Can a Commercially Available Mobile ECG Device Reduce Urgent Healthcare Visits? Studies Say Yes!

The skeptical cardiologist proclaimed in 2018 that “AliveCor’s Mobile ECG With Kardia Pro Is Eliminating Any Need For Short or Long Term Cardiac Monitors For Most of My Afib patients“. At the time I naively presumed the rest of the cardiologists in the country would follow the pathway I had blazed for them through the bewildering, expensive and depressing morass of long-term cardiac monitors.

This clearly didn’t happen and I rarely encounter a patient outside my practice who is being monitored by a consumer-level personal ECG device like KardiaMobile or Apple Watch.

Perhaps, other cardiologists require published literature rather than my anecdotal evidence. Although, I must say, that the anecdotal evidence I witness every day is powerful and has convinced this skeptic of the value of such remote monitoring beyond a shadow of a doubt.

Early in the COVID-19 pandemic, I wrote “Atrial fibrillation in the time of Coronavirus: a call for more personal remote ECG monitoring” and as the pandemic persists so does the need to utilize more frequently remote telehealth visits as well as mobile ECG (mECG) monitoring.

I’m happy to report, therefore, that a paper entitled “Usefulness of Mobile Electrocardiographic Devices to Reduce Urgent Healthcare Visits” was published recently which confirms exactly what I observed in 2018.

The author’s premise was that due to mECGs quick, accurate, and remote personal diagnosis of different arrhythmias their use should improve triage of patients reporting symptomatic episodes and therefore cut down on in-person visits for evaluation.

They performed a retrospective review of the EHR records and KardiaPro database for patients who had records for about 1 year prior to purchasing a KardiaMobile device.

I have described in detail in previous posts how we utilize Alivecor’s Kardia device in conjunction with the cloud-based KardiaPro subscription service to manage our afib patients remotely.  (See here and here.) The Apple Watch ECG can also be utilized for this purpose but is more expensive than Kardia and has no online review service.

The authors identified 128 patients and prospectively followed them for one year tracking metrics of monitor usage and health care visits.

They found:

 Patients were less likely to have cardiac monitors ordered (30 vs 6; p <0.01), outpatient office visits (525 vs 382; p <0.01), cardiac-specific ED visits (51 vs 30; p <0.01), arrhythmia-related ED visits (45 vs 20; p <0.01), and unplanned arrhythmia admissions (34 vs 11; p <0.01) in the year after obtaining a KardiaMobile device compared to the year prior to obtaining the device.

Clearly, this study has serious limitations as it is a before and after observational study without a control group, however, since it was published in a peer-reviewed medical journal perhaps it can tip the cardiologic scales more than my personal observations of the same phonomena.

Another study from 2020 found that “Smartphone ECG Monitoring System Helps Lower Emergency Room and Clinic Visits in Post–Atrial Fibrillation Ablation Patients.

This study used a device I’m not familiar with, the ECG check

The ECG Check device (Cardiac Designs Inc, San Francisco, CA) is an over-the-counter smartphone-based ECG monitor that is FDA 510k cleared (K170506) and is CE Marked (0086). The device uses 2 metal pads which measure a single-lead electrical tracing and wirelessly transmits this transmission to the paired smart device via the Bluetooth protocol 

The ECG Check study was a retrospective look at post-ablation AF patients, comparing those who were utilizing the device versus those who weren’t whereas the KardiaMobile study was 3/4 AF patients with a smattering of different arrhythmias making up the other quarter.

Its design and methods and are so weak it doesn’t add to the scientific literature at all. It was published in a journal I have never heard of “Clinical Medicine Insights: Cardiology” which I suspect as being predatory and “pay to publish” in nature.

The people at ECG check have no supporting scientific literature listed on their website whereas AliveCor has about 180 papers using KardiaMobile.

Given the dramatic reduction that I have noticed in my use of long-term monitors  as well as  office and ER visits in this population, CMS and third-party insurers would be wise to explore Kardia monitoring as a more cost-effective way of monitoring afib and other cardiac arrhythmia patients. However, payors, as far as I know, are still not reimbursing for Kardia or Apple Watch.

Despite that, I encourage my fellow cardiologists to embrace this patient empowering technology. Although it doesn’t put a lot of dollars in your pockets it keeps your patients out of EDs.

Monitoring Rhythmically Yours,

-ACP

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21 thoughts on “Can a Commercially Available Mobile ECG Device Reduce Urgent Healthcare Visits? Studies Say Yes!”

  1. Are either of the single or six lead Kardias of benefit to those of us with cardiac pacemakers / defibrillators?

    Reply
    • Alex,
      I would say neither is particularly of benefit to the layperson as ECGs are particularly difficult to interpret in patients with pacemakers. Sophisticated GE algorithms on 12-lead ECGs in my experience fail to accurately identify rhythm properly in patients with pacemakers.
      Dr P

      Reply
  2. I bought an Apple Watch on leaving hospital to quickly and conveniently monitor heart and Oxygen Saturation after an episode of Pulmonary Emboli plus leg DVT. I was in ICU for 4 days.

