CoChat
Sign Up
Cited by 829Non-Invasive Vital Sign MonitoringECG Monitoring and AnalysisMobile Health and mHealth Applications

Smart wearable devices in cardiovascular care: Where we are and how to move forward

Open access
Bayoumy, Karim, Gaber, Mohammed, Elshafeey, Abdallah, Mhaimeed, Omar, Dineen, Elizabeth H., Marvel, Francoise A., Martin, Seth S., Muse, Evan D. +3 more·2021·Nature Reviews Cardiology
DOI 10.1038/s41569-021-00522-7PMC PMC7931503
Open this paper in CoChat — free accountOpen PDF

Abstract

Technological innovations reach deeply into our daily lives and an emerging trend supports the use of commercial smart wearable devices to manage health. In the era of remote, decentralized and increasingly personalized patient care, catalysed by the COVID-19 pandemic, the cardiovascular community must familiarize itself with the wearable technologies on the market and their wide range of clinical applications. In this Review, we highlight the basic engineering principles of common wearable sensors and where they can be error-prone. We also examine the role of these devices in the remote screening and diagnosis of common cardiovascular diseases, such as arrhythmias, and in the management of patients with established cardiovascular conditions, for example, heart failure. To date, challenges such as device accuracy, clinical validity, a lack of standardized regulatory policies and concerns for patient privacy are still hindering the widespread adoption of smart wearable technologies in clinical practice. We present several recommendations to navigate these challenges and propose a simple and practical ‘ABCD’ guide for clinicians, personalized to their specific practice needs, to accelerate the integration of these devices into the clinical workflow for optimal patient care. In this Review, Elshazly and colleagues summarize the basic engineering principles of common wearable sensors and discuss their broad applications in cardiovascular disease prevention, diagnosis and management. Smart wearables generate a plethora of data through various sensors and software algorithms and understanding their basic engineering principles and limitations can be helpful for clinicians and scientists. Evidence supports the use of wearable devices in cardiovascular risk assessment and cardiovascular disease prevention, diagnosis and management, but large, well-designed trials are needed to establish their advantages. Several challenges still hinder the widespread adoption of wearables in clinical practice, including a concern for device accuracy, patient privacy and cost, and how to separate actionable data from noise. Overcoming these challenges requires that various stakeholders come together to develop comprehensive evaluation frameworks, pragmatic regulatory policies, clinical trials and medical education curricula. A practical ‘ABCD’ guide for clinicians can facilitate the integration of these devices in routine clinical practice.

AI snapshot

Written from the paper’s full text.

TL;DR

This narrative review summarizes engineering principles, clinical applications, and adoption barriers for smart wearable devices in cardiovascular care, including arrhythmia screening, heart failure management, and cardiac rehabilitation. It proposes an “ABCD” guide for clinicians and argues that accuracy, clinical validity, regulatory policy, privacy, and evidence gaps still limit widespread clinical integration.

Key findings

  • An estimated 20% of US residents own a smart wearable, and the global market is expected to grow at a compound annual growth rate of 25%, reaching US$70 billion by 2025.
  • In validation studies, the Apple Watch 3 had a mean difference of –1.80 beats per minute and 95% agreement versus ECG over 24 h, whereas the Fitbit Charge 2 had a mean difference of 3.47 beats per minute and 91% agreement; chest-strap monitors had the best concordance during cardiac rehabilitation (Lin’s concordance coefficient rc = 0.99), while 5% of wrist-worn HR measurements were substantially inaccurate.
  • The Apple Heart study enrolled 419,297 participants and reported a positive predictive value of 84% for the irregular notification algorithm and 71% for individual tachograms; the IPED trial found symptomatic rhythm detection in 55.6% of the intervention group versus 9.5% of controls, with mean time to detection of 9.5 days versus 42.9 days.
  • Heart failure telemonitoring trials showed mixed results: TIM-HF2 (1,571 patients) found lower all-cause mortality (HR 0.70, 95% CI 0.50–0.96), TEMA-HF1 (164 patients) found an absolute all-cause mortality reduction of 12.5%, but BEAT-HF (1,457 patients) found no reduction in hospital readmission and had low adherence (61.4% for telephone calls and 55.4% for telemonitoring within 30 days).

Methods

  • Narrative review of wearable sensors and cardiovascular applications, covering activity, heart rate/rhythm, blood pressure, biochemical, and biomechanical sensors.
  • Synthesizes published literature from the past 15 years, including key clinical outcome studies, and presents tables of commercial devices, PubMed/ClinicalTrials.gov study counts, and FDA status as of October 2020.
  • Proposes a practical “ABCD” guide for clinicians; no primary data collection or systematic meta-analysis is reported.

Limitations

  • Stated: device accuracy, clinical validity, lack of standardized regulatory policies, and patient privacy concerns hinder widespread adoption; there is a paucity of meaningful use criteria and robust clinical evidence, with very few trials examining superiority of wearables for clinical outcomes.
  • Stated: heart failure telemonitoring trials have heterogeneous inclusion criteria, device types, and variables, often lack blinding, and can have low adherence; cuff-less BP studies are limited by small sample sizes and lack of external validation.
  • Evident from the text: as a narrative review, it does not use a systematic search or quantitative synthesis, and the device/study counts in Table 1 depend on specified PubMed and ClinicalTrials.gov search terms.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1038/s41569-021-00522-7

Cites

112 of 112 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 164 cited sources checked · 0 supported · 0 flagged

  • Findingnone given

    Small proof-of-concept studies of wearables are abundant.

    “Small, proof-of-concept studies are abundant but the larger, well-designed randomized trials, such as those examining wearables in peripheral vascular disease or AF, set a worthy example for others to follow.”
    Quote in the paperSubstantial claim
  • Findingnone given

    Larger well-designed randomized trials examining wearables in peripheral vascular disease or AF exist.

    “Small, proof-of-concept studies are abundant but the larger, well-designed randomized trials, such as those examining wearables in peripheral vascular disease or AF, set a worthy example for others to follow.”
    Quote in the paperNot a substantial claim
  • Premisecitation

    Barometric measurements can be error-prone because the device might mistake natural changes in ambient temperature and pressure as a change in altitude.

