Risk factor management of atrial fibrillation using mHealth: The Atrial Fibrillation - Helping Address Care with Remote Technology (AF-HEART) Pilot Study.

Background: Personalized treatment of atrial fibrillation (AF) risk factors using mHealth and telehealth may improve patient outcomes. Objective: The purpose of this study was to assess the feasibility of the Atrial Fibrillation Helping Address Care with Remote Technology (AF-HEART) intervention on the following patient outcomes: (1) heart rhythm tracking; (2) weight, alcohol, blood pressure (BP), and sleep apnea reduction; (3) AF symptom reduction; and (4) quality-of-life (QOL) improvement. Methods: A total of 20 patients with AF undergoing antiarrhythmic therapy, cardioversion, and/or catheter ablation were enrolled and followed for 6 months. The AF-HEART intervention included remote heart rhythm, weight, and BP tracking; televisits with a dietician focusing on AF risk factors; and referrals for sleep apnea and hypertension treatment. Results: Patients transmitted a median of 181 rhythm recordings during the 6-month follow-up period. Patients lost an average of 3.5 kilograms at 6 months (P = .005). Patients had improved SF-12 scores (P = .01), AFSS score (P = .01), EQ-5D score (P = .006), and AFEQT Global Score (P = .03). There was significant correlation between weight loss and decrease in symptom severity (r = -0.45, P = .05), and between % weight loss and decrease in symptom severity (r = -0.49, P = .03). Conclusion: This study described the feasibility of the AF-HEART intervention for (1) consistent remote tracking of heart rhythm, weight, and BP; (2) achievement of weight loss; (3) reduction of symptoms; and (4) improvement in QOL. Expansion to a larger randomized study is planned.

Cardiac symptom burden and arrhythmia recurrence drives digital health use: results from the iHEART randomized controlled trial.

AIMS: Digital health can transform the management of atrial fibrillation (AF) and enable patients to take a central role in detecting symptoms and self-managing AF. There is a gap in understanding factors that support sustained use of digital health tools for patients with AF. This study identified predictors of Alivecor® KardiaMobile ECG monitor usage among patients with AF enrolled in the iPhone®Helping Evaluate Atrial fibrillation Rhythm through Technology (iHEART) randomized controlled trial. METHODS AND RESULTS: We analysed data from 105 English and Spanish-speaking adults with AF enrolled in the intervention arm of the iHEART trial. The iHEART intervention included smartphone-based electrocardiogram self-monitoring with Alivecor® KardiaMobile and triweekly text messages for 6 months. The primary outcome was use of Alivecor® categorized as: infrequent (≤5 times/week), moderate (>5 times and ≤11 times/week), and frequent (>11 times/week). We applied multinomial logistic regression modelling to characterize frequency and predictors of use. Of the 105 participants, 25% were female, 75% were White, and 45% were ≥65 years of age. Premature atrial contractions (PACs) [adjusted odds ratio (OR): 1.23, 1.08-1.40, P = 0.002] predicted frequent as compared to infrequent use. PACs (adjusted OR: 1.17, 95% confidence interval 1.06-1.30, P = 0.003), lower symptom burden (adjusted OR: 1.06, 1.01-1.11, P = 0.02), and less treatment concern (adjusted OR: 0.96, 0.93-0.99, P = 0.02) predicted moderate as compared to infrequent use. CONCLUSIONS: Frequent use of AliveCor® is associated with AF symptoms and potentially symptomatic cardiac events. Symptom burden and frequency should be measured and incorporated into analyses of future digital health trials for AF management.

Worldwide Survey of COVID-19-Associated Arrhythmias.

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Increased body mass index, age, and left atrial size are associated with altered intracardiac atrial electrograms in persistent atrial fibrillation patients.

