Clinical eHealth 7 (2024) 41–50

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Clinical eHealth
journal homepage: ww.keaipublishing.com/CEH

Wearable dynamic electrocardiogram monitor-based screening for atrial

fibrillation in the community-dwelling elderly population
Lili Wei a,b,c,1, Enyong Su a,c,1, Jianfang Xie d, Wangqiong Xiong e, Xiaoyue Song a, Junqiang Xue a,
Chunyu Zhang a, Ying Hu b,c, Peng Yu f,⇑, Ming Liu c,g,⇑, Hong Jiang a,c,⇑
a
Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional
Medicine, Shanghai, China
b
Shanghai Xuhui Central Hospital, Zhongshan-Xuhui Hospital, Fudan University, Shanghai, China
c
Shanghai Engineering Research Center of AI Technology for Cardiopulmonary Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
d
Department of Scientific Research and Education, Qingpu Branch, Zhongshan Hospital, Fudan University, Shanghai, China
e
Department of Cardiology, Qingpu Branch, Zhongshan Hospital, Fudan University, Shanghai, China
f
Department of Endocrinology and Metabolism, Fudan Institute of Metabolic Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
g
Department of Health Management Center, Zhongshan Hospital, Fudan University, Shanghai, China

a r t i c l e i n f o a b s t r a c t

Article history: Background: Atrial fibrillation (AF) is a major public health problem with high rates of morbidity, disabil-
Received 20 January 2024 ity and mortality, especially in the elderly population. This study explored the diagnosis and treatment
Revised 28 February 2024 status of AF in adults aged 65 years in the community through wearable dynamic electrocardiogram
Accepted 4 March 2024
(ECG) monitoring.
Available online 7 March 2024
Methods: We conducted a cross-sectional study in 4 random communities within the Qingpu district of
Shanghai, China. Between January 1, 2020 and June 30, 2022, the ECGs of 3852 adults aged 65 years or
Keywords:
older were examined through wearable dynamic ECG monitoring. Data from 3839 participants were ulti-
Atrial fibrillation
Electrocardiogram
mately analyzed. Multivariate logistic regression was used to determine the independent predictors of
Anticoagulant therapy AF.
Ischemic stroke Results: Wearable dynamic ECG monitoring detected AF in 360 elderly people, 78 of whom were diag-
Elderly population nosed with AF for the first time. Multivariate logistic regression analysis revealed that snoring, renal dys-
function, coronary heart disease and high CHA2DS2-VASc score were independent risk factors for AF.
Among patients with unknown AF, 68 (87.20 %) met the criteria for anticoagulant therapy based on
the CHA2DS2-VASc score. Only 4 (5.88 %) patients were taking anticoagulants. Of the patients with a clear
history of AF, 249 (84.98 %) needed an anticoagulant strategy, but only 18 (7.23 %) took oral anticoagu-
lants.
Conclusion: Many elderly people have silent AF, and wearable dynamic ECG monitoring can be used to
screen for AF effectively.
Ó 2024 The Authors. Publishing services by Elsevier B.V. on behalf of KeAi Communications Co. Ltd. This is
an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction It is estimated that by 2050, there will be 6 million cases of AF in

the United States,4,5 with another 14 million in Europe6,7 and 72
Atrial fibrillation (AF) is the most common cardiac dysrhythmia. million in Asia.8
According to the Framingham Heart Study, the number of patients AF increases the risk of multiple cardiovascular readmissions by
diagnosed with AF has increased threefold over the last 50 years.1 8-fold.9 Heart failure occurs in more than 50 % of patients with
Faced with the double pressure of an aging population and the con- AF.10,12 The risk of ischemic stroke in patients with AF is approxi-
tinuing prevalence of cardiovascular risk factors, it is expected that mately five times great than that in patients without AF.13 Age is
the prevalence of AF will continue to rise in the next 30–50 years.2,3 an independent risk factor for AF.14 The incidence of AF in patients
aged less than 49 years, 60–70 years, and 80 years and older is 0.
12 %–0.16 %, 3.7 %–4.2 % and 10 %–17 %, respectively.15 The risk
⇑ Corresponding authors. of fatal cardiovascular and cerebrovascular events associated with
E-mail addresses: [email protected] (P. Yu), [email protected] AF increases with age.14 In particular, AF patients older than
(M. Liu), [email protected] (H. Jiang).
1 85 years of age have a 12-fold greater risk of ischemic stroke than
These authors contributed equally to this work.

