Impact of Mobile Health Devices for the Detection of Atrial Fibrillation: Systematic Review

Background Atrial fibrillation (AF) is the most common arrhythmia, and its prevalence is increasing. Early diagnosis is important to reduce the risk of stroke. Mobile health (mHealth) devices, such as single-lead electrocardiogram (ECG) devices, have been introduced to the worldwide consumer market over the past decade. Recent studies have assessed the usability of these devices for detection of AF, but it remains unclear if the use of mHealth devices leads to a higher AF detection rate. Objective The goal of the research was to conduct a systematic review of the diagnostic detection rate of AF by mHealth devices compared with traditional outpatient follow-up. Study participants were aged 16 years or older and had an increased risk for an arrhythmia and an indication for ECG follow-up—for instance, after catheter ablation or presentation to the emergency department with palpitations or (near) syncope. The intervention was the use of an mHealth device, defined as a novel device for the diagnosis of rhythm disturbances, either a handheld electronic device or a patch-like device worn on the patient’s chest. Control was standard (traditional) outpatient care, defined as follow-up via general practitioner or regular outpatient clinic visits with a standard 12-lead ECG or Holter monitoring. The main outcome measures were the odds ratio (OR) of AF detection rates. Methods Two reviewers screened the search results, extracted data, and performed a risk of bias assessment. A heterogeneity analysis was performed, forest plot made to summarize the results of the individual studies, and albatross plot made to allow the P values to be interpreted in the context of the study sample size. Results A total of 3384 articles were identified after a database search, and 14 studies with a 4617 study participants were selected. All studies but one showed a higher AF detection rate in the mHealth group compared with the control group (OR 1.00-35.71), with all RCTs showing statistically significant increases of AF detection (OR 1.54-19.16). Statistical heterogeneity between studies was considerable, with a Q of 34.1 and an I2 of 61.9, and therefore it was decided to not pool the results into a meta-analysis. Conclusions Although the results of 13 of 14 studies support the effectiveness of mHealth interventions compared with standard care, study results could not be pooled due to considerable clinical and statistical heterogeneity. However, smartphone-connectable ECG devices provide patients with the ability to document a rhythm disturbance more easily than with standard care, which may increase empowerment and engagement with regard to their illness. Clinicians must beware of overdiagnosis of AF, as it is not yet clear when an mHealth-detected episode of AF must be deemed significant.

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Mobile Health Versus Standard Care for the Detection of Atrial Fibrillation: a Systematic Review (Preprint)

10.2196/preprints.26161 ◽

2020 ◽

Author(s):

Tom E Biersteker ◽

Martin J Schalij ◽

Roderick W Treskes

Keyword(s):