BACKGROUND: There are limited studies evaluating whether atrial fibrillation (AF) patients with increased BMI, age, and left atrial (LA) size have altered intracardiac electrogram (EGM) morphology. METHODS: We analyzed left atrial intracardiac EGMs acquired during invasive electrophysiology study in 54 patients with AF. EGM correlations were assessed among AF risk factors including age, left atrial size, and BMI. RESULTS: BMI correlated positively with DF (r2 = 0.17, p = 0.009) and MP (r2 = 0.16, p = 0.01) with dominant frequency (DF) and mean spectral profile (MP) greater among obese individuals. Age was negatively associated with mean amplitude (r2 = 0.42, p < 0.001) and width (r2 = 0.32, p < 0.001); age was positively correlated with MP (r2 = 0.24, p < 0.001). LA size was negatively correlated with mean amplitude (r2 = 0.18, p = 0.03) and width (r2 = 0.23, p = 0.01); LA size was positively correlated with DF (r2 = 0.22, p = 0.01) and MP (r2 = 0.23, p = 0.01). Mean amplitude and width were decreased among subjects with a severely enlarged LA; DF and MP were increased in those with severely enlarged LA. The associations with BMI and LA size remained significant in multiple regression models that included age, male gender, time since AF diagnosis, and LVEF. CONCLUSIONS: EGM morphology of AF patients with increased BMI, older age, and an enlarged LA possessed decreased amplitude and decreased width and increased DF and MP. These findings suggest that atrial remodeling due to increased age, LA size, and BMI is associated with differences in local atrial activation, decreased refractoriness, and more heterogeneous activation. These novel findings point out clinical risk factors for atrial fibrillation that may affect electrogram characteristics.

Exploring Depressive Symptoms and Anxiety Among Patients With Atrial Fibrillation and/or Flutter at the Time of Cardioversion or Ablation.

BACKGROUND: Depression and anxiety in patients with atrial fibrillation (AF) and/or atrial flutter may influence the effectiveness of cardioversion and ablation. There is a lack of knowledge related to depressive symptoms and anxiety at the time of these procedures. OBJECTIVE: We aimed to describe the prevalence and explore potential covariates of depressive symptoms and anxiety in patients with AF at the time of cardioversion or ablation. We further explored the influence of depressive symptoms and anxiety on quality of life at the time of procedure and 6-month AF recurrence. METHODS: Depressive symptoms, anxiety, and quality of life were collected at the time of cardioversion or ablation using the Patient Health Questionnaire-9, State-Trait Anxiety Inventory, and Atrial Fibrillation Effect on Quality of Life questionnaire. Presence of AF recurrence within 6 months post procedure was evaluated. RESULTS: Participants (N = 171) had a mean (SD) age of 61.20 (11.23) years and were primarily male (80.1%) and white, non-Hispanic (81.4%). Moderate to severe depressive symptoms (17.2%) and clinically significant state (30.2%) and trait (23.6%) anxiety were reported. Mood/anxiety disorder diagnosis was associated with all 3 symptoms. Atrial fibrillation symptom severity was associated with both depressive symptoms and trait anxiety. Heart failure diagnosis and digoxin use were also associated with depressive symptoms. Trends toward significance between state and trait anxiety and participant race/ethnicity as well as depressive symptoms and body mass index were observed. Study findings support associations between symptoms and quality of life, but not 6-month AF recurrence. CONCLUSION: Depressive symptoms and anxiety are common in patients with AF. Healthcare providers should monitor patients with AF for depressive symptoms and anxiety at the time of procedures and intervene when indicated. Additional investigations on assessment, prediction, treatment, and outcome of depressive symptoms and anxiety in patients with AF are warranted.

Inappropriate implantable cardioverter-defibrillator shocks in repaired tetralogy of fallot patients: Prevalence and electrophysiological mechanisms.

