By Stavros Stavrakis, MD, PhD, Assistant Professor of Medicine, Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
I was recently asked by a friend to comment on the future of telemedicine. I immediately thought of a recent incident with a patient of mine that exemplified how telemedicine may work in the future, at least in the field of electrophysiology. This 45-year-old male patient underwent ablation for drug refractory, symptomatic, paroxysmal atrial fibrillation (AF). Six months after the ablation, we decided to withdraw anticoagulation based on his low CHA2DS2-VASc score. At the same time, I asked him to monitor his rhythm daily, and whenever he experienced symptoms, to use the AliveCor® Heart Monitor. After about five months, he felt the onset of palpitations. His transmitted rhythm strip showed a regular narrow complex tachycardia, assuming a post-ablation atrial tachycardia. I told him to take flecainide 300mg and atenolol 50mg (these were the medications he was on before the ablation). The tachycardia terminated within one hour, as confirmed by a subsequent rhythm strip.
I believe smartphone-based ECG rhythm monitoring is definitely a valuable tool for diagnosing arrhythmias and can certainly guide management. Importantly, community-wide screening of AF using iPhone ECGs in pharmacies has been shown to be feasible and cost-effective, leading to prescription of anticoagulation therapy.1 The largely preventable stroke risk of those with newly identified AF highlights the likely benefits of community-wide screening of AF using these devices.1 These results are consistent with two recent large randomized trials in patients with cryptogenic stroke, which showed that prolonged rhythm monitoring using either a 30-day event monitor2 or an implantable loop recorder,3 identified AF that would have otherwise been undetectable. In light of the recent evidence that shorter duration but more frequent intermittent rhythm monitoring strategies are significantly more efficient to detect asymptomatic AF,4 it is possible that identification of occult AF may be done by intermittent monitoring using smartphone-based ECG applications, although the monitoring frequency that would result in reduction of strokes remains unclear. In addition, use of smartphone-based ECGs may reduce health care expenditure, not only by preventing strokes, but also by reducing emergency department visits in cases where the diagnosis can be made remotely and therapy can implemented promptly, as illustrated in the above case.
Although smartphone-based ECG rhythm monitoring applications such as the AliveCor Heart Monitor provide physicians the ability to diagnose patients with intermittent symptoms, there is one caveat: the magnitude of this potentially limitless source of data is enormous (and terrifying). Are we, as physicians, able to handle this huge amount of information? Unless we develop strategies to appropriately manage this wealth of information, our ability to remotely diagnose AF and other arrhythmias may not be as helpful as it originally sounds. Such strategies may include an automated algorithm that diagnoses AF with high sensitivity and specificity, such as the one used in a recent Australian study.1 These characteristics will allow physicians to review only those recordings that are read by the device as AF, in order to decrease the burden of having to review each and every transmitted recording. It is encouraging to note that an automated AF detection algorithm has recently received FDA clearance and is available on the updated AliveCor ECG app. With these tools in our hands, the future of telemedicine in the smartphone era will definitely be bright, leading to improved patient care.
Disclosure: Dr. Stavrakis reports grants from AliveCor, outside the submitted work.
1. Lowres N, Neubeck L, Salkeld G, et al. Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies. The SEARCH-AF study. Thromb Haemost. 2014;111:1167-1176.
4. Charitos EI, Ziegler PD, Stierle U, et al. How often should we monitor for reliable detection of atrial fibrillation recurrence? Efficiency considerations and implications for study design. PLoS One. 2014;9:e89022.