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.

[Application of photoplethysmography for atrial fibrillation in early warning, diagnosis and integrated management].

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. Early diagnosis and effective management are important to reduce atrial fibrillation-related adverse events. Photoplethysmography (PPG) is often used to assist wearables for continuous electrocardiograph monitoring, which shows its unique value. The development of PPG has provided an innovative solution to AF management. Serial studies of mobile health technology for improving screening and optimized integrated care in atrial fibrillation have explored the application of PPG in screening, diagnosing, early warning, and integrated management in patients with AF. This review summarizes the latest progress of PPG analysis based on artificial intelligence technology and mobile health in AF field in recent years, as well as the limitations of current research and the focus of future research.

Air pollution may increase the sleep apnea severity: A nationwide analysis of smart device-based monitoring.

Obstructive sleep apnea (OSA) can lead to sleep deprivation, accidents, and cardiovascular diseases. However, research on the short-term effects of air pollutants on OSA severity is limited and inconsistent. We conducted a novel case time series analysis using a nationwide dataset among Huawei smart device users to assess the association between air pollution and OSA severity in a population at moderate-to-severe risk of OSA. Fixed-effects regression models were used to assess the associations between air pollution and the risk of OSA exacerbation, apnea-hypopnea index (AHI), and oxygen saturation. A total of 51,842 participants who were at moderate-to-severe risk of OSA (mean age [SD]: 45.4 [11.0], 95.5% male) were included, with 6,232,056 person-days of monitoring. The associations of fine particulate matter, nitrogen dioxide, carbon monoxide, and sulfur dioxide with OSA severity could occur during the sleep period, and last for 2 days. An increase of 1 interquartile range in the moving average concentrations of air pollution during the sleep period and the 2 previous days was associated with a 1.14%-4.31% increase in the risk of OSA exacerbation, an increase in AHI by 0.05-0.17 events/h, and a decrease in oxygen saturation (%) by 0.003-0.014. The exposure-response curves were almost linear. The associations between air pollutants and OSA were consistently stronger in participants aged 45 years or older. By virtue of the smart device-based technology, this large-scale, nationwide, longitudinal study provides compelling evidence that short-term exposure to air pollution may worsen sleep apnea. Our findings highlight the significance of ongoing efforts to improve air quality in mitigating OSA severity and the relevant disease burden in an aging era.

Diagnostic validation of smart wearable device embedded with single-lead electrocardiogram for arrhythmia detection.

Objective: To validate a single-lead electrocardiogram algorithm for identifying atrial fibrillation, atrial premature beats, ventricular premature beats, and sinus rhythm. Methods: A total of 656 subjects aged 19 to 94 years were enrolled. Participants were simultaneously tested with a wristwatch (Huawei Watch GT2 Pro, Huawei Technologies Co., Ltd, Shenzhen, China) and a 12-lead electrocardiogram for 3 minutes. A total of 1926 electrocardiogram signals from 628 subjects (282 men and 346 women) aged 19 to 94 years (median 64 years) were analyzed using an algorithm. Results: The numbers of subjects with atrial fibrillation, atrial premature beats, ventricular premature beats, and sinus rhythm were 129, 141, 107, and 251, respectively, and together they had a total of 1926 electrocardiogram signals. For the three-class classification system, the recall, precision, and F1 score were 97.6%, 96.5%, 97.0% for sinus rhythm; 96.7%, 96.9%, 96.8% for atrial fibrillation; and 92.8%, 94.2%, 93.5% for ectopic beats, respectively. The macro-F1 score of the three-class classification system was 95.8%. For the four-class classification system, the recall, precision, and F1 score were 97.6%, 96.5%, 97.0% for sinus rhythm; 96.7%, 96.9%, 96.8% for atrial fibrillation; 90.5%, 89.4%, 89.9% for atrial premature beats; and 86.1%, 89.6%, 87.8% for ventricular premature beats, respectively. The macro-F1 score of the four-class classification system was 92.9%. Conclusions: The single-lead electrocardiogram algorithm embedded into smart wearables demonstrated good performance in detecting atrial fibrillation, atrial/ventricular premature beats, and sinus rhythm, and thus would facilitate atrial fibrillation screening and management.