    “However, barometric measurements can be error-prone because the device might mistake natural changes in ambient temperature and pressure as a change in altitude10.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [10] Bolanakis, D. E. MEMS barometers and barometric altimeters in industrial, medical, aerospace, and consumer applications. IEEE Instrum. Meas. Mag. 20, 30–55 (2017). source

      Not checked in the free run.

  • Premisecitation

    Wrist placement has taken precedence over ankle placement in commercial wearables owing to increased compliance and convenience.

    “However, wrist placement has taken precedence over ankle placement in commercial wearables owing to increased compliance and convenience8.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [8] Troiano, R. P., McClain, J. J., Brychta, R. J. & Chen, K. Y. Evolution of accelerometer methods for physical activity research. Br. J. Sports Med. 48, 1019–1023 (2014). source

      Not checked in the free run.

  • Premisecitation

    Over 24 h, the Apple Watch 3 had a mean difference of -1.80 beats per minute and a mean agreement of 95% compared with the gold standard ECG.

    “Over 24 h, the Apple Watch 3 had a mean difference of –1.80 beats per minute and a mean agreement of 95% compared with the gold standard ECG22;”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [22] Nelson, B. W. & Allen, N. B. Accuracy of consumer wearable heart rate measurement during an ecologically valid 24-hour period: intraindividual validation study. JMIR mHealth uHealth 7, e10828 (2019). source

      Not checked in the free run.

    • Rests on an assumption: ECG sensors are the gold standard for heart rate and heart rhythm measurement.
  • May combine two claims. 46
  • Classified as probably not a substantial claim. 24

  • May combine two claims.

    Premisecitation

    Physical activity is inversely correlated with adverse cardiovascular outcomes and all-cause mortality.

    “Physical activity is inversely correlated to adverse cardiovascular outcomes5 and all-cause mortality and is recommended by the AHA as one of the ‘Life’s Simple 7’ lifestyle recommendations to promote heart health6.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [5] Blond, K., Brinkløv, C. F., Ried-Larsen, M., Crippa, A. & Grøntved, A. Association of high amounts of physical activity with mortality risk: a systematic review and meta-analysis. Br. J. Sports Med. 54, 1195–1201 (2020). source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In healthy populations, a high resting heart rate is associated with an increased risk of coronary artery disease and all-cause death.

    “In healthy populations, a high resting HR has been associated with an increased risk of coronary artery disease and all-cause death12 and is also well recognized as a predictor of adverse outcomes in patients with heart failure (HF)13.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [12] Zhang, D., Wang, W. & Li, F. Association between resting heart rate and coronary artery disease, stroke, sudden death and noncardiovascular diseases: a meta-analysis. Can. Med. Assoc. J. 188, E384–E392 (2016). source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In patients with established heart disease undergoing phase II or phase III cardiac rehabilitation, the accuracy of wrist-worn devices varied substantially by the type of activity and 5% of heart rate measurements were substantially inaccurate.

    “the accuracy of wrist-worn devices varied substantially by the type of activity and 5% of HR measurements were substantially inaccurate23.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [23] Etiwy, M. et al. Accuracy of wearable heart rate monitors in cardiac rehabilitation. Cardiovasc. Diagn. Ther. 9, 262–271 (2019). source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    A centrally located sensor on the torso is best suited for detecting posture, acceleration and whole-body movements and offers the least errors compared with other body locations.

    “A centrally located sensor on the torso (embedded into vests, mounted by straps or attached to the skin) is best suited for detecting posture, acceleration and whole-body movements and offers the least errors compared with other body locations7.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [7] Yang, C. C. & Hsu, Y. L. A review of accelerometry-based wearable motion detectors for physical activity monitoring. Sensors 10, 7772–7788 (2010). source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Skin colour, moisture and tattoos have been postulated to affect PPG accuracy.

    “Skin colour, moisture and even tattoos have also been postulated to affect PPG accuracy20”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [20] Dagher, L., Shi, H., Zhao, Y. & Marrouche, N. F. Wearables in cardiology: here to stay. Heart Rhythm 17, 889–895 (2020). source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    One study showed similar device performance across a full range of skin tones.

    “although one study showed similar device performance across a full range of skin tones21.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [21] Bent, B., Goldstein, B. A., Kibbe, W. A. & Dunn, J. P. Investigating sources of inaccuracy in wearable optical heart rate sensors. NPJ Digit. Med. 3, 18 (2020). source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Using more sensors leads to better estimation of physical activity and energy expenditure but can put further strain on battery life.

    “Although the use of more sensors leads to better estimation of physical activity and energy expenditure, this approach can also put further strain on battery life11.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [11] Muralidharan, K., Khan, A. J., Misra, A., Balan, R. K. & Agarwal, S. Barometric phone sensors: more hype than hope! Proc. Workshop Mob. Comput. Syst. Appl. 14, 1–6 (2014).

      Not checked in the free run.

  • May combine two claims.

    Premisereasoning

    Subjective reporting of physical activity levels is limited by a lack of sufficient detail, recall bias, and a failure to objectively assess physical activity in a real-life environment.

    “This approach is limited by a lack of sufficient detail, recall bias and a failure to objectively assess physical activity in a real-life environment.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    In a small study, mean biases between cuff-less wearable and ambulatory devices over 24 h were 0.5 mmHg for systolic BP and 2.24 mmHg for diastolic BP, with mean bias widening over 7 days to -12.7 mmHg for systolic BP and -5.6 mmHg for diastolic BP.

    “Mean biases between the wearable and ambulatory devices over 24 h were 0.5 mmHg (–10.1 mmHg to 11.1 mmHg) for systolic BP and 2.24 mmHg (–17.6 mmHg to 13.1 mmHg) for diastolic BP, with the mean bias widening over 7 days to –12.7 mmHg for systolic BP and –5.6 mmHg for diastolic BP.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [28] Islam, S. M. S. et al. Validation and acceptability of a cuffless wrist-worn wearable blood pressure monitoring device among users and health care professionals: mixed methods study. JMIR mHealth uHealth 7, e14706 (2019). source

      Not checked in the free run.

  • May combine two claims.

    Interpretationcitation

    PPG heart rate readings from wrist-worn devices during activity should be interpreted with caution, whereas less convenient chest-strap monitors are more accurate.

