The latest addition to medical haute couture may be a necklace outfitted with a pendant that people can use to screen themselves for signs of an abnormal heart rhythm condition known as atrial fibrillation.

Fashioned by a team of Finnish researchers, the pendant houses a portable electrocardiogram (EKG) designed to transmit heart readings to a cellphone app and ultimately to a cloud-based server. Once there, the information is fed into an artificial intelligence (AI) algorithm.

“The EKG measurement is very easy to do,” explained study author Elmeri Santala, a PhD candidate in clinical research in the faculty of health sciences at the University of Eastern Finland. “The user only needs to place the necklace EKG device between the palms of his/her hands or between the chest and the palm, and start the EKG measurement from the [phone] application.”

The app then gathers a 30-second EKG reading, Santala explained. That reading is immediately forwarded to the cloud-based AI, which produces nearly instantaneous diagnostic results. Those results can then be sent both to the patient and to a physician for final review.

Highly accurate interpretation

To date, Santala and his colleagues have tested the EKG necklace on 145 Finnish people. All underwent both a standard EKG reading and a self-administered necklace reading.

Working with cardiologists, the study team concluded that the necklace was able to generate highly accurate EKG recordings.

The team also found that the AI system was highly accurate at interpreting those recordings. It achieved 95% to 98% accuracy in identifying those patients who had experienced an atrial fibrillation-generated abnormal heart rhythm (“test sensitivity”) and 100% accurate in identifying those who had not (“test specificity”).

And because “atrial fibrillation is the most common arrhythmia, and a fast-growing public health problem worldwide,” the hope is that the necklace will boost the ability “for anyone who feels at risk of developing a-fib” to conduct routine self-monitoring, Santala said.

In the United States — where a-fib affects about 2.7 million Americans — both the American Heart Association and American Stroke Association say that getting screened during a primary care check-up “can be useful.”

And while the U.S. Preventive Services Task Force has not yet advocated routine EKG screening for people who lack symptoms (citing a lack of evidence that screenings would be helpful), the European Society of Cardiology has taken a different tack. It recommends occasional screening for those over 65, and routine screening for those over 75 as well as for those who face a high risk for stroke.

Cautious optimism

But following that advice can prove difficult, said Santala, given that a-fib “is often symptomless and intermittent, making its detection and diagnosing challenging”.

Santala acknowledged that patients already have a number of effective invasive and noninvasive a-fib monitoring options. Those include small wearable devices such as the “Holter monitor” – which attaches to the chest with electrodes – and invasive heart recording devices (called loop recorders) that must be implanted surgically. There’s also EKG apps that run on the Apple iWatch.

However, such options “are expensive and require interpretation by health care professionals,” said Santala. By contrast, the necklace “is simple to use and allows repetitive self-monitoring of heart rhythm, thereby improving the likelihood of detecting atrial fibrillation”.

Necklace pricing is yet to be determined, said Santala, but it will be “less expensive than an Apple iWatch”.

A couple of US experts reacted to the Finnish effort with cautious optimism.

“The general rule is the more you screen for a-fib, the more you’ll find,” said Dr Patrick Ellinor, director of the cardiac arrhythmia service at Massachusetts General Hospital in Boston.

‘Of sufficient quality’

“And every one that sells any kind of device that’s on you wants to add an EKG to that device because the best technology is the one that’s actually on you and that you’ll use,” Ellinor said.

“The most famous example is probably the iWatch, which looks good, so people do wear them. But that’ll set you back about $500 (R9 200). So if this necklace works well, looks good, and has a price point that’s less than that, then I would say it could be a reasonable option,” Ellinor added.

But Dr Gregg Fonarow, director of the Ahmanson-University of California, Los Angeles, Cardiomyopathy Center, said that while the necklace’s ability to accurately record EKGs was “found to be of sufficient quality”, more research is needed.

“Further large outcome studies are needed to determine if detection and treatment of atrial fibrillation using these types of devices can actually reduce the risk of having a stroke,” Fonarow stressed.

Santala and his colleagues reported their findings in an online presentation that posted this week on the European Society of Cardiology’s website. Such research should be viewed as preliminary until published in a peer-reviewed journal.

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• Researchers have found that people who stuck to healthy eating had an up to 21% lower risk of cardiovascular disease
• Healthy diets concentrated on unrefined plant foods and the scaling down of meat and sugar  
• Such eating patterns lowered cardiovascular risk in all racial and ethnic groups 

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Sticking with a healthy diet can lower your risk for stroke and heart attack, a new study suggests.

