3 Questions with Annabelle Volgman, MD, from AHA 2018
Dr. Volgman is a Professor of Medicine and Senior Attending Physician at Rush Medical College and Rush University Medical Center in Chicago, Illinois. She is also the Medical Director of the Rush Heart Center for Women and is board-certified in Internal Medicine, Cardiovascular Disease, and Clinical Cardiac Electrophysiology.
There were several presentations about new concepts in the diagnosis and management of Afib. What are some of the key takeaways from these discussions?
Dr. Volgman: We know that Afib remains a global issue and is associated with a 5-fold increase in stroke risk. However, the US Preventive Service Task Force has found insufficient evidence for opportunistic ECG screening; that is, screening asymptomatic patients for Afib. But this is where the tides might be turning. We have data from studies such as REHEARSE-AF and mSTOPS that show us the presence of Afib in asymptomatic patients, using medically sanctioned devices. The sessions at AHA largely focused on the role of consumer devices: Can they accurately identify Afib, and will they have clinical significance going forward? Because an Afib episode can come and go, some patients may have undetected Afib, and therefore may not receive timely treatment, which could ultimately affect stroke risk. So, several technology companies are looking into the most accurate way of documenting this and are developing artificial intelligence (AI)-based devices that will help us obtain data in patients out of the office.
Are there studies in the pipeline we should be looking for?
Yes. One presentation featured recent research performed by the American Heart Association (AHA) in >500,000 people with health insurance. The study found that the risk for Afib was very low in people younger than 65 years, but the risk increases from 0.5% to 5.6% in people >65 years. Five key factors were present in 92% of patients with Afib: age, hypertension, congestive heart failure, coronary artery disease, and chronic respiratory failure. These findings will need to be validated in other databases, but the hope is that this information may help inform a predictive model for Afib.
Of particular interest is the Apple Heart Study, which is the largest Afib screening study ever done. The study has just entered its final phase of data collection, but we learned more about its design and objectives at AHA. The study goals are 3-fold: to assess whether patients who receive irregular pulse notifications are found to have Afib on ECG patch monitoring, to determine whether patients who receive an irregular pulse notification obtain medical attention, and to determine the accuracy of irregular-pulse detection by the Apple watch compared with the simultaneous ECG patch recordings.
How do you think use of these technologies will affect providers, specifically primary care providers?
Dr. Volgman: Although these devices can help identify important information and empower our patients to seek treatment and manage their arrhythmias, we may see false-positives. Patients who notice an irregularity in their heart rhythm, whether it’s a false-positive or actual arrhythmia, may become concerned and want to see their doctor, so we could be looking at more use of healthcare resources down the line. We as cardiologists will need to help primary care providers deal with patients’ fears and questions.
In the meantime, providers can reassure young people who have a low risk for stroke that irregular heartbeats often have reversible causes, such as stress, anxiety, alcohol intake, caffeine intake, and electrolyte abnormalities. However, if patients are already at a high risk for stroke (i.e., older than 65 years; have a history of diabetes, hypertension, congestive heart failure, and/or atherosclerosis), they may warrant anticoagulation.