https://doi.org/10.1016/j.ceh.2024.03.001
2588-9141/Ó 2024 The Authors. Publishing services by Elsevier B.V. on behalf of KeAi Communications Co. Ltd.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
L. Wei, E. Su, J. Xie et al. Clinical eHealth 7 (2024) 41–50

non-AF patients of the same age.13 AF is sometimes asymptomatic, Then, we input the syntax to Stata, namely, power oneproportion
and elderly people often have multiple comorbidities and are at 0.018 0.027, power (0.80). The result was n = 1946. The number
high risk for ischemic stroke and other arterial thromboembolic of enrolled patients was approximately twice the minimum
events. Therefore, screening the above population for silent AF requirement. The inclusion criteria were as follows: 1) registered
has become a focus. residents of the community; 2) aged 65 years or older; 3) cooper-
Electrocardiography (ECG) is the gold standard for diagnosing ated with wearing the dynamic ECG monitoring equipment; and 4)
AF.16,17 Therefore, the purpose of this study was to use wearable completed a structured questionnaire on health information. The
dynamic ECG monitoring to screen community-dwelling people exclusion criterion was skin allergy to the wearable dynamic ECG
aged 65 years and older and living in the community, clarify the monitor components.
diagnosis and treatment status of AF in the elderly population. Written informed consent was obtained from all participants.
The research protocol was approved by the Medical Ethics Com-
mittee of Qingpu Branch of Zhongshan Hospital Affiliated to Fudan
2. Material and methods University (No.2019-25).

2.1. Study design and participants

2.2. Data collection
We increased awareness of the characteristics and hazards of AF
through community workers and family doctors and encouraged A structured questionnaire was given to gather the subjects’
community members to participate in AF screening. We conducted clinical characteristics, including sex, age, liver function and renal
a cross-sectional study of participants aged 65 years or older living function, and to record their habits in relation to snoring, smoking
in 4 random communities in the Qingpu District of Shanghai (one and alcohol consumption. Personal history of hypertension, dia-
of the three provinces with the greatest proportion of the popula- betes mellitus, hyperlipidemia, coronary artery disease, hyperthy-
tion aged 60 years and older in the seventh national population roidism, peripheral artery embolism, heart failure, ischemic stroke
census of China)18 between January 1, 2020, and June 30, 2022. and bleeding and interview information concerning history of car-
The calculation of sample sizes was based on previous literature,19 diovascular medication use, including anticoagulant therapy, anti-
in which the prevalence of AF in 65-year-olds was 3 %, and the platelet therapy, antiarrhythmic therapy, angiotensin-converting
awareness of AF was approximately 87 %. In this study, we antici- enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs)
pated that the screening tool could increase awareness to 90 %. and calcium receptor antagonists (CCBs), were collected. We also

Fig. 1. ECG signals detected by the wearable dynamic ECG monitor. (A) Normal ECG; (B) AF ECG. Abbreviations: ECG, electrocardiogram; AF, atrial fibrillation.

