Since it is common for AF to present at rates >120 BPM, AW ECG will fail to notify many (if not most) of its users that they are in AF.
AliveCor’s Kardia mobile ECG device (both the single lead and the six lead), on the other hand, has no problems identifying AF >120 BPM. I have found that the Kardia ECG was highly accurate in patients with rapid AF from using the device in hundreds of my patients since 2013.
After writing about the AW AF flaw I opened my KardiaPro dashboard which connects to the online ECG recordings each of my patients has made.
Two of my patients with paroxysmal AF had gone into AF in the last 2 days and made recordings.
Both of them had rates > 120 BPM. In both cases, Kardia had easily made the diagnosis. AW would have declared these “inconclusive.”
Patients should be aware of this AW AF flaw. The absence of a declaration of possible AF on the AW ECG should not reassure anyone of the absence of AF.
AW users should have their high rate recordings reviewed by a cardiologist.
Alternatively, they could purchase a Kardia device and utilize it for heart rates over 120 BPM.
The skeptical cardiologist keeps his eyes open for new, potentially improved ways of personal mobile ECG monitoring and when I saw the following comments on an afib forum I was intrigued:
I recently started using a SonoHealth product that I find MUCH MUCH superior to Kardia..
Really? MUCH MUCH superior? The more someone utilizes all caps
to emphasize theirs points the less I tend to believe them. But, as I am on a mission to discover the truth in all things cardiologic I went to the SonoHealth website and encountered this:
The EKGraph would indeed appear to be MUCH MUCH superior to Kardia mobile ECG if the website marketing can be believed.
Like the Kardia the EKGraph offers a personal ECG monitor obtained using the fingertips and syncing to an app on your smartphone.
The EKGraph claims to have 3 lead capability, something it emphasizes in its marketing but it is only capable of displaying one lead at a time and , similar to Kardia one can obtain lead II and precordial ECG leads by putting one electrode on the leg or chest.
Also similar to Kardia, the EKGraph promises “rhythm detection.” As we shall learn, however, rhythm detection by the EKGraph cannot be trusted whereas Kardia has a wealth of published data supporting its accuracy.
Unlike the Kardia, the EKGraph does have a “bright LCD screen” which displays the ECG wave pattern and heart rate along with the heart rhythm diagnosis.
I emailed SonoHealth and they were kind enough to send me one of their ECG devices to demo. After spending some time with it I can say unequivocally that it should not be purchased or utilized by any patient who wants reliable personal mobile ECG monitoring with accurate diagnoses.
A few days later a package arrived containing the EKGraph in an Applesque box which also contiained a USB charging cable. In addition they included a carrying case and a tube of ECG gel.
Working With The SonoHealth APP
To make a recording one puts the metal strip on the left side of the device on hand, arm or leg and the other metal strip on the right side of the device on an opposing limb or the chest.
This very happy model gives you a feel for the size of the device and the method of making a Lead I recording.
It is possible to made a decent single lead ECG tracing with this device and view the tracing on the associated smartphone app. However, the recordings are typically very noisy and full of artifact making it hard to discern the rhythm. The software appears to lack appropriate filtering.
The SonoHealth app is free but getting it registered was a problem. On the company website support area several readers have complained of the same problem over the last few months:
I am having trouble registering on the phone because when I hit the red button to register, I see the email and username fields at the top of the form, but when I click on email, the info fields jump to name, and I can’t scroll up to access those two fields. I then get a notification that those two fields are required to register. Any suggestions?
There is no response to this issue posted 3 months ago from the company.
Syncing with the app via Blutooth is straightforward. Pressing the sync button transfers all new tracings to the app where they can be reviewed.
Tracings can be emailed or printed.
The major problem with the EKGraph is that its ability to diagnose rhythm is very limited. This device has no published data verifying the accuracy of its rhythm diagnoses whereas the Apple Watch 4 and Kardia ECG devices do. It it is not approved by the FDA.
I used the device on my self and despite identical rhythms the EKGraph called one “tachycardia” and the other “bradycardia.”
I tried using the SonoHealth on patients in my office who were in normal sinus rhythm and received wild, seemingly random diagnoses.
