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How Remote Afib Monitoring Has Reshaped My Practice

— The Skeptical Cardiologist outlines the benefits of a mobile ECG device

MedpageToday
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I previously detailed my early experience utilizing AliveCor's ECG device in conjunction with their KardiaPro cloud service to monitor my patient's with atrial fibrillation (afib). Since that post, the majority of my new afib patients have acquired the Kardia device and use it regularly to help us monitor their afib.

This capability has revolutionized my management of atrial fibrillation. In those patients who choose to use AliveCor, there is really no need for long-term monitors (Holter monitors, Zio patches, cardiac event monitors) and no need for patients to come to the office to get an ECG when they feel they have gone into afib.

When one of my Kardia Pro patients calls with symptoms or concern of afib, I quickly pull up their chart at Kardiapro.com and review their recordings to determine if they are in or out of rhythm. Most treatment decisions can then be handled over the phone without the need for ordering a monitor or an emergency room or office visit.

One 24-hour period will suffice to show how important KardiaPro is now to my management of my patients with afib.

A Day In The Afib Life

Tuesdays I spend working in the heart station at my hospital. Typically, on these days I will supervise stress tests, read ECGs and echocardiograms, and perform transesophageal echocardiography and electrical cardioversion. On a recent Tuesday, I had three patients scheduled for .

The day before, one of these patients called indicating that he suspected he had (NSR) based on his Kardia readings. He had had a prior cardioversion after which we knew (thanks to daily Kardia recordings) he reverted to afib in 5 days. Subsequently, we had started him on flecainide (Tambocor) for maintenance of NSR and scheduled him for the cardioversion. Patients not uncommonly convert to NSR after starting flecainide, but if they don't we proceed to an electrical cardioversion.

I logged into KardiaPro and reviewed his dashboard and, sure enough, his last two ECGs showed sinus rhythm. I congratulated him on this and we canceled his cardioversion for the next day, saving the lab the time and expense of a cancellation the day of the procedure. The patient avoided much stress, time, and inconvenience.

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ECG recordings showing the patient had transitioned from afib (bottom two panels) to NSR (top two panels) after starting flecainide.

It is important to note that, in this patient, there was no great jump in heart rate with afib compared to NSR. For many patients, the rate is much higher with the development of afib and this is often detected by non-ECG wearable monitors (like an Apple Watch.) But for patients like this one, an ECG is the only way to know what the rhythm is.

A second patient with afib, who had elected not to acquire an AliveCor ECG device, showed up for his cardioversion on Tuesday. After evaluating his rhythm, it was clear he had spontaneously reverted back to NSR. Prior to my adoption of KardiaPro, this was a common scenario.

The third scheduled cardioversion of the day showed up in afib and we successfully cardioverted him back to NSR. I had not addressed utilizing AliveCor with him. Prior to the procedure, he asked me about likely outcomes.

My standard response to this question is that we have a 99.9% success rate in converting patients back to NSR at the time of the cardioversion. However, I can't predict how long you will stay in NSR after the cardioversion. NSR could last for 5 days or it could last for 5 years. Adding medications like flecainide or amiodarone (Nexterone, Pacerone) can significantly reduce the risk of afib recurrence after cardioversion.

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At this point he asked me "How do I know if I am in afib?" Whereas many afib patients immediately feel bad and are aware that they have gone out of rhythm, others like this man are not aware.

Prior to AliveCor, my answer would have been to check the pulse daily or look for evidence of high or irregular heart rates on blood pressure monitors or fitness wearables. This scenario provided a wonderful opportunity to test the AliveCor's accuracy at detecting afib in him. I pulled out my trusty AliveCor mobile ECG, and we made this recording prior to the cardioversion:

After the cardioversion, we repeated the AliveCor recording and the rhythm (AliveCor's interpretation) had changed from afib to NSR.

This patient purchased a Kardia device the next day, and since the cardioversion he's made a daily recording confirming NSR. I just logged into KardiaPro and, sure enough, he made a recording last night that showed NSR.

Later in the week, I received a call from a patient I had electrically cardioverted a few days earlier. His Kardia device had detected that he had gone back into afib.

I logged into my Mac and saw his KardiaPro chart:

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Kardia Pro displays green dots corresponding to NSR and orange triangles corresponding to afib, with 100% accuracy in this patient.

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With perfect precision, KardiaPro had verified NSR after the cardioversion lasting for 36 hours. For some reason, after dinner the day after the cardioversion, the patient had reverted back to afib. This knowledge greatly facilitates subsequent treatment and eliminates the need for in-office ECGs and long-term monitors.

Utilization of the Kardia device with the KardiaPro monitoring service has proved for me to be a remarkable improvement in the management of patients with afib. Managing non-Kardia afib patients feels like navigating a forest with a blindfold.

The improvement is so impressive that I find myself exclaiming to my assistant, Jenny, several times a week, "How do other cardiologists intelligently care for afibbers without AliveCor?"

I have a few patients who balk at the $15 per month charge for KardiaPro and ask why the device and this monthly charge aren't covered by insurance or Medicare. Given the dramatic reduction that I have noticed in my use of long-term monitors as well as office and ER visits in this population, the Centers for Medicare and Medicaid Services and third-party insurers would be wise to explore Kardia monitoring as a more cost-effective way of monitoring afib patients.

As a side note, I realize this post appears to be an unmitigated enthusiastic endorsement of a commercial product, which is quite uncharacteristic for the Skeptical Cardiologist. One might wonder if I am somehow biased or compensated for endorsement of Kardia. In all honesty, this sprang from my love of the device's improvement in my afib management and I have received no payment -- monetary or otherwise -- from AliveCor, nor do I own any of their stock.

, is a private practice noninvasive cardiologist and medical director of echocardiography at St. Luke's Hospital in St. Louis. He blogs on nutrition, cardiac testing, quackery, and other things worthy of skepticism at , where a version of this post first appeared.