Atrial Fibrillation ◽

Systematic Review ◽

Mobile Health ◽

Standard Care ◽

Detection Rate ◽

Control Group ◽

Forest Plot ◽

Study Results ◽

Statistical Heterogeneity

BACKGROUND Atrial fibrillation (AF) is the most common arrhythmia, and its prevalence is increasing. Early diagnosis is important to reduce the risk of stroke. Mobile health (mHealth) devices, such as single-lead ECG devices, have been introduced to the worldwide consumer market over the past decade. Studies have, among other factors, assessed the usability of these devices for the detection of AF. OBJECTIVE To conduct a systematic review of diagnostic detection rate of AF by mHealth devices, compared with standard follow-up. METHODS Setting: Clinical or outpatient care. Participants: Patients over the age of 16 with an indication for ECG follow-up. Intervention: The use of trans-telephonic ECG recordings or an mHealth device, defined as a novel device for the diagnosis of rhythm disturbances, which is either a handheld electronic device or a patch-like device that is installed on the patient’s chest. Main outcome measures: The odds-ratio (OR) of AF detection, comparing mHealth devices to standard care. Review methods: Two reviewers screened the search results and extracted data, as well as performing the risk of bias assessment. A heterogeneity analysis was performed, a Forest plot was made to summarize the results of the individual studies, and an Albatross plot was made to allow the P-values to be interpreted in the context of the study sample size. RESULTS A total of 3384 articles were identified after a database search. Fourteen studies with a total of 4617 study participants were selected for qualitative synthesis, consisting of eight cohort studies, four randomized-controlled trials (RCT’s) and two case-control studies. Between study populations, 42 to 87% were male; mean age varied from 44 to 73 years. Nine studies used a handheld single-lead ECG device for a duration of 28 days to 1 year, five studies used a body patch for a duration of 1 to 14 days. Standard follow-up consisted of Holter monitoring in 12 studies, while one study used implantable loop recorders and the final study used a 12-lead ECG as standard follow-up. All studies but one showed a higher AF detection rate in the mHealth group compared with the control group (OR 1.00 – 35.71), with all RCT’s showing statistically significant improvements of AF detection (OR 1.54 – 19.16). The statistical heterogeneity between studies was considerable, with a Q of 34.1 and an I2 of 61.9, and therefore it was decided to not pool the results into a meta-analysis. CONCLUSIONS Although the results of 13 out of 14 studies support the effectiveness of mHealth interventions compared with standard care, with the remainder study showing equal effectiveness, it cannot be concluded for those interventions to be more effective than standard follow-up as due to considerable clinical and statistical heterogeneity, study results could not be pooled. However, smartphone connectable ECG devices provide patients with the ability to document a rhythm disturbance more easily than with standard care, which may increase empowerment and engagement with regard to their illness. Yet, clinicians must beware of overdiagnosis of AF, as it is not yet clear when an mHealth-detected episode of AF has to be deemed significant.

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Does pre-notification increase questionnaire response rates: a nested randomised control trial

10.1101/2021.02.19.21252107 ◽

2021 ◽

Author(s):

Benjamin Woolf ◽

Phil Edwards

Keyword(s):

Systematic Review ◽

Response Rates ◽

Risk Of Bias ◽

Randomised Control Trial ◽

Questionnaire Response ◽

Potential Study ◽

Study Results ◽

Study Participants ◽

Unclear Risk

AbstractBackgroundStudy results can be badly affected by non-response. One way to potentially reduce non-response is by sending potential study participants advance communication. During the update of a systematic review examining the effect of pre-notification on response rates, a number of study authors needed to be contacted for further information.ObjectivesTo conduct an RCT to investigate the effect of pre-notification, nested within the request for further information for a systematic review.MethodsStudy authors included in the systematic review, whose studies were at unclear risk of bias, and who were contactable, were randomly sent or not set a pre-notification email prior to being sent the request for further information email.ResultsAt the end of follow up, 14/33 (42.4%) authors in the pre-notification condition had returned responses to the questionnaire, and 18/42 (42.9%). There was not evidence of a difference between these groups.ConclusionsThis study’s results do not support the hypothesis that pre-notification does increase response from participants.

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Abstract 18434: Coronary Artery Calcium Progression and Atrial Fibrillation: The Multi-ethnic Study of Atherosclerosis (MESA)

Circulation ◽

10.1161/circ.132.suppl_3.18434 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Wesley T O'Neal ◽

Jimmy T Efird ◽

Waqas T Qureshi ◽

Joseph Yeboah ◽

Alvaro Alonso ◽

...

Keyword(s):

