Getting to the Heart of the Matter

Kathleen T. Hickey is an associate professor at Columbia University School of Nursing. She also holds a joint appointment in the Department of Medicine, Division of Cardiology (Electrophysiology) as both a family and adult nurse practitioner. This year Hickey was inducted as a Fellow of the New York Academy of Medicine; she is also a Fellow of the American Heart Association and a Fellow of the American Academy of Nursing. Previously, she was a Robert Wood Johnson Nurse Faculty Scholar.  In 2014 she received the International Society on Nursing Genetics Founders Research Award. Her interdisciplinary clinical and research is focused on cardiogenetics, the clinical care and management of patients with arrhythmias, and the prevention of sudden cardiac death. She was the first recipient of Columbia University School of Nursing’s Outstanding Young Investigator Award in 2007 and is a graduate of the Summer Genetics Institute of the National Institute of Nursing and the Summer Human Genome Institute of the National Institutes of Health. Hickey has published in numerous peer reviewed journals, and teaches and mentors DNP and master’s students at Columbia Nursing.

One of your current studies is Use of the iPhone to Help Evaluate Atrial Fibrillation Rhythm through Technology (iHEART). What is the goal of this study?  

The long-term goal is to use mobile health cardiac monitoring technology to detect the presence of recurrent atrial fibrillation (AF) and improve patient self-management and outcomes. Atrial fibrillation is an irregular and often rapid heart rate that usually causes poor blood flow to the body. While atrial fibrillation symptoms include heart palpitations, shortness of breath, and weakness, approximately 70 percent of AF episodes are asymptomatic, making detection challenging.

As a cardiovascular nurse practitioner, I have seen cases of patients in AF reporting racing of the heart or experiencing no symptoms at all. Such episodes rarely occur while the patient is with a health care provider. As a result, proper diagnosis often means patients have to walk around with bulky heart monitors that record every heartbeat for an extended period of time. With a special app, patients can now use their phones to conduct and send us actual electrocardiogram (ECG) results that they obtain by holding their phone close to the chest or using their fingertips.

The app allows patients to self-capture ECG rhythms from their phones from virtually anywhere, within seconds of symptoms or on a routine, daily for those without symptoms who wish to monitor their rhythms or have been instructed to do so.

How is the study progressing?

A total of 300 patients with a prior history of atrial fibrillation are being enrolled. Half receive an iPhone equipped with the app and the control group receives standard cardiac care. Patients in the study group will record a daily ECG for six months and transmit the strip to a secure portal, which I check daily.

If I see anything awry, I’ll call the patient to get more information. Patients have also called me and said that felt something at 4:00 a.m. and recorded and sent a transmission of their ECG at that time, which I can look at via the secure portal. I’ll also send the strip to their physician, who can determine if the patient’s medication should be adjusted or other treatment started. Of course, we tell patients that if they have sustained symptoms or chest pain, they should go to the emergency room.

In addition, patients receiving the iHEART protocol will get three tailored text messages per week out of a bank of 360 that I collaborated with the American Heart Association on developing. The messages deal with AF and co-existing risk factors that can contribute to AF. We want people to get messages on modifiable risk factors, such as obesity and lack of exercise. For example, we’ll send links from the American Heart Association’s website about healthy cooking or how many grams of sugar are in a can of soda.

It is very early in the study but we are seeing that patients are adapting well to the intervention. They understand how the process works and are successfully transmitting ECG strips. In a few cases we have detected AF and physicians have stepped in to carefully guide patients through medication adjustments or other interventions as needed.

What are the implications of this work?

The use of mobile health tools for individuals with chronic cardiovascular conditions may promote more self-management, increased patient-provider communication, and better adherence to treatment. Also, we may be able to adjust patients’ medication as a first step and keep them out of the emergency room. Even with the costs of using technology factored in, that will mean real cost savings.

In addition, we’ll be assessing whether study patients report a higher quality of life than the control group. For example, in our pilot study patients reported that they felt more secure knowing that someone was reviewing their daily ECGs. And the findings could prefigure a substantial shift in how we educate patients to keep them on the right track in terms of adhering to and avoiding certain unhealthy behaviors and lifestyles.  

What does your work in genetics entail?

At Columbia I am part of a team that includes physicians, geneticists, and genetics counselors. We evaluate patients with cardiac problems who are referred to us. This includes conducting family pedigrees, which are detailed histories of family members with cardiac problems. In many cases patients and family members undergo genetic testing, since some types of heart disease can be inherited.

Conditions such as high blood pressure and coronary artery disease (blockages in the arteries that supply the heart with blood) run in families. But these are likely caused by a number of genetic changes in conjunction with lifestyles and behaviors. In these cases, genetic testing is not yet available. But there are other less common inherited heart diseases that are precipated by only one or a handful of genetic changes. These include inherited heart conditions that impinge on the electric system of the heart, causing abnormal heart rhythms called arrhythmias. Genetic testing can identify family members with a propensity for these conditions, which can then be managed by changes in lifestyle or medical treatment.

You are your colleagues encourage families to discuss their health histories. Can you elaborate?

With inherited heart diseases, as well as other diseases shown to have a genetic component, including certain cancers, family members as well as the patients themselves may be in need of medical care. Holidays such as Thanksgiving, Christmas, and Hanukah are times when extended families gather together. These are ideal occasions for family members to discuss their histories, no matter how far back certain cases may go. As we say, ‘If you don’t ask, you won’t know.’ When families discover that, for example, three great uncles had suffered strokes, that should be a signal for family members to get in touch with their physicians or nurse practitioners to discuss next steps. Being proactive in such cases is potentially life-saving.