Whatever algorithm the device is using to diagnose rhythm is clearly not making allowances for poor quality recordings.
This patient is in NSR but the EKGraph calls it “tachycardia, VPB bigeminy” mistaking the artifact between the normal QRS beats and ventricular ectopic beats.
Multiple Sketchy Companies Utilizing Similar Hardware
I have noted other mobile ECG device with a remarkably similar appearance to the EKGraph. A search on Amazon yields AliveCor’s devices and the SonoHealth Ekgraph . The Amazon comparison page shows 3 additional EKGraph identical-appearing devices seemingly from 3 different sketchy companies all priced at $79.
A consumer asked SonoHealth about the identical external appearance of SonoHealth’s and EMAY’s devices and the company’s response was::
As a small new company making a new design for the outside shell didn’t seem viable. A mold from scratch costs anywhere from $65,000-$85,000. So our manufacturer allowed us to use their current mold to make the EKGraph.
So even though the outside is similar the software side is totally different. We have new and improved software. There’s also our own SonoHealth app that we developed from scratch.
SonoHealth is a USA company that provides excellent customer support.
I would disagree with SonoHealth’s assessment-there is nothing to suggest their software is either new or improved or even accurate.
The app that they developed from scratch is clunky and difficult to use.
Ratings and Online Presence of SonoHealth
SonoHealth posts on its website alleged reviews of EKGraph. They are uniformly positive. It’s hard to find anything that isn’t 5/5 stars. Apparently, all the problems I found with the product are unique to me.
However, these reviews should be taken with a grain of salt. A few weeks after acquiring my SonoHealth EKGraph I received an email from the company offering a gift card if I followed their precise instructions in writing a review:
TERMS: In order to receive the $10 giftcard reward you MUST write both a Companyand a Product review. We will send each reviewer the egiftcard to the email that they provided when leaving the review. (For verification purposes, the email you enter when leaving the review must match the email associated with your order.)
This manipulation of the review process is shady and calls into question the validity of any review on the company website or Amazon.
Let The (Mobile ECG) Buyer Beware
The SonoHealth EKGraph is capable of making a reasonable quality single lead ECG. Presumably all the other devices utilizing the same hardware will work as well.
However, the utility of these devices for consumers and patients lies in the ability of the software algorithms to provide accurate diagnoses of the cardiac rhythm.
Apple Watch 4 and AliveCor’s Kardia mobile ECG do a very good job of sorting out atrial fibrillation from normal rhythm but the SonoHealth EKGraph does a horrible job and should not be relied on for this purpose.
The companies making and selling the EKGraph and similar devices have not done the due diligence Apple and AliveCor have done in making sure their mobile ECG devices are accurate. As far as I can tell this is just an attempt to fool naive patients and consumers by a combination of marketing misinformation and manipulation.
I cannot recommend SonoHealth’s EKGraph or any of the other copycat mobile ECG devices. For a few dollars more consumers can have a proven, reliable mobile ECG device with a solid algorithm for rhythm diagnosis. The monthly subscription fee that AliveCor offers as an option allows permanent storage in the cloud along with the capability to connect via KardiaPro with a physician and is well worth the dollars spent.
The skeptical cardiologist primarily makes decisions on blood pressure treatment these days based on patient self-monitoring. If high readings are obtained in the office I instruct patients to use an automatic BP cuff at home and make a measurement when they first get up and again 12 hours later. After two weeks they report the values to me.
Although I’ve been recommending self-monitoring to my patients for decades it is only recently that guidelines have endorsed the approach and good scientific studies verified its superiority. I was pleased when the 2017 ACC/AHA guidelines for High Blood Pressure made home self-monitoring of BP a IA recommendation.
And last year a very good study, the TASMNH4 was published which demonstrated the superiority of self-monitoring compared to usual care.
TASMINH4 was a parallel randomised controlled trial done in 142 general practices in the UK, and included hypertensive patients older than 35 years, with blood pressure higher than 140/90 mm Hg, who were willing to self-monitor their blood pressure. Patients were randomly assigned (1:1:1) to self-monitoring blood pressure (self-montoring group), to self-monitoring blood pressure with telemonitoring (telemonitoring group), or to usual care (clinic blood pressure; usual care group).
