Last week we highlighted the importance of safeguarding the unserved cardiac patient population by providing daily ECG readings. We focused on comorbidities, such as hypertension and heart failure, that are often linked to atrial fibrillation (AF). We also highlighted the importance of ECG data sent directly to a provider and how it empowers them to hit the rewind button on the potential sequelae that follows.
Let’s dive into another group of patients who are often overlooked and whose risk factors are underestimated. There are a variety of interventions that leave patients at-risk for the development of AF…from simple cardiac procedures to complex cardiac interventions to chemotherapy infusions. This subset of patients may begin outpatient cardiac rehabilitation (CR) immediately or simply be asked to follow up with their physician weeks later.
There is often a gap in cardiac monitoring that would otherwise prevent complications or at least “catch them in the act.” How can we ensure the safety of these patients while reducing the costs for all entities involved with a simple daily ECG reading?
Post-Intervention AF
One-third of cardiac bypass surgery patients and 40% of those undergoing valvular surgery develop postoperative atrial fibrillation (POAF) (1). Occurrence is usually detected within the first 3 days and 80% of readmissions are within 30 days of discharge (1)(2). Caution should be used with chemotherapy drugs as they have a significant risk of cardiotoxicity. In one study with Ibrutinib therapy, 29% of participants without baseline AF developed AF, and the participants who had baseline heart failure increased their risk of AF to 71% after one year of the therapy (3). The Mayo Clinic Cardiology Update: The Heart of the Matter 2022 continued to provide insight on patients who were post-intervention. Several experts highlighted the Cardiac Rehab (CR) patient and the data that wearable technology provides. CR decreases mortality by as much as 50% and hospital readmission for any cause by 25% (4). Patients who qualify for wearable ECG devices on average have the device for 12 weeks and then monitoring ceases. Is it best practice to discontinue monitoring completely? Imagine if every CR patient received a de-escalation of care from continuous to intermittent monitoring. This would provide a customized care plan with safety net for patients who still need some ECG monitoring.
Intermittent vs. Continuous Monitoring
Physicians are tasked with making a clinical judgment on which patients need continuous ECG monitoring versus those who simply need a daily reading. There is a window of time post-intervention where patients are at greatest risk for paroxysmal AF and continuous monitoring has its place in the care continuum. The trick is understanding that once a patient no longer meets criteria for 24/7 monitoring, this does not mean that there should be an absence of ECG monitoring. The other consideration for those patients who would typically be placed on a continuous wearable device is that the level of compliance needs to be much greater. Dr. Fernandes Regis, a presenter at the Cardiology Update, enlightened his audience that of all patients referred to CR, 80% declined to participate (4). Many patients in these prescribed programs do not wish to wear a data collection device 24/7 for the full length of time suggested. Intermittent monitoring can be used as an alternative, or as a “step-down” option, and would serve as a way to prevent gaps in monitoring and data collection. In as little as 45 seconds, the patient can complete the task of monitoring their heart rhythm and the provider can make critical decisions to manage the patient. The hōm ecg+ device is a simple and realistic solution that can protect vulnerable patient populations and an excellent alternative to traditional monitoring solutions.
Stay tuned as we wrap up the series and focus on the bigger picture.
For more information about the Hom ECG+ solution, click here.
References:
Racca, V., Torri, A., Grati, P., Panzarino, C., Marventano, I., Saresella, M., & Castiglioni, P. (2020). Inflammatory Cytokines During Cardiac Rehabilitation After Heart Surgery and Their Association to Postoperative Atrial Fibrillation. Scientific Reports, 10(1), 1–11.
Sharma, V., Glotzbach, J. P., Ryan, J., & Selzman, C. H. (2021). Evaluating Quality in Adult Cardiac Surgery. Texas Heart Institute Journal, 48(1), 1–7. https://doi-org.proxygsu-grl1.galileo.usg.edu/10.14503/THIJ-19-7136
Onitilo, A. A., Piwuna, T. O., Islam, N., Furuya-Kanamori, L., Kumar, S., & Doi, S. A. R. (2022). Determinants of Atrial Fibrillation Development among Patients undergoing Ibrutinib Therapy. Clinical Medicine & Research, 20(1), 16–22.
Regis Fernandes, MD. Cardiac Rehab: Who Should Be Participating in 2022. Presented at Mayo Clinic Cardiology Update: The Heart of the Matter 2022. August 2022.