TY - JOUR
AU1 - Linz, Dominik
AU2 - Hermans, Astrid
AU3 - Tieleman, Robert G
AB - Abstract Current atrial fibrillation (AF) guidelines recommend screening for AF in individuals above 65 years or with other characteristics suggestive of increased stroke risk. Several mobile health (mHealth) approaches are available to identify AF. Although most wearables or ECG machines include algorithms to detect AF, an ECG confirmation of AF is necessary to establish a suspected diagnosis of AF. Early detection of AF is important to allow early initiation of AF management, and early rhythm control therapy lowered risk of adverse cardiovascular outcomes among patients with early AF aged >75 or with a CHA2DS2-VASc score ≥2 and cardiovascular conditions in the EAST-AFNET 4 study. Strategies for early AF detection should be always linked to a comprehensive work-up infrastructure organized within an integrated care pathway to allow early initiation and guidance of AF treatment in newly detected AF patients. In this review article, we summarize strategies and mHealth approaches for early AF detection and the transition to early AF management including AF symptoms evaluation and assessment of AF progression as well as AF risk factors. Atrial fibrillation, Screening, Management, Mobile health, Integrated care Introduction Atrial fibrillation (AF) is the most common sustained heart rhythm disorder and affects 43.6 million patients across the world.1 The number of affected individuals is expected to double or triple within the next two to three decades following an increased AF incidence and ageing of European populations.2 Atrial fibrillation can be associated with significant symptoms, cognitive decline, and reduced quality of life. It doubles mortality and causes marked morbidity on a population level, even after adjustment for confounders.2 The timing of AF detection and restoration of normal sinus rhythm in AF patients can matter. Detection and treatment of AF before it becomes symptomatic can prevent the development of heart failure and stroke. Furthermore, preclinical and mechanistic clinical studies showed that AF is associated with electrophysiological and structural remodelling processes.3 A part of this remodelling process can be attributed to AF itself and AF can perpetuate its own progression to a more stable and treatment resistant disease state (‘AF begets AF’).4 Based on these pathophysiological considerations, early restoration of sinus rhythm should be effective in reducing the progression of AF and associated complications such as stroke, hospitalization, and heart failure. However, several studies performed before 2002 did not show a clear reduction in the complications of AF through rhythm control, mainly by antiarrhythmic drugs, compared to rate control.5–9 Since 2002, the treatment AF catheter ablation has emerged as an important therapy for the treatment of AF. The recent EAST-AFNET 4 study revisited the question of rhythm and rate control and showed for the first time, that early rhythm control with antiarrhythmic drugs and ablation therapy in patients with early AF aged >75 or with a CHA2DS2-VASc ≥2 and cardiovascular conditions leads to a reduction in death, stroke, and cardiovascular events when compared with rate control.10 To allow early AF treatment and management, AF needs to be detected early and linked to a comprehensive work-up infrastructure. This paper focusses on strategies and mobile health (mHealth) approaches for early AF detection and the transition to early AF management including AF symptoms evaluation and assessment of AF progression as well as AF risk factors. Early detection of atrial fibrillation Current AF guidelines recommend screening of individuals above 65 years or with other characteristics suggestive of increased stroke risk.2 Atrial fibrillation screening in asymptomatic individuals aged <65 years with a low stroke risk is not justified, as the prevalence of AF in this population is low and the benefit of early treatment of asymptomatic AF remains unclear.11 Atrial fibrillation screening can be performed opportunistically or systematically and primary care, pharmacies, or community screening during special events may represent good settings for AF screening.2,11 In a recent meta-analysis, the efficacy of the different screening types (systematic vs. opportunistic or general practice vs. community screening) did not differ.12 More rigorous screening methods are needed and repeated rhythm assessments may be associated with significantly better effectiveness compared with single rhythm assessment.13 However, the appropriate frequency of rhythm monitoring is undefined. For AF screening, different technologies and approaches are available: (semi-) continuous rhythm monitoring by cardiac implantable electronic devices (CIEDs), wearables (e.g. smart watches), handheld devices (e.g. AliveCor, MyDiagnostick, etc.) or app-based mHealth solutions using PPG technology through the smartphone’s built-in camera (e.g. FibriCheck, Happitech, Preventicus, etc.) have been developed and validated (Figure 1).2,14 Most of the devices and apps are CE marked and some of them are connected to secured and certified clouds, allowing remote access of the data by treating physicians or allied healthcare professionals. Importantly, based on the current international AF Guidelines of the ESC, a single-lead ECG recording of 30 s or longer or a 12-lead ECG of an AF episode is required to establish a definitive diagnosis of AF.2 Figure 1 Open in new