The home BP goal was 135/85 mm Hg, 5 mm Hg lower than the office BP goal. At one year both home self-monitoring groups had significantly lower systolic blood pressure than the usual care group.
This trial was not powered to detect cardiovascular outcomes, but the differences between the interventions and control in systolic blood pressure would be expected to result in around a 20% reduction in stroke risk and 10% reduction in coronary heart disease risk. Although not significantly different from each other at 12 months, blood pressure in the group using telemonitoring for medication titration became lower more quickly (at 6 months) than those self-monitoring alone, an effect which is likely to further reduce cardiovascular events and might improve longer term control.
Advantages of Home Self-Monitored Blood Pressure-Limitations of Office BPs
Every patient I see in my office gets a BP check. This is typically done by one of the office assistants who is “rooming” the patient using the classic method with , listening with stethoscope for Korotkov sounds. If the BP seems unexpectedly high or low I will recheck it myself.
Often the BP we record is significantly higher than what the patient has been getting at home or at other physician offices.
There are multiple factors that could be raising the office BP: mental stress from driving to the doctor or being hurried or physical stress from walking from the parking lot.
In addition, I feel that multiple assessments of out of office BP over the course of the day and different days are more likely representative of the BP that we are consistently exposed to rather than one reading in the doctor’s office.
Accuracy and technique in the doctor’s office is also an issue.
Interestingly, we have assumed that manual office BP measurement is superior to automatic but this recent paper found the opposite:
Automated office blood pressure readings, only when recorded properly with the patient sitting alone in a quiet place, are more accurate than office BP readings in routine clinical practice and are similar to awake ambulatory BP readings, with mean AOBP being devoid of any white coat effect.
A patient left a comment to that paper which is quite insightful:
I had a high blood pressure event several years ago. Since then I have monitored my BP at home, sitting with both feet flat on the floor, not eating or drinking, not speaking or moving around, on a chair with a back, and without clothes on the arm being used for the measure. My BP remains normal.
I have never had my BP taken correctly in a doctor’s office. They will do it while I am speaking with the doctor, sitting on an exam table with my legs swinging, with the monitor band over my heavy winter sweater, right after I have sat down. They do not ensure that my arm is supported or at the right height. If I recommend that I take off my sweater, or move to a chair with a back, they tell me that is not needed. I have decided to refuse such measurements. How can they possibly be monitoring my health this way?
This patient’s observations are not unique and I suspect the majority of office BPs have most if not all of the limitations she describes.
Self Monitoring Improves Patient Engagement In BP Control
I have found self-monitoring of patient’s BP to substantially enhance patient engagement in the process. Self-monitoring patients are more empowered to understand the lifestyle factors which influence their BP and make positive changes.
Blood pressures are amazingly dynamic and as patient’s gain understanding of what influences their BP they are going to be able to take control of it.
I take my BP almost daily and adjust my BP medications based on the readings. After prolonged work or exercise in heat, for example, BPs will decline to a point where I’m light headed or fatigued. Less BP med at this time is indicated. Conversely, if I’ve been overly stressed BPs increase and upward titration of medication is warranted.
With some of my most engaged and enlightened patients we perform similar titrations depending on their circumstances. Sometimes patients perform these titrations on their own and tell me about them at the next office visit.
What’s The Best Way To Communicate Home BPs?
Many of my patients provide me with a hand-written record of their BPs over two weeks. Some mail them to me, others bring them in to the office. We scan these into the EMR. I look at these and make an estimate of the average systolic blood pressure, the variation over time and the variation during the day. It’s not feasible for me or my staff to enter the numbers or precisely obtain an average.
Some patients send us the numbers through the internet-based patient portal into the EMR. This is preferable as I can view these and respond quickly and directly back to the patient with recommendations.
