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PERSPECTIVES
When smartwatches contribute to health anxiety in
patients with atrial fibrillation
Lindsey Rosman, PhD,*Anil Gehi, MD, FHRS,*Rachel Lampert, MD, FHRS
†
From the *Department of Medicine, Divsion of Cardiology, University of North Carolina at Chapel Hill,
Chapel Hill, North Carolina, and
†
Department of Internal Medicine, Section of Cardiovascular
Medicine, Yale School of Medicine, New Haven, Connecticut.
Landmark studies have demonstrated that wrist-worn wear-
able devices (eg, smartwatches, fitness bands) can provide
potentially actionable data to improve real-time surveillance
of respiratory diseases, such as influenza,
1
and facilitate the
detection of irregular heart rhythms.
2
Although these tools un-
doubtedly will transform health care and energize scientific
research, important ethical, legal, and social issues have
been raised and require careful public deliberation.
3
We
have identified another aspect of the digital health revolution
that has not yet received due attention: the unanticipated and
potentially negative effects of wearable devices on patients’
psychological health, quality of life, and health care utilization.
Although unlimited access to digital health information
can motivate some individuals to engage in healthy behav-
iors, these data may inadvertently contribute to pathologic
symptom monitoring and impaired function in others. Pa-
tients with intermittent atrial fibrillation (AF) may be espe-
cially susceptible to excessive cardiac monitoring with a
wearable device given the transient, unpredictable nature of
arrhythmias and the ongoing risk of recurrence despite med-
ical or procedural therapy. Anxiety is prevalent among those
with AF and has been associated with a higher AF symptom
burden, worse quality of life, and increased health care con-
sumption.
4,5
Thus, technologies that heighten awareness and
attention to normal and potentially abnormal fluctuations in
heart rates may lead to substantial increases in anxiety in pre-
disposed persons and prompt unnecessary medical care.
To illustrate this point, we describe a case from our cardiol-
ogy clinic of a 70-year-old woman with paroxysmal AF. One
year after her initial AF diagnosis, a clinical health psychologist
(LR) diagnosed her as having new-onset health anxiety that was
primarily triggered by excessive cardiac monitoring with a
commercially available smartwatch. No evidence of previous
mental health problems was noted in her medical records. She
had hypertension, a moderate risk of stroke (CHA
2
DS
2
-VASc
score 3), and arrhythmia burden ,1%, and she was compliant
with oral anticoagulation and antihypertensive therapies.
Smartwatch data provided by the patient revealed that she had
performed 916 electrocardiograms (ECGs) over a 1-year
period. Of those ECG recordings, 701 were sinus rhythm, 55
were possible AF, 30 indicated low or high heart rate, and
130 were inconclusive. As shown in Figure 1,smartwatch
ECG monitoring increased over time. Acute escalations in
ECG-taking behaviors were frequently triggered by smartwatch
notifications that were either innocuous (eg, transient exercise-
induced elevations in heart rate), inconclusive, or indicative of
possible AF. Notably, irregular rhythm notifications and find-
ings of uncertain significance (“inconclusive”ECG) produced
a relatively similar behavioral response, suggesting that ambig-
uous data may have been misinterpreted as actual health threats.
Based on diagnostic interview and validated question-
naires,
6,7
it became apparent that our patient had developed
an enduring belief that smartwatch notifications were a sign
of worsening cardiac function, leading to a vicious cycle of
excessive worry, preoccupation with cardiac stimuli and sensa-
tions, and compensatory behaviors (eg, habitual cardiac moni-
toring with the smartwatch and repeatedly seeking reassurance
from health care professionals). Despite repeated medical
assessment and reassurance, this maladaptive pattern resulted
in 12 ambulatory clinic and emergency department visits and
numerous telephone calls to health care providers. Because
she was asymptomatic and receiving appropriate anticoagula-
tion therapy, none of these clinical encounters led to alterations
in medical treatment. Furthermore, her constant worry and
frequent health care visits had a profoundly negative impact
on her mental health, relationships, and quality of life. The pa-
tient was referred to our cardiac psychologist (LR) for further
psychological evaluation, and she ultimately was diagnosed
with illness anxiety disorder (formerly known as hypochon-
driasis). The patient subsequently completed 6 sessions of
cognitive behavioral therapy to target health anxiety
8
associ-
ated with AF, which resulted in complete symptom remission.