“Although each healthy eating pattern represents a different combination of dietary constituents, our study indicates that greater adherence to any of the four healthy eating patterns we looked at is associated with a lower risk of cardiovascular disease and the health benefits persist across racial and ethnic groups,” said study author Zhilei Shan. He is a research associate in the department of nutrition at Harvard T.H. Chan School of Public Health, in Boston.

For the study, Shan’s group focused on dietary scores for four healthy eating patterns: Healthy Eating Index-2015; Alternate Mediterranean Diet Score; Healthful Plant-Based Diet Index; and Alternate Healthy Eating Index.

Although each diet was different, they all stressed eating whole grains, vegetables, fruits, legumes and nuts, while eating less red and processed meat and sugar-sweetened drinks.

Long-term health benefits

The researchers compared each diet with the risk for cardiovascular disease using data on nearly 75 000 women in the Nurses’ Health Study and nearly 91 000 women in the Nurses’ Health Study II. They also used data on more than 43 000 men in the Health Professionals Follow-Up Study.

Over several decades of follow-up, the researchers found that people who kept to a healthy eating pattern had a 14% to 21% lower risk of cardiovascular disease, compared with people who didn’t always eat a healthy diet.

All of the healthy eating patterns had a similar effect in lowering cardiovascular risk in all racial and ethnic groups – including the risk of heart disease and stroke.

According to researcher Dr Frank Hu, “These data provide further evidence to support current dietary guidelines that following healthy eating patterns confers long-term health benefits on cardiovascular disease prevention.” Hu is a professor of nutrition and epidemiology at Harvard.

“There is no one-size-fits-all diet that is best for everyone. One can combine foods in a variety of flexible ways to achieve healthy eating patterns according to individuals’ health needs, food preferences, and cultural traditions,” he said in a school news release.

The study was published online on 15 June in JAMA Internal Medicine.

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• One of the results of the coronavirus pandemic may be a mental health pandemic
• We should expect mental health problems like depression, anxiety, substance abuse and an increase in suicide
• To cope with this psychological aftermath, doctors need better training in how to treat addiction, depression, PTSD and grief

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As many places start to look forward to life after the first wave of the coronavirus, another type of illness could be about to follow in its wake.

“We’re going to have many more mental health issues as time goes on,” said Dr Rima Styra, a psychiatrist at Toronto’s University Health Network and associate professor of psychiatry at the University of Toronto. “And people will refer to it as a mental health pandemic.”

US crisis centres already report being flooded with calls. The Well Being Trust, a foundation that focuses on mental health issues, predicts the pandemic could cause 75 000 “deaths of despair” from suicide or addiction.

Not everyone will have a problem, experts say. And there are ways for everyone to support people at risk.

Post-traumatic stress 

But the past offers a warning. After the 2003 epidemic of SARS, or severe acute respiratory syndrome, studies in Hong Kong found 40% of the survivors had post-traumatic stress symptoms.

Styra was co-author of a study of 129 people quarantined in Toronto because of SARS. About 30% showed symptoms of post-traumatic stress disorder and depression. More time in quarantine was associated with more symptoms.

Yuval Neria, director of the PTSD programme at the New York State Psychiatric Institute, said we’re in uncharted territory in terms of predicting the current pandemic’s effects.

“I don’t think the mental health consequences will be limited to PTSD only,” said Neria, who also is a professor in the department of psychiatry and epidemiology at Columbia University Medical Center in New York City. “In fact, I think we should expect other mental health problems, such as depression, anxiety, substance abuse and potentially increase in suicide. They are already there and kind of showing themselves.”

Workers “who continue to serve us while we self-isolate at home” could be at particular risk. But, he said, “there is so much to learn here. It’s a big unknown, and we badly need good research.”

For example, he said, “Being isolated for a long time, without social support, is very unique to this pandemic on a global scale.” As is the wave of grief that will follow tens of thousands of deaths.

Ambiguous threat

Neria, a combat veteran whose own experiences with war trauma guided his decision to research the topic, has studied how PTSD follows wars, natural disasters and events such as 9/11. The pandemic is like and unlike those.

“Disasters are usually limited to space and time. And there is an onset of a disaster – which may take some time – but there is an end,” he said. “But I think viruses have their own way to inflict adversities on us. The threat is ambiguous. [It] is everywhere and nowhere. It’s ongoing. It may take a long time.”

Anxiety alone doesn’t lead to PTSD. It is sparked by a trauma – a direct threat to life, such as an assault, exposure to war, or being treated in an intensive care unit. Symptoms may include flashbacks, nightmares and becoming hypervigilant or emotionally numb.

Neria said the crisis highlights the need to upgrade the entire mental health system. In particular, he said, doctors need better training in how to treat addiction, depression, PTSD and grief.

