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 1

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 3

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

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Goodlin S. J Am Coll Cardiol 2009; 54(5): 386-96. 6

Non-invasive remote monitoring in HF patients Veenis et al. Neth Heart J. 2020; 28: 3-13. 7

Remote monitoring using CIED Veenis et al. Neth Heart J. 2020; 28: 3-13. 8

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 Whellan et al. J Am Coll Cardiol 2010; 55: 1803-10. 9

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

Heart logic 11

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Heart Logic 15

Multisense trial Boehmer J et al. J Am Coll Cardiol HF 2017; 5: 216-25. 16

Gardner R et al. Circ Heart Fail 2018; 11: 1-10. 17

Pulmonary artery pressure sensor 18

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) Abraham W et al. Lancet 2011; 377: 658-66. 19

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 Abraham W et al. Lancet 2011; 377: 658-66. 20

Guidelines in HF Ponikowski P et al. Eur J Heart Fail. 2016; 18(8): 891-975. 21

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 Parkash R et al. Can Journ Gen Int Med. 2018; 13: 21-25. January C et al. Circ 2019. 140: e125-151. 22

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 Nault I et al. J Electrocardiol. 2019; 53: 57-63. 23

ILRs 24

ILR 25

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 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. 26

Results Healey J et al. N Engl J Med. 2012; 366: 120-9. Hazard ratio, 2.49; 95% CI, 1.28 to 4.85; P = 0.007 27

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 Halcox J et al. Circ. 2017;136: 1784-94. 28

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 Halcox J et al. Circ. 2017;136: 1784-94. Canada is between $120-150 29

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 Perez M et al. N Engl J Med. 2019; 381; 20: 1909-17. 30

Results Perez M et al. N Engl J Med. 2019; 381; 20: 1909-17. 31

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) Perez M et al. N Engl J Med. 2019; 381; 20: 1909-17. 32

Blue Sync technology •Enhanced security •Minimizes battery drain •Improved patient satisfaction •Improved clinic efficiency 33

Guidelines in AF Kirchhof P et al. Eur Heart J. 2016; 37: 2893-2962. January C et al. Circ 2019. 140: e125-151. 34