Chapters Transcript Video Cardiology in Motion: How Wearable Devices are Changing Patient Care Back to Symposium So we're gonna talk about how wearable devices are changing patient care and I'm gonna go over the main wearable devices that you guys as primary care providers or people out in the public, you'll see and what our decisions are on which devices to prescribe to the patient. So these are my disclosures. I provide consulting for Johnson and Johnson and I run steering committees for trials and consulting for Boston Scientific. So why does this matter in your primary care clinic? Um, you can see the picture on the right. Patients are increasingly arriving with their own data. So primary care physicians are on the front lines interpreting the data. Many patients have Apple Watches or Fitbits or, um, any kind of monitors, and they're showing up up to your clinic, not our clinics, because they need a referral. And they show up and they say, hey, my watch says, do I have, it says I have 5% AFib. I have 10% AFib, I may have an arrhythmia, see your doctor. What and so it's important to realize what's out there, what's coming about, uh, because you guys are on the front lines and then it allows for trends to be seen earlier and allows for earlier intervention. One of the things, uh, which is really poor across all subspecialties across the United States is access to subspecialty care. So whether you wanna see an interventionist or you wanted to. See an electrophysiologist, my patients, our patients always complain they can't see us, and I'm like that's because we're better with our hands than our brains. And so, uh, we only do one office day a week or one office day every 2 weeks. We're usually using our hands to do procedures or help out in the hospital. And so a primary care doctor who notices, hey, the Apple Watch, it might have a fib. They could recognize it. They can get an EKG. They can order a Holter monitor, um, they could start the process of getting an echocardiogram and starting them on anticoagulation before they get seen in electrophysiology. And you may save a stroke by doing that. So if you get the proper workup done, you may save a stroke by putting that patient on anticoagulation. So this is where digital health is changing. Um, on the top you see the traditional model of healthcare where anything we invent medications, tests or devices has to go through clinical trials. Then the FDA reviews you submit, um, because I do this for Boston, you submit 50 pages of trial data with adverse events, um. Our research coordinators know this you submit all of that to the FDA. The FDAA takes months and months to decide, and then they approve something. It goes back to the healthcare providers and then goes to their patients. Wearables are totally different. So in wearables you don't need any testing. You don't need clinical data, um, you go directly to marketing. You put it on the shelf of Target or Best Buy, you may do a study, you may not do a study, you may not need FDA clearance and it goes directly to patients and consumers who show up in your office and you're task to interpret the data. And so where the opportunities lie, we'll see this in the future, more and more trials developing for digital health and wearables and more to come in the years to uh years beyond. So this is atrial fibrillation. It's the most common arrhythmia I see in practice and us as electrophysiologists, we see. It's difficult to detect unless symptomatic. 1 in 4 patients, 1 in 4 people in the United States will get diagnosed with AFib. About 30% of AFib is silent, meaning that patients won't recognize the symptoms of AFib, and they, the first opportunity they may have to recognize they have AFib is a stroke. The treatments are expensive and the consequences if left untreated are devastating. So every year we see a couple of patients in end-stage heart failure because their AFib was missed. We see a couple of patients with strokes. And so we are trying to prevent that by giving primary care providers the tools and knowledge, um, for earlier intervention. So here's the gold standard of atrial fibrillation. You could see on the left is an EKG which shows the irregularity, irregularly irregular pattern of AFib. On a 12 lead EKG and you can see on the right how cumbersome it is. You have this machine, archaic machine. You have to hook up a bunch of stickers, uh, from the arms, the legs to the chest, and it prints a paper that helps you diagnose AFib. A lot of primary care providers have this in the office. They have it in emergency rooms, but patients do not have access to this at home. Some offices are running behind. They may not have access to it, um, but this is the gold standard of diagnosing AFib. And right now, the US Preventive Task Force, so this comes from the Annals of Internal Medicine, which shows, and this is how all prevention stuff works, the balances of benefits and harms of screening of AFib are insufficient. So we don't have a recommendation on whether every patient should be screened with an EKG or screened for AFib. And so the level of evidence is grade one. However, now we have better sensors. So on the left, you see the classic electrical activity sensors. So these are your Holter monitors. These are your mobile telemetry monitors. You could have single ECG devices, and those look at electrical heart rhythm directly from the heart. On the right, you see non-electrical cardiac activity sensors. So these are things like your Apple Watch, which uses the pulse and uses vibrations or PPG. To look at whether you could have a fib based on the irregularity of the pulse that it sends. And so you could use different seismographs, you could use different kinds of optical sensors to design devices where patients can wear it without measuring electricity. So these are the three main types of devices which I want to show you guys and make sure you're aware of that are that are out there. So on the left is consumer smartwatch. So this is PPG