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Interview by Jodie Elrod

In this interview, Scott Ceresnak, MD, Director of Pediatric Electrophysiology at Stanford and Lucile Packard Children’s Hospital, discusses how wearable devices like the Apple Watch are transforming the diagnosis and management of pediatric arrhythmias. Drawing on findings from the PAWS study, Dr Ceresnak explains why smartwatches captured arrhythmia events in twice as many pediatric patients as traditional patch monitors, particularly in children with sporadic symptoms. He also explores the limitations of current wearable electrocardiogram (ECG) technology, the need for pediatric-specific algorithms, and how extended wearable monitoring could reshape future clinical workflows for pediatric cardiology.

Can you start with a brief introduction about yourself?

My name is Dr Scott Soreznak. I'm a professor of pediatrics in pediatric cardiology at Stanford and Lucile Packard Children's Hospital. I'm the director of pediatric electrophysiology and director of electrophysiology and the arrhythmia program here at Stanford.

How are wearable devices like the Apple Watch currently being integrated into the evaluation and monitoring of pediatric patients with suspected arrhythmias, and how does that differ from traditional approaches?

We see many pediatric patients at Stanford who come to us with palpitations that feel like their heart is beating very fast. Historically, the way we monitored these patients and tried to capture a single-lead ECG during an episode of palpitations was with a Holter monitor—typically a 24-hour monitor with wires attached to the chest and connected to a device worn on the belt. You can imagine that kids often don’t like feeling different, and if they came to school with visible wires, other children might ask questions, which would make many patients uncomfortable.

Over the last few years, there have been major advances in technology with the development of patch monitors that sit directly on the chest and record the ECG. These monitors are usually hidden under a shirt, so no one can see them. They’ve truly been a revolutionary technology. Instead of monitoring for just 24 to 48 hours, they can now record for 2 weeks or sometimes even longer. That’s really been the evolution in how we evaluate children with palpitations.

After the Stanford Apple Heart Study, people began using the Apple Watch more frequently for atrial fibrillation (AF) detection in adults. We then started seeing many more kids using smartwatches—often their parents’ watches—to help detect arrhythmias. These devices became another useful tool alongside patch monitors. The watch can capture a single-lead ECG that can then be shown to me or another pediatric cardiologist to help determine whether a child is experiencing an arrhythmia and whether it is something concerning as a cause of palpitations.

We published a paper a few years ago showing that children were increasingly using smartwatches to detect arrhythmias. We were able to use that data to develop highly effective treatment plans and, in some cases, even cure children of certain arrhythmias.

The PAWS study found the Apple Watch captured arrhythmia events in twice as many patients as patch monitors—what do you think is driving that difference in detection?

I think it’s a few things. Number one is time. As I mentioned before, traditional Holter monitoring was typically limited to 24 to 48 hours. The patch monitors we use now can usually record for about 2 weeks. But for children who have very sporadic symptoms—for example, symptoms that only occur once a month—you could place a patch monitor, wear it for a couple of weeks without capturing an episode, remove it, and then the child has an episode shortly afterward.

That’s one of the major advantages of the smartwatch. If a child is wearing it regularly throughout the day—when most pediatric arrhythmias tend to occur—they have the opportunity to capture episodes that happen infrequently, whether that’s once a month or even once every few months. In the past, those episodes were often very difficult to capture with our more limited-duration monitoring tools.

So I think one of the biggest benefits is that it allows us to monitor children over much longer periods of time and capture symptoms that are more sporadic in nature. Another option we sometimes use is an implantable loop recorder, but for young children, that requires anesthesia, a small incision, and placement of a monitor under the skin that can remain in place for several years. It’s an excellent tool, but smartwatches offer a noninvasive alternative that many kids are already comfortable using in their daily lives.

What are the biggest challenges clinicians face when interpreting wearable-derived ECG data in children? Where do wearable devices still fall short in reliably diagnosing pediatric arrhythmias?

I could answer that in a couple of different ways. First, the smartwatch has been shown in adults to be a really fantastic tool for detecting AF, which is the most common arrhythmia in humans. AF is a chaotic electrical activity that originates in the upper chambers of the heart. While it’s very common in adults, it’s actually quite rare in children. The types of arrhythmias we see in pediatric patients are often different from those typically seen in adults.

The algorithms built into the watch are excellent at detecting AF, and that is really what the FDA approval is focused on—AF detection. Because AF is uncommon in children, the current algorithms are not specifically designed to identify many of the pediatric arrhythmias we commonly see. As a result, interpretation still requires physician oversight at this point.

I think that’s one important difference. Another is the ability to capture continuous recordings. The current ECG feature on the watch is patient-activated. In other words, the patient has symptoms such as palpitations and then records an ECG using the watch.

One advantage of patch monitors is that they provide continuous ECG recording for the entire time the patient is wearing the device. So if a child wears a patch for 2 weeks, we can review the heart rhythm and heart rate continuously over that entire period. With the watch, the single-lead ECG is only recorded during a triggered event when the patient actively starts the recording, rather than continuously throughout the day.

That’s another limitation that hopefully may change in the future. So while these are really excellent and exciting tools, they do still have some important limitations.

With the PAWS study showing higher event capture compared to patch monitors, how might these findings influence future clinical workflows or guidelines for diagnosing and managing pediatric arrhythmias?

That is an important question. Right now, the standard clinical tools we use are Holter monitors, patch rhythm monitors, and implantable loop recorders. But I do think there is an important role for smartwatches in extended rhythm monitoring, and that they have the potential to make a major difference in how we understand pediatric heart rhythms, diagnose pediatric arrhythmias, and ultimately treat them.

These tools give us an opportunity to capture arrhythmias that we might otherwise miss, especially in patients who have very sporadic symptoms. I also think there is a significant opportunity moving forward to develop pediatric-specific algorithms—not just for AF detection, but algorithms built using data from children and designed specifically for pediatric arrhythmias, rather than adapting adult algorithms to fit a pediatric population.

So I think there are many exciting opportunities ahead. Even at a basic level, one thing I hope changes in the future is access to the ECG feature itself. If you look at the current FDA approval for using the ECG function on the watch, users must be 22 years of age or older. That means access to the ECG feature is still limited for children.

My hope is that this will evolve over time, so that even basic access to ECG recording technology can become more readily available for pediatric patients.

The transcripts were edited for clarity and length.