More and more patients are utilizing their smart phones to record and aggregate their health data and will bring them in for me to look at during an office visit. I’ve described one stylish and slick BP cuff, the QardioArm which has neither tubes nor wires and works through a smartphone app. Omron , also has multiple cuffs which communicate via BlueTooth to store data in a smartphone app.
Ideally, we would have a way for me to view those digitally recorded BPs with nicely calculated averages online and within the EMR. Unfortunately, such connectivity is not routinely available.
However, for my patients who are already monitoring their heart rhythms with a Kardia mobile ECG and are connected with me online through KardiaPro Remote I can view their BP recordings online.
I’ll discuss in detail in a subsequent post the Omron Evolv home automatic BP cuff (my current favorite) which is wireless and tubeless and connects seamlessly to KardiaPro allowing me to view both BP and heart rhythm (and weight) recordings in my patients
To me, this empowerment of patients to record, monitor and respond to their own physiologic parameters is the future of medicine.
From the 2017 ACC/AHA BP guidelines
and the proper technique for office BP measurement
The skeptical cardiologist is a firm believer in the benefit of maintaining normal rhythm in most patients who develop atrial fibrillation (AF, see here.)
Sometimes this can be accomplished by lifestyle changes (losing pounds and cutting back on alcohol , treating sleep apnea, etc.) but more often successful long term maintenance of normal rhythm (NSR) requires a judicious combination of medications and electrical cardioversions (ECV).
It is also greatly facilitated by a compliant and knowledgeable patient who is regularly self-monitoring with a personal ECG device.
My article on electrical cardioversion (see here) was inspired by a patient (we’ll call her Sandy) who asked me in April of 2016, “how many times can you shock the heart?”
In 2016 I performed her fifth cardioversion and last week I did her sixth.
Her story of AF is a common one which exemplifies how excellent medical management of AF can cure heart failure and mitral regurgitation and create decades of AF-free, happy and healthy existence.
A Tale Of Six Cardioversions
Sandy had her first episode of atrial fibrillation in 2001 and underwent a cardioversion at that time and as far as she knew had no AF problems for 14 years. I’ve seen numerous cases like this where following a cardioversion, patients maintain NSR for a long time without medications but I’ve also seen many in whom AF came back in days to months.
In 2015 she saw her PCP for routine follow-up and AF with a rapid rate was detected. She had been noticing shortness of breath on exertion and a cough at night but otherwise had no clue she was out of rhythm.
When I saw her in consultation she was in heart failure and her echocardiogram demonstrated a left ventricular ejection fraction of 50% with severe mitral regurgitation. She quickly went back into AF after an electrical cardioverson (ECV) and reverted to AF again following a repeat ECV after four days on amiodarone.
Since amiodarone can take months to reach effective levels in the heart we tried one more time to cardiovert after loading on higher dosage amiodarone for one month. This time she stayed in NSR
Following that cardioversion she has done extremely well. Her shortness of breath resolved and follow up echocardiograms have demonstrated resolution of her mitral regurgitation.
She had purchased a Kardia mobile ECG device for personal monitoring of her rhythm and we were able to monitor her rhythm using the KardiaPro dashboard. Recordings showed she was consistently maintaining NSR after her 2016 ECV
I’ve written extensively on the great value of KardiaPro used in conjunction with the Kardia mobile ECG device for monitoring patients pre and post cardioversion for atrial fibrillation. Sandy does a great job of making frequent Kardia ECG recordings, almost on a daily basis so even though she has no symptoms we are alerted to any AF within 24 hours of it happening.
Amiodarone-The Big Medical Gun For Stopping Atrial Fibrillation
The recurrence of AF Sandy had in 2016 occurred 8 months after I had lowered her amiodarone dosage to 100 mg daily.
Amiodarone is a unique drug in the AF toolkit.
It is the by far the most effective drug for maintaining sinus rhythm, an effect that makes it our most useful antiarrhythmic drug (AAD).
It is cheap and well-tolerated.
Uniquely among drugs that we use for controlling atrial fibrillation it takes a long time to build up in heart tissue and a long time to wear off.
It is the safest antiarrhythmic drug from a cardiac standpoint. Unlike many of the other AADs we don’t have to worry about pro-arrhythmia (bringing out more dangerous rhythms such as ventricular tachycardia or ventricular fibrillation) with amio.