Structured Rehabilitation for Patients with Atrial Fibrillation Based on an Integrated Care Approach: Protocol for a Prospective, Observational Cohort Study.

Background: Guideline-recommended integrated care based on the ABC (Atrial fibrillation Better Care) pathway for "general" patients with atrial fibrillation (AF) improves clinical outcomes, as demonstrated in our prior mobile Atrial Fibrillation Application (mAFA)-II cluster randomized trial. The present study aims to investigate whether mAFA III-supported structured follow-up rehabilitation packages adapted to patient risk profiles and different treatment patterns (eg, for patients receiving drug treatment only, AF ablation, or left atrial appendage occlusion [LAAO]) will improve guideline adherence and reduce the risk of adverse cardiovascular events. Methods and Analysis: In this prospective, observational mAFA III pilot cohort study, patients with AF aged ≥ 18 years will be enrolled using the mAFA III App for self-management. Assuming an annual rate of composite outcome of "ischaemic stroke or systemic embolism, all-cause death and cardiovascular hospitalization" of 29.3% for non-ABC pathway compliance compared with 20.8% for ABC pathway compliance, at least 1475 patients would be needed to detect the outcome of the A, B and C components of the ABC pathway, assuming a withdrawal rate of 20% in the first year. The primary endpoint is adherence to guidelines regarding the A, B and C components of the ABC pathway. Ancillary analyses will be performed to determine the impact of the ABC pathway using smart technologies on the outcomes among the "high-risk" population (eg, ≥75 years old, with multimorbidities, with polypharmacy) and the application of artificial intelligence machine-learning AF risk prediction management in assessing AF recurrence. The individualised anticoagulants with AF burden will be monitored by smart devices. Trial Registration Number: ISRCTN13724416.

Generalisability of and lessons learned from a mixed-methods study conducted in three low- and middle-income countries to identify care pathways for atrial fibrillation.

BACKGROUND: Identifying existing care pathways is the first step for understanding how services can be improved to enable early diagnosis and effective follow-up care for non-communicable diseases (NCDs); however, evidence on how care pathways can and should be identified in low- and middle-income countries (LMICs) is lacking. OBJECTIVE: To describe generalisability and lessons learned from recruitment and data collection for the quantitative component of a mixed methods study designed to determine the care pathway for atrial fibrillation (AF) in Brazil, China and Sri Lanka. METHODS: Adults (≥18 years) that spoke the local language and with an AF diagnosis were eligible. We excluded anyone with a hearing or cognitive impairment or ineligible address. Eligible participants were identified using electronic records in Brazil and China; in Sri Lanka, researchers attended the outpatient clinics to identify eligible participants. Data were collected using two quantitative questionnaires administered at least 2-months apart. A minimum sample size of 238 was required for each country. RESULTS: The required sample size was met in Brazil (n = 267) and China (n = 298), but a large proportion of AF patients could not be contacted (47% and 27%, respectively) or refused to participate (36% and 38%, respectively). In Sri Lanka, recruitment was challenging, resulting in a reduced sample (n = 151). Mean age of participants from Brazil, China and Sri Lanka was 69 (SD = 11.3), 65 (SD = 12.8) and 58 (SD = 11.7), respectively. Females accounted for 49% of the Brazil sample, 62% in China and 70% in Sri Lanka. CONCLUSIONS: Generalisability was an issue in Brazil and China, as was selection bias. Recruitment bias was highlighted in Sri Lanka. Additional or alternative recruitment methods may be required to ensure generalisability and reduce bias in future studies aimed at identifying NCD care pathways in LMICs.

Effects of the ABC pathway on clinical outcomes in a secondary prevention population of Chinese patients with atrial fibrillation: A report from the Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry.