42
L. Wei, E. Su, J. Xie et al. Clinical eHealth 7 (2024) 41–50

calculated CHA2DS2-VASc scores [congestive heart failure (1 (Fig. 1). Each ECG report had a consistent diagnosis by at least
point), hypertension (1 point), age 75 years (2 points), diabetes two doctors. All participants wore dynamic ECG monitors continu-
(1 point), stroke/transient ischemic attack (2 points), vascular dis- ously for at least 24 h.
ease (1 point), age 65–74 years (1 point), female Sex (1 point)]20–23
and HAS-BLED scores [uncontrolled hypertension (1 point), abnor- 2.4. Outcomes
mal renal/liver function (1 point or 2 points), stroke (1 point),
bleeding history or predisposition (1 point), labile international The outcome events that we recorded were ischemic stroke,
normalized ratio (1 point), age >65 years (1 point), and concomi- heart failure and peripheral artery embolism. The occurrence of
tant drug/alcohol use (1 point or 2 points)]24,25 to assess the risk these events was adjudicated by specialists. Ischemic stroke and
of ischemic stroke and bleeding among elderly people with AF. peripheral artery embolism were demonstrated by imaging.
Congestive heart failure was defined based on evidence for signs,
2.3. Wearable dynamic ECG monitor screening for AF symptoms, elevated natriuretic peptide levels, and
echocardiography.
A 3-lead wearable dynamic ECG monitor (Registration Number:
Shanghai Machinery Approval 20222070199; SID Medical Co., 2.5. Statistical analysis
Ltd.), which allows continuous monitoring of ECG data for up to
72 h and can continue recording after charging, was used for Continuous variables are presented as the mean ± standard
screening AF. The ECG data collected by the eccentric electrode deviation, while categorical variables are described as percentages.
were amplified, filtered and stored through the ECG acquisition Continuous variables and categorical variables were compared
module. Doctors specializing in ECG from the Qingpu Branch of using Student’s t test and the v2 test, respectively. Multivariate
Zhongshan Hospital Affiliated to Fudan University downloaded logistic regression analysis was carried out to identify independent
the ECG data from the monitors for analysis and diagnosis predictors of AF, and the risk and strength of association are

Fig. 2. Study flow chart.

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L. Wei, E. Su, J. Xie et al. Clinical eHealth 7 (2024) 41–50

indicated as odds ratios (ORs) and 95 % confidence intervals (CIs), Table 2

respectively. p < 0.05 was considered to indicate statistical signif- Other arrhythmias except AF.

icance. The data were analyzed using SPSS software (version 20.0). Rhythm type AF (n = 371) (%) Non-AF
(n = 3468) (%)
Atrial premature beat, n (%) 132 (35.58) 1603 (46.22)
3. Results Atrial tachycardia, n (%) 35 (9.43) 426 (12.28)
Supraventricular tachycardia, n (%) 1 (0.27) 2 (0.06)
Ventricular premature beat, n (%) 81 (21.83) 495 (14.27)
3.1. Characteristics of the study population
Ventricular tachycardia, n (%) 0 (0) 2 (0.06)
Second-degree type II 0 (0) 1 (0.03)
From January 1, 2020, to June 30, 2022, 3877 community- sinoatrial block, n (%)
dwelling people aged 65 years or older were invited to participate
Data are expressed as the number (%) of subjects. Abbreviations: AF: atrial
in screening for AF, and 25 people were unsuccessful in participat- fibrillation.
ing in the project because they refused to sign the informed con-
sent form. A total of 3852 participants were enrolled in this No significant differences were found in sex, smoking or alcohol
study (Fig. 2). However, thirteen elderly people were excluded consumption history, or history of abnormal liver function, dia-
because their skin was sensitive to the wearable dynamic ECG betes mellitus, hyperlipidemia or hyperthyroidism between these
monitor. Therefore, 3839 were included in the final analysis. A two groups (all p > 0.05) (Table 1). Hypertension was the most
total of 360 elderly people were diagnosed with AF by wearable common complication in both groups (73.58 % and 65.74 %, respec-
dynamic ECG monitoring, 78 of whom were newly diagnosed with tively). ACEIs/ARBs were the most common medication prescribed
AF, and 282 had AF identified using 12-lead resting ECG or 24-h in both the AF group and the non-AF group (29.38 % and 34.17 %,
ambulatory ECG in their personal history. A total of 3479 residents respectively).
were not found to have an AF rhythm under screening, 11 of whom In addition to AF, wearable dynamic ECG monitoring also
had a history of AF. detected many other types of arrhythmias, including atrial prema-
We divided the 3839 eligible participants into AF and non-AF ture beats, atrial tachycardia, supraventricular tachycardia and
groups for further analysis (Table 1). There were 371 patients in ventricular premature beats, in the above groups (Table 2). In par-
the AF group and 3468 people in the non-AF group. The AF group ticular, 2 patients with ventricular tachycardia and 1 with second-
was older than the non-AF group (76.25 ± 7.39 vs. 74.14 ± 7.94 ye degree type II sinoatrial block were first identified in the non-AF
ars, p < 0.001). The AF group had significantly greater incidences of group.
snoring (30.46 % vs. 21.57 %, p < 0.001), renal dysfunction (2.96 %
vs. 0.75 %, p < 0.001), hypertension (73.58 % vs. 65.74 %,
p = 0.002), coronary artery disease (40.7 % vs. 13.67 %, p < 0.001), 3.2. Risk factors for AF diagnosis
heart failure (1.62 % vs. 0.4 %, p = 0.002) and ischemic stroke
(18.87 % vs. 13.24 %, p = 0.003) than the non-AF group. Participants Univariate analysis demonstrated that AF was associated with
diagnosed with AF also had a higher CHA2DS2-VASc score than age, snoring, renal dysfunction, hypertension, coronary artery dis-
those without evidence of AF (3.33 ± 1.30 vs. 2.87 ± 1.35, ease, heart failure and the CHA2DS2-VASc score (all p < 0.01)
p < 0.001). In terms of cardiovascular drug therapy, anticoagulant (Table 3).
drugs, antiplatelet drugs and antiarrhythmic therapy were pre- Multivariate analysis revealed that a habit of snoring (OR:
scribed more often in the AF group than in the non-AF group (all 1.533, 95 % CI [1.197–1.964], p = 0.001), renal dysfunction (OR:
p < 0.001). 2.521, 95 % CI [1.165–5.456], p = 0.019), coronary artery disease
(OR: 3.753, 95 % CI [2.964–4.751], p < 0.001) and a high
CHA2DS2-VASc score (OR: 1.168, 95 % CI [1.407–1.703],
Table 1 p = 0.005) were independent predictors of AF (Table 4).
Baseline characteristics of the study population.

