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EP on EP Episode 102: Mobile Technology in AF Mana ...
EP on EP Episode 102: Mobile Technology in AF Mana ...
EP on EP Episode 102: Mobile Technology in AF Management
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Video Transcription
Hi, I'm Eric Frostowski, and welcome to another segment of EP on EP. I'm delighted to have with me today my guest, Dr. Daniel Morin, who is the professor of medicine at the Ochsner Medical Center. Daniel, welcome to the show. Thanks so much. It's really great to be here. So here's the thing. We're getting deluged with patients sending us all kinds of stuff. What I'd like to center our discussion today, and we can take it in many forms, is what do we do with all this mobile technology? So let's just for a starter talk about AFib, because that's where a lot of it is. So what are the patient options out there? Because you see things on TV, the patients come in. So what do you talk to patients about when you're in the office about, if they're interested, which kind of thing would be best for them? Yeah, well there's a million different ways that patients can try to find their own atrial fibrillation or find the reason why they're having palpitations or whatnot. It can range from something that you use on occasion, like the CardioMobile device, for example, where you put your hands on there when you're having palpitations. The advantage to that is that you can carry it around and then you get a recording when there's an actual symptom. The drawback to that is that it's not always recording. There are some other devices, Apple Watch, other kinds of Fitbit and things along those lines that can tell you if, it can tell the patient if it suspects atrial fibrillation, but not all of those will produce an actual EKG that's actionable by somebody like you or me. That's one of the drawbacks of that form. In that school of that, though, there's this whole class of worried well out there, as they're called. You and I both deal with them. They can drive you crazy, right? They're not seeing us until they get a watch or a card, and then they go, oh my God, and they call you, and then they send you a strip every other minute. Let's put it this way. In the management, and I know you have some feelings on this, the patient taking charge somewhat of their management, how do you deal with all that, where your role comes in and what they're in charge of, and how do you mesh that together? Let's start by saying that the number one thing that we want to do is take care of patients as well as we can. That does involve finding as much atrial fibrillation as we can as well. In some ways, putting an EKG on a patient such that they can use it and empower themselves to maybe help to find what arrhythmia they're having, that is an advantage in terms of increasing the sensitivity that we're actually going to find atrial fibrillation if it's existent. However, these devices are not very specific, at least in present iterations. As you're saying, we can get lots, and lots, and lots of tracings, and it's just impossible for Eric Prostowski to sit there and flip through, as good as you are, to flip through every single one of these things. Nor do I want to be flipping through them all. It becomes extremely challenging, the deluge that you're describing. We're all in the same deluge, and sometimes, I'm sure you've had this, it's a patient that you were seeing for something else, and they bought a watch, or they bought a cardi, and they start sending you strips all the time. I know this may be a little medical-legal, but what is our obligation to see things that we didn't order, and we don't particularly want to see, because we don't know the context. What if you get seven seconds of AFib recorded? What does that mean? Do you have to start them on anticoagulant? How do you deal with those things? We simply don't know. I'm not a lawyer. I don't think you're a lawyer. No, not a lawyer. But I can say that it concerns me, and I think it concerns a lot of people, exactly what you're talking about. And part of it is because we don't know. We don't have enough data to know whether six seconds of atrial fibrillation is important, or six minutes, or six hours, or six days. And along those lines, sometimes, even if atrial fibrillation is not present, or only present in very small amounts, some patients will have bad outcomes. And that can be medically, legally, really risky for us. Yes. So, now let's take it the other way, that we prescribe. There are patients, I don't know if you're doing the same thing I am, I was always prescribing a wearable, not a mobile device, necessarily. But there are patients that I feel comfortable giving them something that can record an ECG, like an Apple Watch, or a Fitbit, or even a casiocardia. We don't get duration, right? And I'm guessing you're not going to anticoagulate someone for five seconds of a-fib. I wouldn't. Yeah, me neither. So, how do we deal with that problem? It might be a way to screen for potential atrial fibrillation that we think might be of important duration, whatever important duration