Background: The atrial fibrillation better care (ABC) pathway is a simple, comprehensive framework that facilitates provision of integrated care for atrial fibrillation (AF) patients. Objective: We evaluated management of AF patients in a secondary prevention cohort using the ABC pathway and examined the impact of ABC adherence on clinical outcomes. Methods: The Chinese Patients with Atrial Fibrillation registry is a prospective registry conducted in 44 sites across China between October 2014 and December 2018. The primary outcome was the composite of all-cause mortality/any thromboembolism (TE), all-cause death, any TE and major bleeding at 1 year. Results: Of the 6420 patients, 1588 (24.7%) had a prior stroke or transient ischemic attack and were identified as the secondary prevention cohort. After excluding 793 patients due to insufficient data, 358 (22.5%) were ABC compliant and 437 (27.5%) ABC noncompliant. ABC adherence was associated with a significantly lower risk of the composite outcome of all-cause death/TE, odds ratio (OR) 0.28 (95% confidence interval [CI]: 0.11-0.71) and all-cause death, OR 0.29 (95% CI: 0.09-0.90). Significant differences were not observed for TE, OR 0.27 (95% CI: 0.06-1.27) and major bleeding, OR 2.09 (95% CI: 0.55-7.97). Age and prior major bleeding were significant predictors of ABC noncompliance. Health-related quality of life (QOL) was higher in the ABC compliant group versus the noncompliant group (EQ score 0.83 ± 0.17 vs. 0.78 ± 0.20; p = .004). Conclusion: ABC pathway adherence in secondary prevention AF patients was associated with a significantly lower risk of the composite outcome of all-cause death/TE and all-cause death, as well as better health-related QOL.

Mobile health technology integrated care in atrial fibrillation patients with diabetes mellitus in China: A subgroup analysis of the mAFA-II cluster randomized clinical trial.

BACKGROUND: The Mobile Health Technology for Improved Screening and Optimized Integrated Care in AF (mAFA-II) prospective randomized trial showed the efficacy of a mobile health (mHealth) implemented 'Atrial fibrillation Better Care' (ABC) pathway for the integrated care management of patients with atrial fibrillation (AF). In this ancillary analysis, we evaluated the effect of mAFA intervention according to the history of diabetes mellitus (DM). METHODS: The mAFA-II trial enrolled 3324 AF patients across 40 centres in China, between June 2018 and August 2019. In this analysis, we assessed the interaction between history of DM and the effect of mAFA intervention on the risk of the primary composite outcome of stroke, thromboembolism, all-cause death and rehospitalizations. Results were expressed as adjusted hazard ratio (aHR) and 95% confidence intervals (95%CI). The effect of mAFA intervention on exploratory secondary outcomes was also assessed. RESULTS: Overall, 747 (22.5%) patients had DM (mean age: 72.7 ± 12.3, 39.6% females; 381 allocated to mAFA intervention). mAFA intervention was associated with a significant risk reduction for the primary composite outcome both in patients with and without DM (aHR [95%CI]: .36 [.18-.73] and .37 [.23-.61], respectively, p for interaction = .941). A significant interaction was found only for the composite of recurrent AF, heart failure and acute coronary syndromes (pint =.025), with lower effect of mAFA intervention in patients with DM. CONCLUSIONS: A mHealth-technology implemented ABC pathway showed a consistent effect in reducing the risk of the primary composite outcome in AF patients with and without DM. TRIAL REGISTRATION: WHO International Clinical Trials Registry Platform (ICTRP) Registration number: ChiCTR-OOC-17014138.

Mobile Health-Technology-Integrated Care for Atrial Fibrillation: A Win Ratio Analysis from the mAFA-II Randomized Clinical Trial.

