the 2 months before 12-month follow-up. Reductions in sexual concerns were evident 1 month after implant, with continued reductions through 12 months (patient 6.48 ± 4.03 to 5.22 ± 3.38, P = .004; partner 6.93 ± 4.01 to 5.2 ± 3.56, P < .001). Patient physical health predicted sexual activity 3 months after implant placement (P = .04); general ICD concerns (P < .001) predicted patient ICD-related sexual fears at 3 months. At 12 months, baseline general ICD concerns (P < .02) predicted sexual fears. CLINICAL IMPLICATIONS: ICD patients and partners report low levels of sexual activity at the time of initial ICD implant, with reported increases in sexual activity over the 12-month recovery period: Sexual concerns were highest immediately after ICD implant. STRENGTHS & LIMITATIONS: Notably, the major strengths of this study were the repeated measures and longitudinal study design; the main limitation of the study was the lack of a "usual care" control group. CONCLUSION: Sexual activity at the time of an initial ICD implant is low, and sexual concerns are most prominent for both patients and partners immediately after implant placement. Baseline physical health predicts subsequent sexual activity at 3 months, while general ICD-related worry predicts sexual fears at 3 and 12 months. Streur MM, Rosman LA, Sears SF, et al. Patient and Partner Sexual Concerns During the First Year After an Implantable Cardioverter Defibrillator: A Secondary Analysis of the P+P Randomized Clinical Trial. J Sex Med 2020;17:892-902.

Association of prescription opioids and incident cardiovascular risk factors among post-9/11 Veterans.

Reports indicate that long-term opioid therapy is associated with cardiovascular disease (CVD). Using VA electronic health record data, we measured the impact of opioid use on the incidence of modifiable CVD risk factors. We included Veterans whose encounter was between October 2001 to November 2014. We identified Veterans without CVD risk factors during our baseline period, defined as the date of first primary care visit plus 365 days. The main exposure was opioid prescriptions (yes/no, long-term (i.e. ≥90 days) vs no opioid, and long-term vs short-term (i.e. <90 days)), which was time-updated yearly from the end of the baseline period to February 2015. The main outcome measures were incident CVD risk factors (hypertension, dyslipidemia, diabetes, obesity, and current smoking). After excluding prevalent CVD risk factors, we identified 308,015 Veterans. During the first year of observation, 12,725 (4.1%) Veterans were prescribed opioids, including 2028 (0.6%) with long-term exposure. Compared to patients without opioid use, Veterans with opioid use were more likely to have CVD risk factors. Those with long-term exposure were at higher risk of having hypertension (adjusted average hazards ratio [HR] 1.45, 99% confidence interval [CI] 1.33-1.59), dyslipidemia (HR 1.45, 99% CI 1.35-156), diabetes (HR 1.30, 99% CI 1.07-1.57), current smoking status (HR 1.34, 99% CI 1.24-1.46), and obesity (HR 1.22, 99% CI 1.12-1.32). Compared to short-term exposure, long-term had higher risk of current smoking status (HR 1.12, 99% CI 1.01-1.24). These findings suggest potential benefit to screening and surveillance of CVD risk factors for patients prescribed opioids, especially long-term opioid therapy.

Posttraumatic Stress Disorder and Risk for Stroke in Young and Middle-Aged Adults: A 13-Year Cohort Study.

