Remote monitoring of AF and HF Kiran Sidhu MD, FRCPC 1 Conflict of - - PowerPoint PPT Presentation

Remote monitoring of AF and HF

Kiran Sidhu MD, FRCPC

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Conflict of Interest Disclosures

• Grants/research support: NA
• Consulting fees: NA
• Speaker fees: NA
• Other: NA

Objectives

• Review the latest remote monitoring options in HF and AF
• Discuss the real-world application of these options
• Review the role of remote monitoring in the latest guidelines

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Tran et al. CMAJ Open. 2016; 4(3): E365-70.

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Goodlin S. J Am Coll Cardiol 2009; 54(5): 386-96.

Non-invasive remote monitoring in HF patients

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Veenis et al. Neth Heart J. 2020; 28: 3-13.

Remote monitoring using CIED

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Veenis et al. Neth Heart J. 2020; 28: 3-13.

PARTNERS HF

• Observational study, 1024 patients

enrolled in 100 US centres – this analysis includes 694 patients

• Inclusion: LVEF < 35%, NYHA III or

IV, QRS > 130 ms

• Looked at AF duration, rates during

AF, OptiVol, patient activity, night heart rate, heart rate variability, %CRT pacing, ICD shocks for VT/VF

• Criteria: OptiVol > 100 or 2 of the

above factors

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Whellan et al. J Am Coll Cardiol 2010; 55: 1803-10.

PARTNERS HF

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Whellan et al. J Am Coll Cardiol 2010; 55: 1803-10.

Heart logic

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Heart Logic

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Multisense trial

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Boehmer J et al. J Am Coll Cardiol HF 2017; 5: 216-25.

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Gardner R et al. Circ Heart Fail 2018; 11: 1-10.

Pulmonary artery pressure sensor

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Cardiomems

• 550 HF patients (NYHA III) with a

prior HFH in the last year

• Randomized at 64 US centres,

single blind

• In the treatment arm – clinicians

used daily PA pressure measurements to make decisions vs. control group (both groups had standard of care)

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Abraham W et al. Lancet 2011; 377: 658-66.

Cardiomems

• Length of stay shorter in the

treatment arm (2.2 vs. 3.8 days, p=0.02)

• More med changes (9.1 vs. 3.8, p<

0.001)

• Effects seen in both HFpEF (0.16 vs.

0.33, p<0.0001) and HFrEF (0.36 vs. 0.47, p=0.007)

• ICER $13979 per QALY gained

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Abraham W et al. Lancet 2011; 377: 658-66.

Guidelines in HF

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Ponikowski P et al. Eur J Heart Fail. 2016; 18(8): 891-975.

Societal impact of AF

• Atrial fibrillation affects ~ 350 000

Canadians

• Lifetime risk for development of AF

is 26% for men, 23% for women

• Estimated costs of

$4800/patient/year of AF

• FHS showed 1.5-1.9 fold mortality

risk

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January C et al. Circ 2019. 140: e125-151. Parkash R et al. Can Journ Gen Int Med. 2018; 13: 21-25.

Cardiostat

• Single center study of 212 patients

comparing Holter to Cardiostat

• Similar rates of detection of

AF/flutter

• More noise seen with Cardiostat
• PVC morphology better

discriminated by Holter given 3 leads

• Cardiostat is water resistant, leads

can be changed and can be worn upto 2 weeks

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Nault I et al. J Electrocardiol. 2019; 53: 57-63.

ILRs

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ILR

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ASSERT

• 2580 patients with CIED
• Age>65 with HTN, no prior AF
• Patients monitored for 3 months to detect

subclinical atrial tachyarrhythmias (atrial rate > 190 bpm for > 6 minutes)

• Follow-up: mean of 2.5 years for ischemic

stroke/systemic embolism

• Study population ~ 77 year old males,

average CHADs score 2.2

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Hazard ratio, 5.56; 95% CI, 3.78 to 8.17; P<0.001)

Healey J et al. N Engl J Med. 2012; 366: 120-9.

Results

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Hazard ratio, 2.49; 95% CI, 1.28 to 4.85; P = 0.007

Healey J et al. N Engl J Med. 2012; 366: 120-9.

REHEARSE AF

• 1001 pts, RCT, comparing the AliveCor

Kardia Monitor (iECG) to routine care (RC)

• Inclusion: Patients ≥ 65 years, CHADS-

VASc ≥ 2, no known prior AF

• iECG arm – twice weekly ECGs over 12

months and additional if symptomatic

• Primary outcome: time to diagnosis of AF

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Halcox J et al. Circ. 2017;136: 1784-94.

Results

• 19 pts iECG vs. 5 pts RC

diagnosed with AF (HR, 3.9; 95% CI=1.4–10.4; P=0.007)

• 42% of the pts in the iECG arm

were asymptomatic

• No SS difference in the number of

strokes or TIAs (6 vs. 10, p=0.34)

• Cost is $10780 per additional AF

diagnosis

• Cost of AliveCor device in

Canada is between $120-150

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Halcox J et al. Circ. 2017;136: 1784-94.

APPLE HEART

• Prospective, single arm, open label pragmatic

study with 419,297 participants over 8 months

• Inclusion: owning a Apple iPhone/Watch, age>22,

US citizen, speaks English

• Exclusion: history of reported AF, anticoagulation
• Co-primary outcome:
• AF > 30 seconds on ECG patch monitoring in a

patient who received an IR pulse notification

• Simultaneous AF on ECG patch during times

when patient had IR tachogram

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Perez M et al. N Engl J Med. 2019; 381; 20: 1909-17.

Results

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Perez M et al. N Engl J Med. 2019; 381; 20: 1909-17.

Results

• Of the 2089 IR tachograms

sampled in those who received a notification – 1489 showed simultaneous AF on ECG patch (PPV 0.71)

• In the remaining 600 – frequent

PACs were seen in 77%, frequent PVCs in 16% and AT (≥ 3 beats) in 38%, sinus arrhythmia in 4.7%

• 86 participants had IR pulse

notifications while wearing an ECG patch – 72 of these showed AF (PPV 0.84)

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Perez M et al. N Engl J Med. 2019; 381; 20: 1909-17.

Blue Sync technology

• Enhanced security
• Minimizes battery drain
• Improved patient satisfaction
• Improved clinic efficiency

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Guidelines in AF

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January C et al. Circ 2019. 140: e125-151. Kirchhof P et al. Eur Heart J. 2016; 37: 2893-2962.