Category Archives: Atrial Fibrillation

AfibAlert Versus AliveCor/Kardia: Which Mobile ECG Device Is Best At Accurately Identifying Atrial Fibrillation?

The skeptical cardiologist has been testing the comparative accuracy of two hand-held mobile ECG devices in his office over the last month. I’ve written extensively about my experience with the AliveCor/Kardia (ACK) device here and here. Most recently I described my experience with the Afib Alert (AA) device here.

Over several days I had my office patients utilize both devices to record their cardiac rhythm and I compared the device diagnosis to the patient’s true cardiac rhythm.

Normal/Normal

In 14 patients both devices correctly identified normal sinus rhythm. AFA does this by displaying a green check mark , ACK by displaying the actual recording on a smartphone screen along with the word Normal.

The AFA ECG can subsequently uploaded via USB connection to a PC and reviewed in PDF format. The ACK PDF can be viewed instantaneously and saved or emailed as PDF.

 

Normal by AFA/Unreadable or Unclassified by AliveCor

In 5 patients in normal rhythm (NSR) , AFA correctly identified the rhythm but ACK was either unreadable (3) or unclassified (2). In the not infrequent case of a poor ACK tracing I will spend extra time adjusting the patient’s hand position on the electrodes or stabilizing the hands. With AFA this is rarely necessary.

In this 70 year old man the AFA device recording was very good and the device immediately identified the rhythm as normal.

Chaput AFA SR

ACK recording was good quality but its algorithm could not classify the rhythm.

GC Unclassified

A 68 year old man who had had bypass surgery and aortic valve replacement had a very good quality AFA recording with correct classification as NSRChaput AFA SR

AliveCor/Kardia recordings on the same patient despite considerable and prolonged efforts to improve the recording were poor and were classified as “unreadable”

Scott AC unreadable
Alivecor tracing shows wildly varying baseline with poor definition of p wave

 

False Positives

There were 3 cases were AFA diagnosed atrial fibrillation (AF) and the rhythm was not AF. These are considered false positives and can lead to unncessary concern when the device is being used by patients at home. In 2 of these ACK was unreadable or unclassified and in one ACK also diagnosed AF.

A 90 year old woman with right bundle branch block (RBBBin NSR was classified by AFA as being in AF.

VA AFA read as AF
Slight irregularity of rhythm combined with a wider than normal QRS from right bundle branch block and poor recording of p waves likely caused AFA to call this afib
VA unclassified RBBB
AliveCor tracing calls this unclassified. The algorithm does not attempt to classify patients like this with widened QRS complexes due to bundle branch block.

The ACK algorithm is clearly more conservative than AA. The ACK manual states:

If you have been diagnosed with a condition that affects the shape of your EKG (e.g., intraventricular conduction delay, left or right bundle branch block,Wolff-Parkinson-White Syndrome, etc.), experience a large number of premature ventricular or atrial contractions (PVC and PAC), are experiencing an arrhythmia, or took a poor quality recording it is unlikely that you will be notified that your EKG is normal.

 

One man’s rhythm confounded both AFA and AC. This gentleman has had atrial flutter in the past and records at home his rhythm daily using his own AliveCor device which he uses in conjunction with an iPad.IMG_8399.jpg

During our office visits we review the recordings he has made. He was quite bothered by the fact that he had several that were identified by Alivecor as AF but in fact were normal.

Screen Shot 2017-05-06 at 11.48.47 AM
These are recordings Lawrence made at home that i can pull up on my computer. He makes a daily recording which he repeats if he is diagnosed with atrial fibrillation. In the two cases above of AF a repeat measurement was read as normal. Of the two cases which were unclassified , one was normal with APCs and the other was actually atrial flutter

A recording he made on May 2nd at 845 pm was read as unclassified but with a heart rate of 149 BPM. The rhythm is actually atrial flutter with 2:1 block.

Screen Shot 2017-05-06 at 11.47.37 AM

Sure enough, when I recorded his rhythm with ACK although NSR (with APCS) it was read as unclassified

Screen Shot 2017-05-06 at 11.49.49 AM

AFA classified Lawrence’s rhythm as AF when it was in fact normal sinus with APCs.

AFA Mcgill AF

 

 

One patient a 50 year old woman who has a chronic sinus tachycardia and typically has a heart rate in the 130s, both devices failed.

We could have anticipated that AC would make her unclassified due to a HR over 100 worse than unclassified the tracing obtained on her by AC (on the right)was terrible and unreadable until the last few seconds. On the other hand the AFA tracing was rock solid throughout and clearly shows p waves and a regular tachycardia. For unclear reasons, however the AFA device diagnosed this as AF.

