A smartwatch can tell you when it&#;s time to see a cardiologist
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A cardiologist sometimes has to be a detective.
Take the case of the 75-year-old woman who wasn&#;t an athlete, yet one measure of her heart health seemed to say otherwise.
&#;It didn&#;t make sense,&#; said Dr. Sarah Taylor, a cardiologist who specializes in heart rhythm disorders.
The woman was wearing a watch that, among other things, recorded her heart rhythm.
&#;So I looked a little deeper,&#; said Taylor, who is with Rochester Regional Health. &#;Her rhythm actually was atrial fibrillation that had not been detected otherwise. There would have been no other way to detect she had atrial fibrillation other than the watch. So there&#;s a lot of hidden information in there that, with a little insight, can really lead to positive changes.&#;
Smartwatches, probably the most common type of wearable monitoring device aimed at consumers, have evolved from simply tracking steps to being able to detect atrial fibrillation. The arrhythmia can be a risk factor for stroke, particularly when a person has underlying health conditions.
Some of the devices and associated smartphone apps can record oxygen levels which, combined with other measures, can indicate sleep apnea, a condition where a person stops breathing for periods of time while they are asleep.
Software also can track heart rate variability, which can be a marker of stress.
&#;It&#;s very interesting how you can use that to implement wellness techniques in your day,&#; Taylor said. &#;These devices that give you feedback on a minute-by-minute basis or even a day-to-day basis help you figure out what in your life is working well, what is giving you stress and what can you modify.&#;
Many cardiologists share experiences similar to Taylor&#;s.
Dr. Mehmet Aktas is on the advisory board of the American Heart Association and is an electrophysiologist with UR Medicine Cardiac Care. One reason he said he bought a smartwatch with monitoring capabilities was to keep up with his patients.
&#;When a patient said to me, &#;Doc, my watch alerted me to the presence of atrial fibrillation,&#; it was hard for me to understand how that alert occurred. But then reading about the information, learning the algorithm that&#;s involved in setting this alert, I had a stronger understanding of what that information meant. It has allowed me to relate to some of the data that my patients were presenting to me in clinic.&#;
He also uses the data to monitor his own health. But he&#;s in the business of interpreting heart data, so he knows what he&#;s looking at.
Aktas said that, for the layperson, information overload is a concern and there is the possibility of false alarms that can lead to anxiety and unnecessary procedures.
&#;I think this is one of the areas that really requires additional research to try to figure out which populations would benefit from devices like this, where having a wearable might improve their outcome,&#; he said.
His conclusion is similar to what some research has shown.
A study from by the National Library of Medicine https://pubmed.ncbi.nlm.nih.gov// concluded that detecting atrial fibrillation is feasible, but their use needed to evaluated in large population samples.
Over the past year, research reported by the American College of Cardiology https://www.acc.org/About-ACC/Press-Releases//04/04/15/45/Smartwatch-App-Found-to-Accurately-Detect-Atrial-Fibrillation and a study in the Journal of the American Heart Association concluded that wearables can be screening tools and help in long-term management of atrial fibrillation.
The devices have not been studied as extensively for other heart conditions. Dr. Jonathan Rodriguez, attending cardiologist at Finger Lakes Health, said the devices are not appropriate for evaluating chest pain that may be associated with a heart attack.
&#;I do have some older patients who have smartwatches, and the majority of those don&#;t have the kind of problem that a smartwatch would be able to help them with. But at the end of the day, it&#;s still just a screening tool. Anything that would require a change in medication or anything like that would need more.&#;
As for their ability of the devices to detect atrial fibrillation, &#;I think it&#;s becoming more and more useful,&#; he said. &#;AFib is probably under-diagnosed in the population because a lot of patients can have subclinical atrial fibrillation, meaning they don&#;t have any symptoms.&#;
But access to the devices is not being enjoyed equally. He said that cost and lack of an internet connection can be barriers, something he compared to the inequity with telemedicine that happened during the pandemic. An individual&#;s comfort with technology also can prevent them from experiencing potential benefits of the devices.
Rodriguez said most of the marketing is toward younger people, when it&#;s older adults who may have a greater need.
&#;I think younger people are using them for step-counting rather than biometric information,&#; he said. But the devices can help track activity and body composition, important if a person is trying to lose weight.
&#;Obesity is an issue,&#; he said. &#;Along with obesity comes sleep apnea, so it can give them hard information, like your blood oxygen is dipping into the seventies when you&#;re asleep. This is not a good thing and, there are long-term consequences with that and you should do something about it.&#;
For people looking for motivation, the devices can be better than a lecture.
Craig Dennison, exercise physiologist/program coordinator for UR Medicine&#;s Cardiac Rehabilitation program, gets questions from patients about which type of device to get.
&#;I&#;m like, what is your main criteria,&#; he said.
He said he&#;s skeptical of a watch that claims to take blood pressure. &#;Without compressing the blood vessels in the arm and then releasing them, I have no idea how you accurately get a blood pressure.&#;
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For patients who want to track their heart rate, he has suggested a heart-rate monitor with a chest strap, which is picking up the electrical signal from your heart and sending it to your watch or app. &#;Those are highly, highly accurate.&#;
For someone who wants to increase their activity, he said a simple fitness tracker can do the job.
&#;Looking at the number of steps you take per day is a great baseline way to increase your physical activity. We&#;ll say, if you want to get one, get one and over a week don&#;t even think about what you&#;re doing. Just wear it for a week and see how many steps per day you&#;re averaging.
&#;If you&#;re doing 3,500 steps per day. Let&#;s see if you can get up to 4,000 steps per day and then just slowly increase that over time. That does work. That is a motivational tool because it&#;s simple feedback.&#;
Patti Singer is a freelance writer in Rochester. Contact her at [ protected].
