Elsevier

Journal of Electrocardiology

Volume 55, July–August 2019, Pages 87-90
Journal of Electrocardiology

Clinical stage of acquired immunodeficiency syndrome in HIV-positive patients impacts the quality of the touch ECG recordings

https://doi.org/10.1016/j.jelectrocard.2019.05.011Get rights and content

Highlights

  • Many ambulatory HIV patients have unreadable ECGs recorded by a touch ECG device.

  • The number of unreadable ECGs increases with the clinical severity of HIV.

  • Handheld touch ECG devices may underestimate cardiac arrhythmias in HIV patients.

Abstract

Introduction

HIV patients are at higher risk for cardiovascular disease and cardiac arrhythmias which can be recorded by a handheld single‑lead ECG device. Quality of ECG depends on the skin condition, which worsens with the progression of HIV infection.

Objective

To study the quality of the ECG signal acquired by a mobile ECG device in patients with different clinical stages of human immunodeficiency virus (HIV) infection.

Patients and methods

We studied the quality of 30-second single lead ECGs obtained by a handheld ECG device (Kardia; AliveCor Inc., San Francisco, USA) in 263 Kenyan adults (203 women) in various stages of HIV. The recordings were made during routine check-ups at the outpatient clinics. ECG quality was categorized as readable (not interfering with clinical interpretation) or unreadable (impossible clinical interpretation). The progression of the HIV infection was estimated using the World Health Organization AIDS Clinical Staging (WACS) scale, ranging from stage 1 (asymptomatic generalized lymphadenopathy) to stage 4 (wasting syndrome and Kaposi sarcoma).

Results

The median age of patients was 46 (39–53) years. ECG was readable in 201 patients (76.4%) and unreadable in 62 (23.6%). The WACS score > 1 was associated with 3.95 odds ratio (95% confidence interval 2.14–7.29; p < 0.0001) for the acquiring an unreadable ECG (univariate logistic regression adjusted to age, sex, body mass index and time since HIV).

Conclusions

ECG quality recorded by a touch ECG device worsens with advancing HIV infection. For this reason, the accuracy of arrhythmia diagnosis by mobile ECG appears to be limited in HIV patients.

Introduction

Human immunodeficiency virus (HIV) causes the acquired immunodeficiency syndrome (AIDS), a progressively destructive process complicated by malnutrition, waste, development of other infectious and neoplastic diseases, and shorter life duration [1,2]. HIV patients have typical, not related to AIDS, risk factors for the cardiovascular (CV) disease (e.g., diabetes, obesity or smoking) [3]. However, the presence of AIDS or its pharmacological treatment adds new CV risk factors such as proatherogenic dyslipidemia, chronic inflammation or increased activity of the renin-angiotensin-aldosterone system [4]. Consequently, hypertension, premature ischemic heart disease or atrial fibrillation (AF) are frequent in HIV patients.

The AF risk increases with the HIV load and AIDS duration [4]. To avoid clinical complication of untreated AF (e.g., ischemic stroke), HIV patients should regularly have their ECG checked. Still, the acquisition of standard 12‑lead ECG is unavailable for many patients living in places with limited resources healthcare system. For them, using a mobile ECG device seems a practical solution [5].

There is an increasing number of studies showing the clinical utility of mobile ECG technologies, including handheld devices. Kardia (AliveCor Inc., San Francisco, USA) is an example of the handheld touch ECG device capable of recording a single‑lead ECG and transmitting it to a smartphone. In contrast to the standard 12‑lead ECG recorders that use patient cables and adhesive electrodes, Kardia requires minimal training and may be readily used anytime and anywhere, both by medical professionals, patients themselves and by their family members. This device received the Food and Drug Administration clearance for the diagnosis of AF and has been used in many clinical studies [[5], [6], [7], [8], [9], [10], [11]]. It is possible to acquire multiple non-standard ECG leads with Kardia by holding one metal sensor in the right hand and touching different body locations with another sensor [10]. Due to a poor skin-sensor interface, the quality of the ECG signal is sometimes far from optimal and may negatively impact proper ECG interpretation. The quality of the ECG depends on many factors like sensor pads cleanness, air humidity and temperature and, most importantly, skin conductive properties which frequently change in the course of HIV infection due to xerodermic state and dermatoses [12].

In this study, we investigated the quality of the ECG signal acquired by a touch ECG device (Kardia) in patients with different clinical stages of established HIV infection at two outpatient clinics in Kenya.

Section snippets

Study design

In this prospective study, 30-second ECGs were recorded by Kardia in 263 adult HIV positive patients at the outpatient clinics of the Mission Hospitals in Muthale and Mutomo in Kitui County, Kenya during routine check-ups. No exclusion criteria were applied. The ECGs were collected between August and September of 2016. The local Bioethical Committee at the Strathmore University in Nairobi, Kenya approved the study (permission reference number SU-IRB 0073/16), and each participant gave informed

Results

The median age of all patients was 46 (39–53) years, 203 were women (77%). There were 181 (68.8%) of asymptomatic HIV positive patients in WACS = 1, and 82 (31.2%) symptomatic patients with WACS > 1. For all patients, the median time since HIV diagnosis was 7 (5–9) years, WACS score 1 (1–2), body mass index 21.1 (19.1–24.3) kg/m2 and heart rate 76 (68–86) beats/min.

The ECGs were readable in 201 patients (76.4%) and unreadable in 62 (23.6%), including 58 (22.1%) individuals with an uncertain

Discussion

In this study, we have found that a 30-second ECG acquired by a touch ECG device may be, on average, unreadable in >20% of HIV patients. This rate increases to 40–50% with the progression of clinical staging of HIV infection, regardless of patients' age, gender, duration of HIV infection and body mass index. We were surprised to find out, that it is four-fold more probable to record an unreadable ECG by Kardia in patients with the more advanced stage of HIV infection, i.e., WACS over 1.

Stage 1

Funding

This work was supported by an unrestricted Student's Grant of the Student Scientific Society, Poznan University of Medical Sciences, Poznan, Poland [165/2016].

Declaration of Competing Interest

Dr. Suave Lobodzinski is a consultant to Apple Corporation and AliveCor Inc.

No other authors declared any potential conflict of interests.

Acknowledgment

We are grateful to all medical personnel from the outpatient clinics of the Mission Hospitals in Muthale and Mutomo in Kitui County, Kenya who allowed us to perform a basic clinical examination and collect ECGs by Kardia from patients visiting their clinics.

References (22)

  • N. Lowres et al.

    Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies

    The SEARCH-AF study Thromb Haemost

    (2014)
  • Cited by (0)

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