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. 2021 Jan 29;2(1):4-54.
doi: 10.1016/j.cvdhj.2020.11.004. eCollection 2021 Feb.

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

Niraj Varma  1 , Iwona Cygankiewicz  2 , Mintu P Turakhia  3 , Hein Heidbuchel  4 , Yufeng 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

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

Niraj Varma et al. Cardiovasc Digit Health J. .

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 ("mHealth") 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 mHealth. The promises of predictive analytics but also operational challenges in embedding mHealth into routine clinical care are explored.

Keywords: ACC, American College of Cardiology; ACS, acute coronary syndrome; AED, automated external defibrillator; AF, atrial fibrillation; AHA, American Heart Association; AHRE, atrial high-rate episode; AI, artificial intelligence; APHRS, Asia Pacific Heart Rhythm Society; BP, blood pressure; CIED, cardiovascular implantable electronic device; CPR, cardiopulmonary resuscitation; EHR A, European Heart Rhythm Association; EMR, electronic medical record; ESUS, embolic stroke of unknown source; FDA (U.S.), Food and Drug Administration; GPS, global positioning system; HCP, healthcare professional; HF, heart failure; HR, heart rate; HRS, Heart Rhythm Society; ICD, implantable cardioverter-defibrillator; ILR, implantable loop recorder; ISHNE, International Society for Holter and Noninvasive Electrocardiology; JITAI, just-in-time adaptive intervention; MCT, mobile cardiac telemetry; OAC, oral anticoagulant; PAC, premature atrial complex; PPG, photoplethysmography; PVC, premature ventricular complexes; SCA, sudden cardiac arrest; TADA, Technology Assissted Dietary Assessment; VT, ventricular tachycardia; arrhythmias; atrial fibrillation; comorbidities; digital medicine; heart rhythm; mHealth.

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Figures

Central Figure
Central Figure
Figure 1
Figure 1
Application of digital health technologies in arrhythmias (Many of these sectors are interconnected).
Figure 2
Figure 2
mHealth devices for arrhythmia monitoring according to indications. Traditional wearable monitors are used for defined, short periods of time. Advantages are continuous monitoring and ability to use multiple leads that 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, and discontinuous monitoring. AF = atrial fibrillation; BP = blood pressure; BrS = Brugada syndrome; HF = heart failure; HR = heart rate; ILR = implantable loop recorder; 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
mHealth and AF. Applications include screening for AF in general or high-risk populations, managing comorbidities and lifestyles important for prevention and control, as well as managing treatment of known AF. AF = atrial fibrillation; DM = diabetes; HTN = hypertension; 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 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 therby 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.
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References

References Section 9

    1. Boehmer J.P., Hariharan R., Devecchi F.G., Smith A.L., Molon G., Capucci A., An Q., Averina V., Stolen C.M., Thakur P.H., Thompson J.A., Wariar R., Zhang Y., Singh J.P. A multisensor algorithm predicts heart failure events in patients with implanted devices: results from the MultiSENSE study. JACC Heart Fail. 2017;5:216–225. doi: 10.1016/j.jchf.2016.12.011. - DOI - PubMed
    1. Choi P.J., Oskouian R.J., Tubbs R.S. Telesurgery: Past, pres- ent, and future. Cureus Journal of Medical Science. 2018;10 doi: 10.7759/cureus.2716. - DOI - PMC - PubMed
    1. Curry S.J., Krist A.H., Owens D.K., Barry M.J., Caughey A.B., Davidson K.W.…Wong J.B. US Preventive Services Task Torce, screening for atrial fibrillation with electrocardiography: US preventive services task force recommendation statement. Journal of the American Medical Association. 2018;320:478–484. - PubMed
    1. Haidegger T., Sándor J., Benyó Z. Surgery in space: The future of robotic telesurgery. Surgical Endoscopy. 2011;25:681–690. doi: 10.1007/s00464-010-1243-3. - DOI - PubMed
    1. Jiang X., Ming W.K., You J.H. The cost-effectiveness of dig- ital health interventions on the management of cardiovascular dis- eases: Systematic review. Journal of Medical Internet Research. 2019;21 doi: 10.2196/13166. - DOI - PMC - PubMed

