Objective: Smartwatches with photoplethysmographic (PPG) sensors are ideal for early atrial fibrillation (AF) detection through continuous monitoring. However, prior deep learning was limited either to controlled environments, to minimize motion artifacts, or to short duration data collection. Additionally, premature atrial/ventricular contractions (PAC/PVC), which often confound AF detection algorithms, remains understudied due to limited datasets. Current state-of-the-art methods achieve only 75% sensitivity for PAC/PVC class on minimally motion artifact corrupted PPG data, despite showing 97% AF detection accuracy. Methods: We addressed the above limitations using data from the recently completed NIH-funded Pulsewatch clinical trial which collected over two weeks of smartwatch PPG data from 106 subjects. Our computationally efficient 1D bi-directional Gated Recurrent Unit deep learning model incorporated multi-modal inputs (1D PPG, accelerometer, and heart rate data) to classify normal sinus rhythm, AF, and PAC/PVC. Results: Our model achieved an unprecedented 83% sensitivity for PAC/PVC detection while maintaining a high accuracy of 97.31% for AF detection, outperforming the best retrained state-of-the-art model by 20.81% and 2.55%, respectively. It was also 14 times more computationally efficient and 2.7 times faster. Testing on two external PPG datasets collected with a different smartwatch and a fingertip PPG sensor, our model demonstrated better generalizability with macro-averaged AUROC values of 96.22% and 94.17%, respectively. Conclusion: A light-weight multimodal input deep learning model can accurately distinguish PAC/PVC from AF, reducing false positive detection of AF. Significance: Accurate AF and PAC/PVC detection with minimal false positive detection can enhance clinical and public acceptance of smartwatch-based AF monitoring.

Worldwide, there are differences in hypertension control by sex. The use of home blood pressure monitoring (HBPM) is associated with lower average blood pressures and higher medication adherence. However, little is known about adherence trajectories and sex differences in HBPM. This study characterizes adherence to HBPM among those with and without hypertension. Electronic Framingham Heart Study participants were instructed to perform HBPM weekly for 1 year. Adherence was defined as having 1 measurement per week averaged over 4-week segments. Primary exposures of hypertension status and sex were self-reported. Group-based trajectory modeling was used to identify adherence trajectories. Logistic regression was applied to investigate factors associated with membership in each trajectory group in the sex-stratified and whole cohorts. Among 990 participants (58% women, age 53±9 years, 26% hypertension), three groups with distinct HBPM adherence patterns were identified: yearly discontinuation, gradual decrease, and high adherence. Participants with hypertension were more likely to maintain high adherence compared to those without (OR 1.55; 95% CI 1.08-2.23), with similar findings seen among women with hypertension (OR 2.24; 95% CI 1.35-3.72) but not men. In women, these findings remained significant when adjusting for anxiety, depression, and blood pressure, but were attenuated by adjusting for age and income. This study highlights HBPM adherence trajectories and shows that women with hypertension were more likely to be in the high adherence group, though these associations were attenuated after adjusting for demographic factors and co-morbidities. Future studies should explore strategies to enhance adherence in populations at risk of early discontinuation. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement The Framingham Heart Study is supported by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health and Boston University School of Medicine, under NIH award 75N92019D00031. The eFHS research study was supported by grant R01HL141434 and Robert Wood Johnson Award. Dr. Kovell is supported by the National Heart, Lung, and Blood Institute through K23HL163450. DDM is supported by R01HL155343, R01HL141434, R33HL158541, U54HL143541 and U54HL143541-05S1, and UG3NS135168. AS is supported by U54HL143541 and U54HL143541-05S1, U01HL146382, and UG3NS135168; EJB is supported by R01HL092577; American Heart Association AF AHA_18SFRN34110082; R01HL141434. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: University of Massachusetts Chan Medical School I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data used in this manuscript can be made available pending approval of the Framingham Heart Study investigators/steering committee.

BackgroundIn older adults with atrial fibrillation (AF), the presence of comorbid chronic kidney disease (CKD) may be more challenging for optimal disease management, influence stroke prophylaxis with oral anticoagulation, and impact bleeding risk. We examined the prevalence and burden of CKD in older patients with AF, patterns of anticoagulation prescribing according to CKD stage, and major bleeding events.MethodsPatients aged 65 years and older with AF were enrolled in a cohort study from clinics in Massachusetts and Georgia between 2016 and 2018. Kidney function was assessed with estimated glomerular filtration rate (GFR) values at study enrollment. Anticoagulation therapy with direct acting oral anticoagulation therapy (DOAC) or warfarin; and major bleeding events were ascertained from medical records. Cox proportional hazards model was used to estimate the multivariable adjusted risk of two-year major bleeding events.ResultsParticipants' (n = 1,244) mean age was 75 years; 48% were women, and 86% were White. Overall, 25% had a normal GFR, 44%, 28%, and 3% had mild, moderate, and severe CKD/kidney failure, respectively. Patients with severe CKD/kidney failure were more likely to be the oldest participants, dependent in their instrumental activities of daily living, and had the highest burden of frailty, multimorbidity, and polypharmacy. Approximately 44% of patients with normal GFR and 39% of those with mild CKD were prescribed a DOAC, while a majority of those with severe CKD/kidney failure (69%) were prescribed warfarin. Overall, 8% (n = 105) experienced a major bleeding event over the 2-year follow-up. After adjusting for sociodemographic, psychosocial, geriatric, and clinical variables, patients with severe CKD/kidney failure (HR: 2.81 [95% CI:1.10-7.17]) had a higher bleeding risk than those with a normal GFR.ConclusionsIn managing older patients with AF and comorbid CKD, healthcare providers should be increasingly aware of the increased burden of frailty, dependence for care, multimorbidity, polypharmacy, and the high risk of major bleeding especially among those with severely impaired kidney function. This finding emphasizes the need for a more holistic and multidisciplinary approach to stroke prophylaxis in older adults with AF and comorbid CKD.

