Research Letters

Six-lead device superior to single-lead

smartwatch ECG in atrial fibrillation detection
Josca Scholten, BSc a,b , Ward P.J. Jansen, MD a , Thomas Horsthuis, MD, PhD a , Anuska D. Mahes, BSc a ,
Michiel M. Winter, MD, PhD b , Aeilko H. Zwinderman, PhD c , Jan T. Keijer, MD, PhD a , Madelon Minneboo, MD,
PhD a,b , Joris R. de Groot, MD, PhD b , and Jouke P. Bokma, MD, PhD a,b North Holland, The Netherlands

This was a head-to-head comparative study on different electrocardiogram (ECG)-based smartwatches and devices for atrial
fibrillation detection. We prospectively included 220 patients scheduled for electrical cardioversion and recorded ECGs with
3 different devices (Withings Move ECG, Apple Watch 5, Kardia Mobile 6-leads) as well as the standard 12-lead ECG (gold
standard), both before and after cardioversion.
All atrial fibrillation detection algorithms had high accuracy (sensitivity and specificity: 91–99%) but were hampered by unin-
terpretable recordings (20–24%). In cardiologists’ interpretation, the 6-lead device was superior (sensitivity 99%, specificity
97%) to both single-lead smartwatches (P < .05) for atrial fibrillation detection. (Am Heart J 2022;253:53–58.)

Atrial fibrillation (AF) is the most common tach-
yarrhythmia with a cumulative lifetime risk of approxi-
mately 37%.1 Because AF is asymptomatic in a subset of
patients, stroke can be the first clinical manifestation of
“silent” AF.2 Screening for “silent” AF may prevent stroke
but accurate AF diagnosis by the screening test is of
paramount importance to appropriately start preventive
anticoagulant treatment. Worldwide use of commercially
available devices for electrocardiogram (ECG) based AF
detection is increasing despite lack of comparative data
between single-lead smartwatches and novel six-lead de-
vices.3-5 Therefore, head-to-head comparisons between
devices reliability are needed to inform AF screening in
high-risk patients but also to improve interpretation of
device ECGs presented directly by individuals. We per-
formed a proof-of-concept, head-to-head comparison be-
tween smartphone ECG smartwatches/devices for AF de-
tection.
Materials and methods
This was a prospective, nonrandomized, adjudicator-
blinded study in a non-academic, regional hospital (Ter-
gooi Hospital, Blaricum, The Netherlands). Adult patients
From the a Department of Cardiology, Tergooi Hospital, Blaricum, North Holland, the
Netherlands, b Location Academic Medical Center, Department of Cardiology, Amster-
dam University Medical Center, Meibergdreef 9, Amsterdam, North Holland 1105 AZ,
the Netherlands, c Location Academic Medical Center, Department of Clinical Epidemiol-
ogy, Biostatistics and Bioinformatics, Amsterdam University Medical Center, Amsterdam,
North Holland, the Netherlands
Submitted March 7, 2022; accepted June 29, 2022
Corresponding author at: Location Academic Medical Center, Department of Cardiology,
Amsterdam University Medical Center, Meibergdreef 9, Amsterdam, North Holland 1105
AZ, the Netherlands.
E-mail address: j.p.bokma@amsterdamumc.nl.
0002-8703
© 2022 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ahj.2022.06.010
admitted for electrical cardioversion (ECV) for AF or
atrial flutter (AFL) were included between February 2020
and March 2021 (Fig. 1 for inclusion and exclusion cri-
teria). This study was reviewed by the medical ethical
board of Amsterdam University Medical Center and con-
forms to the declaration of Helsinki. No extramural fund-
ing was used to support this work. The authors are solely
responsible for the design and conduct of this study, all
study analyses, the drafting and editing of the paper and
its final contents.
Standard 12-lead ECGs in supine position were
recorded followed by consecutive, supervised thirty sec-
ond ECGs by different devices, both before and after the
ECV. First, the Withings Move ECG (Withings, Issy les
Moulineaux, France) and the Apple Watch series 5 (Ap-
ple Inc, Los Altos) were used to acquire a single-lead
I ECG, according to manufacturer’s instructions. Sub-
sequently, patients were randomly allocated (based on
study inclusion number) to acquire a single-lead II ECG
with either Withings or Apple in a 1:1 ratio. For this pur-
pose, the Withings or Apple Watch was placed on the left
knee and hold with the right hand. Finally, Kardia Mo-
bile 6L (AliveCor, Mountain View) was placed on the left
knee with both thumbs on the device to simultaneously
record a six-lead ECG (leads I, II, III, aVR, aVL, aVF). Dur-
ing all measurements, patients were verbally instructed
how to hold the devices by the study investigator, who
stored the recordings on a mobile device (Apple iPhone
7 Plus).
A single cardiologist, not blinded for other clinical data,
analyzed all standard 12-lead ECG recordings for rhythm
(AF, AFL, or normal), which was considered the gold stan-
dard. Presumed atrial tachycardia was classified as AFL.
In addition, all thirty second ECGs were anonymized and
interpreted by 2 cardiologists independently, blinded to
 American Heart Journal
54 Scholten et al
November 2022

Figure 1

Flow chart of study inclusion. Flow chart of patients screened for inclusion, reasons for dropout and measurements performed. Total 12-L
ECGs performed: n = 415. In 17 cases (4.1%) Kardia 6L was not recorded. In 3 cases (0.7%) Withings was not recorded. In all cases
(n = 415) Apple ECG was recorded. A maximum of 3 attempts to record per device was allowed. Abbreviations: AF, atrial fibrillation; ECV,
electrical cardioversion; SR, sinus rhythm.

