Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Review
. 2021 Feb;14(2):e009204.
doi: 10.1161/CIRCEP.120.009204. Epub 2021 Feb 12.

2021 ISHNE/HRS/EHRA/APHRS Expert 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

Niraj Varma  1 , Iwona Cygankiewicz  2 , Mintu P Turakhia  3 , Hein Heidbuchel  4 , Yu-Feng Hu  5 , Lin Yee Chen  6 , Jean-Philippe Couderc  7 , Edmond M Cronin  8 , Jerry D Estep  1 , Lars Grieten  9 , Deirdre A Lane  10 , Reena Mehra  1 , Alex Page  7 , Rod Passman  11 , Jonathan P Piccini  12 , Ewa Piotrowicz  13 , Ryszard Piotrowicz  13 , Pyotr G Platonov  14 , Antonio Luiz Ribeiro  15 , Robert E Rich  1 , Andrea M Russo  16 , David Slotwiner  17 , Jonathan S Steinberg  7 , Emma Svennberg  18
Affiliations
Review

2021 ISHNE/HRS/EHRA/APHRS Expert 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

Niraj Varma et al. Circ Arrhythm Electrophysiol. 2021 Feb.

Abstract

This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia-Pacific Heart Rhythm Society describes the current status of mobile health technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self-management are novel aspects of mobile health. The promises of predictive analytics but also operational challenges in embedding mobile health into routine clinical care are explored.

Keywords: arrhythmias; atrial fibrillation; comorbidities; digital medicine; heart rhythm; mHealth.

PubMed Disclaimer

Conflict of interest statement

For Disclosures, see the Data Supplement.

Figures

Figure.
Figure.
mHealth tools for the individual. Sensors can be embedded in a variety of wearables. IoT indicates Internet of things—connects from any location to hospital or cloud; see Table 1.
Figure 1.
Figure 1.
Application of digital health technologies in arrhythmias (many of these sectors are interconnected).
Figure 2.
Figure 2.
Mobile health (mHealth) devices for arrhythmia monitoring according to indications. Traditional wearable monitors are used for defined, short periods of time. Advantages are continuous monitoring and the ability to use multiple leads, which may be important for arrhythmia differentiation. These have been used historically for evaluation of palpitations, syncope, and defining QRS morphology. mHealth extends monitoring time indefinitely, to be defined by the user, and to the possibility of monitoring other parameters simultaneously with the ECG, and linking to machine learning. Typically, mHealth utilizes single-channel ECG or derived heart rate (HR) and discontinuous monitoring. AF indicates atrial fibrillation; BP, blood pressure; BrS, Brugada pattern; HF, heart failure; ILR, implantable loop recorder; and LQT, long QT.
Figure 3.
Figure 3.
ECG mobile applications. Left, Fingertip recordings. Right, Card pressed to the chest.
Figure 4.
Figure 4.
Apple watch.
Figure 5.
Figure 5.
Mobile health and atrial fibrillation (AF). Applications include screening for AF in general or high-risk populations, managing comorbidities and lifestyles important for prevention and control (see Section 4), as well as managing treatment of known AF. DM indicates diabetes; ESUS, embolic stroke of unknown source; HTN, hypertension; and NSR, normal sinus rhythm.
Figure 6.
Figure 6.
Digital applications can integrate patient-relayed information of sensor and clinical information with automatic remote analysis but also permit patients to receive advice and treatment adjustments from physicians directly.
Figure 7.
Figure 7.
Connectivity and questions. Multiple levels of cooperation among a variety of stakeholders are needed to capitalize fully on the vast potential of mobile health (mHealth), but many questions remain unanswered. Healthy consumers (increasing) predominate among mHealth users. Only a minority of patients are prescribed these digital tools. Potential health benefits of mHealth may be realized when manufacturer participates with clinic for validation in defined disease states. Parties responsible for data control, and thereby predictive analytics, need to be defined. Ultimately, the payor and physician need to be convinced of benefits before digital tools are firmly embedded in clinical practice.
See this image and copyright information in PMC