    “These studies highlight that PPG HR readings from wrist-worn devices during activity should be interpreted with caution20, whereas less convenient, chest-strap monitors are more accurate.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [20] Dagher, L., Shi, H., Zhao, Y. & Marrouche, N. F. Wearables in cardiology: here to stay. Heart Rhythm 17, 889–895 (2020). source

      Not checked in the free run.

  • May combine two claims.

    Interpretationnone given

    Blood pressure can now be measured without a cuff, increasing the feasibility and ease of monitoring BP throughout the day.

    “BP can now be measured without a cuff, increasing the feasibility and ease of monitoring BP throughout the day.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Minimally invasive continuous glucose monitors have been clinically validated but are difficult to embed in consumer-grade wearables and mostly function as a stand-alone product.

    “One example of biochemical sensors are the minimally invasive continuous glucose monitors that have been clinically validated but are difficult to embed in consumer-grade wearables and mostly function as a stand-alone product31.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [31] Bailey, T. S. Clinical implications of accuracy measurements of continuous glucose sensors. Diabetes Technol. Ther. 19 (Suppl. 2), S51–S54 (2017). source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Cuff-less blood pressure monitoring is still in its infancy and requires further scrutiny.

    “Although encouraging, cuff-less BP monitoring is still in its infancy and requires further scrutiny.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Biochemical sensors can measure body fluid electrolytes with electrochemical transducers, offering valuable information about plasma volume status and analyte concentrations.

    “Biochemical sensors can measure body fluid electrolytes with the use of electrochemical transducers, offering valuable information about plasma volume status and analyte concentrations30.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [30] Kim, J., Campbell, A. S., de Ávila, B. E.-F. & Wang, J. Wearable biosensors for healthcare monitoring. Nat. Biotechnol. 37, 389–406 (2019). source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Non-invasive sensors of sweat and saliva might be more practical to integrate into wearables but still need to be carefully evaluated.

    “Non-invasive sensors of sweat and saliva might be more practical to integrate into wearables but still need to be carefully evaluated32.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [32] Seshadri, D. R. et al. Wearable sensors for monitoring the physiological and biochemical profile of the athlete. NPJ Digit. Med. 2, 72 (2019). source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    The TEN-HMS, TIM-HF and BEAT-HF trials showed that a remote telemonitoring intervention did not reduce heart failure hospitalizations and all-cause mortality.

    “TEN-HMS, TIM-HF and BEAT-HF trials showed that a remote telemonitoring intervention did not reduce HF hospitalizations and all-cause mortality68–70”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [68] Cleland, J. G. F., Louis, A. A., Rigby, A. S., Janssens, U. & Balk, A. H. M. M. Noninvasive home telemonitoring for patients with heart failure at high risk of recurrent admission and death: the trans-European network-home-care management system (TEN-HMS) study. J. Am. Coll. Cardiol. 45, 1654–1664 (2005). source

      Not checked in the free run.

    • cites [69] Koehler, F. et al. Impact of remote telemedical management on mortality and hospitalizations in ambulatory patients with chronic heart failure: the telemedical interventional monitoring in heart failure study. Circulation 123, 1873–1880 (2011). source

      Not checked in the free run.

    • cites [70] Ong, M. K. et al. Effectiveness of remote patient monitoring after discharge of hospitalized patients with heart failure the better effectiveness after transition-heart failure (BEAT-HF) randomized clinical trial. JAMA Intern. Med. 176, 310–318 (2016). source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    Wearables can be used to guide β-blocker titration in patients with chronic coronary syndrome.

    “Wearables can be used to guide β-blocker titration in patients with chronic coronary syndrome; no available clinical studies”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    Wearables can be used to guide rate control in patients with permanent atrial fibrillation.

    “Wearables can be used to guide rate control in patients with permanent AF; no clinical studies available”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    The TEMA-HF1 and TIM-HF-2 trials showed that telemonitoring reduced days lost owing to heart failure hospitalizations and reduced all-cause mortality.

    “The TEMA-HF1 and TIM-HF-2 trial showed that telemonitoring reduced days lost owing to HF hospitalizations and reduced all-cause mortality66,67”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [66] Koehler, F. et al. Efficacy of telemedical interventional management in patients with heart failure (TIM-HF2): a randomised, controlled, parallel-group, unmasked trial. Lancet 392, 1047–1057 (2018). source

      Not checked in the free run.

    • cites [67] Dendale, P. et al. Effect of a telemonitoring-facilitated collaboration between general practitioner and heart failure clinic on mortality and rehospitalization rates in severe heart failure: the TEMA-HF 1 (telemonitoring in the management of heart failure) study. Eur. J. Heart Fail. 14, 333–340 (2012). source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Atrial fibrillation screening via ECG patches in selected high-risk individuals is feasible and clinically valuable.

    “AF screening via ECG patches in selected high-risk individuals is feasible and clinically valuable50”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [50] Steinhubl, S. R. et al. Effect of a home-based wearable continuous ECG monitoring patch on detection of undiagnosed atrial fibrillation. JAMA 320, 146 (2018). source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Physical activity interventions did not show long-term behavioural changes or did not improve clinical outcomes.

    “PA interventions did not show long-term behavioural changes or did not improve clinical outcomes”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [44] Finkelstein, E. A. et al. Effectiveness of activity trackers with and without incentives to increase physical activity (TRIPPA): a randomised controlled trial. Lancet Diabetes Endocrinol. 4, 983–995 (2016). source

      Not checked in the free run.

    • cites [45] Wang, J. B. et al. Wearable sensor/device (Fitbit One) and SMS text-messaging prompts to increase physical activity in overweight and obese adults: a randomized controlled trial. Telemed. e-Health 21, 782–792 (2015). source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    Wearables can be used to objectively and frequently assess heart failure prognosis via 6-minute walk tests or measuring heart rate variables such as heart rate recovery or variability.

    “wearables can be used to objectively and frequently assess HF prognosis via 6-minute walk tests or measuring heart rate variables such as heart rate recovery or variability; no clinical studies available”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Interpretationnone given

    Atrial fibrillation screening through PPG coupled with ECG is feasible and practical.

    “AF screening through PPG coupled with ECG is feasible and practical; no clinical studies available; the HEARTLINE study aims54 to examine this application and its effect on clinical outcomes”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Adoption of smart wearables accelerated after the COVID-19 pandemic and the explosive growth of telehealth.