BACKGROUND: Patients with Tetralogy of Fallot (TOF) are at increased risk for sudden cardiac death, often undergo implantable cardioverter defibrillator (ICD) implantation at younger ages, and are at greater risk of experiencing inappropriate shocks. We investigated occurrences of ICD shocks in TOF patients to identify prevalence, characteristics associated with inappropriate shocks, and therapeutic interventions after inappropriate shocks. METHODS: Records of patients with repaired TOF and ICD implantation who were followed at Columbia University Irving Medical Center between 1/1/2000 and 5/1/2019 were analyzed. RESULTS: 44 patients with repaired TOF and ICD implantation were reviewed. Mean age at implantation was 39 ± 13 years. Eight (18%) patients received both appropriate and inappropriate shocks, 6 (14%) received only appropriate shocks, and 3 (7%) received only inappropriate shocks. Three patients received inappropriate shocks for sinus tachycardia, 7 for atrial arrhythmias, and 1 for noise artifact. Inappropriately shocked patients had lower beat per minute (bpm) cutoff values for ICD therapy (mean = 162 ± 24 bpm vs. 182 ± 16 bpm, p = 0.007). After inappropriate shocks, 1 patient underwent lead replacement, 1 had the VT cutoff increased, and 6 were treated with medications. CONCLUSIONS: One quarter of TOF patients with ICDs experienced inappropriate shock therapy, the timing of which was most often clustered within the first two years after implant or years later. Lower shock therapy zones were associated with increased risk for inappropriate shocks, and the majority of inappropriate shocks resulted from atrial arrhythmias with rapid ventricular response. Treatments for inappropriate shocks included increasing VT therapy bpm and rhythm and/or rate control medications.

Restructuring Electrophysiology During the COVID-19 Pandemic: A Practical Guide From a New York City Hospital Network.

The coronavirus disease 2019 crisis is a global pandemic of a novel infectious disease with far-ranging public health implications. With regard to cardiac electrophysiology (EP) services, we discuss the "real-world" challenges and solutions that have been essential for efficient and successful (1) ramping down of standard clinical practice patterns and (2) pivoting of workflow processes to meet the demands of this pandemic. The aims of these recommendations are to outline: (1) essential practical steps to approaching procedures, as well as outpatient and inpatient care of EP patients, with relevant examples, (2) successful strategies to minimize exposure risk to patients and clinical staff while also balancing resource utilization, (3) challenges related to redeployment and restructuring of clinical and support staff, and (4) considerations regarding continued collaboration with clinical and administrative colleagues to implement these changes. While process changes will vary across practices and hospital systems, we believe that these experiences from 4 different EP sections in a large New York City hospital network currently based in the global epicenter of the coronavirus disease 2019 pandemic will prove useful for other EP practices adapting their own practices in preparation for local surges.

Mobile Electrocardiogram Monitoring and Health-Related Quality of Life in Patients With Atrial Fibrillation: Findings From the iPhone Helping Evaluate Atrial Fibrillation Rhythm Through Technology (iHEART) Study.

BACKGROUND: Atrial fibrillation (AF) is associated with high recurrence rates and poor health-related quality of life (HRQOL) but few effective interventions to improve HRQOL exist. OBJECTIVE: The aim of this study was to examine the impact of the "iPhone Helping Evaluate Atrial Fibrillation Rhythm through Technology" (iHEART) intervention on HRQOL in patients with AF. METHODS: We randomized English- and Spanish-speaking adult patients with AF to receive either the iHEART intervention or usual care for 6 months. The iHEART intervention used smartphone-based electrocardiogram monitoring and motivational text messages. Three instruments were used to measure HRQOL: the Atrial Fibrillation Effect on Quality of Life (AFEQT), the 36-item Short-Form Health survey, and the EuroQol-5D. We used linear mixed models to compare the effect of the iHEART intervention on HRQOL, quality-adjusted life-years, and AF symptom severity. RESULTS: A total of 238 participants were randomized to the iHEART intervention (n = 115) or usual care (n = 123). Of the participants, 77% were men and 76% were white. More than half (55%) had an AF recurrence. Both arms had improved scores from baseline to follow-up for AFEQT and AF symptom severity scores. The global AFEQT score improved 18.5 and 11.2 points in the intervention and control arms, respectively (P < .05). There were no statistically significant differences in HRQOL, quality-adjusted life-years, or AF symptom severity between groups. CONCLUSIONS: We found clinically meaningful improvements in AF-specific HRQOL and AF symptom severity for both groups. Additional research with longer follow-up should examine the influence of smartphone-based interventions for AF management on HRQOL and address the unique needs of patients diagnosed with different subtypes of AF.