Characteristics AF Non-AF P-value 3.3. CHA2DS2-VASc score of AF patients and prescription of

(n = 371) (%) (n = 3468) (%)
antithrombotic therapy
Female, n (%) 233 (62.8) 2176 (62.75) 0.982
Age, (years) 76.25 ± 7.39 74.14 ± 7.94 <0.001
The current ACC/AHA 2019, ESC 2020 and APHRS 2021 guideli-
Smoking, n (%) 69 (18.6) 769 (22.17) 0.113
Snore, n (%) 113 (30.46) 748 (21.57) <0.001 nes all recommend the use of the clinical risk factor-based
Alcohol drinking history, n (%) 64 (17.25) 690 (19.9) 0.223
Abnormal liver function, n (%) 0 (0) 3 (0.09) 0.737 Table 3
Renal dysfunction, n (%) 11 (2.96) 26 (0.75) <0.001 Univariate logistic regression analysis of factors associated with AF.
Hypertension, n (%) 273 (73.58) 2280 (65.74) 0.002
OR 95 % CI P-value
Diabetes mellitus, n (%) 8 (2.16) 95 (2.74) 0.509
Hyperlipidemia, n (%) 1 (0.27) 8 (0.23) 0.883 Female 1.002 0.803–1.251 0.982
Coronary artery disease, n (%) 151 (40.7) 474 (13.67) <0.001 Age 1.032 1.019–1.045 <0.001
Hyperthyroidism, n (%) 4 (1.08) 46 (1.33) 0.689 Smoking 0.802 0.61–1.054 0.114
Peripheral artery embolism, n (%) 2 (0.54) 8 (0.23) 0.268 Snore 1.593 1.259–2.015 <0.001
Heart failure, n (%) 6 (1.62) 14 (0.4) 0.002 Alcohol drinking history 0.839 0.063–1.113 0.223
Ischemic stroke, n (%) 70 (18.87) 459 (13.24) 0.003 Renal dysfunction 4.045 3.449–5.449 <0.001
CHA2DS2-VASc score 3.33 ± 1.30 2.87 ± 1.35 <0.001 Hypertension 1.452 1.14–1.847 0.002
Anticoagulant therapy, n (%) 22 (5.93) 5 (0.14) <0.001 Diabetes mellitus 0.782 0.377–1.623 0.51
Antiplatelet therapy, n (%) 70 (18.87) 261 (7.53) <0.001 Hyperlipidemia 1.169 0.146–9.372 0.883
Antiarrhythmic therapy, n (%) 12 (3.23) 27 (0.78) <0.001 Coronary artery disease 4.335 3.449–5.449 <0.001
ACEIs/ARBs, n (%) 109 (29.38) 1185 (34.17) 0.064 Hyperthyroidism 0.811 0.29–2.265 0.689
CCB, n (%) 43 (11.59) 535 (15.43) 0.05 Peripheral artery embolism 2.344 0.496–11.077 0.282
Statins, n (%) 21 (5.66) 127 (3.66) 0.057 Heart failure 4.056 1.549–10.618 0.004
Ischemic stroke 1.942 0.855–4.413 0.113
Data are expressed as the mean ± standard deviation or number (%) of subjects. CHA2DS2-VASc score 1.279 1.183–1.381 <0.001
Abbreviations: AF: atrial fibrillation; ACEIs: angiotensin-converting enzyme inhi-
bitors; ARBs: angiotensin receptor blockers; CCB: calcium receptor antagonist. Abbreviations: AF: atrial fibrillation; OR: odds ratio; CI: confidence interval.

