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Using Patient's Wearables and Trackables to Help Track Heart Health
Michael Massoomi, MD, discusses the latest wave of wearables and trackables to track heart health.
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Learn more about Michael Massoomi, MD
Michael Massoomi, MD
Dr. Michael Reza Massoomi grew up in Atlanta, GA. He completed his undergraduate degree at Georgia Tech and medical school at the Medical College of Georgia. He completed his residency in internal medicine at Emory University then moved to Gainesville, FL, to complete his general and interventional cardiology fellowships at University of Florida, where he also served as chief cardiology fellow.Learn more about Michael Massoomi, MD
Transcription:
The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of .25 AMA PRA category one credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Melanie Cole (Host): There’s so much buzz about the new wearable technology that can monitor heart health and here to tell us why that matters is my guest, Dr. Michael Massoomi. He’s an Interventional Cardiologist at the University Of Florida and he practices at UF Health Shands Hospital in Gainesville. Dr. Massoomi, I’m so glad to have you with us. This is such a great topic. As personal health tech is already common independently at home, sleep studies, Holter monitors; please tell us about this new wave of wearable monitoring devices. What are you seeing?
Michael Massoomi, MD (Guest): Very excited to talk about this. Right now, somewhere around 13% of the people in the United States have a Smart watch and I have a special interest in trying to incorporate use of these devices in daily clinical care in the clinic. And so, I’m seeing a wide variety. I’m seeing patients who wear the devices and don’t really know much about what they can do for them and I see other patients on the other end of the spectrum; who use these devices to try to monitor their activity levels, or who come to me stating that they got an irregular rhythm notification and they want to know what it means.
Host: It really is amazing what’s happening today. So, what are some of the various metrics that can be obtained from a Smart watch and what are the most important ones to track?
Dr. Massoomi: Right now, we can obtain a wide variety of data and it’s available on different devices and it can be – the common devices these days being Fitbits, Garmins, Apple watches, and a few other ones. And some of the basic information can be obtained on any of those. And so, one of the common ones is energy expenditure or just kind of general activity level. And that’s probably one of the ones where I’m most careful and studies that we have which try their best to validate this information show that there’s a lot of variability. And so energy expenditure for example would be the metric that tries to show how many calories a patient has burned in a given day or with a given activity.
And what we find when we try to control using calorimetric studies is that these devices are very – there’s a lot of variability in what they present, and they are typically overestimating the energy expenditure. Sometimes at a margin of around 25%. So, I’m always really cautious when it comes to energy expenditure. I try to specifically tell patients not to use the information about how many calories they’ve burned to make any dietary decisions because I think that’s what will lead you down a dangerous path of probably weight gain.
But I do think it’s important to look at that because the trends can still be meaningful. So, don’t focus too much on what the exact number is, I’ve burned this many calories. But over time, if that’s going up, then that’s probably a good indication that you’ve become more active.
Host: Well certainly it is. And so as far as heart conditions, what can it help to possibly detect whether it’s AFib or O2 saturation, blood pressure, diabetes, glucose levels? I mean we’re hearing so much today doctor. Tell us what heart conditions it can help with.
Dr. Massoomi: Most of these watches now even the base models that start at around a price point of around $100, they have heart rate detection and they do that using a pleth so that’s not ECG, that’s just using the pleth signal like we would do with a pulse ox in the hospital to measure heart rate. Most of the watches don’t do oxygen saturation. But we can use the pleth and get pretty accurate data on heart rate and so, they’ve done a few different studies looking at the accuracy of the information and it turns out most of the Smart watch devices are pretty accurate, typically between five or ten percent of the values that we would obtain if we did a simultaneous ECG which is kind of the reference standard for heart rate.
And so, what this is telling us is that using a pleth based heart rate sensor, is an accurate way to have a watch on what somebody’s heart rate is doing. And so, there’s an additional are which is even more exciting and that’s limited right now to the Apple watch series 4 and now the newly released series 5 which offer the same health features. And the really neat thing there is that there’s two big health features that are available only on those devices and not on any others today.
