Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole. Joining me today is Dr. Baljash Cheema. He's an Assistant Professor of Cardiology at Northwestern Medicine. And today, we're discussing Dr. Cheema's recent research on FibriCheck. Dr. Cheema, thank you so much for joining us today. I'd like you to first start by telling us a little bit about AFib and some of the challenges that we've known over the years of keeping track of ongoing treatment response.

Dr. Baljash Cheema: So, atrial fibrillation is a heart rhythm disturbance in which there is essentially this chaotic movement of electricity through the atria, the top chambers of the heart. And essentially, the heart is out of sync. And so, that doesn't follow the typical rhythmic fashion where the top chambers of the heart contract first, send blood to the bottom chambers, the ventricle, and send blood to the entire body. The atria sort of contract whenever they want to in their own pattern. And that can actually have blood sitting in the heart and not adequately emptying and creates a risk for developing a blood clot in the atria or the top chambers of the heart, specifically the left atrium. And that is particularly dangerous because if that blood clot breakthroughs from the left atrium, it can travel up to the brain and cause a stroke. That's really the thing that we worry the most about. There are patients that have symptoms when they have AFib. They may feel palpitations or their heart racing or feel some discomfort in their chest or even a sensation of shortness of breath, but some people don't feel it at all. They have no symptoms at all related to the AFib. But no matter what, it's still a risk factor for having a stroke, which can be really impairing.

Melanie Cole, MS: So then, tell us a little bit about FibriCheck and the algorithm that it uses. What is it doing? This is an FDA-cleared tool for remote atrial fibrillation detection and monitoring, right? So, it's kind of doing both.

Dr. Baljash Cheema: So, FibriCheck is a company that we've worked with really to trial one of their products. And this is an algorithm that they've created, really a technology that they've created where they're using PPG signals or photoplethysmography, where you put your finger on the camera lens of a smartphone and it can analyze the way the blood is flowing through the tips of your finger and the way light is reflecting off of the blood flow in your finger, and can get a sense of the type of heart rhythm that you're in, and whether it's a normal one or an abnormal one, specifically AFib. So, the technological advance that they've created is the ability to detect AFib through a cell phone camera lens. Now, this fits in the larger ecosystem of what I would say are wearable technologies or wearable sensors. Now, this is built into your smartphone, but it's not exactly a wearable, but it's this group of products that patients-- or maybe they're not even patients-- just consumers can purchase on their own accord and can use these for at-home monitoring of health-related conditions.

There's a lot of competitors in this space. There's a lot of types of products that people and companies have created, like now estimation of your blood pressure, estimation of your risk of having something called sleep apnea or asthma, or detecting how many steps you're walking or your VO2 max, your best measure of your cardiorespiratory fitness. But we are getting into the realm where consumers can purchase equipment that can allow them to get close to making a medical diagnosis on their own accord before they're coming through the doors or a clinic or the doors of our hospital system, and that's where FibriCheck falls in.

Melanie Cole, MS: Wow, isn't that amazing? There are so many, as you say, wearables on the market today. And they have their advantages and disadvantages. And some of them disadvantages might even be the technology involved, especially for older people, but with a cell phone, people are learning to use those. Speak a little bit about the advantages and limitations of FibriCheck compared to some of these other patient-activated wearables that are available.

Dr. Baljash Cheema: I think you outlined there one of the key advantages, that this is an application that is put on a smartphone. And specifically in our trial here in Northwestern and what other sites, both in the US And in Europe, we looked at the ability of this algorithm to work on many different smartphones and many different versions of those smartphones to make sure that it worked on, both Samsungs and iPhones and different operating systems.