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Table 4 Among AF residents dwelling in the community, we investi-

Multivariable logistic regression analysis to identify independent predictors for AF. gated antithrombotic therapy strategies in women with a
OR 95 % CI P-value CHA2DS2-VASc score 3 and in men with a CHA2DS2-VASc score
Age 1.013 0.996–1.039 0.139 2. Among the patients first diagnosed with AF by wearable
Snore 1.533 1.197–1.964 0.001 dynamic ECG monitoring, 2 (4.08 %), 3 (6.12 %) and 44 (89.8 %)
Renal dysfunction 2.521 1.165–5.456 0.019 female patients received anticoagulant therapy, antiplatelet ther-
Hypertension 0.909 0.682–1.211 0.513 apy and no antithrombotic therapy, respectively (Fig. 4A). The
Coronary artery disease 3.753 2.964–4.751 <0.001
Heart failure 1.651 0.590–4.619 0.339
respective numbers of male patients were 2 (10.53 %), 4
CHA2DS2-VASc score 1.168 1.407–1.703 0.005 (21.05 %) and 13 (68.42 %) (Fig. 4A). Among participants with a his-
tory of AF, 13 (8.84 %), 35 (23.81 %) and 99 (67.35 %) female
Abbreviations: AF: atrial fibrillation; OR: odds ratio; CI: confidence interval.
patients received anticoagulant therapy, antiplatelet therapy and
no antithrombotic therapy, respectively (Fig. 4B). The respective
CHA2DS2-VASc score for evaluating anticoagulation indications, numbers of male patients were 5 (4.9 %), 25 (24.51 %) and 72
and oral anticoagulants (OACs) are recommended for women with (70.59 %) (Fig. 4B).
a CHA2DS2-VASc score 3 and men with a score 2.20–23 The In patients with a history of AF, we further analyzed the reasons
patients first diagnosed with AF by wearable dynamic ECG moni- for not receiving anticoagulant therapy in women with a
toring were 57 (73.08 %) females and 21 (26.92 %) males. A total CHA2DS2-VASc score 3 and in men with a CHA2DS2-VASc score
of 49 (85.96 %) women had an OAC-recommendation CHA2DS2- 2 (Fig. 5). Approximately 50 % of patients had a HAS-BLED score
VASc score 3, and 19 (90.48 %) men had an analogous 3 (23.13 % and 30.93 %, respectively) or received antiplatelet
CHA2DS2-VASc score 2 (Fig. 3A). A total of 176 (60.07 %) females therapy (26.12 % and 25.77 %, respectively) among both female
and 117 (39.93 %) males had a history of AF. A total of 147 (83.52 %) patients and male patients. Approximately 23.13 % of the female
women and 102 (87.18 %) men had CHA2DS2-VASc scores 3 and patients and 22.68 % of the male patients were not aware of
2, respectively (Fig. 3B). the thromboembolic risk and therefore did not accept the use of