Worldwide, there are differences in hypertension control by sex. The use of home blood pressure monitoring (HBPM) is associated with lower average blood pressures and higher medication adherence. However, little is known about adherence trajectories and sex differences in HBPM. This study characterizes adherence to HBPM among those with and without hypertension. Electronic Framingham Heart Study participants were instructed to perform HBPM weekly for 1 year. Adherence was defined as having ≥1 measurement per week averaged over 4-week segments. Primary exposures of hypertension status and sex were self-reported. Group-based trajectory modeling was used to identify adherence trajectories. Logistic regression was applied to investigate factors associated with membership in each trajectory group in the sex-stratified and whole cohorts. Among 990 participants (58% women, age 53 ± 9 years, 26% hypertension), three groups with distinct HBPM adherence patterns were identified: "early discontinuation", "gradual decrease", and "high adherence". Participants with hypertension were more likely to maintain "high adherence" compared to those without (OR 1.55; 95% CI 1.08-2.23), with similar findings seen among women with hypertension (OR 2.24; 95% CI 1.35-3.72) but not men. In women, these findings remained significant when adjusting for anxiety, depression, and blood pressure, but were attenuated by adjusting for age and income. This study highlights HBPM adherence trajectories and shows that women with hypertension were more likely to be in the high adherence group, though these associations were attenuated after adjusting for demographic factors and co-morbidities. Future studies should explore strategies to enhance adherence in populations at risk of early discontinuation.

Background:Using Systematic Assessment of Geriatric Elements in Atrial Fibrillation (SAGE-AF) data, determine how well the rich mix of demographic, clinical history, geriatric assessments, and clinically adjudicated events can predict two-year survival. Methods:Subjects were recruited from participating outpatient practices if they had non-valvular AF, were 65 or over with CHA2DS2-VASc scores of at least 2, and were candidates for anticoagulation. Demographics, clinical history, and geriatric qualities of life were assessed by interview and medical records review using standardized protocols and repeated at one and two years. Events identified were abstracted and submitted for adjudication using standard definitions of events and categories. Non-mortality event categories included hospitalizations (cardiovascular, bleeding, other), bleeding (major, clinically relevant non-major, minor), and seven major adverse cardiovascular events. Results:The 1245 subjects experienced 1960 events, primarily hospitalizations (935) and/or bleeding (817); 114 subjects (9.2%) died during two years of follow-up. Events initially abstracted to more than one category (172) were combined, resulting in 1788 unique incidents. Most subjects had zero or one event (69%) and fewer than 7% had more than 3 types. Most variables were significant in bivariate analysis. Using multiple logistic regression with two-year survival as the outcome variable, the best-fit model included event number and type, number of unique incidents, and number of bleeding events (R2 = 0.511, C = 93.1) with sensitivity = 97.9% and specificity = 44.7%. Conclusions:Two-year survival was high. This model, if validated, could have major implications for treatment of patients with AF. Patients in the large group with no or one event are at very low risk of death (under 2%). The small group with high risk for further complications, including death, deserve reassessment to determine if this trajectory can be altered.

Background:Timely detection of atrial fibrillation (AF) is critical for stroke prevention. Smartwatches are FDA-approved devices that can now aide in this detection. Objective:Investigate how socioeconomic status is associated with self-reported psychosocial outcomes, including anxiety, patient activation, and health-related quality of life in stroke survivors using smartwatch for AF detection. Methods:We analyzed data from the Pulsewatch study, a randomized controlled trial (NCT03761394). Participants in the intervention group wore a cardiac patch monitor in addition to a smartwatch for AF detection, whereas the control group wore only the cardiac patch monitor. Generalized anxiety disorder-7 scale, Consumer Health Activation Index and short-form health survey were completed to assess anxiety, patient activation, physical and mental health status at baseline, 14, and 44 days. We used a longitudinal linear regression model to examine changes in psychosocial outcomes in low (<$50K) vs. high (>$50K) income groups. Results:A total of 95 participants (average age 64.9± 9.1 years; 57.9% male; 89.5% non-Hispanic white) were included. History of renal disease (p-value 0.029), statin use (p-value 0.034), depression (p-value 0.004), and anxiety (p-value <0.001), were different between the income groups. In the adjusted model, the low-income group was associated with increased anxiety (β 2.75, p-value 0.0003), and decreased physical health status (β -5.07, p-value 0.02). There was no change identified in self-reported patient engagement and mental health status score. Conclusion:Our findings demonstrate that low SES is associated with worse self-reporting of physical health status, and this may influence psychosocial outcomes in smartwatch users.

Background Multiple chronic conditions (MCCs) are common in patients hospitalized with acute myocardial infarction (AMI). We examined the association of 12 MCCs with the risk of a 30-day hospital readmission and/or dying within one year among those discharged from the hospital after an AMI. We also examined the five most prevalent pairs of chronic conditions in this population and their association with the principal study endpoints. Methods The study population consisted of 3,294 adults hospitalized with a confirmed AMI at the three major medical centers in central Massachusetts on an approximate biennial basis between 2005 and 2015. Patients were categorized as ≤1, 2-3, and ≥4 chronic conditions. Results The median age of the study population was 67.9 years, 41.6% were women, and 15% had ≤1, 32% had 2-3, and 53% had ≥4 chronic conditions. Patients with ≥4 conditions tended to be older, had a longer hospital stay, and received fewer cardiac interventional procedures. There was an increased risk for being rehospitalized during the subsequent 30 days according to the presence of MCCs, with the highest risk for those with ≥4 conditions. There was an increased, but attenuated, risk for dying during the next year according to the presence of MCCs. Individuals with diabetes/hypertension and those with heart failure/chronic kidney disease were at particularly high risk for developing the principal study outcomes. Conclusion Development of guidelines that include complex patients, particularly those with MCCs and those at high risk for adverse short/medium term outcomes, remain needed to inform best treatment practices.

