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Ziopatch cardiac monitor. Zio Patch button and placement. (A) Patients can press a button on the Zio Patch to mark a symptomatic episode. (B) The device is placed over the patient’s left pectoral region. (Images courtesy of iRhythm Technologies, Inc., San Francisco, CA, USA.)
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Background: It is important to evaluate patients with transient ischemic attack (TIA) or stroke for atrial fibrillation (AF) because the detection of AF changes the recommended anti-thrombotic regimen from treatment with an antiplatelet agent to oral anticoagulation. This study describes the diagnostic yield of a patch-based, single-use, and water-...
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Background
Atrial fibrillation (AF) is reported to be a less frequent cause of ischemic stroke in China than in Europe and North America, but it is not clear whether this is due to underestimation. Our aim was to define the true frequency of AF-associated stroke, to determine the yield of 6-day Holter ECG to detect AF in Chinese stroke patients, an...
Ambulatory ECG (AECG) is very commonly employed in a variety of clinical contexts to detect cardiac arrhythmias and/or arrhythmia patterns which are not readily obtained from the standard ECG. Accurate and timely characterization of arrhythmias is crucial to direct therapies that can have an important impact on diagnosis, prognosis or patient sympt...
Citations
... However, accurate identification of AF recurrence despite pharmacologic treatment is often difficult, particularly in paroxysmal AF with low arrhythmic burden [8]. Ambulatory cardiac monitoring with a 24-or 48-h Holter test has been widely used to detect recurrent AF after treatment with AAD and/or catheter ablation, but its efficacy is yet unsatisfactory [9,10]. ...
... Recently, extended monitoring using patch-based cardiac monitoring systems has been demonstrated to have higher diagnostic yields with less patient discomfort due to wearing the device [9]. The multiday continuous cardiac monitor showed a 2-5 times higher efficacy in AF detection, compared to the conventional 24-h Holter test in patients with stroke or transient ischemic attack (TIA) [10][11][12][13][14]. Early detection of drug-refractory AF will help with appropriate decision-making for an adequate rhythm control strategy, and extended cardiac monitoring may result in the timely application of alternative treatment for rhythm control, including catheter ablation therapies. ...
Accurate assessment of the response to the antiarrhythmic drug (AAD) in atrial fibrillation (AF) is crucial to achieve adequate rhythm control. We evaluated the effectiveness of extended cardiac monitoring using an adhesive ECG patch in the detection of drug-refractory paroxysmal AF. Patients diagnosed with paroxysmal AF and receiving AAD therapy were enrolled. The subjects simultaneously underwent 11-day adhesive ECG patch monitoring and a 24-h Holter test. The primary study outcome was a detection rate of drug-refractory AF or atrial tachycardia (AT) lasting ≥30 s. A total of 59 patients were enrolled and completed the study examinations. AF or AT was detected in 28 (47.5%) patients by an 11-day ECG patch monitor and in 8 (13.6%) patients by a 24-h Holter test (p < 0.001). The 11-day ECG patch monitor identified an additional 20 patients (33.8%) with drug-refractory AF not detected by the 24-h Holter, and as a result, the treatment plan was changed in 11 patients (10 catheter ablations, one medication change). In conclusion, extended cardiac rhythm monitoring using an adhesive ECG patch in patients with paroxysmal AF under AAD therapy led to over a threefold higher detection of drug-refractory AF episodes, compared to the 24-h Holter test.
... A 2018 study demonstrated that the detection rate for this device was comparable to the one of the Holter monitor for atrial fibrillation [15]. Considering that the first signs of atrial fibrillation appear within 48 h of a stroke or a TIA in 15% of patients, early prolonged monitoring with the ZioPatch resulted in better diagnostic results than the Holter monitor, which could lead to 10.8 more strokes avoided per year with a projected budget impact of £113,63 [16,17]. ...
Purpose of Review
This review investigates the use of wearable electrocardiograms (ECGs) in the clinic and acute care setting, and their impact on patient care, particularly pertaining to the management of cardiac arrhythmias.