References

References: Section 1

    1. Federal Communications Commission (FCC). Five Questions You Can Ask Your Doctor about Digital Health. Accessed January 26, 2021. https://www.fcc.gov/general/five-questions-you-can-ask-your-doctor-about...
    1. Turakhia MP, Desai SA, Harrington RA. The outlook of digital health for cardiovascular medicine: challenges but also extraordinary opportunities. JAMA Cardiol. 2016;1:743–744. doi: 10.1001/jamacardio.2016.2661 - PubMed
    1. World Health Organization. mHealth new horizons for health through mobile technologies. 2011. Accessed January 26, 2021. https://www.who.int/goe/publications/goe_mhealth_web.pdf
    1. World Health Organization. mHealth: use of appropriate digital technologies for public health. 2018. Accessed January 26, 2021. https://apps.who.int/gb/ebwha/pdf_files/WHA71/A71_20-en.pdf
    1. Varma N, Epstein AE, Irimpen A, Schweikert R, Love C; TRUST Investigators. Efficacy and safety of automatic remote monitoring for implantable cardioverter-defibrillator follow-up: the Lumos-T Safely Reduces Routine Office Device Follow-Up (TRUST) trial. Circulation. 2010;122:325–332. doi: 10.1161/CIRCULATIONAHA.110.937409 - PubMed

References: Section 2

    1. Steinberg JS, Varma N, Cygankiewicz I, Aziz P, Balsam P, Baranchuk A, Cantillon DJ, Dilaveris P, Dubner SJ, El-Sherif N, et al. 2017 ISHNE-HRS expert consensus statement on ambulatory ECG and external cardiac monitoring/telemetry. Ann Noninvasive Electrocardiol. 2017;22:e12447. - PMC - PubMed
    1. Musat DL, Milstein N, Mittal S. Implantable loop recorders for cryptogenic stroke (plus real-world atrial fibrillation detection rate with implantable loop recorders). Card Electrophysiol Clin. 2018;10:111–118. doi: 10.1016/j.ccep.2017.11.011 - PubMed
    1. Sakhi R, Theuns DAMJ, Szili-Torok T, Yap SC. Insertable cardiac monitors: current indications and devices. Expert Rev Med Devices. 2019;16:45–55. doi: 10.1080/17434440.2018.1557046 - PubMed
    1. Tomson TT, Passman R. The reveal LINQ insertable cardiac monitor. Expert Rev Med Devices. 2015;12:7–18. doi: 10.1586/17434440.2014.953059 - PubMed
    1. Ciconte G, Saviano M, Giannelli L, Calovic Z, Baldi M, Ciaccio C, Cuko A, Vitale R, Giacopelli D, Conti M, et al. Atrial fibrillation detection using a novel three-vector cardiac implantable monitor: the atrial fibrillation detect study. Europace. 2017;19:1101–1108. doi: 10.1093/europace/euw181 - PubMed

References: Section 3

    1. Steinberg JS, Varma N, Cygankiewicz I, Aziz P, Balsam P, Baranchuk A, Cantillon DJ, Dilaveris P, Dubner SJ, El-Sherif N, et al. 2017 ISHNE-HRS expert consensus statement on ambulatory ECG and external cardiac monitoring/telemetry. Ann Noninvasive Electrocardiol. 2017;22:e12447. - PMC - PubMed
    1. Gropler MRF, Dalal AS, Van Hare GF, Silva JNA. Can smartphone wireless ECGs be used to accurately assess ECG intervals in pediatrics? A comparison of mobile health monitoring to standard 12-lead ECG. PLoS One. 2018;13:e0204403 doi: 10.1371/journal.pone.0204403 - PMC - PubMed
    1. McCabe PJ, Chamberlain AM, Rhudy L, DeVon HA. Symptom representation and treatment-seeking prior to diagnosis of atrial fibrillation. West J Nurs Res. 2016;38:200–215. doi: 10.1177/0193945915570368 - PubMed
    1. Strickberger SA, Ip J, Saksena S, Curry K, Bahnson TD, Ziegler PD. Relationship between atrial tachyarrhythmias and symptoms. Heart Rhythm. 2005;2:125–131. doi: 10.1016/j.hrthm.2004.10.042 - PubMed
    1. Verma A, Champagne J, Sapp J, Essebag V, Novak P, Skanes A, Morillo CA, Khaykin Y, Birnie D. Discerning the incidence of symptomatic and asymptomatic episodes of atrial fibrillation before and after catheter ablation (DISCERN AF): a prospective, multicenter study. JAMA Intern Med. 2013;173:149–156. doi: 10.1001/jamainternmed.2013.1561 - PubMed

