Assessment of functionalities and attitude toward telemedicine for patients with cardiovascular disease.

Introduction: Many patients with cardiovascular diseases are only seen by a physician once or twice a year unless urgent symptoms. Recent years have shown an increase in digital technologies to follow patients remotely, that is, telemedicine. Telemedicine can be supportive for follow-up of patients at continuous risk. This study investigated patients' attitude toward telemedicine, the defined features they consider important and future willingness to pay. Methods: Cardiology patients with various types of prior telemedicine follow-up or who never had a telemonitoring follow-up were included. A new self-developed survey was implemented electronically and took 5-10 min to complete. Results: In total, 231 patients (191 telemedicine [T] and 40 controls [C]), were included. Most participants owned a smartphone (84.8%) and only 2.2% of the total participants did not own any digital device. The most important feature of telemedicine cited in both groups was personalization (i.e., personalized health tips based on medical history, 89.6%; personalized feedback on entered health parameters 86.1%). The most important motivating factor for the use of telemedicine is recommendation by a physician (84.8%), while the reduction of in-person visits is a minor reason (24.7%). Only half of the participants (67.1%) would be willing to pay for telemedicine tools in the future. Conclusion: Patients with cardiovascular disease have a positive attitude to telemedicine, especially when it allows for more personalized care, and when it is advocated by the physician. Participants expect that telemedicine becomes part of reimbursed care. This calls for interactive tools with proven efficacy and safety, while guarding unequal access to care.

Adherence to oral anticoagulation measured by electronic monitoring in a Belgian atrial fibrillation population.

INTRODUCTION: Stroke prevention using oral anticoagulation (OAC) is the first management priority in atrial fibrillation (AF). Despite the importance of good therapy adherence, real-world adherence is still suboptimal. Patient education and adherence monitoring with new technologies are recommended. The main purpose of this sub-analysis of the AF-EduCare trial was to evaluate the effect of personalized follow-up strategies on adherence to OAC. METHODS: Regimen adherence was monitored by the electronic Medication Event Monitoring System cap at the start of the trial (M1) and after 12 months (M2), each for three months. Patients were part of one of three education groups (In-person, Online or App-based) or the standard care (SC) group. All are qualified for OAC therapy. RESULTS: A total of 768 patients were evaluated (11.8% SC vs. 86.8% any education group, mean age: 70.1 ± 7.9 years). Patients were taking non-vitamin K OAC (once daily 53.8%; twice daily 35.9%) or vitamin K antagonists (9.4%), equally distributed over the different study arms (p = 0.457). Mean therapy adherence was high (M1:93.8 ± 10.8%; M2:94.1 ± 10.1%). During both monitoring periods, the education group scored significantly higher than SC (M1:94.2 ± 10.0% vs. 91.3 ± 15.0%; p = 0.027; M2:94.4 ± 9.3% vs. 91.6 ± 14.0%; p = 0.006). More patients in the In-person and Online groups were able to keep or improve their adherence to > 90% compared to the SC. CONCLUSION: Overall adherence to OAC in all study groups, even in SC, was very high, without attrition over time. Nevertheless, targeted education led to a small but significantly improved adherence compared to SC.

Baseline demographics of a contemporary Belgian atrial fibrillation cohort included in a large randomised clinical trial on targeted education and integrated care (AF-EduCare/AF-EduApp study).