    “its adoption has further accelerated after the coronavirus disease 2019 (COVID-19) pandemic and the explosive growth of telehealth4.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [4] Varma, N. et al. HRS/EHRA/APHRS/LAHRS/ACC/AHA worldwide practice update for telehealth and arrhythmia monitoring during and after a Pandemic. Circ. Arrhythm. Electrophysiol. 13, 1048–1059 (2020).

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Other trials showed no improvement in walking ability or quality of life but improvement in exercise frequency.

    “Other trials showed no improvement in walking ability or quality of life but improvement in exercise frequency90,91”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [90] McDermott, M. M. et al. Effect of a home-based exercise intervention of wearable technology and telephone coaching on walking performance in peripheral artery disease. JAMA 319, 1665 (2018). source

      Not checked in the free run.

    • cites [91] Chan, C. et al. The role of wearable technologies and telemonitoring in managing vascular disease. Vasc. Endovasc. Rev. https://doi.org/10.15420/ver.2019.11 (2020). source

      Not checked in the free run.

  • May combine two claims.

    Interpretationcitation

    Home-based cardiac telerehabilitation using wearable sensors is equivalent or better than centre-based rehabilitation and can increase access to cardiac rehabilitation and reduce the cost.

    “Home-based cardiac telerehabilitation using wearable sensors is equivalent or better than centre-based rehabilitation and can increase access to cardiac rehabilitation and reduce the cost”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [85] Maddison, R. et al. Effects and costs of real-time cardiac telerehabilitation: randomised controlled non-inferiority trial. Heart 105, 122–129 (2019). source

      Not checked in the free run.

    • cites [86] Hannan, A. L. et al. Impact of wearable physical activity monitoring devices with exercise prescription or advice in the maintenance phase of cardiac rehabilitation: systematic review and meta-analysis. BMC Sports Sci. Med. Rehabil. 11, 14 (2019). source

      Not checked in the free run.

  • May combine two claims.

    Interpretationcitation

    Single-lead or 6-lead ECG can reasonably measure the QTc interval but with clinically significant variability.

    “Single-lead or 6-lead ECG was able to reasonably measure the QTc interval but with clinically significant variability”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [78] Castelletti, S. et al. A wearable remote monitoring system for the identification of subjects with a prolonged QT interval or at risk for drug-induced long QT syndrome. Int. J. Cardiol. 266, 89–94 (2018). source

      Not checked in the free run.

    • cites [79] Schram, M. et al. Prediction of the heart rate corrected QT interval (QTc) from a novel, multilead smartphone-enabled ECG using a deep neural network. J. Am. Coll. Cardiol. 73, 368 (2019). source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Challenges such as device accuracy, clinical validity, a lack of standardized regulatory policies and concerns for patient privacy are still hindering the widespread adoption of smart wearable technologies in clinical practice.

    “To date, challenges such as device accuracy, clinical validity, a lack of standardized regulatory policies and concerns for patient privacy are still hindering the widespread adoption of smart wearable technologies in clinical practice.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Interpretationnone given

    Wearables can be used to detect high-risk arrhythmias and stratify patients who might need a defibrillator.

    “Wearables can be used to detect high-risk arrhythmias and stratify patients who might need a defibrillator; no clinical studies available”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Randomized trials showed that wearable-guided exercise prescriptions improve walking ability, speed and oxygen consumption.

    “Randomized trials showed that wearable-guided exercise prescriptions improve walking ability, speed and oxygen consumption88,89”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [88] Gardner, A. W., Parker, D. E., Montgomery, P. S. & Blevins, S. M. Step-monitored home exercise improves ambulation, vascular function, and inflammation in symptomatic patients with peripheral artery disease: a randomized controlled trial. J. Am. Heart Assoc. 3, e001107 (2014). source

      Not checked in the free run.

    • cites [89] Gardner, A. W., Parker, D. E., Montgomery, P. S., Scott, K. J. & Blevins, S. M. Efficacy of quantified home-based exercise and supervised exercise in patients with intermittent claudication: a randomized controlled trial. Circulation 123, 491–498 (2011). source

      Not checked in the free run.

  • May combine two claims.

    Interpretationcitation

    Hyperkalaemia detection via wearable ECG is feasible but has high false-positive rates.

    “Hyperkalaemia detection via wearable ECG is feasible but has high false-positive rates”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [82] Galloway, C. D. et al. Development and validation of a deep-learning model to screen for hyperkalemia from the electrocardiogram. JAMA Cardiol. 4, 428 (2019). source

      Not checked in the free run.

    • cites [83] Galloway, C. D. et al. Non-invasive detection of hyperkalemia with a smartphone electrocardiogram and artificial intelligence. J. Am. Coll. Cardiol. 71, A272 (2018). source

      Not checked in the free run.

  • May combine two claims.

    Interpretationcitation

    Longitudinal HR data can establish what is normal for an individual and recognize important deviations earlier, before cardiovascular disease develops.

    “Moreover, longitudinal HR data can establish what is normal for an individual and, subsequently, recognize important deviations in lifestyle earlier, before cardiovascular disease develops46.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [46] Quer, G., Gouda, P., Galarnyk, M., Topol, E. J. & Steinhubl, S. R. Inter- and intraindividual variability in daily resting heart rate and its associations with age, sex, sleep, BMI, and time of year: retrospective, longitudinal cohort study of 92,457 adults. PLoS ONE 15, e0227709 (2020). source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Initiating hypertension screening in young adulthood is widely recommended to prevent cardiovascular disease.

    “Initiating hypertension screening in young adulthood is widely recommended to prevent cardiovascular disease24.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [24] Whelton, P. K. et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 138, e426–e483 (2018).

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In another gamification study, participants with MapTrek had an average of 1,455 more steps per day and 89.6 additional active minutes per week than the Fitbit-only group.

    “Participants with MapTrek had an average of 1,455 more steps per day and 89.6 additional active minutes per week than the Fitbit-only group42.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [42] Gremaud, A. L. et al. Gamifying accelerometer use increases physical activity levels of sedentary office workers. J. Am. Heart Assoc. 7, e007735 (2018). source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    Continuous wearable BP measurements using novel sensors will potentially facilitate BP measurement during sleep or exercise when oscillometric measurements are not practical.