References: Section 4

    1. Chung MK, Eckhardt LL, Chen LY, Ahmed HM, Gopinathannair R, Joglar JA, Noseworthy PA, Pack QR, Sanders P, Trulock KM; American Heart Association Electrocardiography and Arrhythmias Committee and Exercise, Cardiac Rehabilitation, and Secondary Prevention Committee of the Council on Clinical Cardiology; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; and Council on Lifestyle and Cardiometabolic Health. Lifestyle and risk factor modification for reduction of atrial fibrillation: a scientific statement from the American Heart Association. Circulation. 2020;141:e750–e772. doi: 10.1161/CIR.0000000000000748 - PubMed
    1. January CT, Wann LS, Calkins H, Chen LY, Cigarroa JE, Cleveland JC, Jr, Ellinor PT, Ezekowitz MD, Field ME, Furie KL, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration with the society of thoracic surgeons. Circulation. 2019;140:e125–e151. doi: 10.1161/CIR.0000000000000665 - PubMed
    1. Pizzetti F, Turazza FM, Franzosi MG, Barlera S, Ledda A, Maggioni AP, Santoro L, Tognoni G; GISSI-3 Investigators. Incidence and prognostic significance of atrial fibrillation in acute myocardial infarction: the GISSI-3 data. Heart. 2001;86:527–532. doi: 10.1136/heart.86.5.527 - PMC - PubMed
    1. Gibson CM, Holmes D, Mikdadi G, Presser D, Wohns D, Yee MK, Kaplan A, Ciuffo A, Eberly AL, III, Iteld B, et al. Implantable cardiac alert system for early recognition of ST-segment elevation myocardial infarction. J Am Coll Cardiol. 2019;73:1919–1927. doi: 10.1016/j.jacc.2019.01.014 - PubMed
    1. Holmes DR, Jr, Krucoff MW, Mullin C, Mikdadi G, Presser D, Wohns D, Kaplan A, Ciuffo A, Eberly AL, III, Iteld B, et al. Implanted monitor alerting to reduce treatment delay in patients with acute coronary syndrome events. J Am Coll Cardiol. 2019;74:2047–2055. doi: 10.1016/j.jacc.2019.07.084 - PubMed