BACKGROUND: The Mobile Health (mHealth) Technology for Improved Screening and Optimized Integrated Care in atrial fibrillation (AF) (mAFA-II) cluster randomized trial assessed the efficacy of an integrated care approach in improving the prognosis of AF patients. In this study, we provide a reanalysis of the trial outcomes using the win ratio (WR) approach. METHODS: The mAFA-II trial allocated patients to receive a mHealth-technology implemented Atrial Fibrillation Better Care (ABC) pathway (mAFA intervention) or usual care. The primary outcome was the composite of all-cause death, ischemic stroke or systemic thromboembolism, and rehospitalization. The efficacy of the mAFA intervention was analyzed according to the WR method using the unmatched pairs approach, with the components of the primary outcome analyzed hierarchically as follows: (1) all-cause death; (2) ischemic stroke or thromboembolism; (3) rehospitalization. Results were reported as WR and 95% confidence intervals (CIs). In addition, we calculated win odds (WO) and 95% CI. RESULTS: A total of 3,324 patients were enrolled in the mAFA-II trial and included in this analysis (1,646 allocated to mAFA intervention and 1,678 to usual care). Among 2,761,988 unmatched pairs comparisons, the number of wins was higher in the mAFA intervention group, with a WR: 2.78 (95% CI: 1.85-4.17). WO confirmed the effect of mAFA intervention, although with a lower magnitude (WO: 1.06; 95% Cl: 1.04-1.08). CONCLUSION: In this posthoc WR analysis of the mAFA-II trial, a mHealth-technology-implemented integrated care approach was effective in reducing the risk of the primary composite outcome of all-cause death, ischemic stroke or thromboembolism, and rehospitalization, even when prioritizing fatal events.

Natural Language Processing in a Clinical Decision Support System for the Identification of Venous Thromboembolism: Algorithm Development and Validation.

BACKGROUND: It remains unknown whether capturing data from electronic health records (EHRs) using natural language processing (NLP) can improve venous thromboembolism (VTE) detection in different clinical settings. OBJECTIVE: The aim of this study was to validate the NLP algorithm in a clinical decision support system for VTE risk assessment and integrated care (DeVTEcare) to identify VTEs from EHRs. METHODS: All inpatients aged ≥18 years in the Sixth Medical Center of the Chinese People's Liberation Army General Hospital from January 1 to December 31, 2021, were included as the validation cohort. The sensitivity, specificity, positive and negative likelihood ratios (LR+ and LR-, respectively), area under the receiver operating characteristic curve (AUC), and F1-scores along with their 95% CIs were used to analyze the performance of the NLP tool, with manual review of medical records as the reference standard for detecting deep vein thrombosis (DVT) and pulmonary embolism (PE). The primary end point was the performance of the NLP approach embedded into the EHR for VTE identification. The secondary end points were the performances to identify VTE among different hospital departments with different VTE risks. Subgroup analyses were performed among age, sex, and the study season. RESULTS: Among 30,152 patients (median age 56 [IQR 41-67] years; 14,247/30,152, 47.3% females), the prevalence of VTE, PE, and DVT was 2.1% (626/30,152), 0.6% (177/30,152), and 1.8% (532/30,152), respectively. The sensitivity, specificity, LR+, LR-, AUC, and F1-score of NLP-facilitated VTE detection were 89.9% (95% CI 87.3%-92.2%), 99.8% (95% CI 99.8%-99.9%), 483 (95% CI 370-629), 0.10 (95% CI 0.08-0.13), 0.95 (95% CI 0.94-0.96), and 0.90 (95% CI 0.90-0.91), respectively. Among departments of surgery, internal medicine, and intensive care units, the highest specificity (100% vs 99.7% vs 98.8%, respectively), LR+ (3202 vs 321 vs 77, respectively), and F1-score (0.95 vs 0.89 vs 0.92, respectively) were in the surgery department (all P<.001). Among low, intermediate, and high VTE risks in hospital departments, the low-risk department had the highest AUC (1.00 vs 0.94 vs 0.96, respectively) and F1-score (0.97 vs 0.90 vs 0.90, respectively) as well as the lowest LR- (0.00 vs 0.13 vs 0.08, respectively) (DeLong test for AUC; all P<.001). Subgroup analysis of the age, sex, and season demonstrated consistently good performance of VTE detection with >87% sensitivity and specificity and >89% AUC and F1-score. The NLP algorithm performed better among patients aged ≤65 years than among those aged >65 years (F1-score 0.93 vs 0.89, respectively; P<.001). CONCLUSIONS: The NLP algorithm in our DeVTEcare identified VTE well across different clinical settings, especially in patients in surgery units, departments with low-risk VTE, and patients aged ≤65 years. This algorithm can help to inform accurate in-hospital VTE rates and enhance risk-classified VTE integrated care in future research.