Atrial Fibrillation Is Associated with Recurrent Ventricular Arrhythmias After LVAD Implant: Incidence and Impact in a Consecutive Series.

This study examined left-ventricular assist device (LVAD) patients with pre-LVAD ventricular arrhythmias (VAs) to determine the rate of recurrent post-LVAD VAs and the impact of pre-LVAD atrial fibrillation (AF) on recurrent post-LVAD VAs. Medical records of 195 consecutive LVAD patients were reviewed. Descriptive statistics were generated and Cox proportional hazard models were used to assess the association of clinical variables with the time to recurrent VA. Forty-seven percent of 195 CHF patients who received LVAD-manifested significant VAs prior to LVAD implant (82% Heartmate II, 14% HVAD, 4% other; median follow-up = 17 months), 41% of whom manifested recurrent post-LVAD VAs. Pre-LVAD AF was associated with recurrent VAs (hazard ratio = 3.73; 95% CI 1.33, 10.48; p = 0.012). Recurrent VAs were associated with increased mortality (hazard ratio = 3.06; 95% CI 1.17, 7.98; p = 0.023). A history of AF is prevalent in over half of LVAD patients with recurrent VAs and is associated with time to recurrence of VA.

Recurrent atrial fibrillation/flutter detection after ablation or cardioversion using the AliveCor KardiaMobile device: iHEART results.

OBJECTIVE: This study evaluated the impact of daily ECG (electrocardiogram) self-recordings on time to documented recurrent atrial fibrillation (AF) or atrial flutter (AFL) and time to treatment of recurrent arrhythmia in patients undergoing catheter radiofrequency ablation (RFA) or direct current cardioversion (DCCV) for AF/AFL. BACKGROUND: AF recurrence rates after RFA and DCCV are 20% to 45% and 60% to 80%, respectively. Randomized trials comparing mobile ECG devices to standard of care have not been performed in an AF/AFL population after treatment. METHODS: Of 262 patients consented, 238 were randomized to either standard of care (123) or to receive the iHEART intervention (115). Patients in the intervention group were provided with and trained to use an AliveCor KardiaMobile ECG monitor, and were instructed to take and transmit daily ECG recordings. Data were collected from transmitted ECG recordings and patients' electronic health records. RESULTS: In a multivariate Cox model, the likelihood of recurrence detection was greater in the intervention group (hazard ratio = 1.56, 95% confidence interval [CI]: 1.06-2.30, P = .024). Hazard ratios did not differ significantly for RFA and DCCV procedures. Recurrence during the first month after ablation strongly predicted later recurrence (hazard ratio = 4.53, 95% CI: 2.05-10.00, P = .0006). Time from detection to treatment was shorter for the control group (hazard ratio = 0.33, 95% CI: 0.57-2.92, P < .0001). CONCLUSIONS: The use of mobile ECG self-recording devices allows for earlier detection of AF/AFL recurrence and may empower patients to engage in shared health decision-making.

A Nurse-led Approach to Improving Cardiac Lifestyle Modification in an Atrial Fibrillation Population.