Recent Findings
Wearable ECGs have consistently demonstrated their non-inferiority in detecting arrhythmias when compared to the current standard of care. Different studies have highlighted their ability to improve patient care and reduce healthcare costs, while more devices are being created to work as a screening tool at a larger scale or to fit the physical abilities of a variety of patients.
Summary
The use of wearable cardiac monitoring devices demonstrated considerable symptom–rhythm correlation in various clinical settings, which often resulted in a reduction in time to diagnosis and lower rates of ED visits. However, this relatively new technology raised concerns for patient accessibility and privacy among others. Further research is needed to assess their sensitivity and specificity in the clinical setting, as well as their limitations.
... Unlike the standard spot-check vital sign measurements that are conducted over a short period and could miss changes in parameters, frequent and automated vital sign collection for longer periods using remote patient monitoring (RPM) platforms with data transmission into algorithm-based computerized systems will potentially be better equipped to detect early changes and alerts of various risks [8][9][10][11]. It is also accepted that such systems would be of benefit if they are simple and easy to use, frequently measure multiple vital signs, incorporated into the workflow of the health care providers, improve patient outcomes, and would be of help to the medical staff in addition to other measures to improve patient surveillance [11][12][13][14]. We expect monitoring systems and early warning scores to be sensitive and specific. ...
BACKGROUND:
Patients admitted to general wards are inherently at risk of deterioration. Thus, tools that can provide early detection of deterioration may be lifesaving. Frequent remote patient monitoring (RPM) has the potential to allow such early detection, leading to a timely intervention by healthcare providers.
OBJECTIVE:
Assessing the potential of a novel wearable RPM device (WD) to provide timely alerts in patients at high risk for deterioration.
METHODS:
This prospective observational study was conducted in two general wards of a large tertiary medical center. Patients defined at high risk to deteriorate upon admission and assigned to a telemetry bed were included. On top of the standard monitoring equipment, a wearable monitor was attached to each patient, and monitoring was conducted in parallel. The data gathered by the wearable monitors were analyzed retrospectively, with the medical staff being blinded to it in real-time. Several early warning scores of the risk for deterioration were used, all calculated from frequent data collected by the WD. These included 1) the National Early Warning Score (NEWS), 2) Airway, Breathing, Circulation, Neurology, and Other (ABCNO) Score, and 3) deterioration criteria defined by the clinical team as a "wish list" score. In all three systems, the risk scores were calculated every 5 minutes using the frequent data collected by the WD. Data generated by the early warning scores were compared with the clinical records of actual deterioration among these patients.
RESULTS:
410 patients were recruited and 217 were included in the final analysis. The median age was 71 [IQR 62-78] and 130 (60%) were males. Actual clinical deterioration happened in 24 patients. The NEWS provided a high alert in 16 (67%) of these 24 patients, preceding the actual clinical deterioration by 29 hours on average. The ABCNO provided a high alert in 18 (75%) of these patients, preceding the actual clinical deterioration by 38 hours on average. All 24 patients had early warning based on the "wish list" criteria, 40 hours on average before it was detected by the medical staff. Importantly, early warning based on the "wish list" criteria was also provided in all other patients who did not deteriorate.
CONCLUSIONS:
Frequent remote patient monitoring has the potential for early detection of high risk to deteriorate among hospitalized patients, using both grouped signal-based scores and algorithm-based prediction. In the current study we showed the ability to formulate scores for early warning by using remote patient monitoring. Nevertheless, early warning scores compiled on the basis of these data failed to deliver a reasonable specificity. Further efforts should be directed at improving the specificity and sensitivity of such tools.
... Screening of AF is justified among the high-risk groups, including the elderly and/or patients with other risk factors for stroke. The diagnostic yield for AF increases with the duration, dispersion and number of the screenings (Tung et al., 2015;Chua et al., 2020;Diederichsen et al., 2020). In the long-term continuous monitoring of patients with stroke and transient ischaemic attacks, the first episode of paroxysmal AF was usually detected after 1.5 days of monitoring (Tung et al., 2015). ...