Background and Purpose- In older populations, transient ischemic attack (TIA) and ischemic stroke have been linked to psychological factors, including posttraumatic stress disorder (PTSD). Whether PTSD also increases risk for early incident stroke in young adults is unknown. Methods- We prospectively assessed the incidence of TIA and ischemic stroke in a cohort of 987 855 young and middle-aged Veterans (mean age of 30.29±9.19 years; 87.8% men, 64.4% white) who first accessed care through the Veterans Health Administration from October 2001 to November 2014 and were free of TIA and ischemic stroke at baseline. For each outcome, time-varying multivariate Cox models were constructed to examine the effect of PTSD on incident stroke. We also assessed for effect modification by sex. Additional sensitivity analyses controlled for healthcare utilization. Results- Over a 13-year period, TIA and ischemic stroke were diagnosed in 766 and 1877 patients, respectively. PTSD was diagnosed in 28.6% of the sample during follow-up. In unadjusted analyses, PTSD was significantly associated with new-onset TIA (hazard ratio [HR], 2.02; 95% CI, 1.62-2.52) and ischemic stroke (HR, 1.62; 95% CI, 1.47-1.79). In fully adjusted models, the association between PTSD and incident TIA (HR, 1.61; 95% CI, 1.27-2.04) and ischemic stroke (HR, 1.36; 95% CI, 1.22-1.52) remained significant. The effect of PTSD on ischemic stroke risk was stronger in men than in women (HR, 0.63; 95% CI, 0.47-0.86; P=0.003), but no effect of sex was found for TIA. Conclusions- PTSD is associated with a significant increase in risk of early incident TIA and ischemic stroke independent of established stroke risk factors, coexisting psychiatric disorders, and healthcare utilization. Sex moderated the relationship for adults with ischemic stroke but not TIA. These findings suggest that psychological factors, including PTSD, may be important targets for future age-specific prevention strategies for young adults.

Psychosocial Adjustment and Quality of Life in Patients With Peripartum Cardiomyopathy.

BACKGROUND: Psychological distress can adversely affect heart failure prognosis, yet the immediate and ongoing challenges faced by women diagnosed with peripartum cardiomyopathy (PPCM) are not well studied. OBJECTIVE: We examined psychological distress and quality of life in a large, national sample of patients with PPCM and evaluated whether these characteristics differ among newly diagnosed (0-1 year), short-term (2-4 years), and long-term (5-10 years) survivors. METHODS: One hundred forty-nine patients with PPCM (mean age, 33.9 ± 5.0 years) recruited from a web-based registry completed questionnaires about generalized anxiety (Generalized Anxiety Disorder-7), cardiac anxiety (Cardiac Anxiety Questionnaire [CAQ]), health status (Medical Outcomes Study Short-Form 12 [SF-12] Health Survey), and PPCM-specific quality-of-life concerns. Group differences were evaluated using multivariate statistics with adjustments for disease severity and psychiatric history. RESULTS: Generalized anxiety symptoms higher than the clinical cutoff were reported by 53% of patients with PPCM. Mean scores on the CAQ (1.9 ± 0.7) and CAQ subscale scores (cardiac-specific fear [2.1 ± 0.8], avoidance [1.7 ± 0.9], and heart-focused attention [1.6 ± 0.8]) were elevated in the overall sample. Psychological symptoms and quality-of-life concerns were generally similar across patients except for cardiac avoidance, which was significantly higher in newly diagnosed women after adjustments for disease severity (P = .05) and psychiatric history (P = .01). Peripartum cardiomyopathy-specific quality-of-life concerns were also prevalent; however, group differences were nonsignificant (P = .07). CONCLUSIONS: Generalized anxiety, cardiac anxiety, and quality-of-life concerns are prevalent among patients with PPCM at all stages of recovery. Psychological issues may be an underrecognized aspect of women's recovery from PPCM.

Cumulative Impact of Stressful Life Events on the Development of Takotsubo Cardiomyopathy.