And while not everyone who experiences trauma gets PTSD, Neria said those at risk now are people who have high chances of being exposed to the virus, “especially frontline health care workers, first responders and Covid patients coming out of ventilators and ICUs.”

Dr Laura Hawryluck, lead author of the Toronto SARS study, understands the stresses too well. Like Styra, she treated patients during the SARS outbreak. Then as now, patients had to be isolated.

A mental health crisis

“And the thought of somebody who is desperately ill not having the support of people they love and not having those people around until perhaps the last moments of their lives is very hard emotionally on the health care team.”

Covid-19 has brought more death in less time. Healthcare workers also must worry about protective gear and other vital supplies running out.
On top of that, Styra said, they worry about exposing loved ones to the virus as they continue to deal with aspects of everyday life made harder by the pandemic, from getting groceries to finding child care.

She said anyone with symptoms of a mental health crisis – high levels of anxiety, feeling tearful, having trouble sleeping – should seek help. (The Department of Veterans Affairs offers PTSD-related advice at ptsd.va.gov, as does the National Alliance on Mental Illness at nami.org.) Family members should keep an eye on loved ones as well, Styra said, and encourage them to seek aid if they need it.

Hawryluck encourages health care workers to try to maintain self-awareness and a support network. She also encourages them to seek help if they feel they are not able to cope.

“There’s been a lot more support for healthcare workers and frontline workers and being called heroes and stuff like this” compared with SARS, said Hawryluck, an associate professor of critical care medicine at University Health Network/University of Toronto.

“We aren’t used to this overwhelming support, and it means more than we can ever express.”

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Exposure to trauma and other adverse experiences during childhood increases lifelong risk for cardiovascular disease and death, regardless of a person’s health during young adulthood, new research shows.

The study, published in the Journal of the American Heart Association, found children who experienced severe adversity – such as verbal, physical or emotional abuse or living with drug or alcohol abusers – were 50% more likely to develop cardiovascular disease later in life than those with low exposure to childhood trauma. Those with even moderate exposure were 60% more likely to die from any cause by middle adulthood.

This could be, researchers believe, because people who face severe adversity as children undergo a combination of behavioural and biological responses not yet fully understood. Previous research shows part of what happens is people are more likely to develop unhealthy coping mechanisms, such as smoking and poor eating habits, which contribute to traditional cardiovascular risk factors, such as high blood pressure, obesity, inflammation and diabetes.

But even after controlling for such risk factors, this long-term study found higher rates of heart disease and mortality in those who experienced childhood stress as they reached middle age compared to those who did not.

Origins in childhood experiences

“Childhood trauma impacts your ability to appropriately handle stress,” said lead investigator Jacob Pierce, a fourth-year medical student at Northwestern University’s Feinberg School of Medicine in Chicago. “What our analysis shows is that there are also other risk factors we did not account for that put these people at risk for cardiovascular outcomes later in life.”

Pierce and his team analysed data from 3 646 people in a study conducted from 1985 to 2018 in four cities: Birmingham, Alabama; Chicago; Minneapolis; and Oakland, California.

Participants were enrolled between the ages of 18 and 30 and followed for more than 30 years. The analysis found more than 20% experienced a high rate (four or more out of seven indicators) of exposure to damaging childhood events – and those participants had health troubles from young adulthood well on into middle age.

“The results of this study further confirm that cardiovascular disease is not simply a problem at older ages, but has its origins in childhood experiences,” said Karestan C. Koenen, a professor at Harvard University’s T.H. Chan School of Public Health in Boston. She was not involved in the study.

A complex issue

“Some of the relation between childhood adversity and (cardiovascular disease) seems to be explained by traditional risk factors, but those don’t explain the entire relationship or the relationship with mortality,” Koenen said. She was on a committee that wrote a 2017 American Heart Association scientific statement about childhood adversity and heart health outcomes.

“It’s a complex issue that can’t be boiled down to one reason,” Pierce said. Childhood is a critical period of development for the brain. Exposure to stress activates hormones in the brain, which also are associated with cardiovascular disease, an area of interest for future study, he said. “We really need to look at the biology. What are the mechanisms in the body that are putting these people at risk?”

In the meantime, better and broader approaches to the way we treat children faced with traumatic experiences could help, Koenen said.

“Despite overwhelming evidence that childhood adversity has negative effects on physical and mental health over the life course, preventing childhood adversity is left to paediatricians and others who work with children,” she said. “The public health burden of childhood adversity in the US is a social problem that cannot be placed on the shoulders of individual health providers, but must be tackled on a large scale.”

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