References: Section 5

    1. Hendriks JM, de Wit R, Crijns HJ, Vrijhoef HJ, Prins MH, Pisters R, Pison LA, Blaauw Y, Tieleman RG. Nurse-led care vs. usual care for patients with atrial fibrillation: results of a randomized trial of integrated chronic care vs. routine clinical care in ambulatory patients with atrial fibrillation. Eur Heart J. 2012;33:2692–2699. doi: 10.1093/eurheartj/ehs071 - PubMed
    1. Lin JS, O’Connor EA, Evans CV, Senger CA, Rowland MG, Groom HC. Agency for Healthcare Research and Quality (US); 2014. Behavioral counseling to promote a healthy lifestyle for cardiovascular disease prevention in persons with cardiovascular risk factors: an updated systematic evidence review for the U.S. Preventive Services Task Force [Internet]. Report No.: 13-05179-EF-1. Accessed January 26, 2021. https://www.ncbi.nlm.nih.gov/books/NBK241537/ - PubMed
    1. Angaran P, Mariano Z, Dragan V, Zou L, Atzema CL, Mangat I, Dorian P. The atrial fibrillation therapies after ER visit: outpatient care for patients with acute AF - the AFTER3 study. J Atr Fibrillation. 2015;7:1187 doi: 10.4022/jafib.1187 - PMC - PubMed
    1. U.S. Department of Veterans Affairs. VA to provide capability for veterans to access their VA health data on Apple iPhones. Published on February 11, 2019. Accessed January 26, 2021. https://www.va.gov/opa/pressrel/pressrelease.cfm?id=5199
    1. Chow CK, Ariyarathna N, Islam SM, Thiagalingam A, Redfern J. mHealth in cardiovascular health care. Heart Lung Circ. 2016;25:802–807. doi: 10.1016/j.hlc.2016.04.009 - PubMed

References: Section 6

    1. Piccini JP, Clark RL, Kowey PR, Mittal S, Dunnmon P, Stockbridge N, Reiffel JA, Turakhia MP, Ziegler PD, Kleiman RB, et al. Long-term electrocardiographic safety monitoring in clinical drug development: a report from the Cardiac Safety Research Consortium. Am Heart J. 2017;187:156–169. doi: 10.1016/j.ahj.2017.01.012 - PubMed
    1. Andrade JG, Champagne J, Dubuc M, Deyell MW, Verma A, Macle L, Leong-Sit P, Novak P, Badra-Verdu M, Sapp J, et al. ; CIRCA-DOSE Study Investigators. Cryoballoon or radiofrequency ablation for atrial fibrillation assessed by continuous monitoring: a randomized clinical trial. Circulation. 2019;140:1779–1788. doi: 10.1161/CIRCULATIONAHA.119.042622 - PubMed
    1. Varma N, Stambler B, Chun S. Detection of atrial fibrillation by implanted devices with wireless data transmission capability. Pacing Clin Electrophysiol. 2005;28suppl 1S133–S136. doi: 10.1111/j.1540-8159.2005.00083.x - PubMed
    1. Nguyen KT, Olgin JE, Pletcher MJ, Ng M, Kaye L, Moturu S, Gladstone RA, Malladi C, Fann AF, Maguire C, et al. Smartphone-based geofencing to ascertain hospitalizations. Circ Cardiovasc Qual Outcomes. 2017;10:e003326. - PMC - PubMed
    1. https://www.health-eheartstudy.org/. Accessed January 26, 2021.

References: Section 7

    1. ISO/IEEE 11073-10103:2014. Health informatics — Point-of-care medical device communication — Part 10103: Nomenclature — Implantable device, cardiac. Accessed January 26, 2021. https://www.iso.org/standard/63904.html.
    1. Slotwiner DJ, Abraham RL, Al-Khatib SM, Anderson HV, Bunch TJ, Ferrara MG, Lippman N, Serwer GA, Steiner PR, Tcheng JE, et al. HRS white paper on interoperability of data from cardiac implantable electronic devices (CIEDs). Heart Rhythm. 2019;16:e107–e127. doi: 10.1016/j.hrthm.2019.05.002 - PubMed
    1. Chow CK, Redfern J, Hillis GS, Thakkar J, Santo K, Hackett ML, Jan S, Graves N, de Keizer L, Barry T, et al. Effect of lifestyle-focused text messaging on risk factor modification in patients with coronary heart disease: a randomized clinical trial. JAMA. 2015;314:1255–1263. doi: 10.1001/jama.2015.10945 - PubMed
    1. Spaulding EM, Marvel FA, Lee MA, Yang WE, Demo R, Wang J, Xun H, Shah L, Weng D, Fashanu OE, et al. Corrie health digital platform for self-management in secondary prevention after acute myocardial infarction. Circ Cardiovasc Qual Outcomes. 2019;12:e005509 doi: 10.1161/CIRCOUTCOMES.119.005509 - PMC - PubMed
    1. Ratwani RM, Savage E, Will A, Arnold R, Khairat S, Miller K, Fairbanks RJ, Hodgkins M, Hettinger AZ. A usability and safety analysis of electronic health records: a multi-center study. J Am Med Inform Assoc. 2018;25:1197–1201. doi: 10.1093/jamia/ocy088 - PMC - PubMed