 

 

Accuracy in Patients In Atrial Fibrillation

In 2/4 patients with AF, both devices correctly classified the rhythm..

In one patient AFA correctly diagnosed AF whereas ACK called it unclassified.

This patient was in afib with HR over 100. AFA correctly identified it whereas ACK called in unclassified. The AC was noisy in the beginning but towards the end one can clearly diagnose AFScreen Shot 2017-05-06 at 8.39.06 AMScreen Shot 2017-05-06 at 8.11.53 AM

In one 90 year old man AFA could not make the diagnosis (yellow)

Screen Shot 2017-05-06 at 11.35.40 AM

ACK correctly identified the rhythm as AF

Screen Shot 2017-05-06 at 11.37.51 AM

One patient who I had recently cardioverted from AF was the only false positive ACK. AliveCor tracing is poor quality and was called AF whereas AFA correctly identified NSR>

Screen Shot 2017-05-06 at 8.42.46 AMScreen Shot 2017-05-06 at 8.42.26 AM

 

 

Overall Accuracy

The sensitivity of both devices for detecting atrial fibrillation was 75%.

The specificity of AFA was 86% and that of ACK was 88%.

ACK was unreadable or unclassified 5/26 times or 19% of the time.

 

The sensitivity and specificity I’m reporting is less than reported in other studies but I think it represents more real world experience with these types of devices.

Summary

In a head to head comparison of AFA and ACK mobile ECG devices I found

-Recordings using AfibAlert are usually superior in quality to AliveCor tracings with a minimum of need for adjustment of hand position and instruction.

-This superiority of ease of use and quality mean almost all AfibAlert tracings are interpreted whereas 19% of AliveCor tracings are either unclassified or unreadable.

-Sensitivity is similar. Both devices are highly likely to properly detect and identify atrial fibrillation when it occurs.

-AliveCor specificity is superior to AfibAlert. This means less cases that are not AF will be classified as AF by AliveCor compared to AfibAlert. This is due to a more conservative algorithm in AliveCor which rejects wide QRS complexes, frequent extra-systoles.

Both companies are actively tweaking their algorithms and software to improve real world accuracy and improve user experience but what I report reflects what a patient at home or a physician in office can reasonably expect from these devices right now.

-ACP

How Well Does The AfibAlert Remote Hand-Held Automatic ECG Device Work For Detection of Atrial Fibrillation?

I’ve been evaluating the ability of a mobile hand-held ECG device called AfibAlert to detect atrial fibrillation for the last few weeks.

I found that the device made very reliable and consistent recordings of cardiac rhythm and did a reasonably good job of detecting atrial fibrillation (afib).

The device  came in a plastic case with a USB cable for uploading recordings and two metal bracelets which attach to electrodes and provide an alternative recording method.

The device itself is about 6 by 3 by 1 inch.

 

Recordings are made by placing your thumbs on the silver/siver chloride electrodes

After a few seconds the display in the center will give heart rate and after 45 seconds the
device will make a decision about your rhythm:

If it diagnoses normal sinus rhythm a green check appears and if it diagnoses  afib a red telephone appears.

If it is confused you get yellow circular arrows.

As the maker of the device explains:

Lohman Technologies’ patented algorithm analyzes the patient’s heartbeat and the appropriate icon illuminates to show what action is needed. AfibAlert’s® algorithm was validated against 51,000+ ECG strips from the MIT-BIH Atrial Fibrillation Database with known diagnosis. The Afib monitor’s results were excellent, with 94.6% accuracy in detecting the presence of arrhythmias. Each recording produces a 45-second diagnostic quality ECG rhythm strip

The device I tested does not allow you to immediately see the ECG tracing. The recordings are uploaded to a PC via USB cable and then can be viewed as a PDF document.

I made 17  recordings on patients in my office one day. The age range was 50 to 93 years and most  patients were able to rapidly and easily  grasp the device with thumbs appropriately positioned to make interpretable recordings.

Only 2/17  came back. yellow. In both cases, I repeated the recording and the device was able to make the correct diagnosis. Twice I got the yellow signal on an elderly, partially blind patient who had trouble keeping his thumb on the electrode.

In 15  cases of normal sinus rhythm the device correctly identified NSR.

In one case of atrial fibrillation the device correctly identified atrial fibrillation.

 

 

In one case of SR with
APCs the device
incorrectly identified afib

 

Overall the device correctly classified 88% of the tracings. This was superior to the device I normally utilize ( AliveCor/Kardia mobile ECG)  in head to head comparison (I’ll present this comparison in a subsequent post).