But the advantage there is patients or consumers are not required to wear a new system on their wrist or put their finger on specific sensors that are outside of their cell phone to get these readings. This is already built into your cell phones. There's no additional other hardware that you have to purchase once you have the application. It does still require you to start the app and put your finger on that camera. So, that has a limitation that it's not an automated system that doesn't require any input from the user. And so, there still could be a technological barrier for some. But that's really the advantage that I see is that individuals are not having to purchase a watch or a ring or some other kind of sensor that they're wearing on their body when they want to make a prediction or a measurement on if they're having atrial fibrillation

Melanie Cole, MS: Well, I can certainly see advantages and disadvantages to patients being able to buy these things for themselves. And we all know Dr. Google comes in, and there's all kinds of limitations in that respect for physicians and providers. But speak a little bit about who. You would like as far as patient eligibility and the methods that were used in the research on FibriCheck.

Dr. Baljash Cheema: This is the part of this that I'm so excited about, is I do think we're already in a world, we're certainly going to grow that world in which patients, consumers are purchasing these types of equipment on their own accord. They are getting more educated on what is going on in their own body. They're likely to make some of these diagnoses on their own accord or walk through the doors of our hospital system and say, "Hey, I think I have X, Y, and Z based on these pieces of information, or this AI system that I type my symptoms into, or this wearable sensor that I have been using to record my biosignals, my biomarkers," And so, we have to be prepared for this. We have to be actively involved in doing the research to make sure these algorithms work in the first place. And that's really one of the reasons I'm proud to be a part of this. And so, really our role here was to simply take this technology to find patients in the hospital that were in a normal rhythm, and patients in the hospital that were in an abnormal rhythm, and just test and see if the product could do what it's supposed to do.

Now, these algorithms, these products, these technologies, these are not clinical grade pieces of medical hardware. They're not at the same level of restrictions, qualifications needs that the equipment that I use in our hospital is. They're not regulated the same way by the FDA. So, having peer-reviewed literature that speaks to the fact that these work or don't work is really critically important in being able to adjudicate their benefits.

Melanie Cole, MS: So then, discuss the study's findings, Dr. Cheema, particularly how effective it was in detecting AFib and monitoring events.

Dr. Baljash Cheema: I would say that in our study we showed that it was effective. In the same way that this company has shown in some other studies, but across different age ranges from those that are young, to those that are old, across those with different skin tones, from fair skin to dark skin, and across different categories like your BMI or body mass index. This algorithm was pretty good at being able to detect whether someone was in an abnormal rhythm or in normal rhythm. And so, I can imagine patients going on to use this at home, and then giving us actionable, credible information in the clinical sector, either through messages or coming in to see us to say, "Hey, this is what my smart device detected. What do you think? Do you agree? Is this AFib? Should I be on a blood thinner? What should I be doing to mitigate my risk of a stroke? How should I treat this AFib? Can I get rid of it? What are the different strategies?"

Melanie Cole, MS: Dr. Cheema, how can clinicians use this technology to detect and manage AFib? Speak a little bit about which patients that you would like to see using this.

Dr. Baljash Cheema: So, there are patients that get treatments for atrial fibrillation, some like an ablation that are meant to get rid of that heart rhythm. There are patients that have that heart rhythm and they come in experiencing things like heart failure and have a weakened heart. And then, again, we treat that rhythm and we think that we've gotten rid of it. So, having a tool like this for monitoring at home when a patient feels palpitations or just to randomly check a few days a week is a good surrogate measure, a good way for us to get more information if they're experiencing this rhythm that we're just missing.

Another major bucket of patients are those that come in with what we call a cryptogenic strokes, that means they have a stroke, but we don't know why. And one of the leading causes that in those people that were first labeled a cryptogenic stroke would then go on to get identified with a cause. It's from AFib. We just didn't detect it because patients don't have to be an AFib 24/7. They most often have something called paroxysmal AFib that comes and goes. And so, having a tool in which you can scan for whether that rhythm is present or absent when you feel something is really powerful.