Number one would be fall detection which is a neat algorithm that the device uses joining the accelerometer with other sensors to determine if someone has had what feels like is an unplanned descent, right, a dangerous fall. And then, it will give you notification and say did you fall, are you okay. And if you say yes, I’m okay then it dismissed it. If you don’t respond to the notification; it will assume that you have fallen and are either unconscious or unable to get up and it can automatically call 9-1-1. And so, that’s a really nice feature especially in the elderly population.
And then the second feature which I’m most excited about would be its ability to detect atrial fibrillation and do single lead ECG recording. And so, I’ll just try to clarify a portion of this here. So, you can use an Apple watch series 1, 2, 3, 4 or 5 to do pleth based heart rate detection and it can apply the algorithm to try to determine irregular heart rhythms. And that’s what they did with the Apple heart study, which is a great study, big, big study looking at the ability of a watch that the common folks are wearing to detect AFib. The series 4 and series 5 really add on to that by improving the accuracy because now, if you get a notification that says you have an irregular rhythm, you can immediately on the watch, take a single lead ECG recording which can then confirm or show that maybe it was artifact that this is atrial fibrillation.
And so I think that’s just groundbreaking and it’s something that so many patients already are wearing and with the growth of these devices, it’s only going to become more and more common.
Host: Well absolutely it is and as you say, really it is amazing what they are doing with this technology. Do you feel that it might cause false positive tests which could cause unnecessary tests and anxiety for patients if they notice something or they question something? Do you think that it can maybe not always be terrific as far as that?
Dr. Massoomi: It’s a very good point that you are bringing up. And certainly there’s a difference in patients, right, there are some patients that are highly anxious and it could be anxiety provoking for them and then not the case in other patients. I think this is a good time to kind of discuss our responsibility as physicians in educating ourselves about this information so that when patients do come to us; we feel comfortable enough to look at their phone, to look at their tracings and help make sense out of this.
Now as far as false positives, I can share some specific data that came from the Apple heart study and in that study, they basically had a good level of positive predictive values so there was an 84% positive predictive value for patients having an irregular rhythm notification on their watch for them to have had AFib at the same time. So, these were patients that were earing the watch and wearing an event monitor at the same time to validate. And so 84% of the time that the watch said this is an irregular rhythm; that was indeed atrial fibrillation. And so that’s a good number to know and then also I think we should account for the fact that this was done only up to the series 3 device and the series 4 and 5 devices which are becoming more and more common, actually allow patients to take an ECG right then and so that would increase your sensitivity and specificity, I don’t want to say to 100%, because the tracings can have artifact, but to the highest level that we can really obtain aside from doing a 12 lead ECG.
And so, what I have patients do is I say for those who have a 4 or 5 watch, I say if you get an irregular rhythm notification; I want you to take a recording on your watch immediately. And then when they come in and show me those recordings; then I can confirm okay this atrial fibrillation and as far as I’m concerned; if they show me a recording from their watch and it looks like a clean recording and I see atrial fibrillation; I will use that as diagnostic information to put AFib in their chart and to start them on anticoagulation if it’s indicated.
Host: Wow. But since this is a healthcare device, do you see approval being needed from federal regulators. I mean if you are going to be using it as a diagnostic criterion then do you think that there will have to be some sort of regulation? What’s going on in that department?
Dr. Massoomi: The ECG portion of the watch is actually FDA approved for single lead ECG recording. And really what it comes down to is us being aware of it and recognizing it and actually using the information that’s there. It’s low hanging fruit. This information is already there. We just have to start using it.
Host: Absolutely. As we wrap up, doctor and what an interesting topic. How do you feel this will transform patient care? Tell us where you see the clinical application of this data for other providers and really what you’d want them to know about the accuracy, the metrics and using this wearable technology with their patients.