My bullet points on the AfibAlert device:

-5 stars for Ease of Recording

-5 stars for Quality of recording

In all cases that uploaded, the recordings were very clear and free of artifact. The device did not upload yellow signal events and I presume more artifact is present in these recordings.

-2 stars for Convenience.

I found the software and uploading to be very awkward and slow. The company indicates new software soon to be released along with the ability to interface directly with iPads or smartphones that hopefully will improve this factor.

The inability to instantaneously view the ECG tracings means I cannot use it in my office to screen patients for arrhythmias. However, if a patient is solely using it to determine if afib is present or absent, this information is available right away.

-3 stars for Accuracy.

It does a reasonable job of identifying the patient who is in normal rhythm versus one in atrial fibrillation.

However, like AliveCor and other devices which strictly look at the variability of the pulse, it can be easily fooled by premature beats, especially when they are frequent, and inappropriately classify these as afib resulting in false positives.

In addition, when afib rates are very slow and thus much less variable it is likely AfibAlert will incorrectly classify them as normal thus resulting in false negatives.

False Negatives and False Positives

False negatives result in delayed diagnosis of afib. Patients will be falsely reassured that their rhythm is normal when it is not.

False  positives result in needless anxiety and testing/treatment.

If afib monitoring devices are to be successful they have to have a very low frequency of both types of inaccuracy.

The solution to inaccuracy of interpretation, of course, is to have a cardiologist over-read the tracings.

AfibAlert recordings are available online for review by your personal physician after being uploaded. This requires your physician to have an account with AfibAlert. There is no capability for having the recordings over read by an online cardiologist for a charge.

As far as I can tell the device is only available for purchase in the US and only on the AfibAlert website.

Interestingly, you cannot purchase AfibAlert  without a prescription from a physician.

Why this is mandated for AfibAlert and not AliveCor is a mystery to me.

 

 

Alertly Yours,

-ACP

 

 

Has The Digoxin Death Knell Sounded: Farewell To Foxglove?

The lovely but deadly foxglove plant encountered randomly on a hike through glorious Wales on a dreary, rainy day.

The skeptical cardiologist is fascinated by the cardiac drug digoxin and the plant from which it is derived, the foxglove.

I wrote about “foxglove equipoise” in a previous post, touching on the contributions of William Withering in the 1700s, to understanding the toxicity and therapeutic benefits of the foxglove, and more recent concerns that digoxin increases mortality in patients with heart failure.

At the American College of Cardiology Scientific Sessions in Washington, D.C. yesterday, a paper showing higher mortality for patients on digoxin may be the final nail in the foxglove coffin.

Despite lack of evidence for its safety in the treatment of atrial fibrillation from randomized trials, digoxin is used in 30% of patients with atrial fibrillation (AF) worldwide, and current AF guidelines recommend it for rate control in patients with AF (with and without heart failure).

The investigators used data from the ARISTOTLE study of apixiban versus warfarin for their analysis.

They looked at mortality in patients taking or not taking digoxin at baseline, using a Cox model with propensity weighting, which included demographic features as well as biomarkers and digoxin levels at baseline. Major findings:

-In patients already taking digoxin, mortality was not higher in digoxin users, however, the risk of death was related to dig levels: for every 0.5 ng/ml increase in dig level, the risk of death rose by 19 percent and if dig level was >1.2 ng/ml the death rate increased by 56 percent. 

Patients not taking digoxin before the trial who began taking it over the course of the study had a 78 percent increase in the risk of death from any cause and a four-fold increased risk of sudden death after starting digoxin use.  Most sudden deaths occurred within six months after digoxin was started.

Risk of death with initiation of digoxin was increased in patients with and without heart failure.

The use of foxglove to treat dropsy is a fascinating and instructive chapter in the history of medicine.

This study added to prior systematic reviews suggests that it is time to end the use of digitalis and close the chapter.

William Withering might turn over in his grave but at least we won’t be sending afib patients to join him prematurely!

Dropsily Yours,

-ACP

 

What Is The Cause of Low Voltage (Unreadable or Unclassified) AliveCor/Kardia Mobile ECG Recordings?

The skeptical cardiologist has had several of his readers submit stories and tracings of AliveCor Mobile ECG recordings which yield unclassified or unreadable recordings. In some cases this is due to excess noise but a lot of these tracings suffer from low voltage: the height of the tracing is very small.

John, a skepcard reader, is typical.