Atrial Fibrillation ◽

Coronary Artery ◽

Coronary Artery Calcium ◽

Cox Regression ◽

Chinese Americans ◽

Ethnic Study ◽

Increased Risk ◽

The Mean ◽

Study Participants

Introduction: Coronary artery calcium (CAC) measured at a single time point has been associated with an increased risk for atrial fibrillation (AF). It is currently unknown whether CAC progression over time carries a similar risk. Methods: A total of 5,612 study participants (mean age 62 ± 10; 52% women; 39% whites; 27% blacks; 20% Hispanics; 12% Chinese-Americans) from the Multi-Ethnic Study of Atherosclerosis (MESA) were included in this analysis. Phantom-adjusted Agatston scores for baseline and follow-up measurements were used to compute the change in CAC per year (1 to 100, 101 to 300, and >300 units/year) compared with participants with ≤0 change. The mean time between CT scan for study participants was 2.4 ± 0.84 years. AF was ascertained by review of hospital discharge records and from Medicare claims data through December 31, 2010. Cox regression was used to compute hazard ratios (HR) and 95% confidence intervals (95%CI) for the association between CAC progression and AF and models were adjusted for socio-demographics, cardiovascular risk factors, and baseline CAC. Results: At baseline, 2,904 (52%) participants had no evidence of CAC and 2,708 (48%) had CAC values >0. The mean CAC progression for those with baseline CAC was 46.1 ± 85.2 units per year and for those without baseline CAC was 0.84 ± 4.8 units per year. Over a median follow-up of 5.6 years, a total of 203 (3.6%) incident AF cases occurred. Any CAC progression (>0/year) was associated with an increased risk for AF (HR=1.55, 95%CI=1.10, 2.19) and the risk increased with higher levels of CAC progression per year (≤0/year: HR=1.0 [reference]; 1 to 100/year: HR=1.47, 95%CI=1.03, 2.09; 101 to 300/year: HR=1.92, 95%CI=1.15, 3.20; >300/year: HR=3.23, 95%CI=1.48, 7.05). An interaction was observed by age with the association of CAC progression with AF being stronger for younger (<61 years: HR=3.53, 95%CI=1.29, 9.69) compared with older (≥61 years: HR=1.42, 95%CI=0.99, 2.04) participants (p-interaction=0.037). Conclusion: CAC progression during an average of 5-6 years of follow-up is associated with an increased risk for AF. The associated risk is greater in individuals with faster CAC progression.

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Zidovudine/Lamivudine vs. Abacavir/Lamivudine vs. Tenofovir/Emtricitabine in fixed-dose combinations as initial treatment for HIV patients: a systematic review and network meta-analysis

Colombia Medica ◽

10.25100/cm.v48i2.2774 ◽

2017 ◽

pp. 70-81 ◽

Cited By ~ 2

Author(s):

Juan Carlos Alzate Angel ◽

Marcela María Duque Molina ◽

Héctor Iván García García

Keyword(s):

Systematic Review ◽

Clinical Trials ◽

Initial Treatment ◽

Randomized Clinical Trials ◽

Meta Analysis ◽

Fixed Dose ◽

Eligibility Criteria ◽

Increased Risk ◽

Statistical Heterogeneity

Introduction: Initial treatment of the HIV is based on the use of three drugs, two of which are nucleoside analog reverse-transcriptase inhibitors. There are three combinations of these drugs which have been approved by different guidelines, each with divergent results in terms of efficacy and safety.Objective: To compare the efficacy and safety of these three combinations.Methods: Systematic review and network meta-analysis of randomized clinical trials comparing fixed doses of Tenofovir Disoproxil Fumarate / Emtricitabine (TDF/FTC), Abacavir / Lamivudine (ABC/3TC) and Zidovudine / Lamivudine (ZDV/3TC).Results: Seven clinical trials met the eligibility criteria. The results suggested higher efficacy with TDF/FTC vs. ABC/3TC at 96 weeks and vs. ZDV/3TC at 48 weeks. However, there is clinical and statistical heterogeneity. Subgroup analysis were performed by third drug and by level of viral load prior to treatment, and found no differences in virological control. Network meta-analysis could only be carried out with TDF/FTC vs. ZDV/3TC, and the proportion of patients with virological response, with no differences at 48 weeks nor at 96 weeks. Direct comparisons showed an increased risk of bone marrow suppression of ZDV/3TC vs. TDF/FTC and of ABC/3TC hypersensitivity reactions vs. ZDV/3TCConclusions: The results did not show differences in effectiveness among the interventions. However, due to the heterogeneity of the third drug and the follow-up time between the included studies, this result is not definitive. The results raise the need for further studies to help improve treatment recommendations in patients infected with HIV.