Background: As the prevalence of atrial fibrillation (AF) increases worldwide and AF management becomes ever more diversified and personalised, insights into (regional) AF patient demographics and contemporary AF management are needed. This paper reports the current AF management and baseline demographics of a Belgian AF population recruited for a large multicenter integrated AF study (AF-EduCare/AF-EduApp study). Methods: We analyzed data from 1,979 AF patients, assessed between 2018 and 2021 for the AF-EduCare/AF-EduApp study. The trial randomised consecutive patients with AF (irrespective of AF history duration) into three educational intervention groups (in person-, online-, and application-based), compared with standard care. Baseline demographics of both the included and excluded/refused patients are reported. Results: The mean age of the trial population was 71.2 ± 9.1 years, with a mean CHA2DS2-VASc score of 3.4 ± 1.8. Of all screened patients, 42.4% were asymptomatic at presentation. Being overweight was the most common comorbidty, present in 68.9%, while 65.0% were diagnosed with hypertension. Anticoagulation therapy was prescribed in 90.9% of the total population and in 94.0% of the patients with an indication for thromboembolic prophylaxis. Of the 1,979 assessed AF patients, 1,232 (62.3%) were enrolled in the AF-EduCare/AF-EduApp study, with transportation problems (33.4%) as the main reason for refusal/non-inclusion. About half of the included patients were recruited at the cardiology ward (53.8%). AF was first diagnosed, paroxysmal, persistent and permanent in 13.9%, 47.4%, 22.8% and 11.3%, respectively. Patients who refused or were excluded were older (73.3 ± 9.2 vs. 69.8 ± 8.9 years, p < 0.001) and had more comorbidities (CHA2DS2-VASc 3.8 ± 1.8 vs. 3.1 ± 1.7, p < 0.001). The four AF-EduCare/AF-EduApp study groups were comparable across the vast majority of parameters. Conclusions: The population showed high use of anticoagulation therapy, in line with current guidelines. In contrast to other AF trials about integrated care, the AF-EduCare/AF-EduApp study managed to incorporate all types of AF patients, both out-patient and hospitalised, with very comparable patient demographics across all subgroups. The trial will analyze whether different approaches to patient education and integrated AF care have an impact on clinical outcomes. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT03707873?term=af-educare&draw=2&rank=1, identifier: NCT03707873; https://clinicaltrials.gov/ct2/show/NCT03788044?term=af-eduapp&draw=2&rank=1, identifier: NCT03788044.

Engagement of atrial fibrillation patients with the AF-EduApp, a new mobile application to support AF management.

Introduction: A multidisciplinary approach is needed for the management of atrial fibrillation (AF) in which the patient has a central role. Smart devices create opportunities to improve AF management. This paper aimed to evaluate the in-house developed AF-EduApp application on its usability, satisfaction, and communication effectiveness with the care team. Methods: During a multicenter, prospective randomized controlled trial, 153 AF patients were included in the AF-EduApp study, with a minimum follow-up of 12 months and a maximum follow-up of 15 months if taking oral anticoagulation (OAC). The AF-EduApp contains six main modules: Questionnaires, Education, Measurement data entry, Medication overview with reminders, Appointments, and Communication with the care team. The App focuses on four main goals: (1) to improve AF knowledge, (2) to increase self-care capabilities, (3) electronic monitoring to improve therapy adherence to OAC, and (4) communication with the care team. Patients unable to use the AF-EduApp were assigned to a no-App control group (n = 41) without intervention comparable to the standard care group (SC, n = 346) of the AF-EduCare study. Results: A total of 152 patients effectively used the App during a mean follow-up of 386.8 ± 108. 1 days (one included patient could not install the application due to an iPhone from the United States). They opened the application on average on 130.1 ± 144.7 days. Of the 109 patients still in follow-up after 12 months (i.e. patients who did not withdraw and on OAC), 90 patients (82.6%) actively used the application at least one day in the next 41 days. The Measurement module was the most used, with a median of used days over the total available days of 6.4%. A total of 75 App patients (49.3%) asked questions, mostly clinical-related questions (e.g. medication use, or actionability on clinical entered parameters). A mean score of 8.1 ± 1.7 about the "perceived quality of follow-up in the past year" was given by the App ITT patients, compared to a score of 7.7 ± 2.0 by the SC group (P = .072). Patients who used the App were more attracted to future follow-up with an application compared to patients who would be capable of using the application of the SC group (31.6% vs. 12.5%; P < .001). Conclusion: This study showed a positive attitude towards using a mobile application, with AF patients using the application one-third of the available days. Patients used the App most for entering measured parameters, and to contact the care team.

Cardiorespiratory Polygraphy for Detection of Obstructive Sleep Apnea in Patients With Atrial Fibrillation.