    “Continuous wearable BP measurements using novel sensors will potentially facilitate the measurement of BP during sleep or activities such as exercise when oscillometric measurements are not practical.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    In the mActive trial, the text messaging group increased daily steps by 2,534 compared with the no-texting unblinded group and by 3,376 compared with blinded controls.

    “The text messaging group increased their daily steps by 2,534 compared with the no-texting unblinded group and by 3,376 steps compared with blinded controls40.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [40] Martin, S. S. et al. mActive: a randomized clinical trial of an automated mHealth intervention for physical activity promotion. J. Am. Heart Assoc. 4, e002239 (2015). source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Despite improvement in MVPA at 12 months with activity tracking, with or without incentives, there was no improvement in health outcomes such as weight and BP reduction at 12 months.

    “Moreover, despite the improvement in MVPA at 12 months with activity tracking, with or without incentives, these findings did not translate into an improvement in health outcomes, such as weight and BP reduction, at 12 months.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [44] Finkelstein, E. A. et al. Effectiveness of activity trackers with and without incentives to increase physical activity (TRIPPA): a randomised controlled trial. Lancet Diabetes Endocrinol. 4, 983–995 (2016). source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In the Apple Heart study, the positive predictive value for AF detection was 84% for the irregular notification algorithm and 71% for individual tachograms.

    “The positive predictive value for AF detection was 84% and 71% for the irregular notification algorithm and individual tachograms, respectively19.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [19] Perez, M. V. et al. Large-scale assessment of a smartwatch to identify atrial fibrillation. N. Engl. J. Med. 381, 1909–1917 (2019). source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In women with mean age 72, as few as 4,400 steps per day were associated with a 41% reduction in mortality compared with 2,700 steps per day, but benefits levelled at 7,500 steps per day.

    “Another study of women with a mean (s.d.) age of 72 (5.7) years showed that as few as 4,400 steps per day were significantly associated with a 41% reduction in mortality compared with 2,700 steps per day, but the benefits levelled at 7,500 steps per day39.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [39] Lee, I.-M. et al. Association of step volume and intensity with all-cause mortality in older women. JAMA Intern. Med. 179, 1105 (2019). source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The global burden of AF and its association with stroke, HF and mortality are well established.

    “The global burden of AF and its association with stroke, HF and mortality have been well established49.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [49] Kirchhof, P. et al. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur. Heart J. 37, 2893–2962 (2016). source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In the mSToPS study, ECG monitoring led to a higher rate of new AF diagnosis at 4 months and 1 year and was associated with increased initiation of anticoagulation therapy and outpatient cardiology and primary care visits in patients without previously known AF.

    “The study showed that ECG monitoring led to a higher rate of new AF diagnosis at 4 months and 1 year and was associated with the increased initiation of anticoagulation therapy and outpatient cardiology and primary care visits in patients without previously known AF50.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [50] Steinhubl, S. R. et al. Effect of a home-based wearable continuous ECG monitoring patch on detection of undiagnosed atrial fibrillation. JAMA 320, 146 (2018). source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In a four-arm Singapore trial, a cash incentive was most effective at increasing MVPA at 6 months, but this effect was not sustained 6 months after removal of incentives.

    “The trial showed that a cash incentive was most effective at increasing MVPA at 6 months, but this effect was not sustained 6 months after the removal of incentives.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [44] Finkelstein, E. A. et al. Effectiveness of activity trackers with and without incentives to increase physical activity (TRIPPA): a randomised controlled trial. Lancet Diabetes Endocrinol. 4, 983–995 (2016). source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    The Huawei Band 2 PRO AF algorithm showed a positive predictive value of 99.6% and a negative predictive value of 96.2%.

    “Another study that assessed the use of the Huawei Band 2 (Huawei, China) PRO AF algorithm showed a positive predictive value of 99.6% and a negative predictive value of 96.2%52.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [52] Fan, Y. Y. et al. Diagnostic performance of a smart device with photoplethysmography technology for atrial fibrillation detection: pilot study (Pre-mAFA II registry). JMIR Mhealth Uhealth. 7, e11437 (2019). source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Administering the 6-minute walk test through a pedometer is feasible and can be used to predict HF severity and death.

    “For example, one study showed that administering the 6-minute walk test through a pedometer is feasible and can be used to predict HF severity and death62.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [62] Werhahn, S. M. et al. Designing meaningful outcome parameters using mobile technology: a new mobile application for telemonitoring of patients with heart failure. ESC Heart Fail. 6, 516–525 (2019). source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In the TIM-HF2 trial, the intervention was associated with a smaller proportion of days lost from unplanned HF-related hospital admissions and lower all-cause mortality (HR 0.70, 95% CI 0.50-0.96).

    “The intervention, compared with usual care, was associated with a smaller proportion of days lost from unplanned HF-related hospital admissions and had a lower all-cause mortality (HR 0.70, 95% CI 0.50–0.96) after 393 days of follow-up66.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [66] Koehler, F. et al. Efficacy of telemedical interventional management in patients with heart failure (TIM-HF2): a randomised, controlled, parallel-group, unmasked trial. Lancet 392, 1047–1057 (2018). source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In the TEN-HMS trial, there were no significant differences in days lost owing to hospitalization or death compared with nurse telephone support or usual care at 240 days, although the telemonitoring group had a lower mean duration of hospital admission by 6 days.

    “The TEN-HMS home telemonitoring trial68 used wearable and non-wearable non-invasive monitors (home BP monitor, weigh scale and single-lead ECG on a wrist band) in patients with an LVEF of <40% and a recent hospital admission for HF and showed no significant differences in days lost owing to hospitalization or death compared with nurse telephone support or usual care at 240 days, although the tele”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [68] Cleland, J. G. F., Louis, A. A., Rigby, A. S., Janssens, U. & Balk, A. H. M. M. Noninvasive home telemonitoring for patients with heart failure at high risk of recurrent admission and death: the trans-European network-home-care management system (TEN-HMS) study. J. Am. Coll. Cardiol. 45, 1654–1664 (2005). source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In the TEMA-HF1 trial, the intervention group had significantly lower all-cause mortality (absolute reduction of 12.5%) and a lower number of follow-up days lost to death, hospitalization or dialysis.

