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POSITION PAPER

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 Pacic Heart Rhythm Society

Niraj Varma (ISHNE Chair),

1

Iwona Cygankiewicz (ISHNE Vice-Chair),

2

Mintu Turakhia (HRS Vice-Chair),

3

Hein Heidbuchel (EHRA Vice-Chair),

4

Yufeng Hu (APHRS Vice-Chair),

5

Lin Yee Chen,

6

Jean-Philippe Couderc,

7

Edmond M. Cronin,

8

Jerry D. Estep,

1

Lars Grieten,

9

Deirdre A. Lane,

10Reena Mehra,

1

Alex Page,

7

Rod Passman,

11

Jonathan 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

From the

1

Cleveland Clinic, Cleveland, OH, USA,

2

Medical University of Lodz, Lodz, Poland,

3

Stanford

University, Palo Alto, CA, USA,4

Antwerp University and University Hospital, Antwerp, Belgium, 5

Taipei Veterans General Hospital, Taipei, Taiwan,

6

University of Minnesota, Minneapolis, MN, USA,

7

University of Rochester, Rochester, NY, USA,

8

Temple University, Philadelphia, PA, USA,

9

Hasselt

University, Hasselt, Belgium,

10

University of Liverpool, Liverpool, UK,

11

Northwestern University

Feinberg School of Medicine, Chicago, IL, USA,

12

Duke University, Durham, NC, USA,

13

National

Institute of Cardiology, Warsaw, Poland,

14Lund University, Lund, Sweden,

15

FaculdadedeMedicina,

Centro de Telessa

ude,Hospital das Clínicas, and Departamento de Clínica Médica, UniversidadeFederal de Minas Gerais, Belo Horizonte, Brazil, 16 Cooper Medical School of Rowan University, Camden, NJ, USA, 17 Cardiology Division, NewYork-Presbyterian Queens, and School of Health Policy and Research,

Weill Cornell Medicine, New York, NY, USA, and

18 Karolinska University Hospital, Stockholm, Sweden.

Patient Representative

AbstractThis collaborative statement from the International Society forHolterandNoninvasiveElectrocardiology/Heart Rhythm So- ciety/European Heart Rhythm Association/Asia Pacic 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 theymay be applied to and clinical decisions that may be enabled

are discussed. The facilitation of comorbidity and lifestyle man- agement (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 opera- tional challenges in embedding mHealth into routine clinical care are explored.

2666-6936/This article has been co-published with the permission ofAnnals of Noninvasive Electro-

cardiology, Cardiovascular Digital Health Journal, Circulation: Arrhythmia and Electrophysiology,

European Heart Journal - Digital Health and Journal of Arrhythmia. All rights reserved. © 2021 The

Authors.Annals of Noninvasive Electrocardiologypublished by Wiley Periodicals Inc. on behalf of the International Society for Holter and Noninvasive Electrocardiology /Cardiovascular Digital Health Electrophysiologypublished by Wolters Kluwer Health, Inc. on behalf of the American Heart Asso- ciation,Inc. /EuropeanHeart Journal-Digital Healthpublished by OxfordUniversity Press on behalf of theEuropean Society of Cardiology/Journal of Arrhythmiapublished by Wiley and Sons Australia Ltd on behalf of the Japanese Heart Rhythm Society and the Asia Pacic Heart Rhythm Society. This article is published under the Creative Commons CC-BY license, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. The articles are identical

except for minor stylistic and spelling differences in keeping with each journal's style. Either citation

can be used when citing this article. This is an open access article under the CC BY license (http://

TABLE OF CONTENTS

1. Introduction ..............................................2

Document scope and rationale .................2

2. mHealth Technologies .............................5

2.1. Ambulatory ECG monitoring ...........5

2.2. New mHealth-based modalities for

arrhythmia monitoring ..............................6

2.2.1. ECG-based ................................6

2.2.1.1. Handheld devices ................6

2.2.1.2. Wearable patches .................8

2.2.1.3. Biotextiles ............................8

2.2.1.4. Smartphone and smartwatch-

based devices ....................................8

2.2.2. Non-ECG-based ........................10

2.2.2.1. Photoplethysmography ........10

2.2.2.2. Oscillometry ........................10

2.2.2.3. Mechanocardiography .........11

2.2.2.4. Contactless video

plethysmography ...............................11

2.2.2.5. Smart speakers .....................11

3. mHealth Applications for Arrhythmias ...13

3.1. Atrialfibrillation ...............................13

3.1.1. Undiagnosed atrialfibrillation

identification ........................................13

3.1.2. Targeted identification in high-

risk individuals ....................................16

3.1.3. Diagnostics in people with

established atrialfibrillation ...................17

3.1.4. Atrialfibrillation therapy ...........17

3.2. Sudden cardiac death ........................18

4. Comorbidities ...........................................22

4.1. Ischemic heart disease ......................23

4.2. Heart failure ......................................23

4.2.1. Mobile technologies for

managing heart failure .........................24

4.2.2. Hybrid telerehabilitation in

patients with heart failure ....................254.3. Diabetes ............................................25

4.4. Hypertension .....................................26

4.5. Disorders including sleep apnea .......26

4.6. Lifestyle (SeeFigure 5) ....................27

4.6.1. Physical activity ........................27

4.6.2. Diet ............................................27

5. Patient Self-Management - Integrated

Chronic Care .................................................31

5.1. Patient engagement ...........................31

5.2. Behavioral modification ....................32

5.3. Patients as part of a community .......32

5.4. Maintaining patient engagement ......32

5.5. Digital divide ....................................33

6. Clinical Trials ..........................................35

7. Operational Challenges ............................37

7.1. Healthcare system - eHealth

monitoring and hospital ecosystem ..........37

7.2. Cybersecurity guidance for mHealth

devices ......................................................38

7.2.1. Hacking strategies and methods

in mHealth technologies ......................38

7.2.2. Recommendations to the

manufacturer ........................................39

7.2.3. Recommendations to clinicians

and administrators ................................39

7.2.4. Recommendations to patients ...39

7.3. Reimbursement .................................39

7.4. Regulatory landscape for mHealth

devices ......................................................40

8. Predictive Analytics .................................41

9. Future Directions .....................................43

Concluding Remarks ....................................45

1. Introduction

Document scope and rationale

Digital health is an umbrella term to describe the use of dig- ital information, data, and communication technologies to collect, share, and analyze health information in order to KEYWORDSarrhythmias; atrialbrillation; comorbidities; digital medicine; heart rhythm; mHealth ABBREVIATIONS AI5articialintelligence;ACC5AmericanCollege of Cardiology;ACS5acute coronary syndrome;AED5automated external debrillator;AF5atrialbrillation;AHA5American Heart Association;AHRE5atrial high-rate episode;APHRS5Asia Pacic Heart Rhythm Society;BP5blood pressure;CIED5cardiovascular implantable electronic device;CPR5cardiopulmonary resuscitation; EHR A5European Heart Rhythm Association;EMR5electronic med- ical record;ESUS5embolic stroke of unknown source;FDA (U.S.)5FoodandDrugAdministration;GPS5global positioning system;HCP5healthcare professional;HF5heart failure; HR5heart rate;HRS5Heart Rhythm Society;ICD5implantablequotesdbs_dbs25.pdfusesText_31

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