tabDownload slide Technologies and approaches for atrial fibrillation screening. Figure 1 Open in new tabDownload slide Technologies and approaches for atrial fibrillation screening. Besides, there is increasing evidence for a relationship between atrial high-rate episodes (AHREs) and definitive diagnosis of AF. The ASSERT trial found that AHREs lasting >6 h have a high positive predictive value for ECG-confirmed AF.15 In addition, the ongoing NOAH-AFNET 6 trial will also provide information on the relationship between AHREs and clinically overt AF.16 Atrial high-rate episode detection suggestive for AF might therefore be used as a screening tool for AF. Although some wearables or ECG machines include algorithms to detect AF, a standard 12-lead ECG recording or a single-lead ECG tracing of ≥30 s showing AF needs to be reviewed by a physician to establish a suspected diagnosis of AF.2 Positive screening results, which cannot be confirmed by an ECG documentation of AF, should be managed as negative screening results and no further actions are needed. There are some large studies focusing on AF screening and the establishment of a definite AF diagnosis. In these studies, positive screening results were eventually confirmed using a less than 12-lead ECG tracing or a 12-lead ECG reviewed by an appropriately trained general practitioner or a cardiologist.12 The Apple Heart study included 419 297 self-enrolled smart-watch app users (mean age 40 years), of whom 0.5% received an irregular pulse notification (0.15% of those aged <40 years, 3.2% among those aged >65 years). Subsequent (notification-triggered) 1-week ECG patch monitoring revealed AF in 34% of monitored participants.17 The Huawei Heart study included 187 912 individuals (mean age 35 years, 86.7% male), of whom 0.23% received a ‘suspected AF’ notification. Of those effectively followed up, 87.0% were confirmed as having AF.18 In real life, a variety of consumer-facing wearables, devices, and apps are marketed directly to consumers to detect AF.19 However, the management of the resulting data is not defined, which complicates the clinical implementation and guidance of mHealth use by the treating physician. Additionally, widespread direct-to-consumer screening for asymptomatic AF may result in unintended overutilization of healthcare resources owing to false-positive screening results and use of screening tools by users in whom they have not been adequately studied.20 In a recent survey of health care professionals initiated by the AF-SCREEN international collaboration, 57% of healthcare professionals advised wearables/apps for AF detection. However, the final decision to use these devices is frequently taken by the patient alone.21 The way when and how to perform measurements [(semi-) continuous vs. on-demand and ECG vs. PPG, respectively] are critically dependent on the clinical scenario and setting. As this is difficult for patients to judge, a physician-initiated or at least-guided approach appears to be necessary to allow the selection of the right tool for each patient. Appropriate patient education and screening program organization with rapid clarification of the screening result may reduce anxiety induced by suspicion of abnormalities. Informing patients in a structured way about an AF screening event (why, when, and how to use the screening tool), may contribute to adequate collection of rhythm monitoring data [(semi-) continuous or on-demand] during such a program (Figure 2). Figure 2 Open in new tabDownload slide Organization of an atrial fibrillation screening program. AF, atrial fibrillation. Figure 2 Open in new tabDownload slide Organization of an atrial fibrillation screening program. AF, atrial fibrillation. Assessment of the stage of atrial fibrillation-progression Detection of AF within a screening program supports identification of previously unknown AF, but the screening result per se, even if confirmed by an ECG, does not inform about how long AF is already present, particularly if the patient is asymptomatic. Early rhythm control therapy of AF to prevent the progression of AF from short-lasting self-terminating paroxysms towards more non-self-terminating sustained forms was associated with a lower risk of adverse cardiovascular outcomes than usual care among patients with early AF aged >75 or with a CHA2DS2-VASc ≥2 and cardiovascular conditions in the EAST-AFNET 4 study.10 Detailed and targeted history taking together with long-term rhythm monitoring at the time of AF diagnosis can provide a reference documentation to identify a progression of AF over time and may be useful to monitor the efficacy of rhythm control strategies. For the quantification of AF burden using semi-continuous rhythm monitoring devices, specific patient instructions about frequency and duration of monitoring are crucial to get information about AF triggers, AF burden (time spent in AF), diurnal AF patterns. Not just the way how intermittent AF-episodes initiate (trigger identification) but also the way how AF-episodes spontaneously stop (self-terminating AF) might provide helpful information about the stage of the natural time-course of AF and the underlying mechanisms in an individual patient. High AF burden indicates a more progressed disease. In patients with high or low AF burden, self-terminating short AF episodes suggest a predominant trigger dependent AF mechanism, while long stable AF episodes suggest a predominant structural substrate dependent AF mechanism. Also, the diurnal pattern of AF onset and termination may point towards specific mechanism (e.g. vagal AF or sleep apnoea-related AF in patients with predominant nocturnal AF episodes).22–25 Prevalence of AF progression varies with patient population and duration of follow-up but can be as high as 77% of patients progressing over 14 years.26 AF progression occurred in 13–15% of patients with recent-onset AF during 1-year follow-up.27 In another study in paroxysmal AF patients with 1 year Follow-up, changes in AF burden during the first 6 months compared to the last 6 months were studied. 