and optional single lead EKG. It's worn continuously. The good part of this is it's opportunistic. So it's patients who may be at risk for AFib, but you may never know for a couple of years. So they can wear their Apple Watch every day, they can work out, and who knows, maybe in 3 years you may pick up that, hey, this patient developed AFib. On the middle is a prescription EKG patch. So these are patches like the Zio which we commonly use, the Vital Connect, which we use, the Phillips has one called the mobile telemetry. These are for patients who have symptoms who present to your office, and they say, I'm having these symptoms every week or every 2 weeks, um, because they can't be worn for more than 30 days is the longest I've seen. So, in patients who present and say, I have palpitations every week, I have it every 2 weeks, you may be able to catch something on a Zio or Vital Connect monitor. And the last one is the more I'm recommending more in my clinic called the handheld EKG recorder, and this is a Caria mobile. You may have seen it. It's on Amazon. They have a 6 lead one. And the good benefit of this is the signals are pretty clean and the other benefit is that it costs about 120 bucks. But let's say you have symptoms once every 6 months, but they feel it, they could just record it onto that and you get a nice PDF recording of that. Um, so these are the three that I think about for the management of my patients. So the Apple Watch was introduced in 2014 by Tim Cook, um, who's the outgoing CEO of Apple. It uses a PPPG sensor to passively detect possible AFib based on your radial pulse. It added an EKG feature in series 4, so you could use your finger basically against the crown to record an EKG and you could see on the top left, uh next to the watch, you could see that's a sinus rhythm EKG and it looks pretty good in that single lead. So you could see the P wave, you could see a QRS showing, um, the benefit of that device. And so the Apple Watch study was a large randomized, it wasn't, um, a large multi-center study published in the New England Journal in 2019, which looked at how good the screening was for atrial fibrillation. So what they found was patients with higher risk factors had, were more likely, were higher likelihood of developing Afib. So you can see on the top left, people who are older, um, are more likely, more likely to develop AFib. And you could see on the right, a lot of patients were notified with AFib that did not know they had AFib. Um, so it's a nice screening tool. It's not specific. So it may say someone has AFib when they're actually having sinus rhythm with PACs or a lot of times as EP providers, we get referrals for AFib that's simply wankybock, uh, because it's looking at irregularity of the pattern. It's not looking at sinus P waves, and it can't do a direct interpretation. But let's say you have a high risk patient, you say, hey, you may want to wear an Apple Watch, especially after you, you become age 65, you have diabetes, you have high blood pressure, you're worried about is this patient gonna develop a stroke. I think having them see if they can afford an Apple Watch, which gives you information about the steps along with whether they'll develop AFib is a great idea. This is a case I published. A patient was referred to us for the diagnosis of stroke. So they had a stroke and they had a complete workup. So they had an echocardiogram, which didn't show a shunt. They had a monitor, which showed no evidence of AFib in the hospital. They had carotid ultrasounds. They could not figure out the stroke. And so they were referred to us for a loop recorder implantation, which is an invasive procedure where we put in a loop to look at rhythms for 3 to 5 years. But in the meantime, the patient was smart and said, I'll get my own Apple Watch and I'll see what it shows. And she was getting all of these alerts in the meantime from referral, um, to arrival in clinic, which you can clearly see the Apple Watch showed her that, hey, you have AFib, take a recording. And she took recordings on the right showing Afib. So we were able to start her on an anticoagulation earlier in the process, and she's done well, all because she bought this Apple Watch that showed her that she had AFib. We developed a clinic, um, based on using mobile monitoring. So this is based on CardioM where patients were, could measure their EKGs before coming in for a cardioversion. One of the problems in healthcare always is underutilization and overutilization. So when people say, hey, I'm back in AFib, I tell my scheduler, please schedule that patient for a cardioversion. A lot of patients show up for a cardioversion in sinus rhythm. And so you've used a slot that you may not need. So what we said is, what if we randomize patients to having a cardio mobile at home, which could say whether you're in AFib the night before the procedure, or the, um, or an EKG and it showed no difference. So doing monitoring can can save healthcare costs and reduce morbidity and mortality. This is a nice study, and this is what's gonna happen in the future called the REACT AF trial by Rob Passman in Northwestern, where it's a randomized trial. They're using 100 US sites, they're enrolling 5500 patients. We know that patients with paroxysmal AFib are at highest risk of stroke in the 1st 30 days after they go into AFib. So, a lot of patients will have one or two episodes of AFib, and they come to my clinic and they say, I want to get off blood thinners. We do a shared decision making where I say, we don't have great data, but there's data to come where patients can use their Apple Watch to take the blood thinner for the minimum necessary time needed to prevent stroke and stop it when they're back in sinus rhythm on their own. So it's gonna be an interesting time with more trials coming in the future based on wearables. So here's the EKG patch continuous monitoring. So this is for patients who come to primary care clinic who may be complaining of palpitations, PVCs. I