Background: Obstructive sleep apnea (OSA) is a modifiable risk factor of atrial fibrillation (AF) but is underdiagnosed in these patients due to absence of good OSA screening pathways. Polysomnography (PSG) is the gold standard for diagnosing OSA but too resource-intensive as a screening tool. We explored whether cardiorespiratory polygraphy (PG) devices using an automated algorithm for Apnea-Hypopnea Index (AHI) determination can meet the requirements of a good screening tool in AF patients. Methods: This prospective study validated the performance of three PGs [ApneaLink Air (ALA), SOMNOtouch RESP (STR) and SpiderSAS (SpS)] in consecutive AF patients who were referred for PSG evaluation. Patients wore one of the three PGs simultaneously with PSG, and a different PG during each of three consecutive nights at home. Severity of OSA was classified according to the AHI during PSG (<5 = no OSA, 5-14 = mild, 15-30 = moderate, >30 = severe). Results: Of the 100 included AF patients, PSG diagnosed at least moderate in 69% and severe OSA in 33%. Successful PG execution at home was obtained in 79.1, 80.2 and 86.8% of patients with the ALA, STR and SpS, respectively. For the detection of clinically relevant OSA (AHI ≥ 15), an area under the curve of 0.802, 0.772 and 0.803 was calculated for the ALA, STR and SpS, respectively. Conclusions: This study indicates that home-worn PGs with an automated AHI algorithm can be used as OSA screening tools in AF patients. Based on an appropriate AHI cut-off value for each PG, the device can guide referral for definite PSG diagnosis.

A new smartphone application for integrated transmural care of atrial fibrillation, AF-EduApp: Usability and validation study.

INTRODUCTION: Digital technology creates the opportunity to develop and evaluate new tools, such as smartphone applications, to support integrated atrial fibrillation management. This study aimed to develop, evaluate, and validate a new, integrated care application (AF-EduApp) mainly focusing on targeted atrial fibrillation education to improve patient self-care capabilities and therapy adherence. METHODS: The newly developed AF-EduApp, available for Android and iOS, consists of six different modules. The prototype was validated and optimized for its usability and functionality at Jessa Hospital Hasselt and Antwerp University Hospital in two phases: (1) validity evaluation with interviews of an expert panel with 15 healthcare professionals and 10 atrial fibrillation patients, and (2) a pilot study of 1 month with 20 atrial fibrillation patients. RESULTS: Both experts and patients found that the application aids atrial fibrillation management. Based on the input of patients and experts, the main optimizations concerned the medication module (patient choice on setting reminder; interactivity of reminders with a "taken" or "snooze" function) and development of a clinical dashboard for the caregivers allowing telemonitoring of measurements and feedback to the patients. After the pilot study (n = 20), 16 patients indicated they wanted to use the app for a longer period. The measurement (27%) and education (17%) modules were the two most used modules with a significant improvement in knowledge (71.9% to 87.5%; P = 0.013). DISCUSSION: The AF-EduApp received a positive evaluation from health professionals and atrial fibrillation patients. Further development should be focused on the medication module and improvement of the clinical dashboard.

The value of screening questionnaires/scoring scales for obstructive sleep apnoea in patients with atrial fibrillation.

BACKGROUND: Obstructive sleep apnoea (OSA) is an important modifiable risk factor for atrial fibrillation (AF) but is underdiagnosed in this population. Currently, polysomnography is the gold standard for diagnosing OSA, but is expensive and requires overnight examination. Alternatively, home sleep apnoea testing can be used as a diagnostic tool, but also requires a complete data review. Therefore, these OSA diagnostic modalities are not ideal screening methods. Several OSA screening tools exist, but their value in patients with AF remains unclear. AIM: To test the performance of existing screening questionnaires/scales for clinically relevant OSA in patients with AF referred for diagnostic polysomnography. METHODS: This prospective study compared the performance of seven screening tools (Epworth Sleepiness Scale, Berlin Questionnaire, Sleep Apnea Clinical Score, NoSAS, OSA50, STOP-Bang and MOODS) with polysomnography in the detection of clinically relevant OSA in consecutive patients with AF referred to two sleep clinics. RESULTS: A total of 100 patients referred for polysomnography and known previous AF were included. Polysomnography indicated at least clinically relevant OSA (i.e., apnoea-hypopnoea index≥15 events/hour) in 69% of cases, and 33% had severe OSA (apnoea-hypopnoea index>30 events/hour). In screening for clinically relevant OSA, only the SACS and NoSAS scores had fair areas under the curve (0.704 and 0.712, respectively). None of the seven screening tools was performant enough (i.e., had a fair area under the curve>0.7) in the detection of severe OSA. CONCLUSIONS: In this AF cohort referred for polysomnography, clinically relevant OSA was prevalent. None of the selected screening tools showed sufficient performance as a good discriminative screening tool for clinically relevant OSA in patients with AF. Given these findings, other screening modalities for OSA should be considered in the work-up of patients with AF.