You know, in my clinic, I routinely prescribe Holter monitors or some kind of at-home monitor that can check someone's heart rhythm for a designated period of time. On the long end is typically two weeks. That's a long time to ask someone to wear a monitor at home. But some of my patients have AFib that pops up once every month or once every few months. And so, it's very reasonable that a two week culture monitor did not catch their AFib, and perhaps a much better system would be to tell them, "Hey, when you feel those symptoms that I know that are correlated with your AFib, that you believe are correlated with your AFib, turn that app on and check your heart rhythm."

Melanie Cole, MS: As we look to the future with these types of-- well, we're not calling them wearables-- but devices that can detect and monitor AFib, what further developments with this type of technology do you anticipate? What would you like to see and could it be applied? You're a cardiologist, could this be applied to other conditions? Do you see it working for other things?

Dr. Baljash Cheema: We are fortunate in Northwestern to really have some of the leaders in the world on managing and treating and researching AFib. Dr. Rob Passman is a great example of that and is leading a number of studies that are looking into this. One of the concepts that he has talked about or educated us on is the idea of a pill in the POCAT approach to being on a blood thinner for AFib.

And so, people typically will take a blood thinner for atrial fibrillation to reduce your chances of having a stroke. But blood thinners have their own risk, specifically the risk of having a bleeding event. And so, there is an open question out there about how much AFib is needed for one to be on a blood thinner. And if you don't have AFib often, but you experience it once every few months, should you just take a blood thinner for a period of time around that? But I can see that science evolving and us having a clear answer through a lot of the work that he's leading along with his colleagues. And these types of sensors technologies can help us monitor this at home.

Outside of AFib, I think there really is an endless number of possibilities. I'm a cardiologist, like I mentioned, but I also work in our Human Longevity Clinic and the Human Longevity Lab that studies biomarkers of aging in patients and individuals. There are a number of these technologies that look at processes that decline with aging. And there may be a way to adjust the way that we're living our lives and the way we're exercising and the way we're eating and the way we're managing our sleep one day, the way we're taking supplements or pharmaceuticals that can improve some of these biomarkers of aging that can be measured, these types of technologies that may impact the length of time that one lives their life in a healthy fashion and without having chronic disease systems. There really are an incredible amount of opportunities related to these types of technologies alongside machine learning and AI.

Melanie Cole, MS: It certainly is a pretty exciting time in your field, Dr. Cheema. And tell us a little bit how this demonstrates how Bluhm Cardiovascular Institute is leveraging this kind of technology. And you mentioned it just a little, but to further advance cardiovascular medicine, I'd like you to really give a great summary of what you feel are the most important aspects and anything else that you'd like other physicians to know about FibriCheck and this study's findings.

Dr. Baljash Cheema: Bluhm Cardiovascular Institute really aims to be a leader in the research on cardiovascular medicine, the clinical delivery of cardiovascular medicine And the education of cardiovascular medicine. And so, we are taking care of sick patients and using the greatest in technologies we have to provide excellent care. We have many experts in the research space asking really challenging questions that need answers and have brought extramural funding in, or internal funding in to answer these questions and are leading large studies. And we have dedicated educators and teachers to training the next generation of physicians to be able to deliver in this space.

This is just one small example of the greater ecosystem of clinical research that we're doing here at Bluhm and I really feel fortunate to be a part of it. I think this one study showed that this algorithm from a company called FibriCheck has the ability to predict atrial fibrillation in patients that are experiencing it. But really for me, it's more so that this is a telltale sign of a direction that we're moving in in the field of medicine, which is more at-home monitoring, more integration and use of digital health, data science, more empowerment of our patients. And physicians need to have a front row seat at this to help direct the research to ensure that these things are working the way that they should and to think about how to implement these technologies in the clinical space. And so, I think this really is one small study in my eyes, but a part of a large team of clinicians and researchers that are doing great work here.

Melanie Cole, MS: I agree. And thank you so much, Dr. Cheema. As this progresses, come back on and join us and let us know what more you find out. But thank you so much for sharing that information with us. And to refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/cardiovascula to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole.