4th Annual Comprehensive CV Disease Management: From Fundamentals to Innovations 2020
Khaldoun G. Tarakji, MD MPH
@khaldountarakjiAssociate Section Head, Section of Cardiac Electrophysiology
Director, Center for Digital Health, Heart and Vascular Institute
Director, Center for International Medical Education, Education Institute
Cleveland Clinic, Cleveland Ohio
Wearables and Digital Health in Cardiology
Comprehensive CV Disease Management: Fundamentals to Innovation 2020Valley Health System & Cleveland Clinic
February 7, 2020
Ridgewood, New Jersey
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4th Annual Comprehensive CV Disease Management: From Fundamentals to Innovations 2020
Technology
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4th Annual Comprehensive CV Disease Management: From Fundamentals to Innovations 2020
The Prediction
Physicians: The Concerns
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4th Annual Comprehensive CV Disease Management: From Fundamentals to Innovations 2020
Bad Precedents
Main Stream and Social Media
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4th Annual Comprehensive CV Disease Management: From Fundamentals to Innovations 2020
Burnout
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• > half of individuals who purchase a wearable device stop using it (one third of these before 6 months)
• The gap between recording information and changing behavior is substantial
• Scaring the healthy: Demanding 100% accuracy
Are Patients / Consumers Ready?
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4th Annual Comprehensive CV Disease Management: From Fundamentals to Innovations 2020
Proposed Path to the Evolution of Digital Health
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Physicians: The Opportunities
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4th Annual Comprehensive CV Disease Management: From Fundamentals to Innovations 2020
Opportunities
Patient care
Research
Cost / Value
Global and Future Opportunities
Zungsontiporn N. BMJ 2018
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Why EP?
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4th Annual Comprehensive CV Disease Management: From Fundamentals to Innovations 2020
Patient care
Research
Cost / Value
Global and Future Opportunities
Opportunities
Need: Atrial Fibrillation
• Most common arrhythmia affecting > 5 million people – Chronic condition
• Projected 12 million by 2050
• AF accounts for 15 – 20 % of strokes in US
• Strokes secondary to AF are more detrimental
• 18% of AF triggered strokes present with AF that is newly detected
Benjamin EJ et. al. Circulation. 2018Miyasaka Y et. al. Circulation. 2016Marini C. et. Al. Stroke. 2005Lin HJ et. al. Stroke. 1995
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4th Annual Comprehensive CV Disease Management: From Fundamentals to Innovations 2020
Validation: Smartphone ECG Example
Tarakji el al. Heart Rhythm Journal 2015 William AD et. al. Heart Rhythm. 2018 Oct;15(10):1531‐1535
They work
Patients will adopt them
Automated algorithms are good but not perfect
For clinical decisions, still need physician over‐read
They work
Patients will adopt them
Automated algorithms are good but not perfect
For clinical decisions, still need physician over‐read
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4th Annual Comprehensive CV Disease Management: From Fundamentals to Innovations 2020
So what do I tell my patients?
Daily symptomsPVCs (Burden)
Tired with bradycardiaFrequent episodes
every week
Mittal S et. al. J Am Coll Cardiol 2011
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4th Annual Comprehensive CV Disease Management: From Fundamentals to Innovations 2020
Random episodes Palpitation every
few months
58 year man with palpitation diagnosed as anxiety attacks
DiagnoseDiagnose
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4th Annual Comprehensive CV Disease Management: From Fundamentals to Innovations 2020
62 year old man overseas
I was just diagnosed with AF and had a cardioversion
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4th Annual Comprehensive CV Disease Management: From Fundamentals to Innovations 2020
44 year old man with atrial fibrillation
ManageManage
Started DOAC
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4th Annual Comprehensive CV Disease Management: From Fundamentals to Innovations 2020
Wasserlauf J et al. Circulation AE. 2019
Can wearables replace loops?
What do I tell my neighbors?
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4th Annual Comprehensive CV Disease Management: From Fundamentals to Innovations 2020
• 0.5% got the notification• 34% of those had AF on
subsequent patch• 84% of notification correlated with
AF with simultaneous patch
• What about the other 99.5%• what to do with the info?
• Stay tuned for Guard AF, Heartline
Perez MV et. al. NEJM. 2019
What do I tell my neighbors?
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4th Annual Comprehensive CV Disease Management: From Fundamentals to Innovations 2020
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4th Annual Comprehensive CV Disease Management: From Fundamentals to Innovations 2020
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4th Annual Comprehensive CV Disease Management: From Fundamentals to Innovations 2020
Opportunities
Patient care
Research
Cost / Value
Global and Future Opportunities
Steinhubl et. al. JAMA. 2018Turakhia MP et. al. Am Heart J. Sep 2018*Courtesy Dr. Rod Passman, Northwestern Medical Center
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Rhythm Evaluation for AnticoagulationTherapy for Atrial Fibrillation (REACT‐AF)*
Paradigm shift in conducting research
New Terminology: Site‐Less StudyDirect to Consumer Studye‐consentSelf reporting
Innovative Ideas
Paradigm shift in conducting research
New Terminology: Site‐Less StudyDirect to Consumer Studye‐consentSelf reporting
Innovative Ideas
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4th Annual Comprehensive CV Disease Management: From Fundamentals to Innovations 2020
Opportunities
Patient care
Research
Cost / Value
Global and Future Opportunities
• 100 patients presenting for elective cardioversion for AF
• ECG pre and post Cardioversion
• Simultaneous Kardia Band Smart Watch recording
8% of patients were in sinus rhythm and did not need cardioversion
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4th Annual Comprehensive CV Disease Management: From Fundamentals to Innovations 2020
68 year old woman s/p redo AF ablationRedo PVI
Virtual Visit
Follow up
Virtual Visit
Follow up
• Telehealth market is expected to rapidly rise to 12.13B by 2022
• The Medical Virtualist
• Change in medical school curriculum
• Bedside manner vs Webside manner?
• Telemedicine ≠ Video Chat but could be of great value when supported by additional tools
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4th Annual Comprehensive CV Disease Management: From Fundamentals to Innovations 2020
Opportunities
Patient care
Research
Cost / Value
Global and Future Opportunities
Therapies for the rich
Pekka Raatikainen MJ et. al. Europace. 2014
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4th Annual Comprehensive CV Disease Management: From Fundamentals to Innovations 2020
Smart Devices: Not limited to the rich
Professional Societies and Regulatory Agencies
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4th Annual Comprehensive CV Disease Management: From Fundamentals to Innovations 2020
• 2019 CMS new CPT codes:
• CPT code 99454
• initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days” (technical component)
• CPT code 99457
• “Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified healthcareprofessional time in a calendar month requiring interactive communication with the patient/caregiver during the month” (professional component)
Remote Patient Monitoring Reimbursement
Slotwiner DJ, Tarakji KG, et. al. Heart Rhythm. 2019; 16
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4th Annual Comprehensive CV Disease Management: From Fundamentals to Innovations 2020
2020
Technology
Patients
Physicians
Regulators
• Wearables and apps should be an asset and not a threat or burden
• It is not about the device but about the indication
• Smart devices are only smart if used intelligently
• Work flow is as important as the device itself
Key Takeaways
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4th Annual Comprehensive CV Disease Management: From Fundamentals to Innovations 2020
Thank You
@khaldountarakji
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