    “The intervention group had a significantly lower all-cause mortality (absolute reduction of 12.5%) and a lower number of follow-up days lost to death, hospitalization or dialysis.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [67] Dendale, P. et al. Effect of a telemonitoring-facilitated collaboration between general practitioner and heart failure clinic on mortality and rehospitalization rates in severe heart failure: the TEMA-HF 1 (telemonitoring in the management of heart failure) study. Eur. J. Heart Fail. 14, 333–340 (2012). source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In the TIM-HF trial, there were no differences between groups in cardiovascular and all-cause mortality or in hospitalizations at a median follow-up of 26 months.

    “The TIM-HF trial69 randomly assigned 710 patients with an LVEF of ≤35%, NYHA class II–III and a history of HF decompensation within the previous 2 years to telemonitoring (weight, BP and heart rhythm data transmission) compared with usual care and found no differences between the groups in cardiovascular and all-cause mortality or in hospitalizations at a median follow-up of 26 months.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [69] Koehler, F. et al. Impact of remote telemedical management on mortality and hospitalizations in ambulatory patients with chronic heart failure: the telemedical interventional monitoring in heart failure study. Circulation 123, 1873–1880 (2011). source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    REMOTE-CR was associated with less sedentary time at 24 weeks and was more cost-effective than the centre-based programme.

    “A non-inferiority, randomized trial comparing REMOTE-CR — a real-time, remote telerehabilitation platform that includes the use of a chest-worn wearable sensor (BioHarness 3, Zephyr Technology, USA) — with a centre-based programme showed that REMOTE-CR was associated with less sedentary time at 24 weeks and was more cost-effective than the centre-based programme85.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [85] Maddison, R. et al. Effects and costs of real-time cardiac telerehabilitation: randomised controlled non-inferiority trial. Heart 105, 122–129 (2019). source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The US National Academy of Medicine issued a reference document for responsible development and maintenance of AI in clinical settings that provides a guiding framework for stakeholders.

    “The US National Academy of Medicine issued a reference document for the responsible development and maintenance of AI in the clinical setting that provides a guiding framework for all stakeholders, including AI developers and the medical community99.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [99] Matheny, M., Israni, S. T., Ahmed, M., Whicher, D. & Edu, N. Artificial intelligence in health care: the hope, the hype, the promise, the peril (National Academy of Medicine, 2019). source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Interpretationcitation

    A small false-positive rate in wearable AF screening can increase downstream medical testing and costs if screening is applied to the entire general population.

    “For example, the Apple Heart Study sparked a debate on how a small false-positive rate can increase downstream medical testing and costs if screening is applied to the entire general population.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationcitation

    Meticulous scrutiny of wearable devices through structured frameworks ensures they are worthy of clinician and patient trust by the time they reach the market.

    “Meticulous scrutiny of these devices through such structured frameworks ensures that they are worthy of clinician and patient trust by the time they reach the market.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The Coravos et al. framework covers hardware and software and outlines resources, evaluation criteria and target thresholds for five dimensions: V3; data security and privacy; data rights and governance; utility and usability; and economic feasibility.

    “In this comprehensive framework covering both the hardware and software components of these technologies, the authors outline the potential resources, evaluation criteria and target thresholds for five dimensions: verification, analytical validation and clinical validation (V3); data security and privacy; data rights and governance; utility and usability; and economic feasibility95.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [95] Coravos, A. et al. Modernizing and designing evaluation frameworks for connected sensor technologies in medicine. NPJ Digit. Med. 3, 37 (2020). source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The Hekler et al. framework highlights the importance of the state-space, the readiness to respond to an intervention according to intrinsic factors (state) and contextual factors (space).

    “This framework highlights the importance of the ‘state-space’, essentially the readiness to respond to an intervention according to intrinsic factors (state) and contextual factors (space).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [104] Hekler, E. B. et al. Advancing models and theories for digital behavior change interventions. Am. J. Prev. Med. 51, 825–832 (2016). source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    The Discontinuation Prediction Score had an AUC of 0.9 with high accuracy (>80%) and specificity (>80%).

    “The score had an AUC of 0.9 with high accuracy (>80%) and specificity (>80%).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [105] Zhou, M., Fukuoka, Y., Goldberg, K., Vittinghoff, E. & Aswani, A. Applying machine learning to predict future adherence to physical activity programs. BMC Med. Inform. Decis. Mak. 19, 169 (2019). source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Hekler et al. proposed a framework for the use of digital BCTs, such as just-in-time adaptive interventions, to encourage and maintain health.

    “Hekler et al. proposed a framework for the use of digital BCTs, such as just-in-time adaptive interventions, to encourage and maintain health104.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [104] Hekler, E. B. et al. Advancing models and theories for digital behavior change interventions. Am. J. Prev. Med. 51, 825–832 (2016). source

      Not checked in the free run.

  • May combine two claims.

    Interpretationcitation

    Some behavioural intervention strategies might not be cost-prohibitive for individuals or unprofitable for the manufacturer.

    “Some of these behavioural intervention strategies might not be cost-prohibitive for individuals or unprofitable for the manufacturer, which is encouraging108.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [108] Chia, G. L. C., Anderson, A. & McLean, L. A. Behavior change techniques incorporated in fitness trackers: content analysis. JMIR mHealth uHealth 7, e12768 (2019). source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Digital models often require programming for a strict definition of the desired outcome and the type and amount of intervention proposed and are in constant flux to tailor interventions.

    “However, digital models often require programming for a strict definition of the desired outcome and the type and amount of intervention proposed and are in constant flux to tailor interventions104.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [104] Hekler, E. B. et al. Advancing models and theories for digital behavior change interventions. Am. J. Prev. Med. 51, 825–832 (2016). source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationnone given

    A practical ABCD clinician's guide can facilitate the integration of wearable devices into the clinical workplace.

    “Moreover, a practical ABCD clinician’s guide can facilitate the integration of these devices into the clinical workplace.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationnone given

    A new age of consumer-driven health has arrived.

    “A new age of consumer-driven health has arrived, with great future benefits in cardiovascular disease prevention, diagnosis and management.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    In the USA, CPT codes 99453, 99454, 99457 and 99091 can be used to bill for remote monitoring set up and data review.

    “in the USA, CPT codes 99453, 99454, 99457 and 99091 can be used”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [115] mTelehealth. CMS guidance for remote patient monitoring (RPM) during COVID-19 (CPT Code 99453). mTelehealth https://mtelehealth.com/cms-guidance-for-remote-patient-monitoring-rpm-during-covid-19-cpt-code-99453/ (2020).