ObjectivesTo examine the associations between catheter ablation treatment (CA) vs. medical management and cognitive impairment among older adults with atrial fibrillation (AF).MethodsAmbulatory patients who had AF, were ≥65-years-old, and were eligible to receive oral anticoagulation could be enrolled into the SAGE (Systematic Assessment of Geriatric Elements)-AF study from internal medicine and cardiology clinics in Massachusetts and Georgia between 2016 and 2018. Cognitive function was assessed using the Montreal Cognitive Assessment (MoCA) tool at baseline, 1-, and 2 years. Cognitive impairment was defined as a MoCA score ≤ 23. Multivariate-adjusted logistic regression of longitudinal repeated measures was used to examine associations between treatment with CA vs. medical management and cognitive impairment.Results887 participants were included in this analysis. On average, participants were 75.2 ± 6.7 years old, 48.6% women, and 87.4% white non-Hispanic. 193 (21.8%) participants received a CA before enrollment. Participants who had previously undergone CA were significantly less likely to be cognitively impaired during the 2-year study period (aOR 0.70, 95% CI 0.50–0.97) than those medically managed (i.e., rate and/or rhythm control), even after adjusting with propensity score for CA. At the 2-year follow-up a significantly greater number of individuals in the non-CA group were cognitively impaired (MoCA ≤ 23) compared to the CA-group (311 [44.8%] vs. 58 [30.1%], p = 0.0002).ConclusionIn this 2-year longitudinal prospective cohort study participants who underwent CA for AF before enrollment were less likely to have cognitive impairment than those who had not undergone CA.

BACKGROUND Smartwatches have become readily accessible tools for detecting atrial fibrillation（AF）. There remains limited data on how they affect psychosocial outcomes and engagement in older adults. We examine the health behavior outcomes of stroke survivors prescribed smartwatches for AF detection stratified by age.METHODS We analyzed data from the Pulsewatch study, a randomized controlled trial that enrolled patients（≥ 50 years）with a history of stroke or transient ischemic attack and CHA2DS2-VASc ≥ 2. Intervention participants were equipped with a cardiac patch monitor and a smartwatch-app dyad, while control participants wore the cardiac patch monitor for up to 44 days. We evaluated health behavior parameters using standardized tools, including the Consumer Health Activation Index, the Generalized Anxiety Disorder questionnaire, the 12-Item Short Form Health Survey, and wear time of participants categorized into three age groups: Group 1（ages 50-60）, Group 2（ages 61-69）, and Group 3（ages 70-87）. We performed statistical analysis using a mixedeffects repeated measures linear regression model to examine differences amongst age groups.RESULTS Comparative analysis between Groups 1, 2 and 3 revealed no significant differences in anxiety, patient activation,perception of physical health and wear time. The use of smartwatch technology was associated with a decrease in perception of mental health for Group 2 compared to Group 1（β = –3.29, P = 0.046）.CONCLUSION Stroke survivors demonstrated a willingness to use smartwatches for AF monitoring. Importantly, among these study participants, the majority did not experience negative health behavior outcomes or decreased engagement as age increased.

Background Increasing ownership of smartphones among Americans provides an opportunity to use these technologies to manage medical conditions. We examine the influence of baseline smartwatch ownership on changes in self-reported anxiety, patient engagement, and health-related quality of life when prescribed smartwatch for AF detection. Method We performed a post-hoc secondary analysis of the Pulsewatch study (NCT03761394), a clinical trial in which 120 participants were randomized to receive a smartwatch-smartphone app dyad and ECG patch monitor compared to an ECG patch monitor alone to establish the accuracy of the smartwatch-smartphone app dyad for detection of AF. At baseline, 14 days, and 44 days, participants completed the Generalized Anxiety Disorder-7 survey, the Health Survey SF-12, and the Consumer Health Activation Index. Mixed-effects linear regression models using repeated measures with anxiety, patient activation, physical and mental health status as outcomes were used to examine their association with smartwatch ownership at baseline. Results Ninety-six participants, primarily White with high income and tertiary education, were randomized to receive a study smartwatch-smartphone dyad. Twenty-four (25%) participants previously owned a smartwatch. Compared to those who did not previously own a smartwatch, smartwatch owners reported significant greater increase in their self-reported physical health ( β = 5.07, P < 0.05), no differences in anxiety ( β = 0.92, P = 0.33), mental health ( β = −2.42, P = 0.16), or patient activation ( β = 1.86, P = 0.54). Conclusions Participants who own a smartwatch at baseline reported a greater positive change in self-reported physical health, but not in anxiety, patient activation, or self-reported mental health over the study period.

BackgroundAtrial fibrillation (AF) is a common cause of stroke, and timely diagnosis is critical for secondary prevention. Little is known about smartwatches for AF detection among stroke survivors. We aimed to examine accuracy, usability, and adherence to a smartwatch-based AF monitoring system designed by older stroke survivors and their caregivers. ObjectiveThis study aims to examine the feasibility of smartwatches for AF detection in older stroke survivors. MethodsPulsewatch is a randomized controlled trial (RCT) in which stroke survivors received either a smartwatch-smartphone dyad for AF detection (Pulsewatch system) plus an electrocardiogram patch or the patch alone for 14 days to assess the accuracy and usability of the system (phase 1). Participants were subsequently rerandomized to potentially 30 additional days of system use to examine adherence to watch wear (phase 2). Participants were aged 50 years or older, had survived an ischemic stroke, and had no major contraindications to oral anticoagulants. The accuracy for AF detection was determined by comparing it to cardiologist-overread electrocardiogram patch, and the usability was assessed with the System Usability Scale (SUS). Adherence was operationalized as daily watch wear time over the 30-day monitoring period. ResultsA total of 120 participants were enrolled (mean age 65 years; 50/120, 41% female; 106/120, 88% White). The Pulsewatch system demonstrated 92.9% (95% CI 85.3%-97.4%) accuracy for AF detection. Mean usability score was 65 out of 100, and on average, participants wore the watch for 21.2 (SD 8.3) of the 30 days. ConclusionsOur findings demonstrate that a smartwatch system designed by and for stroke survivors is a viable option for long-term arrhythmia detection among older adults at risk for AF, though it may benefit from strategies to enhance adherence to watch wear. Trial RegistrationClinicalTrials.gov NCT03761394; https://clinicaltrials.gov/study/NCT03761394 International Registered Report Identifier (IRRID)RR2-10.1016/j.cvdhj.2021.07.002

