The Future Role of Health Technology in Atrial Fibrillation
Presenter: Anne B. Curtis, MD, FACC
In addition to what has been discussed about using health technology in the diagnosis of atrial fibrillation (AF), Anne B. Curtis, MD, FACC, University at Buffalo, says we should also be thinking about its use in monitoring and treatment, including assessing the need for treatment, assessing the success of treatment, and looking at adherence to treatment using drugs and lifestyle.
She said technologies for monitoring for AF range from an opportunistic pulse check, to ECGs, to insertable loop recorders, and everything in between.
One potential goal of monitoring for detection of AF is detecting the presence of AF. It has been shown that this is possible with these kinds of devices, and the more prolonged the monitoring the higher the diagnostic rate. It is also known that the more persistent the AF episodes, the easier it is to diagnose with any technology.
Regarding the number and duration of episodes, Dr. Curtis said she thinks most people go with the idea that episodes fewer than 6 minutes don’t require treatment, but said the higher the CHA2DS2-VASc score the more reason there is to reconsider that.
There are trials (Artesia and Noah) being conducted to decide what to do with the intermediate group, with episodes of 6 minutes to 24 hours, and Dr. Curtis said generally accepted today is that over 24 hours of episodes requires anticoagulation based on the CHA2DS2-VASc score.
Another question to consider is how much AF burden is sufficient to warrant therapy, as well as how do you consider number of episodes vs AF burden in making a decision about what to do with a patient.
In making treatment decisions, symptomatic patients should receive anticoagulation based on risk, and treatment tends to vary based on the severity of the patient’s symptoms.
When deciding how much AF is sufficient to warrant treatment in an asymptomatic patient, number and duration of episodes as well as AF burden should be considered, but Dr. Curtis said, “Right now we have some indication that they are at risk the higher the CHA2DS2-VASc score and the higher the burden, but less proof that you can impact that by therapy.”
Dr. Curtis said that raises the question of whether an intensive search for AF in an asymptomatic but high-risk patient leads to improved outcomes after treatment is initiated, and she said so far data are lacking on this.
Another question she raised is whether all heart failure patients should undergo monitoring. She said we know how high a correlation there is between heart failure and AF, so it is a particularly high-risk group that is worth further study.
“Overall,” Dr. Curtis said, “widespread monitoring makes sense only if treatment will improve outcomes.”
She said things like concomitant heart failure and the CHA2DS2-VASc score need to be considered, as well as cost-effectiveness. The goals of treatment of asymptomatic AF are to prevent thromboembolism, prevent adverse cardiac remodeling, and prevent adverse outcomes such as heart failure and dementia.
Previous studies looking at apps for AF have shown that you can have an impact on primary outcomes such as ischemic stroke/systemic thromboembolism, death, and re-hospitalization by employing them. Dr. Curtis thinks use of these apps can be an adjunct to current treatment options, and their use should be considered in many patients. She said some of these apps are available to be used now, but we need to see what happens longterm.
Possible future roles for technology in AF management include diagnosis of AF by smartphone, alerts for recurrences, alerts for uncontrolled heart rates, monitor activity and sleep, incorporate BP reading, and public monitoring in crowds.
In summary, Dr. Curtis said the future of health technology in AF is dependent on the value proven in clinical trials. Widespread monitoring of AF requires demonstration that detection and initiation of treatment will improve outcomes. She said questions to be answered include: Will apps with electronic notification improve compliance; will patients use them long term; do we need incentives; and what do we do about patients who don’t have access to such technology.
Anne B. Curtis, MD, receives honoraria for speaking from Abbott, Medtronic, and Zoll; is on the advisory board of Abbott, Sanofi Aventis, Janssen Pharmaceuticals, and Milestone Pharmaceuticals, and is on the data monitoring board for Medtronic.