Mobile health-technology integrated care in secondary prevention atrial fibrillation patients: a post-hoc analysis from the mAFA-II randomized clinical trial.

AF patients with history of thromboembolic events are at higher risk of thromboembolic recurrences, despite appropriate antithrombotic treatment. We aimed to evaluate the effect of mobile health (mHealth) technology-implemented 'Atrial fibrillation Better Care' (ABC) pathway approach (mAFA intervention) in secondary prevention AF patients. The Mobile Health Technology for Improved Screening and Optimized Integrated Care in AF (mAFA-II) cluster randomized trial enrolled adult AF patients across 40 centers in China. The main outcome was the composite outcome of stroke or thromboembolism, all-cause death, and rehospitalization. Using Inverse Probability of Treatment Weighting (IPTW), we evaluated the effect of the mAFA intervention in patients with and without prior history of thromboembolic events (i.e., ischemic stroke or thromboembolism). Among the 3324 patients enrolled in the trial, 496 (14.9%, mean age: 75.1 ± 11.4 years, 35.9% females) had a previous episode of thromboembolic event. No significant interaction was observed for the effect of mAFA intervention in patients with vs. without history of thromboembolic events [Hazard ratio, (HR): 0.38, 95% confidence interval (CI):0.18-0.80 vs. HR 0.55, 95% CI 0.17-1.76, p for interaction = 0.587); however, a trend towards lower efficacy of mAFA intervention among AF patients in secondary prevention was observed for secondary outcomes, with significant interaction for bleeding events (p = 0.034) and the composite of cardiovascular events (p = 0.015). A mHealth-technology-implemented ABC pathway provided generally consistent reduction of the risk of primary outcome in both primary and secondary prevention AF patients. Secondary prevention patients may require further specific approaches to improve clinical outcomes such as bleeding and cardiovascular events.Trial registration: WHO International Clinical Trials Registry Platform (ICTRP) Registration number ChiCTR-OOC-17014138.

Application of smart devices in investigating the effects of air pollution on atrial fibrillation onset.

Few studies have examined the link between short-term exposure to air pollutants and atrial fibrillation (AF) episodes. This study aims to examine the association of hourly criteria air pollutants with AF episodes. We employ a smart device-based photoplethysmography technology to screen AF from 2018 to 2021. Hourly concentrations of six criteria air pollutants are matched to the onset hour of AF for each participant. We adopt a time-stratified case-crossover design to capture the acute effects of air pollutants on AF episodes, using conditional logistic regression models. Subgroup analyses are conducted by age, gender, and season. A total of 11,906 episodes of AF are identified in 2976 participants from 288 Chinese cities. Generally, the strongest associations of air pollutants are present at lag 18-24 h, with positive and linear exposure-response relationships. For an interquartile range increase in inhalable particles, fine particles, nitrogen dioxide, and carbon monoxide, the odds ratio (OR) of AF is 1.19 [95% confidential interval (CI): 1.03, 1.37], 1.38 (95%CI: 1.14, 1.67), 1.60 (95%CI: 1.16, 2.20) and 1.48 (95%CI: 1.19, 1.84), respectively. The estimates are robust to the adjustment of co-pollutants, and they are larger in females, older people, and in cold seasons. There are insignificant associations for sulfur dioxide and ozone. This nationwide case-crossover study demonstrates robust evidence of significant associations between hourly exposure to air pollutants and the onset of AF episodes, which underscores the importance of ongoing efforts to further improve air quality as an effective target for AF prevention.

Efficacy of mobile health-technology integrated care based on the 'Atrial fibrillation Better Care' (ABC) pathway in relation to sex: a report from the mAFA-II randomized clinical trial.