References Section 1

    1. Abraham W.T., Adamson P.B., Bourge R.C., Aaron M.F., Costanzo M.R., Stevenson L.W.…Yadav J.S. Wireless pulmonary artery haemodynamic monitoring in chronic heart failure: A randomised controlled trial. Lancet. 2011;377:658–666. doi: 10.1016/S0140-6736(11)60101-3. - DOI - PubMed
    1. Chung M.K., Eckhardt L.L., Chen L.Y., Ahmed H.M., Gopinathannair R., Joglar J.A.…Trulock K.M. 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. - DOI - PubMed
    1. Hindricks G., Taborsky M., Glikson M., Heinrich U., Schumacher B., Katz A.…Søgaard P. IN-TIME study group. Implant- based multiparameter telemonitoring of patients with heart failure (IN-TIME): A randomised controlled trial. Lancet. 2014;384:583–590. - PubMed
    1. Slotwiner D.J., Varma N., Akar J.G., Annas G., Beardsall M., Fogel R.I., Yu C.M. HRS Expert Consensus Statement on remote interrogation and monitoring for cardiovascular implantable electronic devices. Heart Rhythm. 2015;12(7):e69–e100. doi: 10.1016/j.hrthm.2015.05.008. - DOI - PubMed
    1. Turakhia M.P., Desai S.A., Harrington R.A. The outlook of digital health for cardiovascular medicine: challenges but also ex- traordinary opportunities. Journal of the American Medical Association Cardiol. 2016;1:743–744. - PubMed

References Table 2

    1. Bumgarner J.M., Lambert C.T., Hussein A.A., Cantillon D.J., Baranowski B., Wolski K.…Tarakji K.G. Smartwatch algorithm for automated detection of atrial fibrillation. Journal of the American College of Cardiology. 2018;71:2381–2388. doi: 10.1016/j.jacc.2018.03.003. - DOI - PubMed
    1. Chan P.H., Wong C.K., Poh Y.C., Pun L., Leung W.W., Wong Y.F.…Siu C.W. Diagnostic performance of a smartphone-based photoplethysmographic application for atrial fibrillation screening in a primary care setting. Journal of the American Heart Association. 2016;5 doi: 10.1161/JAHA.116.003428. - DOI - PMC - PubMed
    1. Cooke G., Doust J., Sanders S. Is pulse palpation helpful in detecting atrial fibrillation? A systematic review. The Journal of Family Practice. 2006;55:130–134. - PubMed
    1. Doliwa P.S., Frykman V., Rosenqvist M. Short-term ECG for out of hospital detection of silent atrial fibrillation episodes. Scandinavian Cardiovascular Journal. 2009;43:163–168. - PubMed
    1. Kearley K., Selwood M., Van den Bruel A., Thompson M., Mant D., Hobbs F.R., Fitzmaurice D., Heneghan C. Triage tests for identifying atrial fibrillation in primary care: A diagnostic accuracy study comparing single-lead ECG and modified BP monitors. BMJ Open. 2014;4 - PMC - PubMed

References Section 2

    1. Ciconte G., Saviano M., Giannelli L., Calovic Z., Baldi M., Ciaccio C.…Pappone C. Atrial fibrillation detection using a novel three-vector cardiac implantable monitor: The atrial fibrillation detect study. Europace. 2017;19:1101–1108. - PubMed
    1. Hindricks G., Pokushalov E., Urban L., Taborsky M., Kuck K.H., Lebedev D.…Pürerfellner H. XPECT Trial Investigators. Performance of a new leadless implantable cardiac monitor in detecting and quantifying atrial fibrillation: Results of the XPECT trial. Circulation Arrhythmia and Electrophysiology. 2010;3:141–147. doi: 10.1161/circep.109.877852. - DOI - PubMed
    1. Mittal S., Rogers J., Sarkar S., Koehler J., Warman E.N., Tomson T.T., Passman R.S. Real-world performance of an enhanced atrial fibrillation detection algorithm in an insertable cardiac monitor. Heart Rhythm. 2016;13:1624–1630. doi: 10.1016/j.hrthm.2016.05.010. - DOI - PubMed
    1. Musat D.L., Milstein N., Mittal S. Implantable loop recorders for cryptogenic stroke (plus real-world atrial fibrillation detection rate with implantable loop recorders) Cardiac Electrophysiology Clinics. 2018;10:111–118. doi: 10.1016/j.ccep.2017.11.011. - DOI - PubMed
    1. Nölker G., Mayer J., Boldt L.-H., Seidl K., Van driel V., Massa T.…Lewalter T. Performance of an implantable cardiac monitor to detect atrial fibrillation: Results of the DETECT AF study. Journal of Cardiovascular Electrophysiology. 2016;27:1403–1410. doi: 10.1111/jce.13089. - DOI - PubMed