... The diagnostic yield for AF increases with the duration, dispersion and number of the screenings (Tung et al., 2015;Chua et al., 2020;Diederichsen et al., 2020). In the long-term continuous monitoring of patients with stroke and transient ischaemic attacks, the first episode of paroxysmal AF was usually detected after 1.5 days of monitoring (Tung et al., 2015). Small ECG devices designed for long-term rhythm monitoring, such as ECG patches, have been proposed to be beneficial for AF screening. ...
Aim: Atrial fibrillation (AF) detection is challenging because it is often asymptomatic and paroxysmal. We evaluated continuous photoplethysmogram (PPG) for signal quality and detection of AF.
Methods: PPGs were recorded using a wrist-band device in 173 patients (76 AF, 97 sinus rhythm, SR) for 24 h. Simultaneously recorded 3-lead ambulatory ECG served as control. The recordings were split into 10-, 20-, 30-, and 60-min time-frames. The sensitivity, specificity, and F1-score of AF detection were evaluated for each time-frame. AF alarms were generated to simulate continuous AF monitoring. Sensitivities, specificities, and positive predictive values (PPVs) of the alarms were evaluated. User experiences of PPG and ECG recordings were assessed. The study was registered in the Clinical Trials database (NCT03507335).
Results: The quality of PPG signal was better during night-time than in daytime (67.3 ± 22.4% vs. 30.5 ± 19.4%, p < 0.001). The 30-min time-frame yielded the highest F1-score (0.9536), identifying AF correctly in 72/76 AF patients (sensitivity 94.7%), only 3/97 SR patients receiving a false AF diagnosis (specificity 96.9%). The sensitivity and PPV of the simulated AF alarms were 78.2 and 97.2% at night, and 49.3 and 97.0% during the daytime. 82% of patients were willing to use the device at home.
Conclusion: PPG wrist-band provided reliable AF identification both during daytime and night-time. The PPG data’s quality was better at night. The positive user experience suggests that wearable PPG devices could be feasible for continuous rhythm monitoring.
... Recently, to make long-term monitoring more acceptable for patients, wearable or patch recorders are being more popular. In a study utilizing ECG patch (ZioPatch, iRhythm) a detection rate for AF in patients with a recent history of stroke was 5%, with a median recording duration of 13 days [16]. In our study, single 7-day recording performed just after stroke identified 7 cases (9%) of AF and another 7-day Holter at the end of a 3-year observation-additional 3 cases of AF (a total of 10/78 cases, 13%). ...
Introduction:
Silent atrial fibrillation (AF) is a common cause of cryptogenic ischemic stroke (CIS). The 24-h-Holter is insufficient to reveal an occult arrhythmic cause of stroke and the strategy to select the patients for long-term monitoring is missing.
Objectives:
The aim of the study was to evaluate 7-day-Holter monitoring to identify cases with the arrhythmic cause of stroke in CIS patients in whom 24-h-Holter was free from arrhythmia, and to assess the relation between supraventricular (SV) runs in baseline Holter and the incidence of AF in a 3-year follow-up period.
Methods:
78 patients (aged 60 ± 9 years, 45 males) with CIS and no arrhythmic findings in 24-h-Holter were enrolled. All patients had 7-day-Holter monitoring after stroke and were followed up for 36 months, and then 7-day Holter was repeated. We assessed SV runs (≥5 QRS) in the initial 7-day Holter and analyzed the relation of the findings with clinical characteristics of novel AF episodes revealed early after stroke and during a 3-year follow-up.