Fig. 3. Stroke risk assessment of patients with AF. CHA2DS2-VASc score of (A) patients diagnosed with AF for the first time and (B) patients with a history of AF. Abbreviation:
AF, atrial fibrillation.

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L. Wei, E. Su, J. Xie et al. Clinical eHealth 7 (2024) 41–50

Fig. 4. Antithrombotic therapy of AF patients with CHA2DS2-VASc scores 2 (men) or 3 (women). The percentages of patients treated with anticoagulant therapy,
antiplatelet therapy, and no antithrombotic therapy among (A) patients diagnosed with AF for the first time and (B) patients with a history of AF. Abbreviation: AF, atrial
fibrillation.

anticoagulants. Given the side effects such as bleeding and renal ischemic stroke. However, only 1 (4.48 %) patient received antico-
dysfunction associated with anticoagulants, 15.67 % of female agulant therapy. Among the participants with a history of AF, 6
patients and 11.34 % of male patients refused to take anticoagulant (2.05 %), 59 (20.14 %) and 2 (0.68 %) had complications of heart fail-
drugs. ure, ischemic stroke and peripheral artery embolism, respectively.
Fifty (84.75 %) patients complicated with ischemic stroke and 2
(100 %) with peripheral artery embolism were not treated with
3.4. Clinical complications in AF patients
anticoagulant drugs.
Table 5 indicates that the proportions of ischemic stroke were
4.65 %, 85 %, 100 % and 100 % in female AF patients with 4. Discussion
CHA2DS2-VASc scores of 4, 5, 6 and 7, respectively. The percent-
ages of the above events were 75 %, 100 % and 100 % in male AF According to a meta-analysis of 66 cohort studies, AF increased
patients with CHA2DS2-VASc scores of 4, 5 and 6, respectively. the risk of all-cause mortality by 46 %, ischemic heart disease by
These results suggested that the incidence of thromboembolic 61 %, chronic kidney disease by 64 %, sudden cardiac death by
events increases with the CHA2DS2-VASc score, with a signifi- 88 %, and major cardiovascular events by 96 %.26 The epidemiology
cantly greater percentage of female AF patients having a of AF has changed over the past 15 years, as patients have aged and
CHA2DS2-VASc score 5 and male AF patients having a are more affected by cardiovascular and noncardiovascular comor-
CHA2DS2-VASc score 4. bidities.27 Approximately 10 % of patients hospitalized for ischemic
We further investigated antithrombotic therapy strategies for stroke are first diagnosed with AF during their stay.28 Approxi-
AF patients with outcome events, including heart failure, ischemic mately 1.4 % of patients aged 65 years or older had unknown AF
stroke and peripheral artery embolism (Table 6). Among the partic- detected on a single time-point ECG or pulse test.28 In this study,
ipants who were found to have new-onset AF, 11 (14.10 %) had 9.66 % of individuals had an ECG indicating AF rhythm or a clear
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L. Wei, E. Su, J. Xie et al. Clinical eHealth 7 (2024) 41–50

Fig. 5. Distribution of reasons for not receiving anticoagulant treatment in patients with a history of AF. The percentages of not treating with anticoagulant therapy in (A)
female patients with CHA2DS2-VASc scores 3 and in (B) male patients with CHA2DS2-VASc scores 2. Abbreviation: AF, atrial fibrillation.

Table 5
Association of thromboembolic events with CHA2DS2-VASc score in AF patients.