Amiodarone, however, is not for all patients-it has significant long term side effects that necessitate constant vigilance by prescribing physicians including thyroid, liver and lung toxicity.
I monitor my patients on amiodarone with thyroid and liver blood tests every 4 months and a chest x-ray yearly and I try to utilize the minimal dosage that will keep them out of AF.
In Sandy’s case it was apparent that 100 mg was too little but with an increase back to 200 mg daily, the AF remained at bay.
In early 2017, Sandy read on Facebook that amio was a “poison” and after discussing risks and benefits we decided to lower the dosage to 200 mg alternating with 100 mg. It is common and appropriate for patients to be fearful of the potential long term and serious consequences of medications. For any patient taking amiodarone I always offer the option of stopping the drug with the understanding that there is a strong likelihood of recurrent AF within 3 months once the drug wears off.
In October, 2018 with Sandy continuing to show normal heart function and maintain SR as documented by her daily Kardia ECG tracings we decided to further lower the dosage to 100 mg daily.
Six months later she noted one day that her Kardia reading was showing a heart rate of 159 bpm and diagnosing atrial fibrillation. AF had recurred on the lower dosage of amiodarone. She had no symptoms but based on prior experience we knew that soon she would go into heart failure.
Thus, her amiodarone was increased and a sixth cardioversion was performed. We could find no trigger for this episode (unless the bloody mary she consumed at a Mother’s Day Brunch 2 days prior was the culprit.)
Medical Management With Antiarrhythmics Versus Ablation
Many patients seek a “cure” for atrial fibrillation. They hear from friends and neighbors or the interweb of ablation or surgical procedures that promise this. Stopafib.org, for example, promotes these types of procedures saying “Catheter ablation and surgical maze procedures cure atrial fibrillation”
In my experience the majority of patients receiving ablation or surgical procedures (Maze procedure and its variants) ultimately end up having recurrent episodes of atrial fibrillation. Guidelines do not suggest that anticoagulants can be stopped in such patients. Often, they end up on AADs.
I’ve prepared a whole post on ablation for AF but the bottom line is that there is no evidence that ablation lowers the AF patient’s risk of dying, stroke, or bleeding. My post will dig deeper into the risks and benefits of ablation.
There is no cure for AF, surgical, catheter-based or medical.
In the right hands most patients can do very well with medical management combined with occasional cardioversion.
Who posseses the right hands?
In my opinion, most AF patients are best served by a cardiologist who has a special interest in atrial fibrillation and takes the time to read extensively and keep up with the latest developments and guideline recommendations in the area. This does not need to a be an electrophysiologist (EP doctor-one who specializes in the electrical abnormalities of the heart and performs ablations, pacemakers and defibrillators.)
I have a ton of respect for the EP doctors I work with and send patients to but I think that when it comes to doing invasive, risky procedures the decision should be based on a referral/recommendation from a cardiologist who is not doing the procedure.
In many areas of cardiology we are moving toward an interdisciplinary team of diagnosticians, interventionalists, surgeons and non-cardiac specialists to make decisions on performance of high-risk and high-cost but high-benefit procedures like valve repair and replacement, closure of PFOs and implantation of left atrial appendage closure devices.
It makes sense that decisions to perform high-risk , high-cost atrial fibrillation procedures also be determined by a multi-disciplinary team with members who don’t do the procedure.
This is a rule of thumb that can also be applied to many surgical procedures as well. For example, the decision to proceed to surgical treatment of carotid artery blockages (carotid endarterectomy) is typically made by the vascular surgeons who perform the procedure. In my opinion this decision should be made by a neurologist with expertise in neurovascular disease combined with a good cardiologist who has kept up with the latest studies on the risks and benefits of carotid surgery and is fully briefed on the latest guideline recommendations.
As I described here, the Kardia Band (KB) is an FDA-approved Apple Watch accessory available to the general public without a prescription which records a high quality single-lead ECG.