By Sarah Handzel, BSN, RN
For better or worse, smart devices that monitor various aspects of health have been integrated into society. In , the Pew Research Society found that 21% of Americans used smartwatches or other wearable fitness trackers, and the number has continued to climb since then.1 As technology improves, more people are using products featuring wearable ECG devices to monitor their cardiovascular health in particular.
While it's true that such devices can give important insight into a person's health status, not all are created equal. Many cardiologists question the accuracy of the devices, while others believe these tools may be useful in the diagnostic process. Regardless of opinion, wearable ECG devices have already empowered many consumers to take greater charge of their own health.
Currently, there are numerous digital ECG devices available to consumers. Many smartwatches and other fitness trackers feature single-lead ECG, as do wearable patches and chest straps. Many of these products also pair with apps that store ECG tracings, which can be shared with physicians remotely.
Other wearables, such as patches, adhere to the skin, are water-resistant and wireless, and are generally well tolerated from a patient perspective. Some patches offer up to 30 days of continuous monitoring, collecting large amounts of data for cardiologists to sort through.
These devices appeal to consumers because they are easy to use, relatively inexpensive, and offer insight into the state of an individual's cardiovascular health. However, not all wearable devices are cleared by the FDA. In other words, not all have demonstrated the same effectiveness and accuracy as other rhythm-monitoring devices, such as the standard 12-lead ECG.
A large determinant of wearable ECG devices' value comes down to the device's sensitivity and specificity.2 Sensitivity, or the ability of a test to correctly identify patients with a disease, varies greatly between wearable devices. Device specificity&#;or the ability to rule out patients who do not have a specific disease&#;is also an important consideration.
Unfortunately, many wearable ECGs have high sensitivity and low specificity&#;that is, they catch a large number of false positives because they cannot differentiate them from true positive results. This presents a significant problem, as specificity becomes more important in populations with low disease prevalence.
A variety of studies have questioned the accuracy of consumer devices for several cardiac conditions, such as Afib, with mixed results. One meta-analysis in the Journal of Atrial Fibrillation found conflicting results among included studies; depending on the study criteria, smartwatches either statistically oversensed or undersensed Afib among study participants. However, the ultimate conclusion of the meta-analysis suggests that there is no significant difference in Afib detection between smartwatches and composite ECG monitoring, Holter monitoring, patch monitoring, and loop recorder.3
According to a review in Nature Reviews Cardiology, single-lead ECGs can help diagnose simple, common arrhythmias like Afib.4 However, they are not useful in diagnosing more complex arrhythmias and other conditions, such as myocardial infarction. Another study in Frontiers in Cardiovascular Medicine compared three wearable ECG devices to conventional 12-lead ECG. In the study, Apple and Samsung smartwatches demonstrated 87% and 88% sensitivity respectively.5 Another device, the Withings smartwatch, demonstrated 78% sensitivity. However, these numbers improved when the researchers excluded non-classified ECGs. An ECG was considered non-classified if the recording was poor or inconclusive, or if the patient's heart rate was less than 50 beats per minute.
Other wearables demonstrate greater sensitivity and specificity. For example, a recent article in the Journal of Cardiovascular Pharmacology and Therapeutics evaluated smartphone-based ECG recordings intended to help diagnose Afib. The device evaluated, KardiaMobile, was used in conjunction with a dedicated smartphone app. According to data gathered from almost 500 participants aged 65 or older, sensitivity and specificity were 100% and 98.7%, respectively.6
Beyond accuracy concerns, many cardiologists should also note that single-lead ECG devices like smartwatches generate tremendous amounts of raw data that must be interpreted professionally. Technology companies have begun to explore machine learning techniques that could help physicians arrive at accurate and timely diagnoses.
This presents a significant challenge. While algorithms used to interpret ECGs are governed by a standard set of parameters, there is no recognized standard for tuning these algorithms. Smartwatches and other wearable ECG products should only use algorithms based on the device's intended purpose. In interpreting test results, clinicians will need to account for this and other factors, which could impact the quality of the data collected.
Many cardiologists still rely on their professional experience to interpret ECGs, including those collected by wearable devices. This mountain of information could become overwhelming as physicians struggle to keep up with consumer demand for health data. As one review in Current Cardiology Reports notes, algorithms governed by parameters like sensitivity, specificity, and positive and negative predictive values may be useful.7 However, clinicians must still account for the characteristics of the algorithms when they interpret the data.
Wearable devices featuring ECG may be used alongside other, more established diagnostic tools, such as 12-lead ECG. While wearables do provide important information that clinicians can use, they only show a small piece of the overall picture of the patient's health status.
Physicians who choose to use information gathered from such technology should be aware of its limitations. They should also be comfortable discussing these limitations with patients in order to appropriately incorporate such devices into treatment plans. As one review in the European Journal of Heart Failure notes, clinician overreading is still mandatory for accurate diagnoses.8
Until such time as machine learning algorithms demonstrate total accuracy in diagnosing various cardiac conditions, physicians should remain skeptical about using wearable ECG devices as the sole diagnostic tool. The data gathered by these devices can be useful, but it is no substitute for a standard 12-lead ECG in making a diagnosis.
References:
Sarah Handzel, BSN, RN, has been writing professionally since after spending over nine years in clinical practice in various specialties.
The opinions, beliefs, and viewpoints expressed in this article are solely those of the author and do not necessarily reflect the opinions, beliefs, and viewpoints of GE Healthcare. The author is a paid consultant for GE Healthcare and was compensated for creation of this article.
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