Female Male
CHA2DS2-VASc score (n = 233) Ischemic stroke Peripheral artery embolism CHA2DS2-VASc score (n = 138) Ischemic stroke Peripheral artery embolism
1 (0) 0 (0) 0 (0) 1 (n = 17) 0 (0) 0 (0)
2 (n = 37) 0 (0) 0 (0) 2 (n = 47) 0 (0) 0 (0)
3 (n = 66) 0 (0) 1 (1.52 %) 3 (n = 47) 0 (0) 0 (0)
4 (n = 86) 4 (4.65 %) 0 (0) 4 (n = 8) 6 (75 %) 0 (0)
5 (n = 20) 17 (85 %) 0 (0) 5 (n = 17) 17 (100 %) 0 (0)
6 (n = 22) 22 (100 %) 0 (0) 6 (n = 2) 2 (100 %) 0 (0)
7 (n = 2) 2 (100 %) 1 (50 %) 7 (0) 0 (0) 0 (0)

Data are expressed as the number (%) of subjects. Abbreviation: AF: atrial fibrillation.

history of AF, and 2.03 % of individuals were diagnosed with AF for the community. Therefore, screening for unknown AF and
the first time. The number of patients with newly detected AF strengthening the management of community-dwelling older
accounted for 21.02 % of the total elderly population with AF in adults with AF are essential. A meta-analysis of 44 prospective

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L. Wei, E. Su, J. Xie et al. Clinical eHealth 7 (2024) 41–50

