Remote heart rhythm assessment using smartphone-based photoplethysmography in primary care to detect undiagnosed atrial fibrillation in patients with chronic obstructive pulmonary disease

Abstract

Abstract Introduction Atrial fibrillation (AF) is the most common cardiac arrhythmia leading to healthcare consultation in primary care. The increased risk to develop AF when suffering from chronic obstructive pulmonary disease (COPD) has been extensively described in literature. However, it remains challenging to perform in-office, opportunistic screening for AF in COPD patients during daily routine using pulse checks or single-spot ECGs due to the increasing pressure on primary care. Purpose The goal of this study was to evaluate the accuracy and effectiveness of a smartphone-based photoplethysmography (PPG) technology to enable remote heart rhythm monitoring and new AF detection in patients with COPD. Methods Diagnosed COPD patients, without an established AF diagnosis, were identified via the electronic medical record. Patients who fulfilled these criteria and hadn’t had an ECG in the past two years were selected to take part in this study. Other inclusion criteria were access to a smartphone and the physical ability to place their fingertip on a smartphone camera. Eligible patients were contacted via text message and after providing informed consent, the study team invited them to activate a 7-day invitation code to access a medically certified smartphone application. Patients were instructed to perform PPG measurements twice daily and when experiencing symptoms. Those with possible AF based on the PPG recordings were invited for a confirmatory ECG to establish the AF diagnosis. Results In total, 90/270 eligible patients (30%) provided informed consent and activated the on-demand invitation code to remotely monitor their heart rhythm using a PPG-based smartphone application. Of these, 50 (55.6%) were female and the median age was 68 years old (IQR: 59-74). The newly discovered AF detection yield was 5.6% (5/90). In-office 12-lead ECG confirmed AF in 3/5 patients (60%). The remaining patients, with a negative in-office 12-lead ECG, were invited for long-term intermittent ECG monitoring using a handheld ECG device (Zenicor). One patient accepted the proposal and paroxysmal AF was confirmed after 4 weeks of intermittent, symptom-triggered ECG monitoring. The remaining patient was not willing to perform long-term monitoring after the negative in-office ECG. However, this patient was diagnosed with paroxysmal AF as well after presentation at the emergency department while suffering from a transient ischemic attack three months after the initial AF detection using PPG technology. Conclusion Remote heart rhythm assessment using smartphone-based PPG in primary care within a COPD population was feasible and resulted in the detection of newly diagnosed AF in COPD patients. All patients identified with possible AF based on PPG monitoring were confirmed and diagnosed via ECG which enabled the initiation of guideline-based AF management.