Atrial Fibrillation and RPM

Atrial fibrillation (AF) is a prevalent and expensive condition with a high rate of morbidity and mortality. The use of remote monitoring can considerably enhance the diagnosis and management of AF particularly by utilizing recent advancements in remote patient monitoring technologies. The way we care for patients with implanted devices is changing thanks to wireless remote monitoring. Early detection of AF with remote monitoring can lead to increased anticoagulant use and a reduction in stroke risk. In individuals with paroxysmal AF, remote monitoring allows for rapid cardioversion and restoration of sinus rhythm. Modifications to pharmacological regimens for both rate and rhythm control can be made to improve chronic patient care. Remote monitoring improves our capacity to monitor patients following AF ablation procedures and helps us better define the procedure. Remote monitoring can improve the quality of life for patients while also making the best use of resources and lowering overall costs.

Identification of Asymptomatic Atrial Fibrillation

Several studies have shown that symptoms are an inaccurate indicator of whether or not an episode of AF has occurred. Approximately 20% of patients with known symptomatic paroxysmal AF experienced asymptomatic episodes as their first recurrence after only 30 seconds of trans-telephonic ECG recording every two weeks. 70 percent of recurrences were asymptomatic in the Prevention of Atrial Fibrillation After Cardioversion (PAFAC) trial, which used daily transtelephonic ECG recording.^[7] In the Suppression of Paroxysmal Atrial Tachyarrhythmias (SOPAT) trial, symptoms were reported in only 46% of daily and symptom-triggered ECGs with AF.^[8]

It’s worth noting that the majority of the patients with symptoms had sinus rhythm (only 37% had AF), implying that the symptoms are neither sensitive nor specific for AF. According to device-based monitoring, the majority of AF events were asymptomatic. Even in patients who were taking stable antiarrhythmic medication, 38% of AF recurrences lasting more than 48 hours were asymptomatic.^[9] Hence, the use of remote patient monitoring devices can be useful to help diagnose atrial fibrillation.

Diagnosis of Atrial Fibrillation and Stroke Prevention

Because stroke is the most common complication of AF, better diagnosis will result in a higher percentage of patients receiving adequate anticoagulant medication and a lower rate of stroke. Several instances have been demonstrated to minimize the risk of stroke in people with AF with the use of warfarin.^[1] It’s been shown that AF-specific data from remote patient monitoring devices can lead to higher warfarin use.^[2]

Patients who require pacemakers because of sinus node dysfunction are at a higher risk of developing AF. Atrial fibrillation was seen in over half of the participants in the Mode Selection Trial (MOST), and it was an independent predictor of stroke and death. Hence, early detection will lead to earlier intervention and management.^[3]

Identification of AF as the cause of a stroke in those who have previously experienced one is difficult. It’s crucial to figure out what’s causing the problem before you start treatment. According to a systematic review of studies using noninvasive cardiac rhythm monitoring in patients with cryptogenic ischemic stroke, a new AF was discovered in about 5% of patients who had Holter monitoring and 5.7% to 7.7% of patients who also had loop event monitors. According to the review of Liao et al., more thorough monitoring will improve diagnostic yield and prompt the start of oral anticoagulation to prevent secondary strokes.^[4] In patients with AF, treatment reduces the incidence of recurrent stroke by more than 50% in some individuals.^[5]

Monitoring of Medical Therapy

In the majority of patients with AF, drug therapy is still the first-line treatment, and rhythm management techniques are frequently preferred. Only sinus rhythm and warfarin use were linked to lower mortality in the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) trial. In the AFFIRM trial’s rate control arm, many medication modifications and drug combinations were required. The duration of episodes can be altered, provided with the proper treatment.^[6] The frequency and duration of the monitoring can be determined remotely with the use of remote patient monitoring. Remote monitoring can be utilized in rate-control strategies to identify rapid ventricular rates and alter the dose of nodal blocking medications, hence better control of atrial fibrillation episodes.

Monitoring After Ablation

The optimum technique to monitor patients following an AF catheter ablation procedure, establish procedural success, and identify follow-up treatment is still under debate. Because of the increased number of AF episodes following surgery, symptom-based monitoring is ineffective. Trans-telephonic event monitoring is superior to ECG, Holter monitoring, and even event monitoring because it provides longer monitoring with automatic arrhythmia identification. Although asymptomatic AF recurrences are common, device-based surveillance has revealed that the majority of these episodes are brief and non-sustained. More information in real time from newer remote monitoring devices makes it easier to keep an eye on patients and respond faster when they have recurrent AF episodes.

Takeaway

Remote patient monitoring is a unique tool for continuous atrial fibrillation monitoring. Continuous monitoring enables patient therapy to be tailored to the individual and therapeutic strategies to be updated on a regular basis. Early identification of AF may result in an immediate treatment response aimed at averting serious adverse outcomes including stroke and heart failure. It also aids in monitoring adherence to medical therapy and atrial fibrillation after ablation.

Read more: Top 3 Benefits of Remote Patient Monitoring for Atrial Fibrillation Patients

References

1. Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation. Analysis of pooled data from five randomized controlled trials. Arch Intern Med. 1994;154:1449–1457.
2. Kim MH, Trohman RG, Christiansen S, et al. Value of pacemaker atrial diagnostic data in patients with paroxysmal atrial fibrillation: an opportunity to improve rates of warfarin utilization. Pacing Clin Electrophysiol. 2007;30:580–583
3. Glotzer TV, Hellkamp AS, Zimmerman J, et al. Atrial high rate episodes detected by pacemaker diagnostics predict death and strokes. Report of the atrial diagnostics ancillary study of the Mode Selection Trial (MOST).
4. Hart RG, Pearce LA, Koudstaal PJ. Transient ischemic attacks in patients with atrial fibrillation: implications for secondary prevention: the European Atrial Fibrillation Trial and Stroke Prevention in Atrial Fibrillation III Trial. Stroke. 2004;35:948–951.
5. Liao J, Khalid Z, Scallan C, et al. Noninvasive cardiac monitoring for detecting paroxysmal atrial fibrillation or flutter after acute ischemic stroke: a systematic review. Stroke. 2007;38:2935–2940.
6. Corley SD, Epstein AE, DiMarco JP, et al. Relationships between sinus rhythm, treatment, and survival in the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) Study. Circulation. 2004;109:1509–1513.
7. 0 Fetsch T, Bauer P, Engberding R, et al. Prevention of atrial fibrillation after cardioversion: results of the PAFAC trial. Eur Heart J. 2004;25:1385–1394.
8. Patten M, Maas R, Karim A, et al. Eventrecorder monitoring in the diagnosis of atrial fibrillation in symptomatic patients: subanalysis of the SOPAT trial. J Cardiovasc Electrophysiol. 2006;17:1216–1220.
9. Orlov MV, Ghali JK, Araghi-Niknam M, et al. Asymptomatic atrial fibrillation in pacemaker recipients: incidence, progression, and determinants based on the atrial high rate trial. Pacing Clin Electrophysiol. 2007;30:404–411.