I’ve been using mine now for a while and can confirm the ease and accuracy of the ECG recordings it makes. I find recordings made with my Apple Watch/Kardia Band are reliably high quality with minimal artifact (unless I’m running on a treadmill.)
Once the 30 second recording is completed, the Kardia app on the Apple Watch takes about 5 seconds to process the information using an AI algorithm and then makes a determination of normal sinus rhythm (NSR), atrial fibrillation or unclassified.
In the JACC study, investigators from the Cleveland Clinic studied 100 consecutive patients presenting for cardioversion from AF with recordings made before and after the procedure. KB interpretations were compared to 12 lead ECGS read by electrophysiologists.
KB interpretations identified AF with 93% sensitivity and 84% specificity. Of the total 169 recordings, 34% were unclassified due to short recordings, low-amplitude p waves, and baseline artifacts.
The authors concluded that the KB algorithm for AF detection, when it is supported by a physician review can reliably differentiate AF from NSR.
(Of note the lead author on this study is on the advisory board of Alivecor the maker of the KB and AliveCor (AliveCor, Mountain View, CA) provided the Kardia Band monitors which were connected to an Apple Watch and paired via Bluetooth to a smartphone device for utilization in the study. AliveCor was not involved in the design, implementation, data analysis, or manuscript preparation of the study.)
My Updated Kardia Experience
I have found the standard Kardia device to be immensely helpful in the management of my afib patients before and after cardioversions (see my prior description here). The paper mentions that 8% of these pre-cardioversion patients showed up for the procedure in normal sinus rhythm, noting that
For each of these patients, the automated KB algorithm did not erroneously identify AF, and the physician interpretation of the KB recording correctly confirmed SR in each case.
Needless to say, it is better to find out a cardioversion is not needed before the patient shows up for the procedure. I would estimate this happens about 5-10% of the time in my practice.
The Kardia device or the KB is also really helpful post cardioversion. If the patient makes daily recordings (which I can review on Kardia Pro online) h/she and I know exactly how long sinus rhythm persisted before reverting back to AF.
This is important information which impacts future management decisions.
Kardia Band Versus Standard Kardia Device
None of my patients have purchased the Kardia Band most likely due to the cost and the fact that they don’t have an Apple Watch. If you have an Apple Watch and want to monitor your heart rhythm I think the KB is a good choice. Otherwise, the original AliveCor mobile ECG device continues to do a fantastic job (in conjunction with Kardia Pro, see here).
The combination of Kardia and Kardia Pro has substantially reduced my use of expensive and annoying long term monitors in my AF population.
In my next update on the KB I will share a reader’s real world description of the pros and cons of the KB (with Smart Rhythm monitoring) in a patient post cardioversion for AF.
In March of 2017 AliveCor introduced Kardia Pro, a cloud-based software platform that allows physicians to monitor patients who use the Kardia mobile ECG device.
I have been utilizing the Kardia mobile ECG device since 2013 with many of my atrial fibrillation (AF) patients and have found it be very useful as a personal intermittent long term cardiac monitor. (see here and here)
I signed up for the Kardia Pro service about 3 months ago and all of my patients who purchased Kardia devices prior to March of 2017 have been migrated automatically to Kardia Pro by AliveCor.
Now (post March 2017), patients who acquire a Kardia device must sign up for the Kardia Pro service at $15 per month to connect with a physician.
I think this is money well spent and I’ll demonstrate how the service works with a few examples.
Monitoring Patients With Atrial Fibrillation
I saw a 68 year old man with persistent atrial fibrillation that was first diagnosed at the time of pneumonia in late 2017.
He underwent a cardioversion after recovering from the pneumonia but quickly reverted back to AF. His prior cardiologist offered him the option of repeat cardioversion and long term flecainide therapy for maintenance of normal sinus rhythm (NSR) but he declined.
When I saw him for the first time in the office a month ago I listened to his heart and to my surprise, noted a regular rhythm: an AliveCor recording in the office confirmed he was in NSR. The patient had been unaware of when he was in or out of rhythm
We discussed methods for monitoring his rhythm at this point which include a 24 Holter monitor, a 7 to 14 day Long Term Monitor, a Cardiac Event Monitor and a Mobile Cardiac Outpatient Telemetry device. These devices are helpful and although expensive are often covered by insurance. They require wearing electrodes or a patch continuously and the results are not immediately available.