References Table 3

    1. Berge T., Lyngbakken M.N., Ihle-Hansen H., Brynildsen J., Pervez M.O., Aagaard E.N.…Tveit A. Prevalence of atrial fibrillation and cardiovascular risk factors in a 63–65 years old general popula- tion cohort: The Akershus Cardiac Examination (ACE) 1950 Study. BMJ Open. 2018;8 - PMC - PubMed
    1. Chan P.H., Wong C.K., Poh Y.C., Pun L., Leung W.W., Wong Y.F.…Siu C.W. Diagnostic performance of a smartphone-based photoplethysmographic application for atrial fibrillation screening in a primary care setting. Journal of the American Heart Association. 2016 Jul 21;5(7) doi: 10.1161/JAHA.116.003428. - DOI - PMC - PubMed
    1. Doliwa R., Sobocinski P., Anggårdh R.E., Frykman Kull V., von Arbin M., Wallén H., Rosenqvist M. Improved screening for silent atrial fibrillation after ischaemic stroke. Europace. 2012;2012(14):1112–1116. doi: 10.1093/europace/eur431. - DOI - PubMed
    1. Engdahl J., Andersson L., Mirskaya M., Rosenqvist M. Stepwise screening of atrial fibrillation in a 75-year-old population: Implications for stroke prevention. Circulation. 2013;127:930–937. - PubMed
    1. Guo Y., Wang H., Zhang H., Liu T., Liang Z., Xia Y.…Lip G.Y.H. MAFA II Investigators. Mobile photoplethysmographic technology to detect atrial fibrillation. Journal of the American College of Cardiology. 2019;74:2365–2375. doi: 10.1016/j.jacc.2019.08.019. - DOI - PubMed

References Section 3

    1. Gropler M.R.F., Dalal A.S., Van Hare G.F., Silva J.N.A. 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 doi: 10.1371/journal.pone.0204403. - DOI - PMC - PubMed
    1. Steinberg J.S., Varma N., Cygankiewicz I., Aziz P., Balsam P., Baranchuk A.…Piotrowicz R. 2017 ISHNE-HRS expert consensus statement on ambulatory ECG and external cardiac moni- toring/telemetry. Annals of Noninvasive Electrocardiology. 2017;22 doi: 10.1111/anec.12447. - DOI - PMC - PubMed
    1. Boriani G., Laroche C., Diemberger I., Fantecchi E., Popescu M.I., Rasmussen L.H.…Lip G.Y. Asymptomatic atrial fibrillation: clinical correlates, management, and outcomes in the EORP-AF Pilot General Registry. The American Journal of Medicine. 2015;128:509–518.e2. - PubMed
    1. Garimella R.S., Chung E.H., Mounsey J.P., Schwartz J.D., Pursell I., Gehi A.K. Accuracy of patient perception of their prevailing rhythm: A comparative analysis of monitor data and questionnaire responses in patients with atrial fibrillation. Heart Rhythm. 2015;12:658–665. - PubMed
    1. McCabe P.J., Chamberlain A.M., Rhudy L., DeVon H.A. Symptom representation and treatment-seeking prior to diagnosis of atrial fibrillation. Western Journal of Nursing Research. 2015;38:200–215. - PubMed