    I was an anomaly with post AZ jab clots as platelets remained normal. The PE caused significant cardiac arrhythmias, since resolved. The lung clots are resolved, but 6 months later the thigh clots are slowly regressing. A lifetime of blood thinners is likely.

    The Apple Watch is used as a rapid screen, as any positive results are checked with my Kardia single lead, plus hospital grade pulse oximeter. If necessary, a recording is sent off for expert appraisal. Apple Watch Oxygen reading may be erroneous when anaemia exists, so checking with a quality pulse ox machine is prudent.

    So the combination of the three gives rapid and reliable results. The combination is excellent for my situation.

    My Polar Vantage V2 watch is excellent for exercise monitoring, and the sleep monitoring feature is very useful.

    Reply
  3. Like I said in the commercial that ran this past year, you can’t see your cardiologist every day, but you can see your Kardia mobile secret day.
    All the best, Warren

    Reply
    • Warren,
      Great tag line
      You can’t see your cardiologist every day, but you can see your KardiaMobile (or apple watch) every day
      dr P

      Reply
  4. I’m feeling more fortunate than ever that I appear to have an EP who is practising enlightened medical management of my Afib. He was enthusiastic about my use of the Kardia device and mentioned the Apple watch if I fancied something more convenient.

    Now, if only I could get him to say “You’re cured!” when, at every 6 monthly follow up, I have gone yet another 6 months episode free after giving up alcohol totally (from a prior very modest amount) Christmas 2018……in addition to the magnesium supplement, keeping an eye on hydration, finally becoming acclimated to high altitude living (after just over 2 years at >6,200ft) and whatever else I might’ve forgotten in my chase to find something to “fix”. He still thinks it might be something to do with the Sotolol and Eliquis.?

    Vivienne

    Reply
    • Hi Vivienne, well done on your adaption to high altitude. Have you had any blood studies done, showing changes associated with higher altitude?

      I had to stop skiing at high altitudes as the intermittent time at elevation did not allow for long term adaption. I agree that decreasing alcohol intake is important.

      High altitude adaption is fascinating, including people, plants and animals.

      One issue that I think deserves more research is how high altitude adaption affects blood viscosity, with implications of increased tendency to form blood clots.

      Regards,

      Chris

      Reply
      • Chris…..not sure what you mean by blood studies so I guess no would be the answer. One of the things my husband noticed when we used to visit our daughter here prior to moving for real, I would have brief episodes of sleep apnea…..presumably altitude induced, not obstructive. Never happened before and it hasn’t happened once I’d got over the initial few months of slow acclimation……a good bit before my first Afib episode. Probably all adds up, though.

        I’m particularly sensitive to altitude change, it seems. Even though I’m OK for 6200ft or so, don’t have venture much further into the mountains and I can get close to passing out. Daughter’s the same. Husband and son in law not so much.

        Anecdotally, my next door neighbour is an intervention cardiologist……probably technically “my” intervention cardiologist as he got me back into sinus rhythm from one episode with a bit of carotid sinus massage. When his parents flew in from Minnesota for his daughter’s high school graduation, his mother had an episode or two of Afib during her stay which disappeared back at sea level. Altitude’s a funny thing.

        Vivienne

        Reply
      • I’ve had a number of patients go into afib while vacationing at high altitudes. I didn’t specifically mention this in the last post but we are able to manage these almost totally with medication adjustments via text/email/phone/EHR without the need for lengthy (and sometimes costly) ER visits if the patient has a device we can record ECg with.
        Also, (and I’ve discussed this in a post or a comment previously) there is good evidence that hypertension is exacerbated at higher altitudes and we’ve had to make med adjustments for this. It’s a pain in the neck but probably a good idea to bring your BP monitor on your vacation. The QardioArm is best for small footprint in the luggage. Lately, I’ve been taking my Omron Evolv.
        dr P

        Reply
    • vivienne,
      Congratulations on controlling your AF with a combination of lifestyle and enlightened medical management!
      My sense is this works for about 90% of patients.
      Eliquis had nothing to do with it but sotalol likely did.
      Dr P

      Reply
  5. Hi Dr. P

    Earlier this year you published a helpful article: “A Comparison of Alivecor’s Kardia 6L and Kardia Single Lead Mobile ECG With and Without the V2 Algorithm” and mentioned “AliveCor doesn’t appear to provide a clear explanation of what the 6-lead diagnostic advantages are for either the doctor or the patient”. As a long time AFib patient, I commented to that article in some detail that I found my Kardia 6L gives me very credible Limb Lead results: Leads I, II, III, aVR, aVL, and aVF (but not the precordial leads V1-V6). This basically gives me useful EKG information about the right sided and posterior aspects of my heart.