Results:
Baseline 7-day-Holter revealed SV runs in 36% of patients and AF in 9% of cases. During a 3-year follow-up, 8 additional cases were confirmed, both in standard care and in repeated Holter (a total of 19% of AF cases). There was no difference with regard to CHADS2VASc score (3.6 ± 1.1 vs. 3.4 ± 1.5; p = NS) and left atrium parameters between patients with SV runs and the non-arrhythmic group. Patients with SV runs had a higher incidence of AF both after stroke and in a 3-year follow-up (46% vs. 4%, RR 11.6, p < 0.001). In 8 cases, patent foramen ovale was detected during follow-up.
Conclusions:
A strategy of baseline 7-day-Holter monitoring after stroke allows for disclosing SV runs in every third case and AF in 9% of stroke survivors. Patients with SV runs have a higher incidence of AF (RR 11.6, p < 0.001) and should be considered for extended continuous ECG monitoring.
... In many settings, the diagnostic yield of AECG increases proportional to duration of monitoring. 8,10,[12][13][14][15][16] An extended duration of monitoring may be achieved with the use of longer-term Holter monitors, or with the use of other modalities. 9,17 ...
Ambulatory external electrocardiography (AECG) monitoring is effective as an evidence-based diagnostic tool when suspicion for cardiac arrhythmia is high. Multiple modalities of AECG monitoring exist, with unique advantages and limitations that predict effectiveness in a variety of clinical settings. Knowledge of these characteristics allows appropriate use of AECG, maximizing patient adherence, diagnostic yield, and cost-effectiveness. In addition, new technology has allowed the development of a modern generation of devices that offer increased efficacy and functionality compared with Holter monitors.
... The ZIO Patch is a water-resistant patch that is placed on the upper side of the left portion of the chest in order to continuously monitor heart rhythms for up to 14 days [67]. A retrospective cohort study measuring compliance and monitoring accuracy found that the median wear time was 13.0 days (IQR 7.2-14.0), ...
... the median analyzable time relative to total wear time was 98.7% (IQR 96.0-99.5%), and AF was detected in 5% of cases [67]. These findings support both the quality of the patch and the high degree of patient compliance in wearing the patch [67]. ...
... and AF was detected in 5% of cases [67]. These findings support both the quality of the patch and the high degree of patient compliance in wearing the patch [67]. In support of these findings, various randomized controlled trials have demonstrated the detection rate of AF to be significantly greater when using the ZIO Patch as compared to delayed ECG monitoring for 4 months [68] and as compared to standard Holter monitoring with an odds ratio of 8.9 (95% CI 1.1-76.0; ...
Purpose of review
Determining the etiology of ischemic stroke is critical to administering targeted therapy to prevent recurrent stroke and further neurologic deterioration. Ischemic strokes of cardioembolic and cryptogenic etiologies are frequent and are often ultimately attributed to atrial fibrillation (AF). However, the paroxysmal nature of AF presents challenges for accurate and timely detection to prevent a recurrent stroke. The purpose of this review is to evaluate serologic, electrographic, echocardiographic, and radiologic markers of AF after an ischemic stroke.
Recent findings
Innovative applications of biotechnologies such as RNA gene expression profiling are being studied to characterize stroke etiology. Extended cardiac rhythm monitoring by implantable and wearable devices allows longer periods to capture paroxysmal AF. Echocardiographic measures including left atrial volume and parameters of left atrial strain increase the probability of detecting AF. Existing radiographic modalities are being investigated in novel ways to assess left atrial abnormalities associated with paroxysmal AF.
Summary
Emerging technologies and novel applications of existing methods are improving AF diagnostics in cryptogenic stroke patients with a high pre-test probability of this etiology. Future research will continue to optimize AF diagnosis after a cryptogenic ischemic stroke to inform clinical practice and prevent recurrent strokes.
... Ambulatory electrocardiographic monitoring greatly minimizes the need for downstream testing and can be accomplished with intermittent 30second monitoring with a handheld device 19,21 or watch, 17 or using continuous monitoring with a Holter or patch device for a variable length of time. 28 There are several ongoing trials using all of these different techniques. 5 There will likely not be 1 best method, as the optimal screening method will likely depend on the population screened and the health care setting of the screening program. ...