I also offered him the option of monitoring his AF using a Kardia device with the recordings connected to me by Kardia Pro.
He purchased the device on his own for $99, downloaded the app for his smartphone and began making recordings.
I enrolled him in my Kardia Pro account and he received an email invitation with a code that he entered which connected his account with mine, allowing me to view all of his recordings as they were made.
When I log into my Kardia Pro account I can now view a graphic display of the recordings he has made with color coding of whether they were considered normal or abnormal by Kardia.
The patient overview page also displays BP information if the patient is utilizing certain Omron devices which work with Kardia.
The display shows that after our office visit he maintained NSR for 3 days (green dots) and then intermittently had ECG recordings classified as AF (yellow dots) or unclassified (black).
The more he used the device and got feedback on when he was in or out of rhythm the more he was able to recognize symptoms that were caused by AF.
I can click on any of the dots and six second strips of the full recording are displayed. In the example below I clicked on 2/27 which has both an unclassified recording (which is atrial flutter) and an AF recording
Clicking on the ECG strips brings up the full 30 second recording on a page that also allows me to assign my formal interpretation. In the example below I added atrial flutter as the diagnosis, changing it from Kardia’s unclassified (Kardia’s algorithm calls anything it cannot clearly identify as AF that is over 100 BPM as unclassified.)
The ECG can then be archived or exported for entry into an EHR.
The benefits of this patient being connected
to me are obvious: we now have an instantaneous patient-controlled method for knowing what his cardiac rhythm is doing whether he is having symptoms or not.
This knowledge allows me to make more informed treatment decisions.
The Kardia Pro Dashboard
When I log into kardia pro I see this screen.
It contains buttons for searching for a specific patient or adding a new patient. Adding new patients is a quick and simple process requiring input of patient demographics including email and birthdate.
From the opening screen you can click on your triage tab. I have elected to have all non normal patient recorded ECGS go into the triage tab.
Another patient’s Kardia Pro page shows that he records an ECG nearly every day and most of the time Kardia documents NSR in the 60s. Overall, he has made 773 recordings and 677 of them were NSR, 28 unanalyzed (due to brevity) , 13 unclassified and 55 showing AF.
Monitoring Rate Control In Patients With AF and Reversion Post-Cardioversion
Another patient I saw for the first time recently has had long-standing persistent AF. His previous cardiologist performed an electrical cardioversion a year ago but the patient reverted back to AF in 40 hours. Before seeing me he had purchased a Kardia mobile ECG device and was using it to monitor his heart rate.
After he accepted my email invitation to connect via Kardia Pro I was able to see his rhythm and rate daily. The Kardia Pro chart belowshows his daily heart rate while in atrial fibrillation. We utilized this to guide titration of his rate controlling medications. Such precise remote monitoring of heart rate in AF (which is often difficult to accurately assess by standard heart rate devices) obviates the need for office visits for 12 lead ECGs or periodic Holter monitors.
I performed a second cardioversion on him after which he made daily recordings documenting maintenance of NSR. With this system we can determine exactly when AF returns, information which will be very helpful in determining future treatment options.
Kardia Pro Plus Kardia Mobile ECG Creates Personal Intermittent Long Term Rhythm Monitor
There are many potential applications of the Kardia ECG device beyond AF monitoring (assessing palpitations, PVCs, tachycardia, etc.) but they are all enhanced when the device is combined with a good cardiologist connected to the device by Kardia Pro.
I’ve gotten spoiled by the information I get from my AF patients who are on Kardia Pro now. When they call the office with palpitations or a sense of being out of rhythm I can determine within a minute what their rhythm is wherever I am (excluding tropical beaches and mountain tops) or wherever the patient is (for the most part.)
On the other hand patients who are not on Kardia Pro have to come into the office for 12-lead ECGs. When they call I feel like my diagnostic tools are limited. Such patients usually end up getting one of the standard Long Term Monitoring (LTM) Devices. If I am fortunate, after a few days to weeks , the results of the LTM will be faxed to my office.