Atrial fibrillation (AF) is a major public health problem and the most common cardiac arrhythmia encountered in clinical practice at this time. AF is associated with numerous symptoms such as palpitations, shortness of breath, and fatigue, which can significantly reduce health-related quality of life and result in serious adverse cardiac outcomes. In light of this, the aim of the present pilot study was to test the feasibility of implementing a mobile health (mHealth) lifestyle intervention titled "Atrial Fibrillation and Cardiac Health: Targeting Improving Outcomes via a Nurse-Led Intervention (ACTION)," with the goal of improving cardiac health measures, AF symptom recognition, and self-management. As part of this study, participants self-identified cardiac health goals at enrollment. The nurse used web-based resources from the American Heart Association (Dallas, TX, USA), which included the Life's Simple 7® My Life Check® assessment, to quantify current lifestyle behavior change needs. Furthermore, on the My AFib Experience™ website (American Heart Association, Dallas, TX, USA), the patient used a symptom tracker tool to capture the date, time, frequency, and type of AF symptoms, and these data were subsequently reviewed by the cardiac nurse. Throughout the six-month intervention period, the cardiac nurse used a motivational interviewing approach to support participants' cardiac health goals. Ultimately, the ACTION intervention was tested in 53 individuals with AF (mean age: 59 ± 11 years; 76% male). Participants were predominantly overweight/obese (79%), had a history of hypertension (62%) or hyperlipidemia (61%), and reported being physically inactive/not preforming any type of regular exercise (52%). The majority (88%) of the participants had one or more Life's Simple 7® measures that could be improved. Most of the participants (98%) liked having a dedicated nurse to work with them on a biweekly basis via the mHealth portal. The most commonly self-reported symptoms were palpitations, fatigue/exercise intolerance, and dyspnea. Seventy percent of the participants had an improvement in their weight and blood pressure as documented within the electronic health record as well as a corresponding improvement in their Life's Simple 7® score at six months. On average, there was a three-pound (1.36-kg) decrease in weight and a 5-mmHg decrease in systolic blood pressure between baseline and at six months. In conclusion, this pilot work provides initial evidence regarding the feasibility of implementing the ACTION intervention and supports testing the ACTION intervention in a larger cohort of AF patients to inform existing AF guidelines and build an evidence base for reducing AF burden through lifestyle modification.

The use of serial cardiac 18F-fluorodeoxyglucose- positron emission tomography imaging to diagnose, monitor, and tailor treatment of cardiac sarcoidosis patients with arrhythmias: a case series and review.

BACKGROUND: Clinically evident cardiac involvement has been documented in 5% of sarcoidosis patients, primarily manifesting as heart block, ventricular arrhythmias, and heart failure. Heart Rhythm Society consensus guidelines recommend advanced cardiac imaging with fluorodeoxyglucose-positron emission tomography (FDG-PET) scan for diagnosis of cardiac sarcoidosis, given endomyocardial biopsy's low sensitivity. CASE SUMMARY: We describe four patients with cardiac sarcoidosis diagnosed with FDG-PET scan performed using a standardized imaging protocol for cardiac sarcoidosis. Serial FDG-PET scans were performed to monitor disease progression and response to therapy. Patients 1 and 2 presented with heart block, Patient 3 with heart failure and ventricular tachycardia (VT), and Patient 4 with VT. Patient 1 showed an initial decrease in standard uptake value (SUV) on immunosuppression, followed by an increase in SUV, necessitating steroid therapy. Patient 2's SUV decreased on immunosuppression. Patient 3 required 3.5 years of immunosuppression for the SUV to decrease to inactive disease levels, with SUV increasing and decreasing at different times during treatment, and subsequently developed VT. For Patient 4, areas of inflammation on the initial scan matched low voltage areas on the patient's EP study, confirming the arrhythmia's pathophysiological basis. DISCUSSION: Cardiac sarcoidosis progression and response to therapy are heterogeneous. Serial FDG-PET scans are useful to diagnose disease, tailor therapy, and monitor the clinical course of disease, allowing treatment decisions to be based on the quantitative level of inflammation seen on FDG-PET.