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IL6 trans-signaling associates with ischemic stroke but not with atrial fibrillation

BMC Neurology ◽

10.1186/s12883-021-02321-6 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Louise Ziegler ◽

Håkan Wallén ◽

Sara Aspberg ◽

Ulf de Faire ◽

Bruna Gigante

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Cox Regression ◽

Secondary Analysis ◽

Men And Women ◽

Increased Risk ◽

Inflammatory Processes ◽

Old Men ◽

Study Participants

Abstract Background Pro-inflammatory processes underlie ischemic stroke, albeit it is largely unknown if they selectively associate with the risk of atherothrombotic or cardioembolic ischemic stroke. Here we analyze whether pro-inflammatory interleukin (IL) 6 trans-signaling, is associated with the risk of ischemic stroke and underlying atrial fibrillation (AF). Methods During a 20-year follow-up, 203 incident ischemic strokes were recorded from national registers in the cohort of 60-year-old men and women from Stockholm (n = 4232). The risk of ischemic stroke associated with circulating IL6 trans-signaling, assessed by a ratio between the pro-inflammatory binary IL6:sIL6R complex and the inactive ternary IL6:sIL6R:sgp130 complex (B/T ratio), was estimated by Cox regression and expressed as hazard ratio (HR) with a 95% confidence interval (CI) in the presence or absence of AF. Risk estimates were adjusted for cardiovascular risk factors and anticoagulant treatment. In a secondary analysis, the association of IL6 trans-signaling with the risk of incident AF (n = 279) was analyzed. Results B/T ratio > median was associated with increased risk of ischemic stroke in study participants without AF (adjusted HR 1.49; 95% CI 1.08–2.06), while an association could not be demonstrated in the presence of AF. Moreover, the B/T ratio was not associated with the risk of AF (HR 0.96; 95% CI 0.75–1.24). Conclusions Pro-inflammatory IL6 trans-signaling, estimated by the B/T ratio, is associated with ischemic stroke in individuals without AF. These findings suggest that the B/T ratio could be used to assess the risk of non-AF associated ischemic stroke.

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P014: Incidental findings in trauma whole-body CT scans: a systematic review

CJEM ◽

10.1017/cem.2020.222 ◽

2020 ◽

Vol 22 (S1) ◽

pp. S69-S69

Author(s):

V. Tsang ◽

K. Bao ◽

J. Taylor

Keyword(s):

Systematic Review ◽

Incidental Findings ◽

Traffic Accidents ◽

Road Traffic ◽

Subsequent Treatment ◽

Whole Body ◽

Trauma Patients ◽

Patient Demographics ◽

Study Results

Introduction: Whole-body computed tomography scans (WBCT) are a mainstay in the work-up of polytrauma or multiple trauma patients in the emergency department. While incredibly useful for identifying traumatic injuries, WBCTs also reveal incidental findings in patients, some of which require further diagnostic testing and subsequent treatment. Although the presence of incidental findings in WBCTs have been well documented, there has been no systematic review conducted to organize and interpret findings, determine IF prevalence, and document strategies for best management. Methods: A systematic review was conducted using MEDLINE, PUBMED, and EMBASE. Specific journals and reference lists were hand-mined, and Google Scholar was used to find any additional papers. Data synthesis was performed to gather information on patient demographics, prevalence and type of incidental findings (IFs), and follow-up management was collected. All documents were independently assessed by the two reviewers for inclusion and any disagreements were resolved by consensus. Results: 1231 study results were identified, 59 abstracts, and 12 included in final review. A mean of 53.9% of patients had at least one IF identified, 31.5% had major findings, and 68.5% had minor findings. A mean of 2.7 IFs per patient was reported for articles that included number of total IFs. The mean age of patients included in the studies were 44 years old with IFs more common in older patients and men with more IFs than women. IFs were most commonly found in the abdominal/pelvic region followed by kidneys. Frequency of follow-up documentation was poor. The most common reported mechanisms of injury for patients included in the study were MVA and road traffic accidents (60.0%) followed by falls from >3m (23.2%). Conclusion: Although there is good documentation on the mechanism of injury, patient demographics, and type of IF, follow-up for IFs following acute trauma admission lacks documentation and follow-up and is an identified issue in patient management. There is great need for systematic protocols to address management of IFs in polytrauma patients.

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Acute Dental Periapical Abscess and New-Onset Atrial Fibrillation: A Nationwide, Population-Based Cohort Study

Journal of Clinical Medicine ◽

10.3390/jcm10132927 ◽

2021 ◽

Vol 10 (13) ◽

pp. 2927

Author(s):

Amaar Obaid Hassan ◽

Gregory Y. H. Lip ◽

Arnaud Bisson ◽

Julien Herbert ◽

Alexandre Bodin ◽

...

