Will the New Apple Watch Keep the Doctor Away?
By Smit Vasaiwala, MD, Cardiology
On September 12, 2018, Apple announced the release of the Series 4 Apple Watch, which has an electrical heart rate sensor with a capability of taking a single lead electrocardiogram (ECG). The watch received FDA clearance for monitoring heart rhythm with the ECG and notification of an irregular rhythm called atrial fibrillation (Afib) that puts patients at risk of stroke. This led to a mixed response from the scientific community.
There are several questions that need to be addressed when discussing the Apple Watch to better understand the implications of this device for the patient, the medical community and the healthcare system as a whole.
First and foremost, what is Afib and what are the risks that it poses for the patient?
Afib is a fast, irregular rhythm that originates in the top chamber of the heart called the atria. This causes the atria to lose the ability to squeeze, causing blood flow to slow, and resulting in the formation of blood clots in the heart. If the blood clot travels to the brain, this can result in a stroke, which can cause significant disability and even death. If a device can aid in detecting Afib before it leads to a stroke, this could be a game changer.
Who is at risk of Afib?
Although Afib can be seen in young and healthy individuals, the patients that are at risk tend to be older and sicker. The earlier Afib is detected, the lower the risk of stroke with proper medical treatment. The stroke risk also increases for people with high blood pressure, diabetes, congestive heart failure and history of prior stroke; therefore, a screening tool that can detect Afib would be most relevant for high-risk patients.
What is an irregular heart beat?
The Apple Watch claims to detect both atrial fibrillation and irregular heartbeats. Afib causes the heart to beat irregularly; however, not all irregular heartbeats are due to Afib. It is important to make this distinction because an irregular heartbeat may simply be due to extra beats either from the top chambers of the heart (premature atrial contractions or PACs) or lower chambers of the heart (premature ventricular contractions or PVCs). These extra beats may not require any further workup. A misdiagnosis of Afib due to PACs or PVCs may result in unnecessary testing or treatment.
How is Afib currently detected and what does the Apple Watch add?
The Apple Watch has a built-in electrical heart rate sensor that can take an electrocardiogram (ECG) similar to a 1-lead ECG. The standard is a 12-lead ECG, usually performed in the doctor’s office. Mobile monitoring for Afib is typically performed with event monitors that are either patch-based or have electrodes capable of producing a 3-lead ECG. There are also implantable monitors that are able to detect Afib; these are typically implanted under the skin with a small surgical procedure. Last year the FDA also approved a watch accessory that does the same thing as the Apple Watch called AliveCor KardiaBand. Unlike the KardiBand, the Apple Watch is the first direct-to-consumer wearable ECG device cleared by the FDA. The advantage of the Apple Watch and KardiaBand monitors is that these devices will allow for screening of Afib for durations that are much longer than the available monitors prescribed the physician and are non-invasive.
Who should wear the Apple Watch?
This depends on who you ask. If the watch is going to be used as a screening tool it should be used by patients who are more likely at risk (i.e., elderly patients with conditions that put them at risk for Afib such as high blood pressure and diabetes). For patients who are younger and otherwise healthy, the likelihood of false positives is going to be high. This may then result in further testing and treatment that is unnecessary.
Are we ready for this technology?
There is no question that as devices such as the Apple Watch become more mainstream, physicians and hospitals are going to have to adapt. What shape that is going to take remains to be seen. Accessibility of these devices for now will remain restricted to those who can afford them, until insurance companies will become willing to provide coverage. This will be a potential opportunity for appropriate patient selection to minimize the risk of false positive detections.
It is an exciting time in medicine as we move into an era of patient-centered medicine, where the patients are going to be more and more empowered to be involved in their own care. Wearable devices such as the Apple Watch are simply a small part of this revolution.
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Smit Vasaiwala, MD, is a cardiologist at Loyola Medicine. His clinical interests include ablation catheter application for complex arrhythmias, ablation of artial fibrillation, ablation of ventricular tachycardia, ablations for arrhythmias, arrhythmia, biventricular pacing, defibrillaor devices, electrophysiology, hypertrophic cardiomyopathy, radiofrequency ablation of cardiac arrhythmia and ventricular tachycardia.
Dr. Vasaiwala earned his medical degree from Loyola University Stritch School of Medicine. He completed his residency in internal medicine at the University of Michigan Medical Center and a fellowship in cardiology and electrophysiology at Loyola University Medical Center.