Coronavirus disease (COVID-19) can cause circulatory shock refractory to medical therapy. Such patients can be managed with mechanical circulatory support (MCS) devices like IABP, Impella, VA ECMO, and Left Ventricular Assist Devices (LVADs). Moreover, patients on long-term durable LVADs are a special population having increased susceptibility and mortality to COVID-19 infection. In this narrative review, we searched PubMed and Medline for studies on COVID-19 patients on short-term MCS devices. We found 36 papers with 110 patients who met our review criteria, including 89 LVAD patients and 21 COVID-19 patients who needed MCS device therapy. These studies were used to extract patient demographics, clinical presentation, MCS device details, management, and outcomes. Mean age of patients with COVID-19 infection on LVADs was 60, 73% were male, and HeartMate 3 was the most common device (53%). Most patients (77.5%) needed hospitalization, and mortality was 23.6%. Among the 21 reported cases of critically ill COVID-19 patients who required MCS, the mean age was 49.8 years, 52% were women, and the most common MCS device used was VA ECMO (62%) in conjunction with an Impella for LV venting. Comorbidities were not present in 43%, but 71% had abnormal ventricular function on echocardiography. MCS is a viable option for managing severe COVID-19 infection with shock, with many reported cases of favorable outcomes.

Background:The detection of atrial fibrillation (AF) in stroke survivors is critical to decreasing the risk of recurrent stroke. Smartwatches have emerged as a convenient and accurate means of AF diagnosis; however, the impact on critical patient-reported outcomes, including anxiety, engagement, and quality of life, remains ill defined.Objectives:To examine the association between smartwatch prescription for AF detection and the patient-reported outcomes of anxiety, patient activation, and self-reported health.Methods:We used data from the Pulsewatch trial, a 2-phase randomized controlled trial that included participants aged 50 years or older with a history of ischemic stroke. Participants were randomized to use either a proprietary smartphone-smartwatch app for 30 days of AF monitoring or no cardiac rhythm monitoring. Validated surveys were deployed before and after the 30-day study period to assess anxiety, patient activation, and self-rated physical and mental health. Logistic regression and generalized estimation equations were used to examine the association between smartwatch prescription for AF monitoring and changes in the patient-reported outcomes.Results:A total of 110 participants (mean age 64 years, 41% female, 91% non-Hispanic White) were studied. Seventy percent of intervention participants were novice smartwatch users, as opposed to 84% of controls, and there was no significant difference in baseline rates of anxiety, activation, or self-rated health between the 2 groups. The incidence of new AF among smartwatch users was 6%. Participants who were prescribed smartwatches did not have a statistically significant change in anxiety, activation, or self-reported health as compared to those who were not prescribed smartwatches. The results held even after removing participants who received an AF alert on the watch.Conclusion:The prescription of smartwatches to stroke survivors for AF monitoring does not adversely affect key patient-reported outcomes. Further research is needed to better inform the successful deployment of smartwatches in clinical practice.

Background:Emphysematous pancreatitis is a severe systemic inflammatory process with reports of pulmonary embolism in the setting of acute pancreatitis rarely described. Case presentation:A 61-year-old woman presented with severe abdominal pain of 1 day duration. She was found to have acute interstitial pancreatitis. During her hospitalization, the patient developed worsening abdominal pain associated with increasing oxygen demands, requiring supplemental oxygen through nasal cannula. Workup showed pulmonary embolism in the posterior segmental branch of the left lower lobar artery and development of emphysematous pancreatitis was noted on imaging. The patient was started on intravenous antibiotics and therapeutic anticoagulation; her condition improved and was discharged home. Conclusion:Patients with severe acute pancreatitis may be at risk for pulmonary embolism due to immobilization and other inflammatory mechanisms. Mitigating individualized risk factors and anticoagulation use as prophylaxis should be considered in patients with pancreatitis to prevent embolism. Early detection by clinicians is critical to reduce misdiagnosis and mortality rates.