Recently, he noted his heart was racing and made an AliveCor recording which came back interpreted by the app as normal

EKG-3
First tracing. Note the QRS complex (the large regular spikes) are 2 boxes high. Right in front of them is a little bump, the p wave indicating normal sinus rhythm

 

Three hours later he made a second recording which has drastically lower voltage: the only deflections visible are tiny QRS complexes, the p waves have disappeared. I think this is also normal sinus rhythm but because p waves can’t be seen this came back uninterpretable and if there were any irregularity AliveCor would have called it atrial fibrillation:

EKG-4
Second tracing. Note the QRS spikes now are less than half of a box tall. There are no consistent p waves visible (unless one has a good imagination). The bumps after QRS spikes are T waves.

John has a theory on the cause of some of his low voltage recordings which I shall reveal in a subsequent post after testing it.

In the meantime, if any readers have suggestions as to causes of low voltage recordings or have noted similar issues please comment below or send recordings and observations to DRP@theskepticalcardiologist.com.

Voltagophilistically Yours,

-ACP

 

 

 

 

Do NOT Rely on AF Detect Smartphone App To Diagnose Atrial fibrillation

I’m writing this brief post as a warning to any individuals who have purchased the  smartphone app AF Detect (screen shot below from Apple app store.) It is not a reliable detector of atrial fibrillation (AF).

screen-shot-2017-02-19-at-11-25-56-am

 

A patient of mine with AF recently  purchased this app unbeknownst to me. He  relied on its faulty information which  reassured hm he was not in AF when in fact he was in AF. Such misinformation has the potential to lead to dangerous delays in diagnosis.

There are multiple reviews on the Apple and Google app sites which confirm the total lack of reliability of this app to diagnose AF with screen-shot-2017-02-19-at-9-18-10-ammultiple instances of both failure to detect known AF and inappropriate diagnosis of AF when rhythm was not AF.

In the description of the app the company says the app will “transform you rmobile device into a personal heart rate monitor and atrial fibrillation detector”.

However after purchasing the app and before using it you see this disclaimer which img_8348states it is not to be used for any medical diagnosis.

 

 

 

 

 

 

I will be performing a more detailed analysis of this app’s performance in the future and contacting the FDA about the danger such inaccurate medical testing confers on victims.

In the meantime if you have any experience with this app or other apps claiming to detect AF reliably using detection of the pulse from finger application to the camera lens please share them with me (via email  DRP@theskepticalcardiologist.com or via comments below.)

-ACP

Sustained Atrial Fibrillation or Not: The Vagaries and Inaccuracies of AliveCor/Kardia and Computer Interpretation of ECG Rhythm

The skeptical cardiologist has often sung the praises of the AliveCor Mobile ECG for home and office heart rhythm monitoring (see  here and here.) However, there is a significant rate of failure of the device to accurately identify atrial fibrillation.  I’ve seen numerous cases where the device read afib as  “unclassified” and normal sinus rhythm (usually with PVCs or PACs) called afib both in my office and with my patient’s home monitors.

In such  cases it is easy for me to review my patient’s  recordings and clarify the rhythm for them.

For those individuals who do not have a img_8322cardiologist available to review the recordings, AliveCor offers a service which gives an option of having either a cardiac technician or cardiologist review the tracing. The “cardiac technician assessment” costs $9 and response time is one hour. The “Clinical Analysis and Report by a U.S. Board Certified Cardiologist” costs $19 with 24 hour response time.

Obviously, I have no need for this service but I’ve had several readers provide me with their anecdotal experiences with it and it hasn’t been good.

One reader who has a familial form of hypertrophic cardiomyopathy utilizes his AliveCor device to monitor for PVCs. One day he made the following recording which AliveCor could not classify:
screen-shot-2017-02-14-at-5-37-42-am
screen-shot-2017-02-14-at-5-43-51-am screen-shot-2017-02-14-at-5-41-41-am

He then requested a technician read which was interpreted as “atrial fibrillation sustained.”

He then had requested the cardiologist reading which came back as Normal Sinus Rhythm.

Finally, he againscreen-shot-2017-02-14-at-5-44-09-am requested the technician
read and got the correct reading this time which is normal sinus rhythm with PACs

When my reader protested to Kardia customer service about this marked inconsistency: three different readings in a 24 hour period, a Kardia  customer service rep responded :

 I was able to review this with our Chief Medical Officer who advised that the recording shows Sinus Rhythm with PACs. The Compumed report seldom provides identification of PACs and PVCs as most cardiologists believe they are not significant findings. The sustained AFib finding was incorrect, so I have refunded the $5 fee you had paid.

Please let us know if you have any other questions.