Atrial fibrillation (AF) is a major, preventable cause of stroke, whose prevalence is increasing with the aging of the population. There are safe and effective anticoagulation therapies to prevent stroke and new technologies that can identify AF in asymptomatic individuals. Ongoing research will determine if AF screening is cost-effective and will define the best screening strategies. The effectiveness of AF screening can be enhanced by simultaneously screening for the cardiovascular conditions that predispose to the development and progression of AF and its complications. Future studies evaluating an integrated screening program on outcomes, health care utilization, and cost are needed.
... It is also accepted that such a system would be of bene t if it frequently and automatically measures numerous vital signs, improves patient surveillance and, ultimately, improves patient outcomes 26,[28][29][30] . While standard vital sign measurement is executed over a single short time period and might miss crucial changes in physiological parameters, frequent remote patient monitoring (RPM) systems are potentially better equipped to detect and alert of changes since the vital signs measurements are taken continuously and for longer periods 26,31,32 . ...
Coronavirus disease 2019 (COVID-19) exerts deleterious effects on the cardiorespiratory system, leading to worse prognosis in the most effected. The aim of this retrospective multi-center study was to describe the variability of key cardiopulmonary vitals amongst hospitalized COVID-19 patients, measured every 15 minutes using a novel wearable chest-monitor. A total of 492 patients were included, with >3 million measurements collected including heart rate, systolic and diastolic blood pressure, cardiac output, cardiac index, systemic vascular resistance, respiratory rate, blood oxygen saturation, and body temperature. We show differential trajectories of these vital signs, apparent within the first 24hrs of monitoring. Importantly, we show for the first time that cardiovascular deterioration appears early after admission and in parallel with changes in the respiratory parameters, and identify sub-populations at high risk. Combining frequent monitoring using wearable technology with advanced big data and AI analysis tools may aid early detection of deterioration of COVID-19 patients.
... However, the overall incidence of follow-up AF in the included trials of our NMA was less than previously reported [30]. A precise and careful algorithm for diagnostic workup of cryptogenic left circulation thromboembolism in the next randomized studies (with the aid of loop recorder or patch-based and water-resistant cardiac patch rhythm monitor) [29,31], associated with better devices and refinement of implantation techniques perhaps will provide us with more precise answers. In this way, the true onset of atrial arrhythmia after implantation of the device could be more clearly evaluated and highlighted, even in asymptomatic patients. ...
Objective
Systematic reviews suggest that patent foramen ovale closure (PFOc) is performed percutaneously with low complication rates. We did a network meta-analysis (NMA) comparing devices for PFO closures, evaluating safety and efficacy of transcatheter PFOc in preventing neurological events in patients with stroke when compared with medical therapy (MT), and assessing risk of atrial fibrillation (AF).
Methods
We searched 3 databases (MEDLINE, EMBASE, CENTRAL/CCTR) identifying six randomized controlled trials from 2012 until December 2019. We performed a Bayesian NMA; number-needed-to-treat and number-needed-to-harm were derived by applying the estimated odds ratios (ORs). The likelihood of being helped or harmed (LHH) was evaluated to estimate the risk-effectiveness balance.
Results
The 3560 patients allocated to PFOc were less subject to a stroke than patients with MT. The overall ORs of PFOc versus MT were 0.41 with fixed-effects, and 0.22 with random-effects model. NMA proves that PFOc induces AF episodes significantly higher than MT, even when analysis is limited to only new episodes of “serious AF.” LHH (0.68 fixed-effects, 0.79 random-effects) showed that strokes saved are less than cases of AFs added. By considering only serious AF, strokes saved are higher than serious AFs induced by the PFOc (LHH was 3.46 and 4.00 respectively).
Conclusions
NMA supported PFOc in patients with cryptogenic stroke, confirming that devices are better than MT, but increase the risk of AF by over 2/4 times (serious or unserious AF). Considering serious AFs (real risky clinical condition), patients have more advantages in being treated, since LHH is ≥ 3–4.