Background: Early detection of AF is critical for stroke prevention. Several commercially available smartwatches are FDA cleared for AF detection. However, little is known about how patient-physician relationships affect patients' anxiety, activation, and health-related quality of life when prescribed smartwatch for AF detection. Methods: Data were used from the Pulsewatch study (NCT03761394), which randomized adults (>50 years) with no contraindication to anticoagulation and a CHA(2)DS(2)-VASc risk score >= 2 to receive a smartwatch-smartphone app dyad for AF monitoring vs. conventional monitoring with an ECG patch (Cardea Solo (TM)) and monitored participants for up to 45 days. The Perceived Efficacy in Patient-Physician Interactions survey was used to assess patient confidence in physician interaction at baseline with scores >= 45 indicating high perceived efficacy in patient-provider interactions. Generalized Anxiety Disorder-7 Scale, Consumer Health Activation Index, and Short-Form Health Survey were utilized to examine anxiety, patient activation, and physical and mental health status, at baseline, 14, and 44 days, respectively. We used mixed-effects repeated measures linear regression models to assess changes in psychosocial outcomes among smartwatch users in relation to self-reported efficacy in physician interaction over the study period. Results: A total of 93 participants (average age 64.1 +/- 8.9 years; 43.0% female; 88.2% non-Hispanic white) were included in this analysis. At baseline, fifty-six (60%) participants reported high perceived efficacy in patient-physician interaction. In the fully adjusted models, high perceived efficacy (vs. low) at baseline was associated with greater patient activation and perceived mental health (beta 12.0, p-value beta 3.39, p-value <0.05, respectively). High perceived self-efficacy was not associated with anxiety or physical health status (beta - 0.61, p-value 0.46; beta 0.64, p-value 0.77) among study participants. Conclusions: Higher self-efficacy in patient-physician interaction was associated with higher patient activation and mental health status among stroke survivors using smartwatches. Furthermore, we found no association between anxiety and smartwatch prescription for AF in participants with high self-efficacy in patient-physician interaction. Efforts to improve self-efficacy in patient-physician interaction may improve patient activation and self-rated health and subsequently may lead to better clinical outcomes. KEY MESSAGES Higher self-efficacy in patient-physician interaction was associated with higher patient activation and mental health status among stroke survivors using smartwatches. No association between anxiety and smartwatch prescription for AF in participants with high self-efficacy in patient-physician interaction. Efforts to improve self-efficacy in patient-physician interaction may improve patient activation and self-rated health and subsequently may lead to better clinical outcomes.

Herein, we are presenting a case of a 33-year-old woman who presented to the emergency department complaining of persistent lower abdominal pain of one-day duration. Physical examination revealed abdominal tenderness with right lower quadrant rebound tenderness. Computed tomography abdomen/pelvis showed a 6 cm possible necrotic mass of the left ovary with moderate amount of complex ascites. A laparoscopic left oophorectomy with bilateral salpingectomy, right ovarian biopsy, and appendectomy were performed without complications. The cut surface of the left ovary showed a 9.7 cm × 8 cm × 4 cm ovarian mass, and the cut surface revealed multiple gray-tan friable papillary excrescence. Microscopic evaluation showed findings consistent with left and right ovarian serous borderline tumor (SBT). Subsequently, a tumor staging was conducted with total laparoscopic hysterectomy, pelvic and periaortic lymph node dissection, and omentectomy. The endometrium sections showed several small foci of SBT within the endometrial stroma, consistent with non-invasive implants of the endometrium. The omentum and lymph nodes were all negative for malignancy. SBTs associated with endometrial implants are very rare with only one case reported in the literature. Their existence can cause diagnostic challenges, and they should be acknowledged for early diagnosis and to plan for patient's treatment and outcome.

In older patients with atrial fibrillation (AF), physical, cognitive, and psychosocial limitations are prevalent. The prognostic value of these conditions for major bleeding is unclear. To determine whether geriatric conditions are prospectively associated with major bleeding in older patients with AF on anticoagulation. Multicenter cohort study with 2-year follow-up from 2016 to 2020 in Massachusetts and Georgia from cardiology, electrophysiology, and primary care clinics. Diagnosed with AF, age 65 years or older, CHA2DS2-VASc score of 2 or higher, and taking oral anticoagulant (n=1,064). A total of 6507 individuals were screened. A six-component geriatric assessment of frailty, cognitive function, social support, depressive symptoms, vision, and hearing. Main outcome was major bleeding adjudicated by a physician panel. At baseline, participants were, on average, 75.5 years old and 49% were women. Mean CHA2DS2-VASc score was 4.5 and the mean HAS-BLED score was 3.3. During 2.0 (± 0.4) years of follow-up, 95 (8.9%) participants developed an episode of major bleeding. After adjusting for key covariates and accounting for competing risk from death, cognitive impairment (hazard ratio [HR] 1.62, 95% confidence interval [CI]: 1.02–2.56) and frailty (HR 2.77, 95% CI 1.38–5.58) were significantly associated with the development of major bleeding. In older patients with AF taking anticoagulants, cognitive impairment and frailty were independently associated with major bleeding.

BACKGROUND:As patient prices for many medications have risen steeply in the United States, patients may engage in cost-reducing behaviors (CRBs) such as asking for generic medications or purchasing medication from the Internet. OBJECTIVE:The objective of this study is to describe patterns of CRB, cost-related medication nonadherence, and spending less on basic needs to afford medications among older adults with atrial fibrillation (AF) and examine participant characteristics associated with CRB. METHODS:Data were from a prospective cohort study of older adults at least 65 years with AF and a high stroke risk (CHA2DS2VASc ≥ 2). CRB, cost-related medication nonadherence, and spending less on basic needs to afford medications were evaluated using validated measures. Chi-square and t tests were used to evaluate differences in characteristics across CRB, and statistically significant characteristics (P < 0.05) were entered into a multivariable logistic regression to examine factors associated with CRB. RESULTS:Among participants (N = 1224; mean age 76 years; 49% female), 69% reported engaging in CRB, 4% reported cost-related medication nonadherence, and 6% reported spending less on basic needs. Participants who were cognitively impaired (adjusted odds ratio 0.69 [95% CI 0.52-0.91]) and those who did not identify as non-Hispanic white (0.66 [0.46-0.95]) were less likely to engage in CRB. Participants who were married (1.88 [1.30-2.72]), had a household income of $20,000-$49,999 (1.52 [1.02-2.27]), had Medicare insurance (1.38 [1.04-1.83]), and had 4-6 comorbidities (1.43 [1.01-2.01]) had significantly higher odds of engaging in CRB. CONCLUSION:Although CRBs were common among older adults with AF, few reported cost-related medication nonadherence and spending less on basic needs. Patients with cognitive impairment may benefit from pharmacist intervention to provide support in CRB and patient assistance programs.