As I pointed out in my post on palpitations, most PVCS are benign but some are not and patients with palpitation would like to know if they are having PVCS and/or PACs when they feel palpitations.

More importantly, the misdiagnosis of afib when the rhythm is NSR with PACs or PVCs can lead to extreme anxiety.

sr-pvcs-with-annotations
This tracing clearly (to me) shows regular and similar upward deflections (red arrow, p waves) which are a similar distance from the QRS complexes which follow (QRS complexes). The green arrows point to irregular deflections due to noise which can confuse computer algorithms (and non-cardiologists.) The distance between the QRS complexes is very regular (black arrow, RR interval). Thus, this is clearly normal sinus rhythm (NSR). Later in the recording PVCs (green arrows) are noted occurring every other beat. The distance between the QRS complexes on either side of the PVC is still the same as two RR intervals. This is clearly ventricular bigeminy.

Heres a recording
I made in my office this morning on a patient with cardiomyopathy and a defibrillator.

This is very clearly NSR with PVCs yet AliveCor diagnosed it as “possible atrial fibrillation.”

The AliveCor algorithm  is not alone in  making frequent errors in the diagnosis of atrial fibrillation.

The vast majority of ECGs performed in the US come with an interpretation provided by a computerized algorithm and medical personnel rely on this interpretation until it can be verified or corrected by an overreading cardiologist.

One study demonstrated that computerized ECG interpration (ECG-C) is correct only 54% of the time when dealing with a rhythm other than sinus rhythm

Another study found that 19% of ECG-C misinterpreted normal rhythm as atrial fibrillation. Failure of the physician ordering the ECG to correct the inaccurate interpretation resulted in change in management and initiation of inappropriate treatment, including antiarrhytmic medications and anticoagulation, in 10% of patients. Additional unnecessary diagnostic testing was performed based on the misinterpreted ECGs in 24% of patients.

When lives or peace of mind are at risk you want your ECG interpreted by a cardiologist.

I would like to take this opportunity to personally issue a challenge to IBM’s Watson.

Hey, Watson, I bet $1,000 I can Interpret cardiac rhythm from an ECG with more accuracy than you can!

Are you listening, IBM?

Do you copy, Watson?

-ACP

AliveCor Mobile ECG Update: Successes and Failures

The  AliveCor/Kardia mobile ECG device is a really nifty way to monitor your heart rhythm. Since acquiring the third generation device (which sits within or on my iPhone case and communicates with a smartphone app) I have begun routinely using it  on my patients who need a heart rhythm  check during office visits. It saves us the time, inconvenience (shirt and bra removal) and expense of a full 12-lead ECG which I would normally use.

In addition, I’ve convinced  several dozen of my patients to  purchase one of these devices and they are using it regularly  to monitor their heart rhythms. Typically, I recommend it to a patient who has had atrial fibrillation (Afib)  in the past or who has intermittent spells of palpitations.

Some make daily recordings to verify that they are still in normal rhythm and others only make recordings when symptoms develop.

Once my email invitation request is accepted I can view the ECGs recorded by my patients who have AliveCor devices as I described here.

This monitoring has in many cases taken the place of expensive, obtrusive and clumsy long term event monitors.

In general, it has been very helpful but the device/app makes occasional mistakes which are significant and sometimes for certain patients it does a poor job of making a good recording.

Alivecor Success Stories

One of my patients,  a spry ninety-something year young lady makes an AliveCor recording every day, since an episode of Afib 9 months ago.

And when I say every day I mean it literally everyday. It could be because she is compulsive or perhaps she has programmed the AliveCor to remind her. When I log in to the AliveCor site and click on her name I can see  these daily recordings:Screen Shot 2016-06-17 at 12.40.07 PM

After a month of normal daily recordings, she suddenly began feeling very light headed and weak with a sensation that her heart was racing.

Screen Shot 2016-06-17 at 12.41.13 PMShe grabbed her trusty iPhone and used the AliveCor device attached to it to make a recording of her cardiac rhythm. This time, unlike the dozens of other previous recordings, the device indicated her heart rate was 157  beats per minutes , about twice as fast as usual.

After 5 hours her symptoms abated and by the time of Screen Shot 2016-06-17 at 12.46.52 PMher next recording she had gone back to the normal rhythm.

She made two other recordings during the time she felt bad and they both confirmed Afib at rates of 140 to 150 beats per minute.

In this case, the device definitely alerted her to a marked and dramatic increase in heart rate but was not capable of identifying this as Afib In my experience with several hundred recordings, the device accurately identifies atrial fibrillation about 80% of the time. On rare occasions (see here) it has misidentified normal rhythm with extra beats as atrial fibrillation

Review Options

AliveCor/kardia users  have the option of having their recordings IMG_6936-1interpreted for a fee by a cardiologist or a technician.