I am optimistic based on this early experience with Kardia Pro that ultimately this service in conjunction with the Kardia Mobile ECG device (or similar products) will replace many of the more expensive and inconvenient long term monitoring devices that cardiologists currently use.
The Skeptical Cardiologist is a strong proponent of empowering patients with atrial fibrillation by utilizing personal cardiac rhythm devices such as Afib Alert or AliveCor’s Kardia.
I’ve written about my experiences with the initial versions of the Kardia mobile ECG device and the service it provides here and here.
I have been monitoring dozens of my afib patients using AliveCor’s Physician Dashboard.
Recently AliveCor changed fundamentally the way their app works such that for new users much of the functionality I described in my previous posts now requires subscribing to their Premium service which costs $9.99 per month or $99 per year.
What Has Changed With The Kardia App
The Kardia device which works with both iOs and Android smart
phones is unchanged and still generates a “medical-grade” single lead rhythm strips which appears within the Kardia app.
The app still is reasonably accurate at identifying atrial fibrillation or normal heart rhythms and offers a fee-based service for interpretation of unclassified ECGs.
However, for new purchasers of Kardia, the capability to access, email or print prior ECG recordings has gone away. Prior to March of this year, Kardia users could access prior ECG tracings which were stored in the cloud by touching the “Journal” button on the app. These older tracings could be emailed and they were available through the cloud for a physician like myself to review at any time.
Now new Kardia purchasers will find that when they make an ECG recording they have the option to email a PDF of the ECG but once they hit the DONE button it is gone and is not stored anywhere.
For my patients purchasing after March, 2017 this means that unless they purchase Kardia Premium service I will not be able to view their ECG recordings online.
An AliveCor account executive summarized for me the changes as follows:
We added a significant number of features over the past year and a half, and grandfathered all users on March 16th, 2017. New users now have the option to download and use Kardia for free, but the premium services are $9.99/mo or $99/year. Kardia Premium allows unlimited storage and history of their EKGs, summary reports with longitudinal data, blood pressure monitoring and tracking weight and medication.
Why Journal Functionality Is Important
If you purchased your AliveCor/Kardia device prior to March 16th, 2017 ago the journal functionality still works. Let’s call such customers “Journal Grandfathered”.
This Journal functionality is important in a number of ways:
My Journal Grandfathered patients can bring their phones with them during an office visit and we can review all of their ECG tracings.
Journal gGandfathered Kardia users can email their old tracings to their physicians or to anyone they wish (even the skeptical cardiologist!). They can also print them out and save PDFs of the tracings.
I can view through my online physician account all of my Journal Grandfathered patients. This means any time a patient of mine makes a recording that is unclassified or suggests atrial fibrillation I can be notified and immediately view it online.
This fundamental change took place as AliveCor attempts to convince purchasers of the Kardia device to use their Premium service.
Why AliveCor Changed The Kardia App Function
Dr. David Albert, inventor and cardiologist and the founder of AliveCor was kind enough to talk with me about this change.
He indicates that of the 150,000 AliveCor users, 10,000 are now using the Kardia Premium service. About 20% of new users elect Kardia Premium.
Prior to the change all AliveCor users had their old ECG recordings stored in the cloud in a HIPPA compliant fashion. This free service was costing AliveCor quite a bit and the company felt it was best to switch to a subscription service to provide this secure cloud storage.
With the change to the (relatively inexpensive) subscription service, patients will get additional features. As the AliveCor account executive described:
Kardia Premium allows unlimited storage and history of their EKGs, summary reports with longitudinal data, blood pressure monitoring and tracking weight and medication.
I’ve looked at the Premium service and it seems quite useful when combined with a connected physician utilizing Kardia Pro. I’ll evaluate the Premium service and the physician Kardia Pro service further and write a full post on its features in the near future.
If you are not grandfathered and want to stick with the Basic Kardia service you still have an immensely useful and inexpensive device which allows personal detection of your cardiac rhythm. Just remember to email yourself the ECG recording you just made before you hit DONE.