feel skipped beats. I feel like I'm passing out. These are the two workhorses that we use at Centera. On the left, you can see the Zio monitor, uh, which tells you what the underlying rhythm is. And usually a cardiologist will give you a patient interpretation on the bottom right. And we try to tailor the interpretation to what's really necessary. So I'll sometimes put in my interpretation, there's no sustained arrhythmias, it's a benign monitor. So it helps primary care decide, does this patient really need a referral to electrophysiology or not. And so we're trying to develop better ways of interpreting these so you're not unnecessarily referring and the patient's waiting 6 months to be told they're fine, um, they just have a couple extra beats. On the right is a vital connect. Uh, it's a similar type of monitor to Zio. Um, you could also have live monitoring. It gives you a similar type of report. Um, they're both skin adhesives. And it basically peels off in a couple of weeks and you mail it in. The other one, which I've said, I use more often in my clinic is a Cardio Mobile. It was founded in 2010 as a first iPhone application. It had a single lead EKG for detection of AFib, and they really led the way in improving efficacy through trials. So if you look at the literature, they've published over 20 papers on how effective this is compared to an EKG and it does almost as well as a 12 lead EKG. It's good for these brief episodes and infrequent. So if a patient comes to your office and say, I have palpitations once every 2 months or 3 months or 6 months, or I'm passing out every 6 months, and I feel it coming on, you may recommend this, which costs about 100 bucks at Target or Walmart or Amazon. And this is a study we published, um, which showed that cardia detection, the app algorithm does well, 66%, but when you add the app algorithm with a physician interpretation, you get a 100% sensitivity and 80% specificity for AFib compared to an EKG. So having the app and you could send PDFs to any cardiologist over an e-consult or you could send it to us via email, we could look at it and say, no, this is not AFib or you really need a 12 lead. This is uninterpretable. So they're not perfect, but with a physician interpretation on top of it, it adds to the sensitivity and specificity. So this is just a summary of the 3 devices and it's important to choose the right tool. So again, the wear time, the best thing to look at here is the wear time and what it, what it's good for. So the smart smartwatch is best for opportunistic screening. So this may be for your grandparents, older patients with risk factors who, who need a watch and. EKG patch is good for diagnostic yields, so palpitations, PVCs, and a handheld is good for symptoms. I have symptoms. I know when it comes on, I push the thing, I get my cardia out and I press it. Then I know, hey, your symptoms are related to AFib or it's related to nothing. And so these are, uh, this is a good slide to have in your deck when you consider what kind of wearable you want for your patient. There are potential pitfalls to all wearables, right? So one of the first is false positives and anxiety. I have patients who hammer my, my chart with, uh, with cardio mobile recordings and I'm like, everything looks good. I have to tell them after 3 or 4 messages that everything is fine, then they believe me and they, then they stopped coming on my chart. Um, single lead limitations, right? Doctor Talrejo will show you some nice, uh, MI pictures and EKGs. We cannot tell, we can't tell whether you're having a heart attack from a cardio mobile or any of these wearables, right? Because it's only giving you one lead. So you can't tell me if I'm having an LAD heart attack or anything like that. So if you're worried about this patient's having ischemia or heart attack, you still need the 12 lead EKG. The data overload, the equity is worrisome, uh, because these are over the counter, so insurance won't cover wearables. They, they won't cover an Apple Watch, they won't cover Cardio Mobile, but the prices are dropping. So Cardio Mobile is around 100, Apple Watches prices are dropping, but equity and how insurance companies, um, I think it's important in the future for insurance companies to actually provide these for their patients to prevent hospitalization, prevent costs downstream. And then incidental findings. So what does it mean if a patient has a few seconds of AFib? Is it clinically relevant? And sometimes we as electrophysiology can help you saying, no, a few seconds of AFib is not really relevant. You really want 6 minutes to 6 hours. So the e-consult mechanism or any email or anything, we can point you to the right direction of what's relevant or what's not. So these are conclusions. Wearables are excellent at raising questions. So they're excellent as does this patient have AFib? Does this patient have anything benign or malignant? They don't answer them. So they need clinicians, whether it's primary care providers, cardiologists, or electrophysiologists to answer the questions. You want to match the tool to the question you're asking. So, depending on what you want, you want to make sure you're picking the right tool. Pre-test probability is everything. Whether we're ordering a stress test on a patient, whether we're ordering a wearable, what kind of device we pick, your pre-test probability of what is the likelihood they have something is going to decide your further care and meet patients where they are, right? If you have a computer tech savvy tech patient. That wants an Apple watch, you say go for it, right? But you also set realistic expectations and say, hey, just send me once a month or once every 3 months of we're recording. Don't keep my charting me, all right? And for further questions you can, there's my email. Published June 30, 2026 Created by Related Presenters Divyang Patel, M.D. Sentara Cardiology Specialists View Full Profile
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