My patients can alert me of a recording and I can go online and read the ECG myself and then contact the patient to inform them of my interpration of their heart rhythm and my recommendations.

Another patient made the recording below:Screen Shot 2016-06-18 at 11.32.26 AMAlthough she is  at high risk of having a stroke during the times she is in Afib, we had been holding the blood thinner I had started her on because of bleeding from her mouth. I had instructed her to take daily recordings of her rhythm with the AliveCor until she was seen by her dentist to evaluate the bleeding.

In this case, the AliveCor performed appropriately, identifying correctly the presence of Afib which was the cause of her nocturnal symptoms.

AliveCor Failures

A young woman emailed me that her AliveCor device on several screen-shot-2016-11-27-at-5-18-23-amoccasions has identified her cardiac rhythm during times of a feeling of heart racing and palpitations as “possible atrial fibrillation.”  When she sent the recordings in to AliveCor to have a paid interpretation, however, the recordings were interpreted as sinus tachycardia with extra beats.  Indeed , upon my review her rhythm was not Afib. Clearly, when the device misidentifies Afib, this has the potential for creating unnecessary anxiety.

It is not uncommon for a full, 12-lead ECG done in the hospital or doctor’s office  by complex computer algorithms to misinterpret normal rhythm as Afib so I’m not surprised that this happens with AliveCor using a single lead recorded from the fingers.

The young woman was advised by AliveCor to try a few things such as using the device in airplane mode, sitting still and wetting her fingers which did not help. She was sent a new device and the problem persisted. She finds that putting the device on her chest gives a better chance of success.

She also runs into a problem I see frequently which is a totally normal recording labeled by the device as  “unclassified.”screen-shot-2016-11-27-at-5-35-05-am

In this example, although I can clearly see the p-waves indicating normal sinus rhythm, the voltage is too low for the device to recognize.

Send Me Your AliveCor Problems and Solutions

I’m interested in collecting more AliveCor/Kardia success and failure stories so please post yours in the comments or email me directly at DRP@theskeptical cardiologist.com.

In addition, I’m interested in any tips AliveCor users have to enhance the success of their recordings: What techniques do you use to make the signal strength and recording better? What situations have you found that tend to worsen the signal strength and recording quality?

Still Unclassified Yours,

-ACP

P.S. Tomorrow is Cyber Monday and I note that Kardia is running a “Black Friday” special through 11/28, offering the device at 25% off.

screen-shot-2016-11-25-at-6-00-14-amP.P.S. Kardia, You should change the statement on your website, “90% of strokes are preventable if you catch the symptoms early.”  makes no sense. I think you mean that some strokes are preventable (I have no idea where the 90% figure come from) if one can detect Afib by utilizing a monitoring device to assess symptoms such as palpitations or irregular heart beat.

 

 

They Were in Normal Sinus Rhythm for Halloween

The skeptical cardiologist likes to see his afib patients stay in the normal rhythm (normal sinus rhythm) after they are cardioverted. On Halloween here in the office at Cardiac Specialists of St. Lukes three of our assistants helped drive home the message with a creative ensemble costume:

img_7951
Three marvelous medical assistants  help maintain normal sinus rhythm and battle the chaos of atrial fibrillation. (From left to right, Trish, Diane, and Jenny)

Speaking of Halloween, rather than handing out candy next Halloween, I’ll be handing out sacks of stroke-bustin’ nuts.

I’m sure the neighborhood kids will love the alternative to all that high fructose corn syrup!

Frightfully Yours

-ACP

 

 

 

Atrial Fibrillation Ablation: Time For A Team Approach?

For many proceduralists in medicine and surgery, there is a tendency to overestimate the value and underestimate the risk of the intervention that they perform. This factor, plus the current medical reimbursement system in the US, which rewards physicians primarily on the quantity of services performed rather than the quality of care, fosters a strong incentive for proceduralists to perform their procedures early and often.

It is rare for a proceduralist to publicly advocate a cautious and circumspect approach to their procedure; the usual public expressions are highly enthusiastic endorsements intended for marketing and increasing volume.

In this regard, it is particularly refreshing to read the thoughts today of a clinical electrophysiologist, whose bread and butter partially consists of doing ablations of atrial fibrillation (AF.)

John Mandrola (who writes a great blog at DrjohnM.org and reports for theheart.org) has written an excellent summary of the things that patients should consider prior to getting an AF ablation which I shall reblog below.