The Mobile Health Technology for Improved Screening and Optimized Integrated Care in AF (mAFA-II) cluster-randomized trial showed that a mobile health (mHealth)-implemented 'Atrial fibrillation Better Care' (ABC) pathway approach reduced the risk of adverse events in atrial fibrillation (AF) patients. Whether this benefit can be applied to both males and females is unclear, especially given the suboptimal management and poorer cardiovascular outcomes in females with AF. In this post-hoc analysis, we performed a sex-stratified analysis of the mAFA-II trial. Between June 2018 and August 2019, adult AF patients were enrolled across 40 centers in China. The primary outcome was the composite of stroke, thromboembolism, all-cause death, and re-hospitalization. The effect of mAFA intervention according to sex was evaluated through adjusted Cox-regression models. Among the 3,324 patients enrolled in the trial, 2,062 (62.0%) patients were males (mean age: 67.5 ± 14.3 years; 1,021 allocated to mAFA intervention) and 1,262 (38.0%) were females (mean age: 70.2 ± 13.0; 625 allocated to mAFA intervention). A significant risk reduction of the primary composite outcome in patients allocated to mAFA intervention was observed in both males (adjusted hazard ratio [aHR] and 95% confidence interval [CI] 0.30 [0.17-0.52]) and females (aHR [95%CI] 0.50 [0.27-0.92]), without statistically significant interaction (p = 0.225). Sex-based interactions were observed for other secondary outcomes, including all-cause death (p = 0.026) and bleeding events (p = 0.032). A mHealth-technology implemented ABC pathway was similarly effective in reducing the risk of adverse clinical events both in male and female patients. Secondary outcomes showed greater benefits of mAFA intervention in men.

Poor adherence to guideline-directed anticoagulation in elderly Chinese patients with atrial fibrillation: a report from the Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry.

AIMS: Adherence to guideline-directed oral anticoagulation (OAC) in patients with atrial fibrillation (AF) improves outcomes, but limited data are available from China. We evaluated the adherence to guideline-directed anticoagulation and its impact on clinical outcomes in a high-risk cohort of elderly Chinese patients. METHODS AND RESULTS: The Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry is a prospective, multicentre study conducted from October 2014 to December 2018. Endpoints of interest were all-cause death, thromboembolic (TE) events and major bleedings in patients with a guideline-directed indication for OACs (CHA2DS2-VASc ≥1 if male or ≥2 if female). The eligible cohort consisted of 5742 patients, of whom 2567 (44.7%) patients were treated with an OAC. Seven independent predictors of OAC undertreatment were identified: age [odds ratio (OR): 1.04; 95% confidence interval (CI): 1.03-1.05; P < 0.001], first diagnosed AF (OR: 1.71; 95%CI: 1.44-2.03; P < 0.001), chronic kidney disease (OR: 1.67; 95%CI: 1.36-2.06; P < 0.001), liver disease (OR: 1.69; 95%CI: 1.19-2.41; P = 0.003), dementia (OR: 1.67; 95%CI: 1.06-2.64; P = 0.026), prior extracranial bleeding (OR: 1.89; 95%CI: 1.35-2.64; P < 0.001), and the use of antiplatelet drug (OR: 6.97; 95%CI: 5.89-8.23; P < 0.001). On multivariate analysis, OAC undertreatment was significantly associated with a higher risk all-cause death (OR: 3.79; 95%CI: 2.61-5.53; P < 0.001) and TE events (OR: 2.28; 95%CI: 1.39-3.72; P = 0.001), and a similar risk of major bleeding as compared with guideline-directed OAC therapy. CONCLUSION: Only 44.7% of all eligible patients were prescribed OAC in accordance with guideline recommendations. The independent predictors for OAC undertreatment were age, first diagnosed AF, chronic kidney disease, chronic obstructive pulmonary disease, prior extracranial bleeding, and the use of the antiplatelet drugs. Guideline-adherent thromboprophylaxis was safe and may be associated with improved survival and less TE among elderly Chinese patients with AF.