Table 6 agement, and cardiovascular and comorbidity management.21

The incidence of complications of AF in the first diagnostic of AF group and history of
AF group.
Compared with other etiologies, ischemic strokes due to AF are
more likely to cause disability or death and tend to result in longer
First diagnosis History hospital stays and higher costs.13,44 The guidelines recommend
of AF of AF
(n = 78) (%) (n = 293) (%)
OACs for AF patients with CHA2DS2-VASc scores 2 (men) or 3
(women).20–23 AF patients with a CHA2DS2-VASc score 3 in our
Heart failure All 0 (0) 6 (2.05)
Anticoagulant therapy
study were also often complicated with thromboembolic events.
No 0 (0) 5 (83.33) In particular, female AF patients with CHA2DS2-VASc scores 6
Yes 0 (0) 1 (16.67) and male AF patients with CHA2DS2-VASc scores 5 all suffered
Ischemic stroke All 11 (14.10) 59 (20.14) ischemic stroke. However, the proportion of eligible AF patients
Anticoagulant therapy currently prescribed anticoagulants is not ideal. Among partici-
No 10 (95.52) 50 (84.75) pants with a history of AF who met the criteria for anticoagulant
Yes 1 (4.48) 9 (15.25)
therapy based on the CHA2DS2-VASc score, only 8.84 % of women
Peripheral artery All 0 (0) 2 (0.68) and 4.9 % of men were receiving anticoagulant therapy, and
embolism Anticoagulant therapy
67.35 % of female patients and 70.59 % of male patients did not
No 0 2 (100)
Yes 0 0 (0) undergo antithrombotic therapy. We investigated the reasons for
not undergoing anticoagulant therapy in the above population
Data are expressed as the number (%) of subjects. Abbreviation: AF: atrial
and found that a HAS-BLED score 3 and receiving antiplatelet
fibrillation.
therapy due to complications associated with coronary artery dis-
ease limited the use of anticoagulants. The risk of bleeding
increases with increasing CHA2DS2-VASc score because ischemic
stroke and major bleeding share some key risk factors, including
hypertension, age and stroke history.45,46 These results showed
cohort studies suggested that hypertension was a strong risk factor
that strengthening the management of risk factors such as blood
for AF, increasing the risk of AF by 68 %.29 Consistent with these
sugar and blood lipids is highly important. Contemporary guideli-
findings, our study showed that hypertension was the most com-
nes and expert consensus recommend the use of oral anticoagu-
mon complication in older adults with AF. ACEIs/ARBs were the
lants alone as the default strategy for reducing bleeding events in
most commonly used drugs by our older AF patients, possibly
patients with stable coronary heart disease combined with
due to their role in reducing blood pressure and improving heart
AF.47,48 The 2018 European Heart Rhythm Association suggested
remodeling to prevent AF.30
that an early (e.g., at 6 months) change from double antiplatelet
AF is characterized by rapid and disordered electrical activity of
therapy to non-vitamin K antagonist (VKA) oral anticoagulant ther-
the atria, with an ECG showing an irregular heart rhythm and an
apy alone could be an alternative for patients with stable coronary
absence of P waves.21 However, AF is often paroxysmal and can
heart disease combined with AF at low ischemic and high hemor-
manifest as a normal ECG. Longer ambulatory ECG recordings
rhagic risk after percutaneous coronary intervention.49 In addition,
(i.e., 24–48 h) are beneficial for detecting AF rhythm patterns.31–
34 a lack of awareness of the dangers of AF among elderly patients
Because approximately one-third of people with AF are asymp-
also led to the underuse of anticoagulation therapy, as has been
tomatic,35 public health efforts have tried to raise awareness about
frequently reported.21,50 These findings indicated that publicizing
screening for AF over the past decade. In recent years, the ESC
of the risk knowledge of AF need to be further strengthened.
guidelines for the diagnosis and treatment of AF have recom-
Among patients who were first diagnosed with AF using a wearable
mended pulse palpation combined with 12-lead ECG for oppor-
dynamic ECG monitor and met the criteria for anticoagulant ther-
tunistic screening in people older than 65 years of age.36–37 An
apy based on the CHA2DS2-VASc score, 4.08 % of women and
increasing number of studies have employed different AF screening
10.53 % of men received anticoagulant therapy, which was pre-
strategies in different settings by using different digital devices,
scribed partly due to the occurrence of thrombotic events. A total
ranging from conventional 12-lead ECG recording to intermittent
of 89.8 % of the female patients and 68.42 % of the male patients
or semicontinuous pulse-based heart rhythm monitoring or con-
had taken no antithrombotic therapy, which was potentially a
tinuous ambulatory ECG monitoring.38–43 In this study, we suc-
greater risk of thromboembolic events. This low anticoagulation
cessfully detected 78 community-dwelling individuals with
rate was alarming. Therefore, there is an urgent need to strengthen
previously undiagnosed AF using a wearable dynamic ECG moni-
screening for AF in the elderly population and guide the timely ini-
tor, which was portable and noninvasive. Moreover, 3 patients
tiation of long-term and standardized anticoagulation treatment in
with ventricular tachycardia or second-degree type II sinoatrial
patients with AF.
block at risk of death were first identified, which prompted them
to be hospitalized for timely assessment and treatment. Therefore,
wearable dynamic ECG monitoring can improve the early diagnosis
of AF and even other malignant arrhythmias in the elderly popula- Limitations
tion and help these people receive early treatment. However, the
wearable dynamic ECG monitor used in this study mainly relies Our study has several limitations. First, the study is cross-
on ECG doctors to diagnose AF. Therefore, we are using machine sectional. Second, the sample was small and included elderly peo-
learning methods to establish an artificial intelligence (AI)- ple living in 4 randomly selected communities, which may not
assisted diagnostic technology based on dynamic ECGs collected fully reflect the current situation of AF diagnosis and treatment
by wearable devices, which will accelerate the application of the in the whole region. However, this sample is still able to demon-
device in screening for AF in the elderly community-dwelling pop- strate the necessity of screening for AF in elderly population. We
ulation, with the overarching aim of realizing early diagnosis and are also establishing an AI-assisted diagnostic technology based
treatment of patients with AF. on the wearable dynamic ECG monitor to extend the device to a
The 2020 ESC guidelines recommend the ABC pathway for broader population. Third, further measures are needed to promote
managing AF patients. The ABC pathway stands on three main pil- anticoagulant therapy and long-term follow-up of patients, espe-
lars: avoiding stroke with anticoagulants, better symptom man- cially in the elderly population with a first diagnosis of AF. We
48
L. Wei, E. Su, J. Xie et al. Clinical eHealth 7 (2024) 41–50

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