BACKGROUND: The role of stressful life events in the onset of Takotsubo cardiomyopathy (TC) is unclear. PURPOSE: This study sought to examine associations between type, timing, and number of stressful life events and onset of TC. METHODS: A case-control study conducted among consecutive incident female TC cases and myocardial infarction (MI) controls admitted to two emergency departments in New England. Healthy female controls (HC) were recruited from a volunteers' registry. Information about the timing, type, and number of triggers during the 6 months preceding hospitalization was systematically collected using the PERI Life Events Scale about 1 month post-discharge. Group differences were evaluated using ANOVA, chi-square, and Kruskal-Wallis statistics. Generalized linear models were used to adjust for confounding variables. RESULTS: Between March 2013 and October 2015, 107 women were enrolled (45 TC, 32 MI, and 30 HC). Specific stressful events (death of a relative or close friend (p = 0.006); illness or injury to a relative or close friend (p = 0.001) were more prevalent in TC cases than MI and HC controls. The onset of TC was associated with exposure to multiple stressful life events during the 6 months preceding the index hospitalization (p < 0.001) but not with exposure to an acute, recent event (p = 0.96). CONCLUSIONS: TC onset was associated with specific life events (death or illness to close relative or friend) and with the number of stressful life events occurring in the 6 months preceding hospitalization. These findings suggest that grief and cumulative stress could play a major role in the onset of TC.

Minding the Genes: a Multidisciplinary Approach towards Genetic Assessment of Cardiovascular Disease.

Genetic assessment for inherited cardiovascular disease (CVD) is increasingly available, due in part to rapid innovations in genetic sequencing technologies. While genetic testing is aimed at reducing uncertainty, it also produces awareness of potential medical conditions and can leave patients feeling uncertain about their risk, especially if there are ambiguous results. This uncertainty can produce psychological distress for patients and their families undergoing the assessment process. Additionally, patients may experience psychological distress related to living with inherited CVD. In order to more effectively manage the psychosocial challenges related to genetic assessment for CVD, a multidisciplinary model expanded to include psychologists and other allied health professionals is outlined. A case study is provided to illustrate how psychological distress can manifest in a patient living with inherited CVD, as well as proposed psychological management of this patient. Finally, a guide for genetic counselors is provided to aid in identifying and managing common psychological reactions to genetic assessment for CVD.

Cognitive-Behavioral Treatment of Posttraumatic Stress in Patients With Implantable Cardioverter Defibrillators: Results From a Randomized Controlled Trial.

Approximately 20% of patients with implantable cardioverter defibrillators (ICDs) suffer from posttraumatic stress disorder (PTSD) due to a history of cardiac arrest, device implantation, and ICD shock. There has been very little examination of treatment of PTSD symptoms in these patients. This study evaluated the effect of a specific cognitive-behavioral therapy (CBT) intervention for ICD patients with high levels of PTSD symptoms: a manualized program consisting of 8 telephone sessions with a trained counselor, a patient education book, and a stress management procedure on compact disc. Participants were 193 ICD patients, who were randomized to CBT or usual cardiac care (UCC) who completed self-report surveys at the time of recruitment and 6 and 12 months after initial measurement. Previous publication on the primary research evaluation questions reported that the CBT condition resulted in greater improvement on PTSD and depression symptoms than the UCC for the general population of ICD patients, but did not evaluate the effect on those with elevated symptoms of PTSD. The authors conducted secondary analyses of the effect of treatment on high and low PTSD symptom groups based on a cutoff for the Impact of Event Scale-Revised (Weiss & Marmar, 1997). Participants in the CBT group who had high symptoms experienced significantly greater symptom reduction from baseline to 12 months (d = 2.44, p = .021) than the UCC group (d = 1.12). Participants with low symptoms had small reductions regardless of group assignment (d = 0.16, p = .031). ICD-focused CBT was sufficient to produce a large, statistically significant reduction in PTSD symptoms in ICD patients with indications for treatment.

A Patient-Centered Intervention Reduces Disparities in Remote Monitoring in Patients With Implanted Cardiac Devices.