Keyword(s):

Atrial Fibrillation ◽

Cohort Study ◽

Multivariable Analysis ◽

National Database ◽

Increased Risk ◽

Periapical Abscess ◽

The Relationship ◽

Onset Atrial Fibrillation ◽

New Onset

There are limited data on the relationship of acute dental infections with hospitalisation and new-onset atrial fibrillation (AF). This study aimed to assess the relationship between acute periapical abscess and incident AF. This was a retrospective cohort study from a French national database of patients hospitalized in 2013 (3.4 million patients) with at least five years of follow up. In total, 3,056,291 adults (55.1% female) required hospital admission in French hospitals in 2013 while not having a history of AF. Of 4693 patients classified as having dental periapical abscess, 435 (9.27%) developed AF, compared to 326,241 (10.69%) without dental periapical abscess that developed AF over a mean follow-up of 4.8 ± 1.7 years. Multivariable analysis indicated that dental periapical abscess acted as an independent predictor for new onset AF (p < 0.01). The CHA2DS2VASc score in patients with acute dental periapical abscess had moderate predictive value for development of AF, with Area Under the Curve (AUC) 0.73 (95% CI, 0.71–0.76). An increased risk of new onset AF was identified for individuals hospitalized with dental periapical abscess. Careful follow up of patients with severe, acute dental periapical infections is needed for incident AF, as well as investigations of possible mechanisms linking these conditions.

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Sex-Specific Associations between Blood Pressure and Risk of Atrial Fibrillation Subtypes in the Tromsø Study

Journal of Clinical Medicine ◽

10.3390/jcm10071514 ◽

2021 ◽

Vol 10 (7) ◽

pp. 1514

Author(s):

Hilde Espnes ◽

Jocasta Ball ◽

Maja-Lisa Løchen ◽

Tom Wilsgaard ◽

Inger Njølstad ◽

...

Keyword(s):

Atrial Fibrillation ◽

Blood Pressure ◽

Proportional Hazards ◽

Cox Proportional Hazards ◽

Pressure Management ◽

Reference Models ◽

Proportional Hazards Regression ◽

Hazard Ratios ◽

Increased Risk

The aim of this study was to explore sex-specific associations between systolic blood pressure (SBP), hypertension, and the risk of incident atrial fibrillation (AF) subtypes, including paroxysmal, persistent, and permanent AF, in a general population. A total of 13,137 women and 11,667 men who participated in the fourth survey of the Tromsø Study (1994–1995) were followed up for incident AF until the end of 2016. Cox proportional hazards regression analysis was conducted using fractional polynomials for SBP to provide sex- and AF-subtype-specific hazard ratios (HRs) for SBP. An SBP of 120 mmHg was used as the reference. Models were adjusted for other cardiovascular risk factors. Over a mean follow-up of 17.6 ± 6.6 years, incident AF occurred in 914 (7.0%) women (501 with paroxysmal/persistent AF and 413 with permanent AF) and 1104 (9.5%) men (606 with paroxysmal/persistent AF and 498 with permanent AF). In women, an SBP of 180 mmHg was associated with an HR of 2.10 (95% confidence interval [CI] 1.60–2.76) for paroxysmal/persistent AF and an HR of 1.80 (95% CI 1.33–2.44) for permanent AF. In men, an SBP of 180 mmHg was associated with an HR of 1.90 (95% CI 1.46–2.46) for paroxysmal/persistent AF, while there was no association with the risk of permanent AF. In conclusion, increasing SBP was associated with an increased risk of both paroxysmal/persistent AF and permanent AF in women, but only paroxysmal/persistent AF in men. Our findings highlight the importance of sex-specific risk stratification and optimizing blood pressure management for the prevention of AF subtypes in clinical practice.

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Impact of atrial fibrillation pattern on outcomes after left atrial appendage closure: lessons from the prospective LAARGE registry

Clinical Research in Cardiology ◽

10.1007/s00392-021-01874-3 ◽

2021 ◽

Author(s):

Shinwan Kany ◽

Johannes Brachmann ◽

Thorsten Lewalter ◽

Ibrahim Akin ◽

Horst Sievert ◽

...

