Brett Nowlan, MD

I received my COVID-19 vaccination today.

It was a well-organized process. I received emails, registered, and booked a date and time. The check-in and screening were smooth, and after a brief wait, I was up. I am part of the first phase of vaccinations, and so not many anecdotal reports to go on—some with sore shoulders; one colleague with a 24-hour febrile reaction.

My injection did not hurt at all. No noticeable reaction in the days following. And just like that, it finally feels like there is a light at the end of the tunnel that is the COVID-19 pandemic. It feels like a lifetime ago that news of a novel virus was beginning to spread around the world.

In our era of news as entertainment, at first it seemed to be overblown and overstated. Then Italy became bad. Then New York City reported cases. Then New York became bad. I have family members who live in Queens, and almost all of them contracted it, although luckily had mild enough cases to not need hospital care. But the daily reports were harrowing, and for the rest of us it was clearly just a matter of time.

I work in a private cardiology practice in Connecticut, and cover our admitting hospital for a week at a time. Suddenly nothing seemed clear, or safe. In our office, we had a series of hastily assembled partner meetings, and then again with our staff, planning our defense. There was suddenly a hunt for PPE, and screening protocols, and quick adoption of a telehealth platform; but still mostly uncertainty.

Our local hospital numbers spiked, and all of the complications we had read about were now in our hands. Hypoxia, and thrombosis, and widespread inflammation, and rapid decompensation. Colleagues started getting infected. Some died.

I was now coming home directly into our garage, stripping off, putting all my non-clothing items into a UV sterilizing oven, and then showering, before greeting my family. Schools closed. Roads were quiet. Even grocery shopping felt hazardous. We never closed our office, but our volume dipped significantly, and now every in-person visit and hospitalization for a cardiac issue came with an additional gamble of infection.

I am fortunate to live in an area where most were taking the pandemic, and it’s restrictions, seriously. Without overwhelming our healthcare facilities, numbers came down, and we all carried on. We are now in the midst of another surge, due to multiple shortcomings - leadership, planning, insight, trust, resolve. It feels different in our office and in the hospital though.

We know more, and there is at least a degree of predictability and familiarity now. Our office volume is busier than ever, as most patients realize we are in this predicament for the long haul. And now there is a vaccine.

In a frustrating time of science and expertise denial, scientists and experts have accomplished a massive flex, and we have a way out. History now awaits our decision on whether to accept this or not. For how little I have been able to help those with COVID-19 up to this point, my biggest contribution as a healthcare worker is to take the vaccination without hesitation. And, by example, lead others to do the same.

Articles

A lipidologist from Connecticut describes his experience during the COVID-19 pandemic and explains why he sees getting the vaccine as his "biggest contribution" to healthcare during the pandemic. 

Brett Nowlan, MD: My Year in COVID-19

This article is the first in a 3-part series titled “

Collaborative Care: Technology’s Evolving Role in Cardiometabolic Health

A long-time patient of mine came into our office for a follow-up recently. He has been experiencing palpitations while hiking with his dogs, and we have been trying to make a formal diagnosis. Holter monitors have not been helpful, due to the intermittent nature of his symptoms. He arrived with data from his KardiaMobile 6L device, which pairs with his smartphone; and presented me with a stack of 6 lead EKG tracings he had obtained the prior weekend. This is now a common enough scenario in my practice to only require a brief acknowledgement.

Smartphones, and now smart watches, are big business, and widespread. In 2019 Pew research data showed that 81% of Americans own smartphones. The 65 years and older demographic has the lowest ownership of smartphones, but even still ownership reached 53%. Health tracking on these devices, and integration with wearable devices, are ubiquitous. Wearable devices alone are expected to have a market size of $70 billion by 2025. Arguably the most immediate impact that healthcare providers will notice with these devices, is in atrial fibrillation detection and management. 

The Apple Watch has an ‘irregular rhythm’ algorithm, designed to detect atrial fibrillation. The Apple Heart Study correlated this algorithm with a wearable EKG patch. Of the over 400,000 monitored participants without a prior diagnosis of atrial fibrillation, 0.52% received notification of an irregular rhythm. Of those that then completed EKG patch confirmation, 34% were diagnosed with atrial fibrillation. Of those who were wearing both an iWatch and an EKG patch simultaneously, the iWatch had an 84% positive predictive value for observing true atrial fibrillation. This is impressive for a multifunctional device that lives on the wrist. The HEARTLINE Study is an ongoing randomized control trial assessing atrial fibrillation detection in patients aged 65 and older, using the Apple Watch.

This data is not limited to Apple products. The single-lead KardiaMobile device from Alivecor has users place their fingers on a recording pad, which communicates the tracing with a smartphone. This device has 87% sensitivity and 97% specificity for the diagnosis of silent atrial fibrillation, compared to a traditional 12-lead EKG.

Fitbit recently received FDA clearance for atrial fibrillation detection with their Fitbit Sense watch. Fitbit submitted multi-site clinical trial data for this clearance, involving 472 participants, demonstrating 98.7% sensitivity for detecting atrial fibrillation, and 100% sensitivity. The Fitbit Heart Study is an ongoing validation of its wearable technology in this regard.

Of course, this technology does not live in isolation. The data that is generated requires analysis, confirmation, and action from the healthcare team. This is yet another time demand in a busy office, and mostly one that cannot be financially compensated. Artificial Intelligence algorithms are rapidly developing to respond to this, and such networks are already in effect. Northshore University HealthSystem is currently teamed up with Carnegie Mellon University and physIQ for remote monitoring of CHF patients post-discharge, using patch-based wearable biosensors, and AI analysis and synthesis. The LINK-HF Study has shown this technology capable of predicting heart failure hospitalizations a median of 6 days in advance, with about 85% sensitivity and specificity.

All this collected data has a privacy concern attached to it. This is a moving target however, with younger generations clearly more at ease with this in concept and practice. Whether this remains true, as this data continues to evolve and increasingly leads to real-world consequences, remains to be seen.

Speaking of real-world consequences, we all have patients whose emotional health is negatively impacted far more than their physical health is helped, with this kind of information.

I have a 96-year old patient who I constantly have to steer away from measuring her own blood pressure, as each measurement gets worse as she becomes more anxious. She has attended walk-in clinics and emergency rooms on a number of occasions after these negative feedback loops. I would dread a wearable device on her wrist. The net impact of unregulated ‘screening’ is likely beneficial for most, but clearly psychologically harmful for some.

Back to my dog-walking patient—with documented symptoms and tracings in hand, he clearly has experienced his palpitations from isolated PVCs. Reassurance for him (and me), and a routine follow-up in six months. Whatever our personal thoughts or degree of buy-in to these devices; they are here to stay, are marketed directly towards patients, and will only become more ubiquitous.

Practical Cardiology Advisory Board member Dr. Brett Nowlan details his experiences with wearables as a practicing cardiologist. 

Brett Nowlan, MD

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Brett Nowlan, MD: My Year in COVID-19

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