Mandrola asks us to consider whether the decision for AF ablation should be made by a team rather than by the proceduralist who stands to benefit from performing the ablation.

I’ve emphasized some points from his post:

-AF ablation is a multi-hour procedure that requires general anesthesia. Up to 80 burns are made in the left atrium, some close to the esophagus and phrenic nerve. There are significant risks to the procedure. The honest long-term success rate barely tops 50%.

-Many patients have to undergo a second procedure, or even third or fourth procedures.

-Some questions an AF team might ask:

  • Have you checked the patient for sleep apnea?

  • Have you asked him to reduce his alcohol intake or weight?

  • Will the AF resolve after the stress of a divorce has worn off?

  • Does the patient know there’s not a shred of evidence that AF ablation reduces stroke or death rates?

 

-Does the patient know that AF is not deadly heart disease? In other words, has fear been sufficiently extracted from the decision?

I, not infrequently, refer appropriate patients to excellent and thoughtful electrophysiologists for a discussion of the pros and cons of ablation and consideration of its performance .  Before sending them, I try to act like the “team” that Mandrola envisions and review the risks and benefits along with alternative approaches.

Below is John’s post in its entirety:

A patient presents with atrial fibrillation (AF) and a rapid rate. He doesn’t know he is in AF; all he knows is that he is short of breath and weak.

The doctors do the normal stuff. He is treated with drugs to slow the rate and undergoes cardioversion. During the hospital stay, he receives a stress test and an implantable loop recorder.

He goes home on a couple of medications. The expensive implanted monitor shows rare episodes of short-lived AF, less than 1% of the time. The patient feels great.

But here’s the kicker: his doctor recommends an AF ablation.

This is nuts. The man has had one episode of AF. He has no underlying heart disease. And he feels well while taking only basic meds. There’s been no discussion of weight loss, exercise, alcohol reduction, or sleep evaluation.

I don’t know how often this happens in the real world, but I suspect that it’s happening more and more. The number of doctors trained in electrophysiology have increased. And, trainees in academic centers spend most of their time mastering the AF ablation procedure.

The Dartmouth Atlas of Healthcare group have shown cardiology to be a supply-sensitive service. Meaning, the more cardiologists there are in an area, the more procedures get done. This build-it-and-they-will-come problem dogs much of US healthcare, not only cardiology. Think MRI and CT centers.

Might a solution to the overuse of AF ablation be a multi-disciplinary heart team?

We already do this for some heart valve surgeries, specifically, transaortic valve replacement (TAVR).

AF ablation is a multi-hour procedure that requires general anesthesia. Up to 80 burns are made in the left atrium, some close to the esophagus and phrenic nerve. There are significant risks to the procedure. The honest long-term success rate barely tops 50%. (Success rates depend somewhat on the type of AF.)

Then there are the repeat procedures. Many patients have to undergo a second procedure, or even third or fourth procedures. (All at many thousands of dollars per case.)

If doctors recommending the procedure had to present the patient to a team of peers, there may be more discussion about the sobering realities of AF care. Questions could arise:

  • Have you checked the patient for sleep apnea?
  • Have you asked him to reduce his alcohol intake or weight?
  • Will the AF resolve after the stress of a divorce has worn off?
  • Does the patient know there’s not a shred of evidence that AF ablation reduces stroke or death rates?
  • Does the patient know that AF is not deadly heart disease? In other words, has fear been sufficiently extracted from the decision?

I recognize that not every decision in medicine should be made by committee. AF ablation, however, might fit some sort of internal review.

The European Heart Journal just published a terrific review on the treatment of persistent AF. In this paper, the treatment of risk factors gets strong mention–as does the sobering results of AF ablation in more advanced forms of AF, and the vast uncertainty surrounding treatment approaches.

I’m not against AF ablation; I perform the procedure often. But after I’m sure all other aspects of atrial-health have been addressed, and the patient is fully informed. It’s a huge mistake to equate AF ablation with ablation of other focal (emphasis on focal) rhythm problems, like supraventricular tachycardia.

I’d have no trouble justifying my AF ablation procedures to a heart team.

JMM

Getting To The Heart Of Father’s Day

The skeptical cardiologist received an email from the folks at AliveCor a few days ago with the subject line:

Dad’s heart matters – Kardia Mobile for Dad will give you peace of mind and make Dad happy

The email contains this image of an older well-dressed man (withScreen Shot 2016-06-18 at 9.03.26 AM lots of bling) standing in a beautiful meadow near the ocean. The man has decided to turn his back on the ocean and check his heart rhythm using the AliveCor/Kardia (AliveCor has changed the name of its ECG devices to Kardia) mobile ECG. This man is a happy dad! (Unless his heart rhythm is interpreted as atrial fibrillation. Then the beach walk is ruined.)