Dr. Massoomi: A few points of I will try to share with people listening is that we can use this information on practically a daily basis. I mean part of my physical exam when patients come in has become to look at their wrist and see if they have a Smart watch. And if they do, I ask for their telephone and I will review their health related apps. I look at their activity level and if I notice that their step count is on the lower side, I try to encourage them to make reasonable goals and to increase it and I show them how to look it so they can track their progress.
So, that’s one good use. I look at their heart rate data and I try to see if they have any strange outliers to suggest that there might be some kind of an underlying dysrhythmia. I look if their watch provides that, if they have an Apple watch, I look to see if they have any AFib notifications and I even use it in patients who have known AFib especially in the Apple watch, it has different heart rate metrics and it can actually give you an average heart rate while walking. So, the watch knows when you are walking and when you are still, and it will give you a separate heart rate average during times of walking which is an important metric for heart rate control in patients who have AFib.
And so I also will look at the resting heart rate and I use the combination of those two pieces of data to titrate drugs like metoprolol or Cardizem that these patients are commonly going to be on for controlling their heart rate. So, I think those are really, really great easy uses for these devices. I also try to take a look at their sleep and just sort of on that and try to get a rough idea of how much they are sleeping and the quality of their sleep. We’re learning more and more about sleep. I like to refer to sleep as the forgotten vital sign and I think there’s just a lot of good correlation with sleep quality and chronic diseases and chronic inflammatory states and we know that poor sleep is a risk factor for obesity, diabetes, and cardiovascular disease including heart attack and stroke. And so I try to use that to open the door and refer people for sleep studies if I think it’s appropriate.
I think there are many, many uses that we can do right now and then I think the door is just open for an expanding area here of more and more uses as we learn more about how to apply this information.
Host: I couldn’t agree more and thank you so much Dr. Massoomi for joining us today and sharing your incredible expertise. What a fascinating topic. That concludes today’s episode of UF Health MedEd Cast with UF Health Shands Hospital. To learn more about this and other healthcare topics at UF Health Shands Hospital, please visit www.ufhealth.org/medmatters to get connected with one of our providers. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. For more health tips and updates on the latest medical advancements and breakthroughs please follow us on your social channels. Until next time, I’m Melanie Cole.
The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of .25 AMA PRA category one credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Melanie Cole (Host): There’s so much buzz about the new wearable technology that can monitor heart health and here to tell us why that matters is my guest, Dr. Michael Massoomi. He’s an Interventional Cardiologist at the University Of Florida and he practices at UF Health Shands Hospital in Gainesville. Dr. Massoomi, I’m so glad to have you with us. This is such a great topic. As personal health tech is already common independently at home, sleep studies, Holter monitors; please tell us about this new wave of wearable monitoring devices. What are you seeing?
Michael Massoomi, MD (Guest): Very excited to talk about this. Right now, somewhere around 13% of the people in the United States have a Smart watch and I have a special interest in trying to incorporate use of these devices in daily clinical care in the clinic. And so, I’m seeing a wide variety. I’m seeing patients who wear the devices and don’t really know much about what they can do for them and I see other patients on the other end of the spectrum; who use these devices to try to monitor their activity levels, or who come to me stating that they got an irregular rhythm notification and they want to know what it means.
Host: It really is amazing what’s happening today. So, what are some of the various metrics that can be obtained from a Smart watch and what are the most important ones to track?
Dr. Massoomi: Right now, we can obtain a wide variety of data and it’s available on different devices and it can be – the common devices these days being Fitbits, Garmins, Apple watches, and a few other ones. And some of the basic information can be obtained on any of those. And so, one of the common ones is energy expenditure or just kind of general activity level. And that’s probably one of the ones where I’m most careful and studies that we have which try their best to validate this information show that there’s a lot of variability. And so energy expenditure for example would be the metric that tries to show how many calories a patient has burned in a given day or with a given activity.