References Table 4

    1. Boyne J.J., Vrijhoef H.J., Crijns H.J., De Weerd G., Kragten J., Gorgels A.P., investigators T.E.H.A.F. Tailored telemonitoring in patients with heart failure: Results of a multicentre randomized controlled trial. European Journal of Heart Failure. 2012;14:791–801. - PubMed
    1. Chaudhry S.I., Mattera J.A., Curtis J.P., Spertus J.A., Herrin J., Lin Z.…Krumholz H.M. Telemonitoring in patients with heart failure. New England Journal of Medicine. 2010;363:2301–2309. - PMC - PubMed
    1. Koehler F., Winkler S., Schieber M., Sechtem U., Stangl K., Böhm M.…Anker S.D. Telemedical Interventional Monitoring in Heart Failure Investigators. Impact of remote telemedical management on mortality and hospitalizations in ambulatory patients with chronic heart failure: The Telemedical Interventional Monitoring in Heart Failure study. Circulation. 2011;123:1873–1880. - PubMed
    1. Ong M.K., Romano P.S., Edgington S., Aronow H.U., Auerbach A.D., Black J.T.…Fonarow G.C. Better effectiveness after transition-heart failure (BEAT-HF) research group. Effectiveness of remote patient monitoring after discharge of hospitalized patients with heart failure: the better effectiveness after transition—heart failure (BEAT-HF) randomized clinical trial. Journal of the American Medical Association Internal Medicine. 2016;176:310–318. - PMC - PubMed
    1. Takahashi P.Y., Pecina J.L., Upatising B., Chaudhry R., Shah N.D., Van Houten H.…Hanson G.J. A randomized controlled trial of telemonitoring in older adults with multiple health issues to prevent hospitalizations and emergency department visits. Archives of Internal Medicine. 2012;172:773–779. - PMC - PubMed

References Section 4

    1. Chung M.K., Eckhardt L.L., Chen L.Y., Ahmed H.M., Gopinathannaie R., Joglar J.A.…Trulock K.M. 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. - DOI - PubMed
    1. January C.T., Wann L.S., Calkins H., Chen L.Y., Cogarroa J.E., Cleveland J.C.…Yancy C.W. 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. - DOI - PubMed
    1. Avila C.O. Novel use of apple watch 4 to obtain 3-lead electrocardiogram and detect cardiac ischemia. The Permanente Journal. 2019;23:19–025. - PMC - PubMed
    1. Chow C.K., Redfern J., Hillis G.S., Thakkar J., Santo K., Hackett M.L.…Thiagalingam A. Effect of lifestyle-focused text messaging on risk factor modification in patients with coronary heart disease: A randomized clinical trial. Journal of the American Medical Association. 2015;314:1255–1263. - PubMed
    1. Clemmensen P., Loumann-Nielsen S., Sejersten M. Telemedicine fighting acute coronary syndromes. Journal of Electrocardiology. 2010;43:615–618. - PubMed

References Section 5

    1. Angaran P., Mariano Z., Dragan V., Zou L., Atzema C.L., Mangat I., Dorian P. The atrial fibrillation therapies after ER visit: Outpatient care for patients with acute AF: the AFTER3 study. Journal of Atrial Fibrillation. 2015;7:1187. - PMC - PubMed
    1. Lin, J. S., O’Connor, E. A., Evans, C. V., Senger, C. A., Rowland, M. G., & Groom, H. C. (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] Rockville (MD): Agency for Healthcare Research and Quality (US); U.S. Preventive Services Task Force Evidence Syntheses, formerly Systematic Evidence Reviews. Report No.: 13-05179-EF-1. - PubMed
    1. Hendriks J.M., de Wit R., Crijns H.J., Vrijhoef H.J., Prins M.H., Pisters R., Pison L.A., Blaauw Y., Tieleman R.G. 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. European Heart Journal. 2012;33(21):2692–2699. doi: 10.1093/eurheartj/ehs071. - DOI - PubMed
    1. Chow C.K., Ariyarathna N., Islam S.M., Thiagalingam A., Redfern J. mHealth in cardiovascular health care. Heart Lung & Circulation. 2016;25:802–807. - PubMed
    1. Coorey G.M., Neubeck L., Mulley J., Redfern J. Effectiveness, acceptability and usefulness of mobile applications for cardiovascu- lar disease self-management: Systematic review with meta-synthesis of quantitative and qualitative data. European Journal of Preventive Cardiology. 2018;25:505–521. - PubMed