References: Section 8

    1. Oxford English Dictionary; “Artificial Intelligence.”. Accessed January 26, 2021. https://www.oed.com/
    1. Kagiyama N, Shrestha S, Farjo PD, Sengupta PP. Artificial intelligence: practical primer for clinical research in cardiovascular disease. J Am Heart Assoc. 2019;8:e012788 doi: 10.1161/JAHA.119.012788 - PMC - PubMed
    1. Davenport T, Kalakota R. The potential for artificial intelligence in healthcare. Future Healthc J. 2019;6:94–98. doi: 10.7861/futurehosp.6-2-94 - PMC - PubMed
    1. Marcolino MS, Oliveira JAQ, D’Agostino M, Ribeiro AL, Alkmim MBM, Novillo-Ortiz D. The impact of mHealth interventions: systematic review of systematic reviews. JMIR Mhealth Uhealth. 2018;6:e23 doi: 10.2196/mhealth.8873 - PMC - PubMed
    1. Steinhubl SR, Muse ED, Topol EJ. The emerging field of mobile health. Sci Transl Med. 2015;7:283rv3 doi: 10.1126/scitranslmed.aaa3487 - PMC - PubMed

References: Section 9

    1. Curry SJ, Krist AH, Owens DK, Barry MJ, Caughey AB, Davidson KW, Doubeni CA, Epling JW, Jr, Kemper AR, Kubik M, et al. US Preventive Services Task Force, screening for atrial fibrillation with electrocardiography: US Preventive Services Task Force recommendation statement. JAMA. 2018;320:478–484. - PubMed
    1. Slotwiner DJ, Abraham RL, Al-Khatib SM, Anderson HV, Bunch TJ, Ferrara MG, Lippman N, Serwer GA, Steiner PR, Tcheng JE, et al. HRS white paper on interoperability of data from cardiac implantable electronic devices (CIEDs). Heart Rhythm. 2019;16:e107–e127. doi: 10.1016/j.hrthm.2019.05.002 - PubMed
    1. Jiang X, Ming WK, You JH. The cost-effectiveness of digital health interventions on the management of cardiovascular diseases: systematic review. J Med Internet Res. 2019;21:e13166 doi: 10.2196/13166 - PMC - PubMed
    1. Pluymaekers NAHA, Hermans ANL, van der Velden RMJ, den Uijl DW, Vorstermans B, Buskes S, Hendriks JM, Vernooy K, Crijns HJGM, Linz D. On-demand app-based rate and rhythm monitoring to manage atrial fibrillation through teleconsultations during COVID-19. Int J Cardiol Heart Vasc. 2020;28:100533 doi: 10.1016/j.ijcha.2020.100533 - PMC - PubMed
    1. Yan BP, Lai WHS, Chan CKY, Au ACK, Freedman B, Poh YC, Poh MZ. High-throughput, contact-free detection of atrial fibrillation from video with deep learning. JAMA Cardiol. 2020;5:105–107. doi: 10.1001/jamacardio.2019.4004 - PMC - PubMed

Appendix References

    1. Department of Health and Human Services Centers for Medicare & Medicaid Services. Published November 23, 2018. Accessed January 26, 2021. https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-2417....
    1. Telemedicine and Digital Health. Medicare’s New Virtual Care Codes: A Monumental Change and Validation of Asynchronous Telemedicine. Published July 18, 2018. Accessed January 23, 2019. https://www.healthcarelawtoday.com/2018/07/18/medicares-new-virtual-care...