And what we find when we try to control using calorimetric studies is that these devices are very – there’s a lot of variability in what they present, and they are typically overestimating the energy expenditure. Sometimes at a margin of around 25%. So, I’m always really cautious when it comes to energy expenditure. I try to specifically tell patients not to use the information about how many calories they’ve burned to make any dietary decisions because I think that’s what will lead you down a dangerous path of probably weight gain.
But I do think it’s important to look at that because the trends can still be meaningful. So, don’t focus too much on what the exact number is, I’ve burned this many calories. But over time, if that’s going up, then that’s probably a good indication that you’ve become more active.
Host: Well certainly it is. And so as far as heart conditions, what can it help to possibly detect whether it’s AFib or O2 saturation, blood pressure, diabetes, glucose levels? I mean we’re hearing so much today doctor. Tell us what heart conditions it can help with.
Dr. Massoomi: Most of these watches now even the base models that start at around a price point of around $100, they have heart rate detection and they do that using a pleth so that’s not ECG, that’s just using the pleth signal like we would do with a pulse ox in the hospital to measure heart rate. Most of the watches don’t do oxygen saturation. But we can use the pleth and get pretty accurate data on heart rate and so, they’ve done a few different studies looking at the accuracy of the information and it turns out most of the Smart watch devices are pretty accurate, typically between five or ten percent of the values that we would obtain if we did a simultaneous ECG which is kind of the reference standard for heart rate.
And so, what this is telling us is that using a pleth based heart rate sensor, is an accurate way to have a watch on what somebody’s heart rate is doing. And so, there’s an additional are which is even more exciting and that’s limited right now to the Apple watch series 4 and now the newly released series 5 which offer the same health features. And the really neat thing there is that there’s two big health features that are available only on those devices and not on any others today.
Number one would be fall detection which is a neat algorithm that the device uses joining the accelerometer with other sensors to determine if someone has had what feels like is an unplanned descent, right, a dangerous fall. And then, it will give you notification and say did you fall, are you okay. And if you say yes, I’m okay then it dismissed it. If you don’t respond to the notification; it will assume that you have fallen and are either unconscious or unable to get up and it can automatically call 9-1-1. And so, that’s a really nice feature especially in the elderly population.
And then the second feature which I’m most excited about would be its ability to detect atrial fibrillation and do single lead ECG recording. And so, I’ll just try to clarify a portion of this here. So, you can use an Apple watch series 1, 2, 3, 4 or 5 to do pleth based heart rate detection and it can apply the algorithm to try to determine irregular heart rhythms. And that’s what they did with the Apple heart study, which is a great study, big, big study looking at the ability of a watch that the common folks are wearing to detect AFib. The series 4 and series 5 really add on to that by improving the accuracy because now, if you get a notification that says you have an irregular rhythm, you can immediately on the watch, take a single lead ECG recording which can then confirm or show that maybe it was artifact that this is atrial fibrillation.
And so I think that’s just groundbreaking and it’s something that so many patients already are wearing and with the growth of these devices, it’s only going to become more and more common.
Host: Well absolutely it is and as you say, really it is amazing what they are doing with this technology. Do you feel that it might cause false positive tests which could cause unnecessary tests and anxiety for patients if they notice something or they question something? Do you think that it can maybe not always be terrific as far as that?
Dr. Massoomi: It’s a very good point that you are bringing up. And certainly there’s a difference in patients, right, there are some patients that are highly anxious and it could be anxiety provoking for them and then not the case in other patients. I think this is a good time to kind of discuss our responsibility as physicians in educating ourselves about this information so that when patients do come to us; we feel comfortable enough to look at their phone, to look at their tracings and help make sense out of this.