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    HIPAA/HITECH privacy and security bureaucratic requirements in the USA are considered outdated and might need to be amended to cope with increasing availability and heterogeneity of technologies that personalize and promote patient engagement.

    “In the USA, HIPAA/HITECH (The Health Insurance Portability and Accountability Act of 1996/Health Information Technology for Economic and Clinical Health Act) privacy and security bureaucratic requirements are, to an extent, considered outdated and might need to be amended to cope with the increasing availability and heterogeneity of technologies that personalize and promote patient engagement112.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [112] Sarpatwari, A. & Choudhry, N. K. Recalibrating privacy protections to promote patient engagement. N. Engl. J. Med. 377, 1509–1511 (2017). source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationcitation

    Opt-in systems with transparent privacy policies might be better equipped to improve patient engagement while maintaining autonomy.

    “Opt-in systems with transparent privacy policies might be better equipped to improve patient engagement while maintaining autonomy112.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [112] Sarpatwari, A. & Choudhry, N. K. Recalibrating privacy protections to promote patient engagement. N. Engl. J. Med. 377, 1509–1511 (2017). source

      Not checked in the free run.

    • Rests on an assumption: Some institutions currently allow patients to waive rigid security standards for sharing health information, but this opt-out system involves additional costs and is biased towards the most engaged patients.

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    Currently, several challenges hinder the widespread use of wearable technologies in clinical practice.

    “Currently, several challenges hinder the widespread use of wearable technologies in clinical practice.”
    Quote in the paperNot a substantial claim
64 of 64

  • The paper relies on this without support.

    ECG sensors are the gold standard for heart rate and heart rhythm measurement.

    “ECG sensors come in various forms and are the gold standard for HR and heart rhythm measurement.”

  • The paper relies on this without support.

    PPG sensors work best when in direct contact with the skin, which is not always the case with wearables secured with straps.

    “The main drawback is that the sensor works best when in direct contact with the skin, which is not always the case with wearables secured with straps.”

  • The paper relies on this without support.

    The accuracy of biochemical sensors changes with skin temperature, skin contamination with dust, dried sweat or other substances, and hair density.

    “However, the accuracy of these sensors changes with skin temperature, skin contamination with dust, dried sweat or other substances, and hair density.”

  • The paper relies on this without support.

    Single-lead ECGs are useful to diagnose simple and common arrhythmias such as atrial fibrillation.

    “Single-lead ECGs are useful to diagnose simple and common arrhythmias such as atrial fibrillation (AF).”

  • The paper relies on this without support.

    Most clinical risk scores do not capture the dynamic changes in personalized risk that closely follow lifestyle habits.

    “However, most of these scores do not capture the dynamic changes in personalized risk that closely follow lifestyle habits.”

  • The paper relies on this without support.

    The incorporation of subjective lifestyle behaviours in risk assessment has been challenging.

    “The incorporation of subjective lifestyle behaviours in risk assessment has been challenging; therefore, objective data derived from wearables provide a renewed opportunity to make the assessment of the risk of cardiovascular disease more accurate, comprehensive and dynamic over a lifetime.”

  • The paper relies on this without support.

    The encouragement of physical activity is a cornerstone of primary and secondary prevention.

    “The encouragement of physical activity is a cornerstone of primary and secondary prevention; therefore, cardiovascular specialists should familiarize themselves with BCT platforms that have been proven to work and recommend them to their patients, particularly those who have failed to follow traditional counselling for the promotion of physical activity.”

  • The paper relies on this without support.

    A prolonged QT interval can predispose patients to life-threatening arrhythmias.

    “A prolonged QT interval can predispose patients to life-threatening arrhythmias.”

  • The paper relies on this without support.

    Cardiac rehabilitation is a mainstay in the management of many cardiovascular conditions because it provides a structured exercise programme together with comprehensive guideline-directed secondary prevention.

    “Cardiac rehabilitation is a mainstay in the management of many cardiovascular conditions because it provides a structured exercise programme together with comprehensive guideline-directed secondary prevention.”

  • The paper relies on this without support.

    In patients with peripheral vascular disease, the first-line treatment for intermittent claudication is a supervised exercise programme of gradually increasing intensity.

    “In patients with peripheral vascular disease, the first-line treatment for intermittent claudication is a supervised exercise programme of gradually increasing intensity.”

  • The paper relies on this without support.

    Abnormal PPG heart rate measurements are often error-prone.

    “For example, abnormal PPG HR measurements are often error-prone and should be interpreted in the context of device placement, user activities and symptoms.”

  • The paper relies on this without support.

    In 2018, the American Medical Association introduced new CPT codes to incentivize adoption of remote monitoring in clinical practice.

    “In 2018, the American Medical Association introduced new CPT (Current Procedural Terminology) codes to incentivize the adoption of remote monitoring in clinical practice.”

  • The paper relies on this without support.

    These CPT codes were included in the 2019 Centers for Medicare and Medicaid Services physician fee schedule and are reimbursed by private insurers.

    “These codes were included in the 2019 Centers for Medicare and Medicaid Services physician fee schedule and are reimbursed by private insurers.”

  • The paper relies on this without support.

    In light of COVID-19, insurers have expanded remote monitoring to include acute as well as chronic conditions.

    “In light of COVID-19, insurers have even expanded remote monitoring to include acute as well as chronic conditions.”

  • The paper relies on this without support.

    Reimbursement for services such as reviewing vitals is currently more straightforward than reviewing physical activity levels or delivering wearable-guided lifestyle interventions.

    “Reimbursement for services, such as reviewing vitals, is currently more straightforward than other services such as reviewing physical activity levels or delivering wearable-guided lifestyle interventions.”

  • The paper relies on this without support.

    Some institutions currently allow patients to waive rigid security standards for sharing health information, but this opt-out system involves additional costs and is biased towards the most engaged patients.

    “Some institutions currently allow patients to waive rigid security standards for sharing health information but this opt-out system involves additional costs and is biased towards the most engaged patients.”

  • The paper relies on this without support.

    Patient records are generally dispersed in data silos across multiple platforms and health-care facilities that are not easily accessible, thereby exposing patients to safety concerns.