62% patients remained stable, 22% showed progression to longer AF episode, 3% developed persistent AF, and 16% of patients showed AF regression.28 The HATCH score (heart failure, age, previous transient ischaemic attack or stroke, chronic obstructive pulmonary disease, and hypertension) is a simple tool to estimate the risk of AF progression in the near future.29 During 1 year of follow-up, ∼50% of the patients with a HATCH score >5 progressed to persistent AF compared with only 6% of the patients with a HATCH score of 0. Rhythm monitoring should be combined with echocardiographic assessment. Evaluation of atrial structural remodelling should eventually go beyond documentation of left atrial size. Left atrial function can be assessed by imaging (e.g. echocardiography or MRI). Atrial activation time determined by transthoracic Doppler tissue imaging can be used as an estimate of the total duration of atrial electrical activation.30 This so-called PA-tdi interval predicts the development of new-onset AF in sinus rhythm patients.31 Biomarkers and imaging such as late enhancement MRI may provide additional information about the underlying substrate and the stage of AF progression at the time point of AF detection.32 How to guide early atrial fibrillation management in newly detected atrial fibrillation patients The transition from the consumer-lead screening scenario to a physician lead comprehensive early AF management scenario remains to be a challenge. For example, in patients with screening-detected AF in pharmacies, only 17% of patients received appropriate anticoagulation.33 In addition to the assessment of stroke risk (preferable by the CHA2DS2-VASc score) and initiation of anticoagulation, a structured assessment of symptoms and comorbidities of screen-detected or suspected AF cases is critical to allow early implementation of the Atrial fibrillation Better Care (ABC) holistic pathway (‘A’ Anticoagulation/Avoid stroke; ‘B’ Better symptom management; and ‘C’ Cardiovascular and Comorbidity optimization) recently introduced in the new AF guidelines.2 Antithrombotic treatment should not be initiated in patients with positive screening results before AF is diagnosed based on an ECG-confirmation. Just positive screening results which are confirmed by a standard 12-lead ECG recording or a single-lead ECG tracing of ≥30 s showing AF should lead to management of previously unknown AF. A summary of a possible symptom and risk factor assessment package for early AF management is summarized in Figure 3. Figure 3 Open in new tabDownload slide Assessment package for optimal atrial fibrillation management. Figure 3 Open in new tabDownload slide Assessment package for optimal atrial fibrillation management. Assessment of symptom burden Patients with AF report a wide variety and severity of symptoms. A detailed and structured assessment of symptoms may help to guide initial early management of the patients. It is widely recognized that many AF episodes are asymptomatic and that the relationship between AF symptoms and AF burden is weak.34 However, in case of symptomatic AF, the control of symptoms is central to improving the quality of life, a major objective of early AF management per society guidelines.2 The best way to assess and categorize symptoms in AF patients, and particularly how to determine AF-related symptoms in AF patients, remains unclear. There are different tools available: the EHRA score, in which symptoms are assessed by physicians by history taking35 or the CCS-SAF scale, which focuses on the combination of patient-reported AF-related symptoms (palpitations, dyspnoea, dizziness/syncope, chest pain, weakness/fatigue), the symptom-rhythm temporal correlation and the assessment of the effect of symptoms on function and quality of life.36 The initial assessment in these classification schemes consists of confirming that the reported symptoms are, in fact, associated with the presence of AF. This is particularly important in the case of paroxysmal AF, in which administering questionnaires in the absence of arrhythmic episodes may lead to underestimation of the illness burden for AF. Rhythm monitoring at the time point of symptom assessment is critical to distinguish between AF-related symptoms (AF-symptoms) and non-specific disease-related symptoms (symptoms in AF). The following approach may be helpful: in higher burden paroxysmal AF, a Holter ECG can be useful and in lower burden, event monitor/wearables can be applied. For persistent AF, electrical cardioversion (ECV) offers the opportunity to probe symptom-rhythm correlation. In patients in whom ECV is successful the time in sinus rhythm can be used to evaluate whether symptoms improve once sinus rhythm is restored (symptom-rhythm correlation), or whether symptom burden remains unaffected (no symptom-rhythm correlation). Additionally, often symptoms are interrogated only once in a structured way at baseline (spot-assessment). However, symptom