Now as far as false positives, I can share some specific data that came from the Apple heart study and in that study, they basically had a good level of positive predictive values so there was an 84% positive predictive value for patients having an irregular rhythm notification on their watch for them to have had AFib at the same time. So, these were patients that were earing the watch and wearing an event monitor at the same time to validate. And so 84% of the time that the watch said this is an irregular rhythm; that was indeed atrial fibrillation. And so that’s a good number to know and then also I think we should account for the fact that this was done only up to the series 3 device and the series 4 and 5 devices which are becoming more and more common, actually allow patients to take an ECG right then and so that would increase your sensitivity and specificity, I don’t want to say to 100%, because the tracings can have artifact, but to the highest level that we can really obtain aside from doing a 12 lead ECG.
And so, what I have patients do is I say for those who have a 4 or 5 watch, I say if you get an irregular rhythm notification; I want you to take a recording on your watch immediately. And then when they come in and show me those recordings; then I can confirm okay this atrial fibrillation and as far as I’m concerned; if they show me a recording from their watch and it looks like a clean recording and I see atrial fibrillation; I will use that as diagnostic information to put AFib in their chart and to start them on anticoagulation if it’s indicated.
Host: Wow. But since this is a healthcare device, do you see approval being needed from federal regulators. I mean if you are going to be using it as a diagnostic criterion then do you think that there will have to be some sort of regulation? What’s going on in that department?
Dr. Massoomi: The ECG portion of the watch is actually FDA approved for single lead ECG recording. And really what it comes down to is us being aware of it and recognizing it and actually using the information that’s there. It’s low hanging fruit. This information is already there. We just have to start using it.
Host: Absolutely. As we wrap up, doctor and what an interesting topic. How do you feel this will transform patient care? Tell us where you see the clinical application of this data for other providers and really what you’d want them to know about the accuracy, the metrics and using this wearable technology with their patients.
Dr. Massoomi: A few points of I will try to share with people listening is that we can use this information on practically a daily basis. I mean part of my physical exam when patients come in has become to look at their wrist and see if they have a Smart watch. And if they do, I ask for their telephone and I will review their health related apps. I look at their activity level and if I notice that their step count is on the lower side, I try to encourage them to make reasonable goals and to increase it and I show them how to look it so they can track their progress.
So, that’s one good use. I look at their heart rate data and I try to see if they have any strange outliers to suggest that there might be some kind of an underlying dysrhythmia. I look if their watch provides that, if they have an Apple watch, I look to see if they have any AFib notifications and I even use it in patients who have known AFib especially in the Apple watch, it has different heart rate metrics and it can actually give you an average heart rate while walking. So, the watch knows when you are walking and when you are still, and it will give you a separate heart rate average during times of walking which is an important metric for heart rate control in patients who have AFib.
And so I also will look at the resting heart rate and I use the combination of those two pieces of data to titrate drugs like metoprolol or Cardizem that these patients are commonly going to be on for controlling their heart rate. So, I think those are really, really great easy uses for these devices. I also try to take a look at their sleep and just sort of on that and try to get a rough idea of how much they are sleeping and the quality of their sleep. We’re learning more and more about sleep. I like to refer to sleep as the forgotten vital sign and I think there’s just a lot of good correlation with sleep quality and chronic diseases and chronic inflammatory states and we know that poor sleep is a risk factor for obesity, diabetes, and cardiovascular disease including heart attack and stroke. And so I try to use that to open the door and refer people for sleep studies if I think it’s appropriate.
I think there are many, many uses that we can do right now and then I think the door is just open for an expanding area here of more and more uses as we learn more about how to apply this information.
Host: I couldn’t agree more and thank you so much Dr. Massoomi for joining us today and sharing your incredible expertise. What a fascinating topic. That concludes today’s episode of UF Health MedEd Cast with UF Health Shands Hospital. To learn more about this and other healthcare topics at UF Health Shands Hospital, please visit www.ufhealth.org/medmatters to get connected with one of our providers. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. For more health tips and updates on the latest medical advancements and breakthroughs please follow us on your social channels. Until next time, I’m Melanie Cole.