    “Patient records are generally dispersed in data silos across multiple platforms and health-care facilities that are not easily accessible, thereby exposing patients to safety concerns.”

  • The paper relies on this without support.

    COVID-19 has launched us into a new era of remote and decentralized patient care.

    “As COVID-19 has launched us at rocket speed into a new era of remote and decentralized patient care”

  • The paper relies on this without support.

    Some smartwatches can share patient ECGs to electronic health records; for example, Apple Watch-derived ECGs can be shared to some electronic health records such as EPIC.

    “some smartwatches can share patient ECGs to electronic health records, for example, Apple Watch-derived ECGs can be shared to some electronic health records such as EPIC”

  • The paper relies on this without support.

    Reimbursement for virtual visits and remote monitoring requires patient consent.

    “Reimbursement for virtual visits and remote monitoring requires patient consent”

  • The paper relies on this without support.

    Cybersecurity breaches are a possibility, especially if non-secure platforms are used.

    “cybersecurity breaches are a possibility, especially if non-secure platforms are used”

  • The paper relies on this without support.

    The patient must consent to the rights for using their data in research or sharing the data with third parties.

    “The patient must consent to the rights for using their data in research or sharing the data with third parties”
22 of 22

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • By examining an individual's activity level, sleep patterns, and heart rate, AI algorithms can forecast the likelihood of heart attacks or strokes.

    “For instance, by examining an individual’s activity level, sleep patterns, and heart rate, AI algorithms can forecast the likelihood of heart attacks or strokes, empowering healthcare providers to take proactive measures [8,20].”

    From The emergence of AI-based wearable sensors for digital health technology: a review (2023) · cites this paper as [20]

  • Photoplethysmography enables continuous and non-invasive measurements of heart rate, blood oxygen saturation, and even blood pressure.

    “Another optical sensing technique is photoplethysmography for vital sign monitoring, which enables continuous and non-invasive measurements of heart rate, blood oxygen saturation, and even blood pressure [20].”

    From The emergence of AI-based wearable sensors for digital health technology: a review (2023) · cites this paper as [20]

  • Comparing data across a wide range of wearable devices becomes challenging, compromising the efficacy of ML algorithms in classifying health conditions.

    “Comparing data across a wide range of wearable devices becomes challenging, compromising the efficacy of ML algorithms in classifying health conditions [20,194].”

    From The emergence of AI-based wearable sensors for digital health technology: a review (2023) · cites this paper as [20]

  • A significant constraint of applying ML algorithms to wearable technology is the lack of standardization in data collection and analysis.

    “A significant constraint of applying ML algorithms to wearable technology is the lack of standardization in data collection and analysis.”

    From The emergence of AI-based wearable sensors for digital health technology: a review (2023) · cites this paper as [20]

  • Signal processing algorithms for high-resolution ECG sensors significantly improved the fidelity of ECG measurements, enabling early detection of arrhythmias, ischemic events, and other cardiac abnormalities.

    “For instance, signal processing algorithms for high-resolution ECG sensors significantly improved the fidelity of ECG measurements, enabling early detection of arrhythmias, ischemic events, and other cardiac abnormalities [20].”

    From The emergence of AI-based wearable sensors for digital health technology: a review (2023) · cites this paper as [20]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Heart-failure table says no studies exist for a studied pedometer application

    Minor

    Table 2 says no clinical studies are available for assessing heart-failure prognosis via wearable-administered six-minute walk tests, but the text describes a pedometer study that used such a test to predict heart-failure severity and death.

1 of 1

Cites

Flagged first, then by citations

Research works printed but not linked: 1

  1. Fitbit. Fitbit launches Fitbit Care, a powerful new enterprise health platform for wellness and prevention and disease management. Fitbit https://investor.fitbit.com/press/press-releases/press-release-details/2018/Fitbit-Launches-Fitbit-Care-A-Powerful-New-Enterprise-Health-Platform-for-Wellness-and-Prevention-and-Disease-Management/default.aspx (2018).

Cited by

Sorted by citations

Related

Authors
Bayoumy, K., Gaber, M., Elshafeey, A., Mhaimeed, O., Dineen, E. H., Marvel, F. A., Martin, S. S., Muse, E. D., Turakhia, M. P., Tarakji, K. G., & Elshazly, M. B.
Affiliations
  • NewYork–Presbyterian Brooklyn Methodist Hospital (US)
  • National Center for Cancer Care and Research (QA)
  • Weill Cornell Medical College in Qatar (QA)
  • University of California, Irvine (US)
  • Johns Hopkins University (US)
  • Scripps Clinic (US)
  • VA Palo Alto Health Care System (US)
  • Cleveland Clinic (US)
Corresponding author
Elshazly, Mohamed B.
ORCID
Venue
Nature Reviews Cardiology
Publisher
Springer Science and Business Media LLC
Published
2021-03-04
Volume
18
Issue
8
Pages
581-599
ISSN
  • 1759-5002 (ISSN-L)
  • 1759-5010
DOI
10.1038/s41569-021-00522-7
PMC
PMC7931503
OpenAlex
W3135128169
Semantic Scholar
8cd5db74e2b338916df16bf7788a92d1df78ee91
Cited by
829
References
112
Citations by year
2026: 121 · 2025: 206 · 2024: 191 · 2023: 159 · 2022: 116 · 2021: 36
FWCI
10.61
Type
journal article
Language
en
Open access
Licence
Locations
  • Nature Reviews Cardiology (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • eScholarship (California Digital Library) (submittedVersion)
Funders
  • Aetna Foundation
  • American Heart Association
  • National Institutes of Health
  • National Heart, Lung, and Blood Institute (P01HL108800)
Topics
  • Physical Sciences › Engineering › Biomedical Engineering › Non-Invasive Vital Sign Monitoring
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › ECG Monitoring and Analysis
  • Health Sciences › Health Professions › General Health Professions › Mobile Health and mHealth Applications
Keywords
wearable devices, cardiovascular care, wearable sensors, remote patient monitoring, arrhythmia detection, heart failure treatment, device accuracy, clinical validity, regulatory policy, patient privacy, clinical integration, COVID-19 pandemic
MeSH terms
Wearable Electronic Devices, Arrhythmias, Cardiac, Humans, Inventions

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-09.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-09.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

Are you an author, or do you see a problem with this page? Request a review