Evaluation of Huawei smart wearables for detection of atrial fibrillation in patients following ischemic stroke: The Liverpool-Huawei stroke study.

BACKGROUND: Atrial fibrillation (AF) often remains undetected following stroke. Documenting AF is critical to initiate oral anticoagulation, which has proven benefit in reducing recurrent stroke and mortality in patients with AF. The accuracy and acceptability of using smart wearables to detect AF in patients following stroke is unknown. METHODS: The aims of the Liverpool-Huawei Stroke Study are to determine the effectiveness, cost-effectiveness and patient and staff acceptability of using Huawei smart wearables to detect AF following ischemic stroke. The study plans to recruit 1,000 adults aged ≥18 years following ischemic stroke from participating hospitals over 12 months. All participants will be asked to wear a Huawei smart band for 4 weeks postdischarge. If participants do not have access to a compatible smartphone required for the study, they will be provided with a smartphone for the 4-week AF monitoring period. RESULTS: Participants with suspected AF detected by the smart wearables, without previous known AF, will be referred for further evaluation. To determine the effectiveness of the Huawei smart wearables to detect AF, the positive predictive value will be determined. Patient acceptability of using this technology will also be examined. Additional follow-up assessments will be conducted at 6 and 12 months, and clinical outcomes recorded in relation to prevalent and incident AF post-stroke. The study opened for recruitment on May 30, 2022, and is currently open at 4 participating hospitals; the first 106 participants have been recruited. One further hospital is preparing to open for recruitment. CONCLUSIONS: This prospective study will examine the effectiveness and acceptability of the use of smart wearables in patients following ischemic stroke. This could have important implications for detection of AF and therefore, earlier prophylaxis for recurrent stroke. The study is registered on https://www.isrctn.com/ (Identifier ISRCTN30693819).

Mobile health-technology integrated care in atrial fibrillation patients with heart failure: A report from the mAFA-II randomized clinical trial.

BACKGROUND: To assess the effect of mobile health (mHealth) technology-implemented 'Atrial fibrillation Better Care' (ABC) pathway-approach (mAFA intervention) in AF patients with Heart Failure (HF). METHODS: From the Mobile Health Technology for Improved Screening and Optimized Integrated Care in AF (mAFA-II) cluster randomized trial, we evaluated the effect of mAFA intervention on the risk of major outcomes in patients with HF using Inverse Probability of Treatment Weighting. Primary outcome was the composite outcome of stroke/thromboembolism, all-cause death, and rehospitalization. The effect of mAFA and the interaction with HF at baseline was assessed through Cox-regressions. RESULTS: Among the 3,324 patients originally enrolled in the trial, 714 (21.5%; mean age: 72.7±13.1 years; 39.9% females) had HF. The effect of mAFA intervention on the primary outcome was consistent in patients with and without HF (Hazard Ratio, (HR): 0.59, 95% Confidence Interval (CI): 0.29-1.22 vs. HR: 0.40, 95%CI: 0.21-0.76, p for interaction=0.438); similar findings were found for rehospitalisations and bleeding events. A trend towards lower efficacy of mAFA in HF patients was observed for all-cause death, while the risk of the composite outcome of 'recurrent AF, HF and acute coronary syndrome' was higher among AF-HF patients allocated to mAFA (p for interaction: <0.001). CONCLUSION: A mHealth-technology implemented ABC pathway provides consistent effects on the risks of primary outcome, rehospitalisation and bleeding, in AF patients both with and without HF. However, AF-HF patients may need tailored approaches to improve their overall prognosis, specifically to reduce the risk of recurrent AF, HF and acute coronary syndrome.

Correction: Vital Signs During the COVID-19 Outbreak: A Retrospective Analysis of 19,960 Participants in Wuhan and Four Nearby Capital Cities in China.

[This corrects the article DOI: 10.5334/gh.913.].

Consumer-Led Screening for Atrial Fibrillation: A Report From the mAFA-II Trial Long-Term Extension Cohort.