Key findings•Receipt of atrial fibrillation (AF) alerts generated by smartwatches in older poststroke adults may be associated with a lower perception of physical health.•AF smartwatch alerts in our poststroke cohort were not related to changes in self-reported anxiety, patient activation or mental health perception.Atrial fibrillation (AF) is the most common arrhythmia and is a common cause of mortality and cerebrovascular events.1Kalantarian S. Ay H. Gollub R.L. et al.Association between atrial fibrillation and silent cerebral infarctions: a systematic review and meta-analysis.Ann Intern Med. 2014; 161: 650-658Crossref PubMed Scopus (109) Google Scholar Therefore, AF detection after a stroke is vital. Algorithms for analysis of pulse data from smartwatches have been approved by the Food and Drug Administration (FDA) for AF detection and are being increasingly recommended for AF screening.2Perez M.V. Mahaffey K.W. Hedlin H. et al.Large-scale assessment of a smartwatch to identify atrial fibrillation.N Engl J Med. 2019; 381: 1909-1917Crossref PubMed Scopus (606) Google Scholar At the same time, ownership of wearable devices has shown a steady annual increase among adults ≥50 years of age, with approximately 42% reporting almost daily use of the technology, thus highlighting the potential of wearable devices for AF monitoring.3American Association of Retired Persons (AARP)2022 Tech Trends and the 50-Plus. December 2021.https://www.aarp.org/content/dam/aarp/research/surveys_statistics/technology/2021/2022-technology-trends-older-americans.doi.10.26419-2Fres.00493.001.pdfDate accessed: March 16, 2022Google Scholar The impact of AF screening on older adults with regard to key outcomes, including psychological well-being, has not been well explored.4Ding E.Y. Svennberg E. Wurster C. et al.Survey of current perspectives on consumer-available digital health devices for detecting atrial fibrillation.Cardiovasc Digit Health J. 2020; 1: 21-29Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Historically, AF has been associated with worse health-related quality of life,5Goren A. Liu X. Gupta S. Simon T.A. Phatak H. Quality of life, activity impairment, and healthcare resource utilization associated with atrial fibrillation in the US National Health and Wellness Survey.PLoS One. 2013; 8e71264Crossref Scopus (24) Google Scholar especially among older adults. Additionally, anxiety among smartwatch users, possibly driven by receipt of alerts for possible rhythm abnormalities, has been reported.6Rosman L. Gehi A. Lampert R. When smartwatches contribute to health anxiety in patients with atrial fibrillation.Cardiovasc Digit Health J. 2020; 1: 9-10Abstract Full Text Full Text PDF PubMed Scopus (4) Google ScholarTo examine the associations between smartwatch alerts for possible AF and psychological health, we analyzed data from the Pulsewatch study,7Dickson E.L. Ding E.Y. Saczynski J.S. et al.Smartwatch monitoring for atrial fibrillation after stroke—the Pulsewatch study: protocol for a multiphase randomized controlled trial.Cardiovasc Digit Health J. 2021; 2: 231-241Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar a multiphase, randomized controlled trial (ClinicalTrials.gov Identifier: NCT03761394) of smartwatches for AF detection among survivors of stroke/transient ischemic attack (TIA). The study enrolled older adult (age ≥50 years) survivors of stroke/TIA with no contraindications to anticoagulation therapy. Phase I intended to assess the accuracy of the smartwatch system and phase II assessed the adherence to it. In phase I, participants were randomized 3:1 (intervention: control) to either receive a smartwatch/smartphone dyad capable of alerting the participant of possible AF and an FDA-approved mobile cardiac outpatient telemetry (MCOT) patch monitor (Cardiac Insight, Bellevue, WA) or receive only the MCOT patch (control) and monitor for AF for 14 days. In phase II, participants were re-randomized (1:1) following a permuted block randomization, to ensure adequate representation of phase I control group participants in the intervention group, who were offered continued use of the smartphone/smartwatch dyad for an additional 30 days. In this analysis, we included participants who received a smartwatch/smartphone dyad and grouped them into those receiving one or more alerts of possible AF detection vs those not receiving any alerts. The smartwatch would alert a participant to “hold still” to minimize motion artifact during the detection of a possible abnormal rhythm, followed by another alert of “abnormality detected” when AF was indeed captured (Figure 1). Trained research staff abstracted data from participants’ medical records, including demographic, clinical, and psychosocial characteristics. The study protocol was approved by the University of Massachusetts Medical School Institutional Review Board (H00016067).The GAD (Generalized Anxiety Disorder)-7 Scale, a standardized 7-item questionnaire (range 0–21), was used to assess anxiety.8Spitzer R.L. Kroenke K. Williams J.B.W. et al.A brief measure for assessing generalized anxiety disorder: the GAD-7.Arch Intern Med. 2016; 166: 1092-1097Crossref Scopus (11954) Google Scholar Presence of anxiety was defined as GAD-7 score ≥5. The Consumer Health Activation Index (CHAI), a validated 10-item scale (range 0–100), was used to evaluate patient activation,9Wolf M.S. Smith S.G. Pandit A.U. et al.Development and validation of the Consumer Health Activation Index.Med Decis Making. 2018; 38: 334-343Crossref PubMed Scopus (23) Google Scholar with CHAI score ≥95 indicative of high activation level. The Physical Component Summary and Mental Component Summary of the Short-Form Health Survey (SF-12), an established 12-item survey (range 0–100), were used to assess health-related quality of life, with higher scores indicative of higher-quality health status.10Brazier J.E. Roberts J. The estimation of a preference-based measure of health from the SF-12.Med Care. 2004; 42: 851-859Crossref PubMed Scopus (955) Google Scholar Questionnaires were delivered to all participants at baseline, 14 days, and 44 days.Baseline participant characteristics were compared using Student t tests for continuous variables and χ2 tests for categorical variables. Approximately one-third of participants demonstrated low anxiety levels at baseline in both groups (receiving alerts vs no alerts). Health status and patient activation were not different between the groups. Mixed-effects repeated measures linear regression models with anxiety, patient activation, and physical and mental health status as outcomes were used to examine their association with receiving alerts. Individual participants were included as the random effect to account for correlation among repeated measures from the same participant. Age, race, sex, baseline depression, cognitive impairment, as well as history of congestive heart failure, history of cardiac arrhythmias, and history of myocardial infarction were included as fixed effects.A total of 94 participants (age 64.6 ± 9.1 years; 44% female; 87 % non-Hispanic white) were included in the analysis. Among participants who received alerts, 12 received 1–3 alerts, 3 received 11–18 alerts, and 1 received 226 alerts. Adjusting for confounders, receiving alerts was not significantly associated with change in self-reported anxiety (β = –0.78; P = .33), patient activation (β = –1.70; P = .60), or mental health status (β 2.85; P = .09), but receipt of an alert was associated with a statistically significant reduction in self-rated physical health status (β = –4.67; P = .04), over the study period.Clinicians are increasingly recommending the use of wearable devices approved for AF detection to patients at risk for the arrhythmia, including older adults with stroke. Our study findings suggest that AF alerts generated by wearable devices are unlikely to lead to significant anxiety among older adults, but an alert may be associated with a lower perception of physical health. Our observation may be explained by the fact that an individual's perception of his or her well-being may be changed because of an alert for AF or, conversely, because of the symptoms from AF. Generalizability of our findings is limited by the small sample size, short observation time, and inclusion of only poststroke adults. Further studies are needed to examine any potential harms of AF screening using wearable devices to assist with their optimal clinical integration and to better inform clinicians and public health guidelines. Key findings•Receipt of atrial fibrillation (AF) alerts generated by smartwatches in older poststroke adults may be associated with a lower perception of physical health.•AF smartwatch alerts in our poststroke cohort were not related to changes in self-reported anxiety, patient activation or mental health perception. •Receipt of atrial fibrillation (AF) alerts generated by smartwatches in older poststroke adults may be associated with a lower perception of physical health.