severity and presentation may show visit-to-visit or even day-to-day variability. Assessment of risk factors and comorbidities Atrial fibrillation almost never comes alone. Assessment of risk factors and comorbidities represent an important component of early AF management.2 Structured testing for the presence of modifiable risk factors such as hypertension, metabolic syndrome/obesity, and sleep apnoea is important, as the so-called ‘up-stream therapy’ of these conditions may influence the outcome of rhythm control strategies.37 Sleep apnoea can be identified in 70% of all AF patients, but most patients reported low daytime sleepiness levels.22 The lack of excessive daytime sleepiness should not preclude patients from being investigated by objective measures (e.g. polygraphy) for the potential presence of concomitant sleep apnoea.38 Strict control of modifiable risk factors may improve arrhythmia-free survival.39,40 Goal-directed weight and risk factor management is associated with a lower progression to persistent AF (3% vs. 41% in patients who did not lose weight) and reversed the type of AF from persistent to paroxysmal or no AF in 88%.41 Recommendations in current AF guidelines pay particular attention to good BP control in AF patients with hypertension to reduce AF recurrences and risk of stroke and bleeding. Additionally, initiation of physical activity and weight-loss should be considered42,43 and optimal management of obstructive sleep apnoea may be considered,22 to reduce AF incidence, AF progression, AF recurrences, and symptoms. Importantly, the management of the continuum of unhealthy lifestyle, risk factor(s), and cardiovascular disease (often without specific threshold values), rather than focusing on one specific risk factor alone. Implementation of early atrial fibrillation management Active patient education is critical for the initiation but also for the success of early AF management.44 The patient’s knowledge gaps about AF can be identified by validated questionnaires45 and online tailored education platforms43 or home-based education and learning programs46–48 can be effective in improving AF knowledge and impact AF outcomes. Informing about treatment options, goals, and success rates as well as of potential risks of possible interventions is important. The patient’s perception of disease burden is important to assess. The patient’s expectations should be realistic and otherwise corrected by the treating physician. The patient should be prepared for a longer treatment trajectory. Atrial fibrillation management does not stop with an intervention such as AF ablation. Patients need to learn how to live with their AF. The implementation and early initiation of a comprehensive and structured AF management program should be best organized in an integrated care program.49–52 Integrated AF management programs, particularly in the setting of a nurse-led program, have been shown to improve patient care and AF outcomes.50,51 Also mHealth-supported remote programs may represent an alternative. In the Huawai study, 95.1% of those with identified AF, entered an integrated AF management program using a mobile AF App, streamlining integrated care of AF patients across all healthcare levels and among different specialties.18,52 Compared with usual care, implementation of the ABC pathway has been significantly associated with lower risk of all-cause death, composite outcome of stroke/major bleeding/cardiovascular death and first hospitalization, lower rates of cardiovascular events, and lower health-related costs.53 Recently, a new TeleCheck-AF program has been initiated across Europe. It consists of remote AF management through teleconsultation supported by an mHealth infrastructure, actively involving patients in the care process and providing comprehensive care by a multidisciplinary team.54 It incorporates three important components: (i) a structured teleconsultation (‘Tele’), (ii) a CE-marked app-based on-demand heart rate and rhythm monitoring infrastructure (‘Check’), and (iii) comprehensive AF management (‘AF’).55 Outcome data are not available yet. Conclusion Early treatment of AF has the potential of improving outcomes and quality of life in AF patients, by preventing the development of complications such as heart failure and stroke, and preventing progression of (the substrate of) the arrhythmia. To allow early treatment, AF needs to be detected early and linked to a comprehensive work-up infrastructure. mHealth approaches can support the early detection of AF and the transition to a structured AF management program which should be best organized in an integrated care pathway. Conflict of interest: none declared. References 1 Chugh SS , Havmoeller R , Narayanan K , Singh D , Rienstra M , Benjamin EJ et al. Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study . Circulation 2014 ; 129 : 837 – 47 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Hindricks G , Potpara T , Dagres N , Arbelo E , Bax JJ , Blomström-Lundqvist C et al. ; ESC Scientific Document Group. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS) . Eur Heart J 2020 ; ehaa612 . 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TI - Early atrial fibrillation detection and the transition to comprehensive management
JF - Europace
DO - 10.1093/europace/euaa424
DA - 2021-04-10
UR - https://www.deepdyve.com/lp/oxford-university-press/early-atrial-fibrillation-detection-and-the-transition-to-4Rv0asblKk
SP - ii46
EP - ii51
VL - 23
IS - Supplement_2
DP - DeepDyve
ER -