Background: There are limited data on mobile health detection of prevalent atrial fibrillation (AF) and its related risk factors over time. Objectives: This study aimed to report the trends on prevalent AF detection over time and risk factors, with a consumer-led photoplethysmography screening approach. Methods: 3,499,461 subjects aged over 18 years, who use smart devices (Huawei Technologies Co.) were enrolled between October 26, 2018, and December 1, 2021. Results: Among 2,852,217 subjects for AF screening, 12,244 subjects (0.43%; 83.2% male, mean age 57 ± 15 years) detected AF episodes. When compared with 2018, the risk (adjusted HRs, 95% CI) for monitored prevalent AF increased significantly for subjects when monitoring started in 2020 (adjusted HR: 1.34; 95% CI: 1.27-1.40; P < .001) or in 2021 (adjusted HR: 1.67; 95% CI: 1.59-1.76; P < 0.001). Of the 961,931 subjects who screening for both AF and OSA, 18,032 (1.9%, 97.8% male, mean age 44 ±17 years) were identified as high risk for OSA, which resulted in a 1.5-fold increase (95% CI: 1.30-fold to 1.75-fold) in the prevalent AF. A total of 5,227 (53.3%, 5,227/9,797) subjects were effectively followed up, from which 4,903 (93.8%, 4,903/5,227) subjects were confirmed with the diagnosis of AF, by the mAFA Telecare Team health providers. Conclusions: Photoplethysmography-based smart devices can facilitate screening for AF with >93% confirmation of detected AF episodes even for the low-risk general population, highlighting the increased risk for detecting prevalent AF and the need for modification of OSA that increase AF susceptibility. (Mobile Health [mHealth] Technology for Improved Screening, Patient Involvement and Optimizing Integrated Care in Atrial Fibrillation [mAFA (mAF-App) II study]; ChiCTR-OOC-17014138).

Consumer-Led Screening for Atrial Fibrillation: Frontier Review of the AF-SCREEN International Collaboration.

The technological evolution and widespread availability of wearables and handheld ECG devices capable of screening for atrial fibrillation (AF), and their promotion directly to consumers, has focused attention of health care professionals and patient organizations on consumer-led AF screening. In this Frontiers review, members of the AF-SCREEN International Collaboration provide a critical appraisal of this rapidly evolving field to increase awareness of the complexities and uncertainties surrounding consumer-led AF screening. Although there are numerous commercially available devices directly marketed to consumers for AF monitoring and identification of unrecognized AF, health care professional-led randomized controlled studies using multiple ECG recordings or continuous ECG monitoring to detect AF have failed to demonstrate a significant reduction in stroke. Although it remains uncertain if consumer-led AF screening reduces stroke, it could increase early diagnosis of AF and facilitate an integrated approach, including appropriate anticoagulation, rate or rhythm management, and risk factor modification to reduce complications. Companies marketing AF screening devices should report the accuracy and performance of their products in high- and low-risk populations and avoid claims about clinical outcomes unless improvement is demonstrated in randomized clinical trials. Generally, the diagnostic yield of AF screening increases with the number, duration, and temporal dispersion of screening sessions, but the prognostic importance may be less than for AF detected by single-time point screening, which is largely permanent, persistent, or high-burden paroxysmal AF. Consumer-initiated ECG recordings suggesting possible AF always require confirmation by a health care professional experienced in ECG reading, whereas suspicion of AF on the basis of photoplethysmography must be confirmed with an ECG. Consumer-led AF screening is unlikely to be cost-effective for stroke prevention in the predominantly young, early adopters of this technology. Studies in older people at higher stroke risk are required to demonstrate both effectiveness and cost-effectiveness. The direct interaction between companies and consumers creates new regulatory gaps in relation to data privacy and the registration of consumer apps and devices. Although several barriers for optimal use of consumer-led screening exist, results of large, ongoing trials, powered to detect clinical outcomes, are required before health care professionals should support widespread adoption of consumer-led AF screening.