•AF smartwatch alerts in our poststroke cohort were not related to changes in self-reported anxiety, patient activation or mental health perception. •Receipt of atrial fibrillation (AF) alerts generated by smartwatches in older poststroke adults may be associated with a lower perception of physical health.•AF smartwatch alerts in our poststroke cohort were not related to changes in self-reported anxiety, patient activation or mental health perception. Atrial fibrillation (AF) is the most common arrhythmia and is a common cause of mortality and cerebrovascular events.1Kalantarian S. Ay H. Gollub R.L. et al.Association between atrial fibrillation and silent cerebral infarctions: a systematic review and meta-analysis.Ann Intern Med. 2014; 161: 650-658Crossref PubMed Scopus (109) Google Scholar Therefore, AF detection after a stroke is vital. Algorithms for analysis of pulse data from smartwatches have been approved by the Food and Drug Administration (FDA) for AF detection and are being increasingly recommended for AF screening.2Perez M.V. Mahaffey K.W. Hedlin H. et al.Large-scale assessment of a smartwatch to identify atrial fibrillation.N Engl J Med. 2019; 381: 1909-1917Crossref PubMed Scopus (606) Google Scholar At the same time, ownership of wearable devices has shown a steady annual increase among adults ≥50 years of age, with approximately 42% reporting almost daily use of the technology, thus highlighting the potential of wearable devices for AF monitoring.3American Association of Retired Persons (AARP)2022 Tech Trends and the 50-Plus. December 2021.https://www.aarp.org/content/dam/aarp/research/surveys_statistics/technology/2021/2022-technology-trends-older-americans.doi.10.26419-2Fres.00493.001.pdfDate accessed: March 16, 2022Google Scholar The impact of AF screening on older adults with regard to key outcomes, including psychological well-being, has not been well explored.4Ding E.Y. Svennberg E. Wurster C. et al.Survey of current perspectives on consumer-available digital health devices for detecting atrial fibrillation.Cardiovasc Digit Health J. 2020; 1: 21-29Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Historically, AF has been associated with worse health-related quality of life,5Goren A. Liu X. Gupta S. Simon T.A. Phatak H. Quality of life, activity impairment, and healthcare resource utilization associated with atrial fibrillation in the US National Health and Wellness Survey.PLoS One. 2013; 8e71264Crossref Scopus (24) Google Scholar especially among older adults. Additionally, anxiety among smartwatch users, possibly driven by receipt of alerts for possible rhythm abnormalities, has been reported.6Rosman L. Gehi A. Lampert R. When smartwatches contribute to health anxiety in patients with atrial fibrillation.Cardiovasc Digit Health J. 2020; 1: 9-10Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar To examine the associations between smartwatch alerts for possible AF and psychological health, we analyzed data from the Pulsewatch study,7Dickson E.L. Ding E.Y. Saczynski J.S. et al.Smartwatch monitoring for atrial fibrillation after stroke—the Pulsewatch study: protocol for a multiphase randomized controlled trial.Cardiovasc Digit Health J. 2021; 2: 231-241Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar a multiphase, randomized controlled trial (ClinicalTrials.gov Identifier: NCT03761394) of smartwatches for AF detection among survivors of stroke/transient ischemic attack (TIA). The study enrolled older adult (age ≥50 years) survivors of stroke/TIA with no contraindications to anticoagulation therapy. Phase I intended to assess the accuracy of the smartwatch system and phase II assessed the adherence to it. In phase I, participants were randomized 3:1 (intervention: control) to either receive a smartwatch/smartphone dyad capable of alerting the participant of possible AF and an FDA-approved mobile cardiac outpatient telemetry (MCOT) patch monitor (Cardiac Insight, Bellevue, WA) or receive only the MCOT patch (control) and monitor for AF for 14 days. In phase II, participants were re-randomized (1:1) following a permuted block randomization, to ensure adequate representation of phase I control group participants in the intervention group, who were offered continued use of the smartphone/smartwatch dyad for an additional 30 days. In this analysis, we included participants who received a smartwatch/smartphone dyad and grouped them into those receiving one or more alerts of possible AF detection vs those not receiving any alerts. The smartwatch would alert a participant to “hold still” to minimize motion artifact during the detection of a possible abnormal rhythm, followed by another alert of “abnormality detected” when AF was indeed captured (Figure 1). Trained research staff abstracted data from participants’ medical records, including demographic, clinical, and psychosocial characteristics. The study protocol was approved by the University of Massachusetts Medical School Institutional Review Board (H00016067). The GAD (Generalized Anxiety Disorder)-7 Scale, a standardized 7-item questionnaire (range 0–21), was used to assess anxiety.8Spitzer R.L. Kroenke K. Williams J.B.W. et al.A brief measure for assessing generalized anxiety disorder: the GAD-7.Arch Intern Med. 2016; 166: 1092-1097Crossref Scopus (11954) Google Scholar Presence of anxiety was defined as GAD-7 score ≥5. The Consumer Health Activation Index (CHAI), a validated 10-item scale (range 0–100), was used to evaluate patient activation,9Wolf M.S. Smith S.G. Pandit A.U. et al.Development and validation of the Consumer Health Activation Index.Med Decis Making. 2018; 38: 334-343Crossref PubMed Scopus (23) Google Scholar with CHAI score ≥95 indicative of high activation level. The Physical Component Summary and Mental Component Summary of the Short-Form Health Survey (SF-12), an established 12-item survey (range 0–100), were used to assess health-related quality of life, with higher scores indicative of higher-quality health status.10Brazier J.E. Roberts J. The estimation of a preference-based measure of health from the SF-12.Med Care. 2004; 42: 851-859Crossref PubMed Scopus (955) Google Scholar Questionnaires were delivered to all participants at baseline, 14 days, and 44 days. Baseline participant characteristics were compared using Student t tests for continuous variables and χ2 tests for categorical variables. Approximately one-third of participants demonstrated low anxiety levels at baseline in both groups (receiving alerts vs no alerts). Health status and patient activation were not different between the groups. Mixed-effects repeated measures linear regression models with anxiety, patient activation, and physical and mental health status as outcomes were used to examine their association with receiving alerts. Individual participants were included as the random effect to account for correlation among repeated measures from the same participant. Age, race, sex, baseline depression, cognitive impairment, as well as history of congestive heart failure, history of cardiac arrhythmias, and history of myocardial infarction were included as fixed effects. A total of 94 participants (age 64.6 ± 9.1 years; 44% female; 87 % non-Hispanic white) were included in the analysis. Among participants who received alerts, 12 received 1–3 alerts, 3 received 11–18 alerts, and 1 received 226 alerts. Adjusting for confounders, receiving alerts was not significantly associated with change in self-reported anxiety (β = –0.78; P = .33), patient activation (β = –1.70; P = .60), or mental health status (β 2.85; P = .09), but receipt of an alert was associated with a statistically significant reduction in self-rated physical health status (β = –4.67; P = .04), over the study period. Clinicians are increasingly recommending the use of wearable devices approved for AF detection to patients at risk for the arrhythmia, including older adults with stroke. Our study findings suggest that AF alerts generated by wearable devices are unlikely to lead to significant anxiety among older adults, but an alert may be associated with a lower perception of physical health. Our observation may be explained by the fact that an individual's perception of his or her well-being may be changed because of an alert for AF or, conversely, because of the symptoms from AF. Generalizability of our findings is limited by the small sample size, short observation time, and inclusion of only poststroke adults. Further studies are needed to examine any potential harms of AF screening using wearable devices to assist with their optimal clinical integration and to better inform clinicians and public health guidelines. The Pulsewatch study is funded by R01HL137734 from the National Heart, Lung, and Blood Institute . Dr Mehawej’s time is supported by 2T32HL120823 from the National Heart, Lung, and Blood Institute . Eric Ding’s time is supported by F30HL149335 from the National Heart, Lung, and Blood Institute .

