Guest Editorial
Mobile Health for Cardiovascular Disease: The New Frontier for AF Management: Observations from the Huawei Heart Study and mAFA-II Randomised Trial Yutao Guo1 and Gregory YH Lip1,2,3 1. Medical School of Chinese PLA, Department of Cardiology, Chinese PLA General Hospital, Beijing, China; 2. Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK; 3. Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
Disclosures: The authors have no conflicts of interest to declare. Received: 27 March 2020 Accepted: 27 March 2020 Citation: Arrhythmia & Electrophysiology Review 2020;9(1):5–7. DOI: https://doi.org/10.15420/aer.2020.12 Correspondence: Gregory YH Lip, Liverpool Centre for Cardiovascular Science, William Henry Duncan Building, 6 West Derby St, Liverpool L7 8TX, UK. E: gregory.lip@liverpool.ac.uk Open Access: This work is open access under the CC-BY-NC 4.0 License which allows users to copy, redistribute and make derivative works for noncommercial purposes, provided the original work is cited correctly.
Cardiovascular disease (CVD) is the leading cause of death and disease globally, representing 31% of all global deaths.1 The traditional management of CVD has largely depended on the face-to-face clinic visits once the clinical events occurred. CVD contributes to and exacerbates the economic burden on households.2 However, most of these complications could be avoided with early diagnosis and effective prevention or interventions.
• ‘B’ Better symptom management with patient-centred symptomdirected shared decisions for rate or rhythm control. • ‘C’ Cardiovascular risk and comorbidity management (blood pressure, sleep apnoea etc) plus lifestyle changes (weight reduction, regular exercise, reducing alcohol/stimulants, psychological morbidity, smoking cessation etc).6,7
AF Screening Using Smart Technology With increasing advances in mobile health (mHealth), smart technology is emerging as a novel tool to improve disease prevention and management. Some exploring studies demonstrated that the alerts or text message intervention using mHealth technology might help patients in implementing changes in lifestyle behaviours or drug adherence.3 However, there are many gaps in knowledge when considering mHealth for CVD management.3,4 For example, how could wearable sensors (mobile devices) be used to improve healthcare, beside using the communication function (mobile phone) of mHealth technologies? Would mHealth-supported approaches impact on important CVD outcomes, including hospitalisations? The Mobile Health technology for improved screening and optimising integrated care in Atrial Fibrillation (the mAFA-II programme) provides some new evidence for this.5 The mAFA II programme included the pre-mAFA phase to investigate the incidence of AF with photoplethysmography (PPG)-based screening strategy among the general population, using Huawei smart devices (hence, called the Huawei Heart Study); and the AFA II trial, which was used to validate a holistic or integrated care approach, the Atrial Fibrillation Better Care pathway (ABC) pathway, supported by mHealth technology for the management of AF. The ABC (AF Better Care) Pathway simplifies the management of AF, as follows (‘easy as ABC…’): • ‘A’ Anticoagulation to avoid stroke – anticoagulation with nonvitamin K antagonist oral anticoagulant or well-managed warfarin.
© RADCLIFFE CARDIOLOGY 2020
The predictive ability of AF screening using smart technology would be influenced by several factors: monitoring technology PPG, single-lead ECG, the frequency of monitoring (single-point or twice a day etc), monitoring duration (7 days, 14 days etc), the type of smart devices (smart bands, ePatch or hand-held devices) and the patient population with different risk profiles. For a single-lead ECG-based approach to detect AF detection, there could also be the instability of signal quality of the wristband due to motion artefacts.8,9 A lower AF burden requires a longer monitoring time. Two large population-based smartwear studies have been published. In the Apple Heart Study: Assessment of Wristwatch-Based Photoplethysmography to Identify Cardiac Arrhythmias; (NCT03335800), 419,297 participants using Apple Watch were recruited over 8 months, and 0.52% received notifications of irregular pulse: AF was present in 34% and 84% of notifications were concordant with AF.10 In the Huawei Heart Study, a PPG algorithm and smart devices used were validated with a total of 29,485 PPG signals before starting the mAFA II programme.11,12 Both the pilot study and the Huawei Heart Study demonstrated a consistent predictive ability for AF of >91% with continuous monitoring mode in a real-world setting.12,13 In the study, about one-third of AF episodes were detected over 14 days. However, the comfort factor of monitoring should be balanced with the monitoring time and type of smart device(s) used. Nearly one-third of subjects refused to use the ECG skin adhesive patch for 14-day monitoring, and some individuals reported skin irritation, resulting in early discontinuation of structured management in one study.14 Even with a PPG technology-based wristband, more frequent monitoring
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