Atrial fibrillation (AF), particularly when paroxysmal and asymptomatic, often goes undiagnosed, increasing the risk of stroke. A recent trial investigated whether remote screening with a commercially available smartwatch could enhance the detection of new-onset AF in an older population with an elevated risk of stroke.²
Mechanism of Application
The intervention utilised a smartwatch equipped with both photoplethysmography (PPG) and single-lead electrocardiogram (ECG) functions. The PPG sensor allows for passive, noninvasive monitoring of the user's heart rhythm, while the single-lead ECG function enables on-demand confirmation of suspected arrhythmias detected by the PPG algorithm.
Methodology
The EQUAL (Detection and Quantification of Atrial Fibrillation in High-risk Patients Using a Smartwatch Wearable [Apple Watch]) trial was a prospective, multicentre, randomised controlled trial conducted in the Netherlands (NCT05686330).¹
The study enrolled 437 patients between November 2022 and December 2023. Participants were aged 65 years or older and had an elevated stroke risk, defined by a CHA₂DS₂-VASc score of ≥2 for men or ≥3 for women. The median age of the cohort was 75 years, 46.7% were female, and the median CHA₂DS₂-VASc score was 3.0.
Patients were randomised 1:1 to either a 6-month (180-day) monitoring period with a smartwatch or to standard care. In the intervention group, ECGs were reviewed remotely by an independent eHealth team within 24 hours. The primary outcome was the incidence of new-onset AF, defined as a confirmed episode lasting at least 30 seconds on a single-lead ECG or via standard ECG methods.
Results
New-onset AF was detected in 21 patients (9.6%) in the intervention group, compared with 5 patients (2.3%) in the standard care group. This represented a risk difference of 7.3 percentage points (95% CI: 2.9–11.7; p=0.001) and a hazard ratio of 4.40 (95% CI: 1.66–11.66).
Notably, several asymptomatic AF episodes were detected exclusively in the intervention group, while paroxysmal AF was observed in both groups.
In Practice
The findings from the EQUAL trial suggest that a 6-month screening programme using a smartwatch can significantly improve the detection rate of new-onset AF in older individuals at high risk for stroke. The authors concluded that the trial “provides evidence that 6-month smartwatch-based AF screening enhances the detection rate of new onset AF compared with standard care in patients at elevated stroke risk.”¹ The ability to identify asymptomatic cases highlights the potential of such technology as a scalable, noninvasive screening tool in clinical practice.
References
1. Van Gelder IC, Rienstra M, Bunting KV, et al. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2024;45(36):3314-3414. https://doi.org/10.1093/eurheartj/ehae176
2. van Steijn NJ, Blommestijn IS, Blok S, et al. Enhanced Detection and Prompt Diagnosis of Atrial Fibrillation Using Apple Watch: A Randomized Controlled Trial. JACC. 2026;87(14):1714-1728. https://doi.org/10.1016/j.jacc.2025.11.032
Disclaimer
The information presented in this article is for educational purposes only. Any quotes included reflect the opinions of the individual quoted, and do not necessarily reflect the views of the publisher. The publisher does not guarantee the accuracy or completeness of the content and accepts no responsibility for any errors, or any consequences arising from its use.