Introduction: Psychosocial impairments (i.e., depression or anxiety) and geriatric impairments are prevalent among older patients with atrial fibrillation (AF) and adversely impact their long-term outcomes. However, little is known about the association between symptoms of anxiety or depression and various impairments associated with older age. Hypothesis: We hypothesize that depression and anxiety would be associated with frailty, cognitive impairment, and low quality of life among older adults with AF. Methods: We analyzed data from the Systemic Assessment of Geriatric Elements-AF study. Participants with AF aged 65 years and older, with a CHA 2 DS 2 -VASc≥2, were recruited from multiple clinics in Georgia and Massachusetts. Patient Health Questionnaire-9 and the Generalized Anxiety Disorder-7 Scale were used to assess depression and anxiety symptoms, respectively. We used a GEE model to examine the association between depression and anxiety at baseline with our principal study outcomes over a 2-year follow-up period. Results: 972 participants (mean age 74 years; 48 % female; 87 % were non-Hispanic White) were included in this study. Participants who met the criteria for anxiety (29%) or depression (26%) at baseline, as compared to those without, were more likely to be frail ( OR = 2.20, 95% CI: 1.58-3.05; OR [OR] = 4.32, 95% CI: 3.16-5.90, respectively) and to have a lower AF related quality of life over 2 years ( OR= 3.21, 95% CI: 2.52-4.11; OR= 3.71, 95% CI: 2.94-4.69, respectively). However, there was no association between depression or anxiety and cognitive impairment. Conclusions: Anxiety and depression in older adults with AF were associated with increased risk of frailty and decreased AF related quality of life. As such, addressing mental health needs of older adults may improve their clinical outcomes and quality of life.