    See: https://theskepticalcardiologist.com/2021/03/07/a-comparison-of-alivecors-kardia-6l-and-kardia-single-lead-mobile-ecg-with-and-without-the-v2-algorithm/#comment-7575

    I hoped you (or Kardia) could guide patients when 6 lead patterns should encourage patients to seek medical advice on a wide range of cardiac patterns other than AFib and similar arrhythmias. My cardiologist says the Kardia is a ‘toy’ of no value beyond alerting patients to possible AFib. I see repeatable atypical patterns on my Kardia when I experience chest discomfort, but my cardiologist does NOT want to see any Kardia readouts. She says I should ignore the Kardia 6L except for AFib.

    I find myself largely alone in trying to decipher patterns I see using my Kardia. My Afib receded after a successful 2020 ablation, and I ‘passed’ several cardiac tests earlier this year, yet I continue to have intermittent microvascular angina discomfort some part of each day. Most of the time, I choose to ignore variable symptoms without worry. Every few days I feel I must lie down for a while, and maybe take Nitro or reduce high BP readings with Benazepril (I also take Amlodipine & Imdur). I’m doing “OK” with watching my diet, lots of rest and moderate exercise, and avoiding stress. But – what do I do with bad days that come maybe once a week or two?

    There is almost NO published guidance for patients on use of the 6 Leads beyond reading a very short list of “canned” Kardia findings approved by the FDA. If my symptoms are serious enough, my cardio simply says I should go to the ER. I’m told: don’t pay attention to the Kardia 6L.

    Are there patient-level guides on use of the Kardia 6L that will help us discern when (a) worse than daily heart symptoms PLUS (b) atypical Kardia 6L lead patterns are good cause to go to the ER?

    Thank you, in advance –

    Reply
    • Frank,
      Re:”I hoped you (or Kardia) could guide patients when 6 lead patterns should encourage patients to seek medical advice on a wide range of cardiac patterns other than AFib and similar arrhythmias”
      and asked if there were patient-level guides on when to go to Er based on non rhythm 6L info.

      There are no such guides.
      I had a long talk with Dr. Dave Albert, the founder and CEO of AliveCor the other day as I am preparing to write about the advantages or lack thereof of the 6L versus the single lead.
      I’ll be posting on that and some things the 6L clearly offers (like accurate QT measurement and QRS axis) that 1L doesn’t.
      But I don’t see anything on the horizon that will clearly tell you to go to the ER without physician input.
      Dr P

      Reply
  6. I am in violent agreement with you, Dr. Pearson! Especially since the Kardia 6L was approved last year, I haven’t ordered a single (costly and annoying) Holter or Event Monitor since! Alas the reason that this has not immediately changed cardiologists clinic practice is not the lack of academic evaluation (let alone the good old(e) “geez, this is clearly a great solution!”, it was summarized in your last sentence, “Although it doesn’t put a lot of dollars in your pockets it keeps your patients out of EDs.”

    I m happy to join your enthusiastic Kardia Klub! Unfortunately, our colleagues will likely only change their behavior when the money COI is removed.

    Thanks for your insightful comments, as always, Dr. Pearson!

    Reply
  7. I’ve used all these devices and each has disadvantages. The main problem is slowness to access. Needed is a watch device where simply touching it gives immediate EKG on the watch dial–No cell phone needed. No app to figure out, No connection to remote monitor or evaluation involved. Patients with AF need to know quickly what rhythm they are in to decide what to do. As an MD with occasional AF, that is what I’m looking for..

    Reply
    • Robert,
      Apple Watch does what you are describing.
      Within a few seconds of clicking the ECG app you are making a recording that appears on the watch dial.
      It is stored on a smartphone app
      Dr P

      Reply
            • I do have a Sense and it is advertised to be able to detect an abnormal rythm with in a 10 minute window. I have not been able to test this feature since I have silent episodes if in fact I do have them. Watch does do a very good job in my non medical opinion of giving you a ekg of 30 sec which can view on the app/phone or download as a pdf and distribute as needed.

              My only concern is that it will only alert to an abnormal rythm after a period of 10 minutes of observed inactivity. Not sure of the relavence of this.

              Reply
          • I had a FitBit- not sure of which model, but a top end one. This was three years ago. It showed that my daily exercise was reassuringly well above daily recommended minimums.

            However close examination of these exercise reports showed they were measuring episodes of sleep time tachycardia as episodes of exercise. Something strange here.

            So I bought a Polar H10 chest strap, plus a Polar Vantage V2 watch- they came as a package.

            The Polar chest strap is the gold standard for measurement as it uses electrode sensing. Most wearable use optical sensing, which can be less reliable.

            The watch was paired with the chest strap, and 24 hour monitoring started. No nocturnal episodes of tachycardia detected by the Polar setup.

            I organised a 30 day 24 hour ECG ( HeartBug) which gave reassuring results, with no evidence of nocturnal tachycardia.

            In my situation, I found the FitBit to be a useful screening device, which prompted me to seek higher quality testing.

            Reply
            • I have to say that I agree with your assessment of the Fitbit. I’m sure it’s capable of meeting all things that it’s advertised to accomplish. I think it’s the conditions that must be met to obtain the results.

              But not wanting to chase after the next greatest thing I am happy with it’s ability to deliver a fairly accurate heart rate reading and convenience of on the wrist ekg.

              Reply

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