BACKGROUND: Remote monitoring (RM) is recommended for patients with cardiovascular implantable electronic devices, yet many individuals, especially those living in underserved communities, fail to receive this guideline-directed care. Multilevel interventions that target patient and clinic-level barriers to RM care may be beneficial. OBJECTIVES: This study sought to evaluate a remotely delivered, patient-centered intervention to improve RM activation and adherence and reduce disparities in RM care. METHODS: The intervention provides home delivery of remote monitor, phone-based education, monitor setup, and facilitation of first transmission. A retrospective cohort analysis was performed using RM data from 190,643 patients (71.6 ± 12.7 years of age, 40.5% female) implanted with a pacemaker or defibrillator at 4,195 U.S. clinics between October 2015 and October 2019. Outcomes included RM activation (12 weeks and 1-year postimplantation) and adherence to clinic-scheduled transmissions. Patients receiving a cardiovascular implantable electronic deviceimplant 0 to 730 days before (control group, n = 95,861) and after (intervention group, n = 94,782) intervention launch were compared using logistic regression and generalized estimating equations. Multivariable models included patient, clinic, and neighborhood socioeconomic characteristics. RESULTS: The odds of achieving guideline-recommended activation were significantly higher in the intervention group at 12 weeks (OR: 2.99; 76.7% vs 60.9%; P < 0.001) and 1 year (OR: 3.05; 88.2% vs 79.3%; P < 0.001). Adherence to scheduled transmissions was also higher in the intervention group compared with the control group (OR: 2.18; 89.1% vs 81.9%; P < 0.001). Preintervention disparities in RM activation and adherence were reduced in underserved groups following the intervention. CONCLUSIONS: A remotely delivered patient-centered intervention was associated with earlier activation and improved adherence to RM while reducing disparities in RM care.

Wearable Devices, Health Care Use, and Psychological Well-Being in Patients With Atrial Fibrillation.

BACKGROUND: Wearables are increasingly used by patients with atrial fibrillation (AF) for symptom monitoring and health management, but their impact on patient health care use and psychological well-being is not well understood. METHODS AND RESULTS: In this retrospective, propensity-matched study of patients with AF, survey and electronic health record data were merged to compare AF-specific health care use (outpatient/inpatient visits, rhythm-related testing, and procedures) and informal health care use (telephone calls and patient portal messages) over a 9-month period between wearable users and nonusers. We also examined the effects of wearable cardiac monitoring features (eg, heart rate alerts, irregular rhythm notification, and ECG) on patient behavior and well-being. Of 172 patients with AF in this analysis (age, 72.6±9.0 years; 42% women), 83 used a wearable. Compared with nonusers, wearable users reported higher rates of symptom monitoring and preoccupation (P=0.03) and more AF treatment concerns (P=0.02). Moreover, 20% of wearable users experienced anxiety and always contacted their doctors in response to irregular rhythm notifications. After matching, AF-specific health care use was significantly greater among wearable users compared with nonusers (P=0.04), including significantly higher rates of ECGs, echocardiograms/transesophageal echocardiogram, and ablation. Wearable users were also significantly more likely to use informal health care resources compared with nonusers (P=0.05). CONCLUSIONS: Wearables were associated with higher rates of symptom monitoring and preoccupation, AF treatment concerns, AF-specific health care use, and use of informal health care resources. Prospective, randomized studies are needed to understand the net effects of wearables and their alerts on patients, providers, and the health care system.

Promises and Perils of Consumer Mobile Technologies in Cardiovascular Care: JACC Scientific Statement.

Direct-to-consumer (D2C) wearables are becoming increasingly popular in cardiovascular health management because of their affordability and capability to capture diverse health data. Wearables may enable continuous health care provider-patient partnerships and reduce the volume of episodic clinic-based care (thereby reducing health care costs). However, challenges arise from the unregulated use of these devices, including questionable data reliability, potential misinterpretation of information, unintended psychological impacts, and an influx of clinically nonactionable data that may overburden the health care system. Further, these technologies could exacerbate, rather than mitigate, health disparities. Experience with wearables in atrial fibrillation underscores these challenges. The prevalent use of D2C wearables necessitates a collaborative approach among stakeholders to ensure effective integration into cardiovascular care. Wearables are heralding innovative disease screening, diagnosis, and management paradigms, expanding therapeutic avenues, and anchoring personalized medicine.