References Section 6

    1. Andrade J.G., Champagne J., Dubuc M., Deyell M.W., Verma A., Macle L.…Khairy P. Cryoballoon or radiofrequency ablation for atrial fibrillation assessed by continuous monitoring: A random- ized clinical trial. Circulation. 2019;140:1779–1788. - PubMed
    1. Chen L.Y., Chung M.K., Allen L.A., Ezekowitz M., Furie K.L., McCabe P.…Turakhia M.P. Atrial fibrillation burden: moving beyond atrial fibrillation as a binary entity: A scientific statement from the American Heart Association. Circulation. 2018;137:e623–e644. - PMC - PubMed
    1. Glotzer T.V., Daoud E.G., Wyse D.G., Singer D.E., Ezekowitz M.D., Hilker C.…Ziegler P.D. The relationship between daily atrial tachyarrhythmia burden from implantable device diagnos- tics and stroke risk: The TRENDS study. Circulation: Arrhythmia and Electrophysiology. 2009;2:474–480. - PubMed
    1. Guo, X., Vittinghoff, E., Olgin, J. E., Marcus, G. M., & Pletcher, M. J. (2017). - PubMed
    1. Volunteer participation in the Health eHeart Study: A comparison with the US population. Science Reports. 2017;(7):1956. doi: 10.1038/s41598-017-02232-y. - DOI - PMC - PubMed

References Section 7

    1. https://www.iso.org/standard/63904.htmlhttps://www.iso.org/standard/63904.html
    1. Chow C.K., Redfern J., Hillis G.S., Thakkar J., Santo K., Hackett M.L.…Thiagalingam A. Effect of lifestyle-focused text messaging on risk factor modification in patients with coronary heart disease: A randomized clinical trial. Journal of the American Medical Association. 2015;314:1255–1263. - PubMed
    1. Ratwani R.M., Savage E., Will A., Arnold R., Khairat S., Miller K.…Hettinger A.Z. A usability and safety analysis of electronic health records: A multi-center study. Journal of the American Medical Information Association. 2018;25:1197–1201. - PMC - PubMed
    1. Slotwiner D.J., Abraham R.L., Al-Khatib S.M., Anderson H.V., Bunch T.J., Ferrara M.G.…Wilkoff B.L. HRS White Paper on in- teroperability of data from cardiac implantable electronic devices (CIEDs) Heart Rhythm. 2019;16:e107–e127. doi: 10.1016/j.hrthm.2019.05.002. - DOI - PubMed
    1. Spaulding E.M., Marvel F.A., Lee M.A., Yang W.E., Demo R., Wang J.…Martin S.S. Corrie health digital platform for self-man- agement in secondary prevention after acute myocardial infarction. Circulation. Cardiovascular Quality & Outcomes. 2019;12 - PMC - PubMed

References Section 8

    1. “Artificial Intelligence”. Oxford English Dictionary. www.oed.com
    1. Attia Z.I., Kapa S., Lopez-Jimenez F., McKie P.M., Ladewig D.J., Satam G.…Friedman P.A. Screening for cardiac contractile dys- function using an artificial intelligence-enabled electrocardiogram. Nature Medicine. 2019;25:70–74. - PubMed
    1. Attia Z.I., Noseworthy P.A., Lopez-Jimenez F., Asirvatham S.J., Deshmukh A.J., Gersh B.J.…Friedman P.A. An artificial intelligence-enabled ECG algorithm for the identification of patients with atrial fibrillation during sinus rhythm: a retrospective analysis of outcome prediction. Lancet. 2019;394:861–867. - PubMed
    1. Awan S.E., Bennamoun M., Sohel F., Sanfilippo F.M., Dwivedi G. Machine learning-based prediction of heart failure readmission or death: Implications of choosing the right model and the right met- rics. European Society of Cardiology Heart Failure Journal. 2019;6:428–435. - PMC - PubMed
    1. Bumgarner J.M., Lambert C.T., Hussein A.A., Cantillon D.J., Baranowski B., Wolski K.…Tarakji K.G. Smartwatch al- gorithm for automated detection of atrial fibrillation. Journal of the American College of Cardiology. 2018;71:2381–2388. - PubMed