Keyword(s):

Atrial Fibrillation ◽

Left Atrial Appendage ◽

Systemic Embolism ◽

Long Term Outcomes ◽

Increased Risk ◽

History Of ◽

One Year ◽

The One

Abstract Background Non-paroxysmal (NPAF) forms of atrial fibrillation (AF) have been reported to be associated with an increased risk for systemic embolism or death. Methods Comparison of procedural details and long-term outcomes in patients (pts) with paroxysmal AF (PAF) against controls with NPAF in the prospective, multicentre observational registry of patients undergoing LAAC (LAARGE). Results A total of 638 pts (PAF 274 pts, NPAF 364 pts) were enrolled. In both groups, a history of PVI was rare (4.0% vs 1.6%, p = 0.066). The total CHA2DS2-VASc score was lower in the PAF group (4.4 ± 1.5 vs 4.6 ± 1.5, p = 0.033), while HAS-BLED score (3.8 ± 1.1 vs 3.9 ± 1.1, p = 0.40) was comparable. The rate of successful implantation was equally high (97.4% vs 97.8%, p = 0.77). In the three-month echo follow-up, LA thrombi (2.1% vs 7.3%, p = 0.12) and peridevice leak > 5 mm (0.0% vs 7.1%, p = 0.53) were numerically higher in the NPAF group. Overall, in-hospital complications occurred in 15.0% of the PAF cohort and 10.7% of the NPAF cohort (p = 0.12). In the one-year follow-up, unadjusted mortality (8.4% vs 14.0%, p = 0.039) and combined outcome of death, stroke and systemic embolism (8.8% vs 15.1%, p = 0.022) were significantly higher in the NPAF cohort. After adjusting for CHA2DS2-VASc and previous bleeding, NPAF was associated with increased death/stroke/systemic embolism (HR 1.67, 95% CI 1.02–2.72, p = 0.041). Conclusion Atrial fibrillation type did not impair periprocedural safety or in-hospital MACE patients undergoing LAAC. However, after one year, NPAF was associated with higher mortality. Graphic abstract

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Prediction of all-cause mortality with malnutrition assessed by controlling nutritional status score in patients with heart failure: a systematic review and meta-analysis

Public Health Nutrition ◽

10.1017/s1368980021002470 ◽

2021 ◽

pp. 1-8

Author(s):

Huiyang Li ◽

Peng Zhou ◽

Yikai Zhao ◽

Huaichun Ni ◽

Xinping Luo ◽

...

Keyword(s):

Heart Failure ◽

Systematic Review ◽

Nutritional Status ◽

Meta Analysis ◽

Predictive Values ◽

Increased Risk ◽

Patients With Heart Failure ◽

All Cause Mortality ◽

Conut Score

Abstract Objective: The aim of this meta-analysis was to investigate the association between malnutrition assessed by the controlling nutritional status (CONUT) score and all-cause mortality in patients with heart failure. Design: Systematic review and meta-analysis. Settings: A comprehensively literature search of PubMed and Embase databases was performed until 30 November 2020. Studies reporting the utility of CONUT score in prediction of all-cause mortality among patients with heart failure were eligible. Patients with a CONUT score ≥2 are grouped as malnourished. Predictive values of the CONUT score were summarized by pooling the multivariable-adjusted risk ratios (RR) with 95 % CI for the malnourished v. normal nutritional status or per point CONUT score increase. Participants: Ten studies involving 5196 patients with heart failure. Results: Malnourished patients with heart failure conferred a higher risk of all-cause mortality (RR 1·92; 95 % CI 1·58, 2·34) compared with the normal nutritional status. Subgroup analysis showed the malnourished patients with heart failure had an increased risk of in-hospital mortality (RR 1·78; 95 % CI 1·29, 2·46) and follow-up mortality (RR 2·01; 95 % CI 1·58, 2·57). Moreover, per point increase in CONUT score significantly increased 16% risk of all-cause mortality during the follow-up. Conclusions: Malnutrition defined by the CONUT score is an independent predictor of all-cause mortality in patients with heart failure. Assessment of nutritional status using CONUT score would be helpful for improving risk stratification of heart failure.

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