Based on findings from the “Reaching the Frail Elderly for the management of Atrial Fibrillation” feasibility study (REAFEL) by Assoc. Prof. H. Dominguez*.

*Frederiksberg-Bispebjerg Hospital, Copenhagen, Denmark.
By Marie Gjengedal, RN, MSc-student

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Background And Purpose

Atrial fibrillation (AF) is the most common serious abnormal heart rhythm and a leading cause of ischemic stroke among frail, elderly patients1. Moreover, AF is linked to heart failure, cardiovascular morbidities2 dementia3, increased mortality as well as reduced health-related quality of life4. The prevalence and incidence of AF increases with age and frailty, and as the population of elderly patients is growing, AF has become an important public health issue5

Since AF symptoms may be non-specific or even absent, the time to diagnosis is often delayed until the patients reach more advanced phases of the arrhythmia6. However, asymptomatic patients experience the  same risk of stroke and related complications as the symptomatic patients7. Thus, early detection and diagnosis of AF is crucial for timely prevention of severe conditions such as stroke and repeated falls among frail, elderly patients8.

The REAFEL (Reaching the Frail Elderly for the Management of Atrial Fibrillation) project aims to enable early detection and diagnosis of AF using telecommunication and Cortrium’s C3+ long term ECG Recorder (Holter monitor). The project is a cross-sectoral collaboration between Cortrium Aps, cardiologist, assoc. prof, Dr. Helena Dominguez from Bispebjerg-Frederiksberg Hospital (BFH) and general practitioners (GPs) in Copenhagen, Denmark.

The project’s overall objective is to improve the communication and collaboration between the patient, the patient’s GP and the hospital cardiologist in a novel, seamless communication model  called the ‘Cardio-relay model’. Cortrium is a partner in the REAFEL project and contributes by providing the C3+ monitor, which is a compact, cableless and easy-to-use Holter monitor, which makes it possible to attach the C3+ monitor at the GP office or at the patient’s home. By participating in the study and wearing the C3+ Holter Monitor, frail and elderly patients can receive specialised advice and treatment from cardiologists at home without attending exhausting hospital visits. Accordingly, using the C3+ as part of the cardio-relay collaboration has the evident potential to reduce the resources required for screening and monitoring arrhythmias in both ambulatory and in-hospital settings.


In the study the Cardio-relay model was implemented in the following way:

(1) The GP sends a message with the heading ‘Cardio-relay’ to the outpatient cardiology clinic at BFH, using the current standards (from MedCom) from the electronic health record systems used in the GP office.  The message is received in the hospital’s electronic health record, ‘Sundhedsplatformen’ (EPIC, Wisconsin, USA).

(2) After the initial message, the cardiologist may exchange further information with the GP and, together, decide if the patient should undergo examination with Holter monitoring.

(3) The C3+ (Figure 1) is then  attached to the patient in the GP clinic or at the patient’s home. The C3+ is collected after Holter recording is completed for the period planned (typically 1 to seven days) and the recording is uploaded to the Cortrium cloud.

(4) Subsequently, the cardiologist evaluates the result of the recording and a new e-consultation is initiated to guide the GP to decide whether there is a need for medicine adjustments or further evaluation. This can include attendance to the cardiology department for focused examinations such as echocardiography or planning video-consultations tailored to the patient’s needs and the available support (family and caregivers). 

Doctors from the Orthogeriatric Department at BFH are also able to use C3+ monitors and collaborate with the cardiologists in a similar manner, sending inquiries through internal messaging in the electronic health record, ‘Sundhedsplatformen’.

Figure 1. The Cortrium C3+ Holter monitor recorder 3 channels ECG (256Hz), accelerometer, ~33 gram, 7 days of battery life, flexible arms, uses standard ECG electrodes.


The duration of the feasibility study was approximately 12 months. The GP clinic, ‘Grøndalslægerne’ participated during the period of  17.03.2019 – 06.03.2020. 

A total of 116 patients were included in the project, of whom 52 patients were included from the GP and 54 were included from Orthogeriatrics at BFH. 

Indication for long-term ECG monitoring was found in 57 of the included patients, who were monitored by wearing the C3+ Holter Monitor. The patients were predominantly monitored for 24 hours. However, due to the C3+‘s long battery life it was possible to conduct continuous recordings for up to seven days. After the initial e-consultation and the findings from the C3+ Holter monitoring, approximately 10 % of the patients were referred to the hospital. 

By using e-consultations and  delegating the management of the C3+ Holter monitoring to the GPs, hospital referrals were redundant in 73 % of the cases.

Atrial fibrillation was diagnosed in five patients from the GP after wearing the C3+. Further clarification on treatment was addressed in two patient cases who were already diagnosed with AF. Moreover, a younger, not frail patient was diagnosed with an abnormal tachycardia and recommended further examination with conventional Holter monitoring at the outpatient clinic. 

Compared to conventional management of newly referred patients for Holter monitoring, it was possible to significantly reduce the time from referral to diagnosis from 70 to 22 days. 


In this feasibility phase of the REAFEL project, less than half of the patients (44 %) met the criteria for being considered ‘frail’, based on age above 75 years, impaired mobility (self-transportation not possible), cognitive impairment (dementia, mental illness) or socioeconomic background (drug or alcohol abuse, cultural or language barriers). However, AF treatment was optimized through C3+ Holter monitoring in 20 % of all patients enrolled from the GPs clinic (5 recently diagnosed and 2 earlier known with previously diagnosed AF). Albeit speculative, it is plausible that these patients would not have been capable of attending hospital visits, thus remaining undiagnosed and at risk of developing ischemic stroke. Most of the  remaining number of patients included in the feasibility study consisted of concerned patients with a low-risk profile who did not accept the GPs low-risk estimate and needed a reassuring assessment despite the GPs’ low-risk estimate. 

For the 10 % of the patients referred to further examination at the hospital, the e-conference allowed to schedule focused appointments based on this dialogue and/or findings from the C3+ Holter monitoring. Since about 90 % of the patient cases could be handled at the GP clinic, the Cardio-relay model has presumably relieved the workload in the outpatient cardiology clinic. It may be of concern that there is a risk of overlooking cardiological issues by not having direct contact with the patient. Thus, it is important to establish certain selection criteria regarding which patients should be examined at the hospital besides at the GP clinic. 

All doctors in the GP clinic were able to initiate an e-conference in REAFEL. The GP nurses have been responsible for attaching the C3+ Holter Monitor to the patients. Furthermore, the nurses have been able to  contact the cardiologist at BFH directly. The inquiries from the nurses did not regard general medical concerns, but rather patients’ drug therapy. These inquiries would otherwise have been asked by the GP doctors. Hence, this has relieved the GPs’ workload without increased burden to the cardiologists.

The GPs from Grøndalslægerne have reported great satisfaction with the project and have not expressed any concerns regarding increased workload. 

The findings from the feasibility study allowed for initiation of a cluster-randomized trial, which is currently ongoing.


This feasibility study demonstrates that the Cardio-relay model has improved the collaboration and the integrated care between GPs, hospital cardiologists and patients suspected with atrial fibrillation. The easy-to-use C3+ Holter Monitor allows for precise and early detection of atrial fibrillation among frail, elderly patients. Since the hands-on management of long-term Holter monitoring can be initiated in the GP clinic, patients are spared from ambulatory hospital visits while still receiving a high quality of treatment and care.  The average time from referral to diagnosis was significantly reduced from 70 to 22 days. Studies are planned to explore the effectiveness of the Cardio-relay model including the use of the C3+ Holter Monitor at a larger scale.


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