Wearable Devices Heighten Symptom Monitoring, Health Care Visits for Atrial Fibrillation

Patients with atrial fibrillation (AF) who use wearable devices, or wearables, excessively monitor their cardiovascular symptoms and report more concerns about their AF treatment than those who do not use wearables, according to a study published in the Journal of the American Heart Association.¹

Affecting more than 33 million adults worldwide, AF is the most common cardiac arrhythmia and is costly to affected patients, their communities, and the health care system.² Thus, identifying novel strategies to enhance clinical AF management is needed to reduce current trends.¹

Wearable health technologies, like smartwatches, are noninvasive methods for long-term continuous key health metric monitoring that have been increasingly used by patients with AF.³ However, this constant flow of data may contribute to obsessive symptom monitoring, greater health care use, and increased anxiety. Patients with AF may especially fall victim because of the high likelihood they unexpectedly experience potentially severe symptoms.⁴

Although there are concerns regarding the potential adverse effects of wearables, they have not been systemically studied.¹ Therefore, the researchers conducted a study to analyze the clinical and psychiatric characteristics of patients with AF who use wearables vs nonusers; they also evaluated the impact of wearables on patient health care use and psychological well-being.

Patients with atrial fibrillation who use wearable devices, like Apple Watches and FitBits, report higher anxiety levels and increased health care usage than nonusers. | Image Credit: sitthiphong - stock.adobe.com

To conduct their study, the researchers recruited patients treated at an academic medical center's outpatient electrophysiology clinic in North Carolina between December 1, 2022, and February 27, 2023. Eligible patients included those 18 years or older with a documented diagnosis of AF or atrial flutter who were enrolled in the electronic health record (EHR)-based patient portal.

They invited eligible patients to participate with a personalized enrollment link via the patient portal. Interested patients completed a web-based consent form and an online survey, which asked about sociodemographic characteristics, psychological well-being, quality of life, and prevalence and patterns of wearable device use; the self-administered survey data were linked to retrospective clinical EHR data.

From the EHR, the researchers obtained data on patients’ baseline comorbidities, medications, cardiovascular risk factors, and history of AF-related procedures. They also collected health care use data, which included visits to the emergency department, hospitalizations, and outpatient cardiology and primary care visits; only AF-related encounters or procedures were included in the analysis.

Patients were considered wearable users if they reported any history or current use of a wearable device in the survey. The researchers included nonusers as a control group to compare their characteristics and patterns of health care use to patients with AF who used wearables.

Of 756 eligible patients who received an electronic invite to participate in the survey, 178 completed it (response rate, 24%). However, the final cohort only included those with both available survey and EHR data (n = 172). The study population consisted of mostly White men with paroxysmal AF, underlying cardiovascular disease, and prescriptions for statins, anticoagulation medications, and β blockers; the mean (SD) age was 72.7 (9.2) years.

Also, 83 patients in the final cohort used a wearable device, most wearing their devices daily (93%); Apple Watch (56%) and FitBit (31%) were the most popular devices. Based on higher mean scores on the Cardiac Anxiety Questionnaire subscale, patients who used wearables reported more frequent cardiovascular symptom monitoring and preoccupation (mean, 1.52 [0.57]) than nonusers (mean, 1.33 [0.56]; P = .03).

Additionally, based on lower mean scores on the Atrial Fibrillation Effects on Quality of Life Questionnaire treatment concern subscale, patients who used wearables reported greater concern about their AF treatment (mean, 77.71 [19.92]) than nonusers (mean, 84.11 [14.99]; P = .02). However, 64% of wearable users said that using their device made them feel safe. More specifically, 45% reported that they check their heart rate or perform an electrocardiogram (ECG) daily, while 19% reported only using heart rate and rhythm monitoring features in response to cardiac symptoms.

The researchers determined that 1 in 5 patients always contacted their doctor after receiving a notification for possible AF. Additionally, 15% of patients said they always feeling anxious, scared, or concerned due to high and low heart rate alerts. Similarly, 20% reported experiencing intense fear and anxiety after receiving an irregular rhythm notification.

AF-specific health care use was significantly greater among those who used wearables (mean, 4.05; 95% CI, 2.91-5.18) than nonusers (mean, 2.70; 95% CI, 1.99-3.41; P = .04), with differences in the number of AF-specific outpatient visits to cardiology and primary care clinics (users: mean, 2.04; 95% CI, 1.51-2.56; nonusers: mean, 1.33; 95% CI, 1.01-1.65; P = .02).

Differences also existed in the number of rhythm-related diagnostic tests and procedures performed (users: 1.84; 95% CI, 1.27-2.42; nonusers: mean, 1.00; 95% CI, 0.62-1.38; P = .004). More specifically, patients with wearables were significantly more likely to receive ablation procedures (P = .03), ECGs (P = .003), and echocardiograms/transesophageal echocardiograms (P = .04).

Lastly, during the follow-up period, wearable users utilized informal health care resources (mean, 5.52; 95% CI, 4.08-6.96) more often than nonusers (mean, 3.90; 95% CI, 3.06-4.72; P = .05). Therefore, they sent significantly more messages to health care providers (mean, 3.59; 95% CI, 2.57-4.61) than nonusers (mean, 2.41; 95% CI, 1.82-3.0; P = .04).

The researchers acknowledged limitations to their findings, one being that minority populations could be underrepresented as they are less likely to be offered access or enroll in patient portals. Also, since this was a retrospective observational study from a single health care system, no causal relationships should be inferred and the findings may differ at other centers. Despite these limitations, the researchers suggested areas for further research based on their findings.

“These findings underscore the need for further investigation into the potential effects of wearable devices on patients’ health care use and psychological well-being, as well as the downstream effects on providers, clinic workflow, and health care expenditures,” the authors concluded. “This work will pave the way forward for the development of evidence-based clinical guidelines and interventions to promote healthy use of wearables in patients with AF.”

References

1. Rosman L, Lampert R, Zhuo S, et al. Wearable devices, health care use, and psychological well-being in patients with atrial fibrillation. J Am Heart Assoc. Published online July 16, 2024. doi:10.1161/JAHA.123.033750
2. Benjamin EJ, Muntner P, Alonso A, et al. Heart disease and stroke statistics-2019 update: a report from the American Heart Association. Circulation. 2019;139(10):e56-e528. doi:10.1161/CIR.0000000000000659
3. Varma N, Cygankiewicz I, Turakhia M, et al. 2021 ISHNE/ HRS/ EHRA/ APHRS collaborative statement on mHealth in arrhythmia management: digital medical tools for heart rhythm professionals: from the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society. Ann Noninvasive Electrocardiol. 2021;26(2):e12795. doi:10.1111/anec.12795
4. Andrade JG, Deyell MW, Macle L, et al. Progression of atrial fibrillation after cryoablation or drug therapy. N Engl J Med. 2023;388(2):105-116. doi:10.1056/NEJMoa2212540