The notion that fear and uncertainty may drive some patients
with AF to engage in hypervigilant self-monitoring behaviors
with a wearable device to “control”or mitigate distress associ-
ated with an unpredictable heart rhythm disorder should come
KEYWORDS Anxiety; Arrhythmia; Atrial fibrillation; Digital health; Smart-
watch; Wearables (Cardiovascular Digital Health Journal 2020;1:9–10)
Address reprint requests and correspondence: Dr Lindsey Rosman,
Department of Medicine, Division of Cardiology, University of North Car-
olina at Chapel Hill, UNC Cardiology, 160 Dental Circle, CB 7075,
Burnett-Womack Building, Chapel Hill, NC 27599-7075. E-mail address:
Lindsey_Rosman@med.unc.edu.
2666-6936/© 2020 The Authors. Published by Elsevier Inc. on behalf of Heart Rhythm Society.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).
https://doi.org/10.1016/j.cvdhj.2020.06.004
as no surprise. Our observations are consistent with established
theoretical models (eg, Uncertainty and Anticipation Model of
Anxiety [UAMA])
9
and are well supported by decades of
neurobiological research demonstrating a robust relationship
among uncontrollable stress, unpredictable aversive health
events, reassurance-seeking behaviors, and the development
of health anxiety.
9
In this context, wearable health technologies
likely fuel the phenomenon. Unlike traditional clinical visits,
which can be expensive or infrequent, wearables provide an un-
precedented level of access to on-demand health data via
affordable, highly engaging, and, in some cases, Food and
Drug Administration–approved devices that continuously rein-
force somatic preoccupation. In susceptible persons, this may
bolster the belief that even those with AF who are at low risk
and are receiving appropriate anticoagulation therapy should
seek care, even when it is not necessary.
Although the prevalence, clinical course, and associated
outcomes of this phenomenon remain unknown, an
increasing number of cases have been reported anecdotally
by colleagues at our institution and other medical centers
nationwide. This suggests that our patient may represent
the tip of an iceberg. By highlighting the practical difficulties
clinicians may face in managing this phenomenon, we hope
to stimulate thoughtful discussion and robust research into
the co-occurrence of health anxiety and wearable devices in
patients with arrhythmias and other medical conditions.
Important questions warrant further investigation. First,
when and in whom is this condition most likely to manifest?
Because individuals with underlying anxiety have elevated
threat expectancies and heightened responses to uncertainty,
9
they may be more likely to develop this maladaptive pattern
of behavior. However, more studies are needed to draw firm
conclusions in this regard. Second, how does this pathology
affect clinical and quality-of-life outcomes; provider burden/
workflow; and health care utilization and expenditures?
Another consideration is the inevitability of false-positive re-
sults. How do patients cope with discrepancies between data
obtained from a wearable device compared to that from a
clinic visit? How do these findings affect patients’trust and
satisfaction with their providers and the health care system?
Further research in these areas will facilitate the adaptation
of existing theoretical models of anxiety to address this
contemporary clinical phenomenon. In addition, a more
nuanced understanding of these issues is essential to educate
the public about incidental findings and inform best practices
for managing patients’questions and concerns about wear-
able health technology.
Wearables can play an important role in promoting patient
empowerment and health care engagement. However, this
will require active involvement and strong collaboration
among all stakeholders—technology companies, behavioral
scientists, health care practitioners, researchers, patients,
and caregivers—to understand the ways in which diverse
segments of society (eg, older adults, individuals with medi-
cal and mental health issues) interact with this technology.
Funding Sources
This study was supported by a grant from the National Heart,
Lung, and Blood Institute of the National Institutes of Health
to Dr Rosman (K23HL141644).
Disclosures
Dr Gehi receives research support from Bristol-Myers
Squibb Foundation; consulting fees from Biosense Webster;
and speaker’s honoraria from Abbott, Biotronik, and Zoll
Medical. Dr Lampert receives research support from Med-
tronic, Boston Scientific, and Abbott; consulting fees from
Medtronic; and honoraria from Medtronic and Abbott. Dr
Rosman has reported that she has no conflicts relevant to
the contents of this paper to disclose.
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Figure 1 Number of patient-initiated electrocardiographic (ECG) record-
ings obtained during the first month of device ownership. Note the marked
increase in recordings after smartwatch notifications for an “inconclusive”
ECG on day 17 and possible atrial fibrillation on day 29. Data obtained
from January 2018 to January 2019.
10 Cardiovascular Digital Health Journal, Vol 1, No 1, July/August 2020