we choose that to be. And so, if a patient brings you something that, of course, they're all very noisy, and so it's difficult to say if it's actually atrial fibrillation. But maybe that's the sensitive screen that we want in order to then apply our more specific monitoring, like in the form of an ILR, or a wearable device that you might get from the office. Well, I'm a part of a national trial, I don't want to plug it, but it's a trial that's being run by Rod Passman, looking at the use of these devices in patients for kind of a spot, you know, a pill in the pocket almost, anticoagulation. I don't want to get in that, because that's a trial that's going to test that hypothesis. But let's get a little bit into screening. So you have a person who's never had a problem that, say, has a high chance VAS, they're over 75, let's give them at least a three or four score, should we be screening for a-fib? I mean, it's a tough question, right? It is a tough question. On the pro side for screening is that if you find atrial fibrillation, you're getting a lot of bang for your buck, potentially. Well, let me stop you on that. There have been some preliminary data suggesting if you anticoagulate those folks, there's not a difference in stroke. Now, granted, the numbers are small, but, right, there are some early papers out there that have made me rethink it, but I don't have the final answer. I think you need a major study, but I'm sure you have patients who say to you, you know, my cousin had a stroke, I want to know if I have a-fib, and then you say, okay, you tell them something to do, and then they record something, but it's like you said, you don't know the duration. So I guess what I'm getting at is an unfair question, because no one knows, but what's your duration cutoff? I mean, if somebody's never had a problem before and they pick it up on one of these things and then you go ahead and do something else, wouldn't you worry about, I've got to do something? And I understand it's not fair, because nobody knows for sure, but you're a smart guy, I want to know your answer. Thank you. Well, I agree that nobody knows for sure, but in general, I'm a really conservative person in terms of stroke. In my mind, a stroke is one of the worst things, if not the worst thing, that can happen to a person. So in the absence of a contraindication to an anticoagulant, for example, I am very likely to treat people even at the six minute cutoff, because there has been some evidence in that direction. Now, is that going to be my hard and fast cutoff forever? Probably not. But I'm waiting for the data to come in that we're talking about. So let's look to the future. We know what's out there now. What do you think should be our, as EPs, what our goals should be? In other words, do you think you're going to get more into AI looking at EKG and that it predicts this person's a high risk for AFib? I'm still struggling with this a little bit, because a lot of patients are requesting these mobile devices, and it's all for risk stratification, right? They're all afraid of strokes. What are you waiting for, I guess? If Dan's sitting there saying, I want this thing, whether it be a device or AI, what is your like, I'm waiting for it? Well, I'm a public health guy, right? So I need, if I'm a public health guy, my absolute dream is a way to screen a large, large number of people in order to enrich that population to a smaller number of people that I can apply a more definitive test to. So if somebody comes up with an AI tool that will say, well, this person has X percent chance, and then we take a look at the cost of the next screening test, that, I think, in my mind, is the holy grail of all screening. Yeah, I think I like that. So basically, you have a pool of people who are at risk of stroke, theoretically, right? Over 75, and et cetera, et cetera. If you had a ECG type of screening test that hones in on that group, and then you get aggressive with that group. Exactly, because we don't want all of those people to have a mobile device that's going to flood us with all of the tracings that we're talking about, and is not specific enough. Dan, great discussion. Thanks so much for being on the show. Thank you. Really appreciate it.
Video Summary
In this segment of EP on EP, Dr. Daniel Morin discusses the use of mobile technology in managing atrial fibrillation (AFib) with host Eric Frostowski. They delve into patient options such as devices like CardioMobile, Apple Watch, and Fitbit for monitoring AFib. The conversation also touches on the challenges of managing patients who self-monitor and send tracings, the uncertainty around interpreting short AFib recordings, and the need for more data to guide treatment decisions. Dr. Morin emphasizes the importance of stroke prevention and discusses the potential role of AI in screening high-risk individuals for AFib. They explore the future goals of EPs, focusing on cost-effective screening methods to target at-risk populations effectively.
Keywords
EP on EP
mobile technology
atrial fibrillation
CardioMobile
AI screening
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