The email asks the question “What if Dad’s heart really was an open book?”

Uhh, he’d be dead? Clearly books don’t function well at pumping 5 or 6 liters of blood through the cardiovascular system every minute whether they are open or closed. Perhaps  the question is using either  the heart or an open book as a metaphor?

The advertisement goes on to suggest that I get my dad an AliveCor device for father’s day  “So you always know what his heart is thinking.”

I believe this is the marketing person’s attempt to extend the metaphor of the open book, i.e., you know exactly what dad’s brain is thinking, now you can extend this knowledge to his heart.  The metaphor of the heart “thinking” is quite poor but poor metaphors are the norm today.

Bad metaphors and bad writing abound on father’s day because 90 million greeting cards are purchased and given as (according to the Greeting Card Association)  “a meaningful expression of personal affection for another person.” Despite the increasing use of Facebook and its ilk to transmit emotions, the Greeting Card Association assures us that “The tradition of giving greeting cards … is still being deeply ingrained in today’s youth, and this tradition will likely continue as they become adults and become responsible for managing their own important relationships.

Mobile Ecg Monitor As A Father’s Day Gift

I have to say that despite the horror of the writing in this email advertisement it got me thinking about getting my father a Kardia device. I’ve suggested  previously that  an AliveCor device would make a good gift for Christmas for a loved one who has intermittent unexplained palpitations or atrial fibrillation but had not considered this for my dad.

For one thing he does not possess a smart phone which is required to  make the Kardia device functional. For another, he doesn’t have atrial fibrillation (that we know of. Perhaps if I knew what his heart was thinking we would find out that it likes to fibrillate late at night,)

Perhaps it’s time to upgrade my Dad to an iPhone I began thinking.

But wait! He has an iPad mini (that he seems to only use for FaceTime conversations.)

Further research reveals that Kardia is not only compatible with iPhone and Android smartphones but apparently iPads and IPod Touch.Screen Shot 2016-06-19 at 8.04.27 AM

Taking Care of Dad’s Heart

What about the rest of the slick advertising copy in my email?

And now you can know the way to help take care of it. Kardia gives Dad a medical-grade EKG in only 30 seconds. It even gives him expert analysis and tracking, with reports getting shared directly with his physician

This part is pretty clear and correct. I use Kardia daily in my office to record patient’s heart rhythm and I have a dozen patients now who make recordings outside of the office. They can have their recordings read by a random cardiologist for a fee or establish a link with me as their provider and I can review them through my account for free.

 Is It The First Father’s Day Gift That Leads To More Father’s Days?

The ad ends with the remarkably brazen statement that “It’s the first Father’s Day gift that leads to more Father’s Days.”

While I find the device more helpful in many instances than current expensive and intrusive long term monitoring devices for detecting and monitoring atrial fibrillation and other abnormal heart rhythms, it is a huge leap to suggest that this translates somehow into a longer life span.

To AliveCor’s credit, despite such ridiculous marketing drivel , studies presented at the recent Heart Rhythm Society Scientific Meetings suggest:

  • Kardia Mobile Superior to Conventional Monitoring: Researchers at the Leeds General Infirmary found that the AliveCor monitor is superior to conventional Holter monitoring in patients with palpitations, providing a higher diagnostic yield, more detected arrhythmias, with a similar workload.

  • Kardia Mobile Leads to Improved Patient Compliance:Researchers at the University of Buffalo found that AliveCor provides a diagnostic yield comparable to a 30-day ambulatory looping event monitor and that the smartphone-based ECG monitor can be used as a first approach for the diagnosis of palpitations.

  • Kardia Mobile provided more information resulting in changes in arrhythmia patient management than traditional external event recorders in a study from researchers at the University of Miami.

  • AliveCor’s AF algorithm was reported to be superior by researchers at Arizona State University to the patient’s own ability to detect AF via symptoms.

    But even if these studies make it to publication they don’t suggest the device provides any improved longevity. In fact, such data, do not exist for any monitoring device.

Happy Father’s Day, Dad! Don’t be surprised when we FaceTime later today that I’ve found another use for your iPad.

Paternally Yours,

-ACP

N.B. Clearly I receive no consulting, speaking or P.R. writing fees of any kind from AliveCor. Nor do they provide me with any free devices. What’s more, when I lose one of their devices they don’t replace it.  I am totally free of any conflict of interest.