other clinical data. The thirty second ECGs were classi-
fied by the cardiologists as supraventricular tachycardia
(SVT) or sinus rhythm (SR). The SVT interpretations were
further divided into AF or AFL, similar to the 12-lead ECG.
If there was uncertainty about the classification (SR vs
SVT), this was noted.
Statistical methods
McNemar’s test for paired dichotomous outcome vari-
ables was used to test differences between devices in the
rate of uninterpretable ECGs (1:1 comparisons). Sensitiv-
ity and specificity of devices for AF detection compared
to the gold standard were determined for the automatic
algorithms and for the 2 cardiologists’ interpretations (av-
eraged), excluding AFL and uninterpretable ECGs (for au-
tomatic algorithm). Wilcoxon signed rank test was used
to compare accuracy of AF detection by the cardiologists
between all devices (1 point attributed if classified in-
correctly, 0 points if classified correctly. Score 0 to 2 for
all devices). Similarly, the proportions of reported uncer-
American Heart Journal
Scholten et al 55
Volume 253

Table I. Sensitivity and specificity for AF detection of ECG device algorithms and cardiologists’ interpretations.

Devices Device algorithms Cardiologists’ Cardiologists’ interpretationAll

interpretationSubgroup patients with SR/AF
“uninterpretable” by algorithm
Uninterpretable Sensitivity Specificity Sensitivity Specificity Sensitivity Specificity
(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI)

Withings 19.8% 97.5% 94.9% 85.3% 88.7% 95.4% 94.9%

lead I (16.0 %-23.6%) (95.1%- (91.4%- (74.5%- (79.3%- (93.2%- (92.7%-
99.9%) 98.4%) 96.1%) 98.1%) 98.6%) 97.1%)
Apple 20.0% 94.4% 98.2% 93.2% 95.9% 96.2% 94.4%
lead I (16.2%-23.8%) (90.6%- (96.2%- (85.8%- (88.0%- (94.2%- (91.1%-
98.2%) 100%) 100%) 100%) 98.2%) 97.7%)
32.0%∗ 95.9% 98.7% 89.7% 77.3% 95.7% 94.7%
Smartwatch (27.5%-36.5%) (92.4%- (96.9%- (83.9%- (67.2%- (92.8%- (91.5%-
lead II 99.4%) 100%) 95.5%) 87.4%) 98.6%) 97.9%)
Kardia 23.6% 99.4% 91.4% 92.6% 93.6% 98.9%∗ 96.7%∗
6 leads (19.5%-27.7%) (98.2%- (86.7%- (83.9%- (85.2%- (97.8%- (94.1%-
100%) 96.1%) 100%) 100%) 100%) 99.3%)
ECGs before and after ECV were pooled, ECGs with AFL were excluded. For the device algorithms, uninterpretable/unrecorded ECGs by devices were excluded. Number
of ECGs: N = 316 for Withings, N = 308 for Apple Watch, N = 272 for lead II, and N = 297 for Kardia Mobile 6L.
For cardiologists’ interpretations, ECGs not classified by cardiologists were excluded. Total number of ECG interpretations N = 487 for ECGs “uninterpretable” by the
algorithm. Cardiologists’ device ECG interpretations: N = 2,913 for all patients with SR/AF section.
AF, atrial fibrillation; AFL, atrial flutter; CI, confidence interval; ECG, electrocardiogram.
∗
indicates P-value < .05 compared to the other devices in correct classifications.

tainty by the cardiologists about the classifications (SR
or SVT) were determined (1 point attributed if uncer-
tain, 0 points if no uncertainty. Score 0-2 for all devices)
and compared using Wilcoxon signed rank test. Finally,
we examined the reliability of cardiologists to differen-
tiate between SR, AF, and AFL. We combined both car-
diologists interpretations (2 points attributed if SR/SVT
classified incorrect, 1 point attributed if SVT (AF/AFL)
sub classification incorrect, 0 points if classified correct)
to compare the different devices using Wilcoxon signed
rank test. Statistical analyses were performed using SPSS
25.0 (IBM).
Results
A total of 220 patients were included (age 70 ± 10
years, female 35%) from a total of 234 screened patients
(online supplementary table). In total, 415 12-lead ECGs
were recorded (45% SR, 45% AF, 10% AFL). Repeat ECGs
were missing in 25 patients (no ECV performed n = 19,
withdrawal/lack-of-time n = 6).
AF algorithms
Withings lead I, Apple lead I, and Kardia 6L had com-
parable proportions of uninterpretable ECGs: 20% (12%
inconclusive, 4% high heart rate, 2% low heart rate, 1%
unclassified), 20% (11% inconclusive, 6% high heart rate,
3% low heart rate), and 24% (15% inconclusive, 3% high
heart rate, 1% low heart rate, 4% unclassified) respec-
tively (P > .05 for all comparisons in percentage unin-
terpretable) (Table 1). The single-lead II had a higher pro-
portion of uninterpretable ECGs: 32% (25% inconclusive,
5% high heart rate, 2% low heart rate)(P < .001 com-
pared to Withings lead I, P < .001 compared to Apple
lead I, and P = .003 compared to Kardia). Excluding un-
interpretable ECGs, sensitivity and specificity of the AF
detection algorithms were 91% to 99%, similar for all de-
vices (Table 1) (P > .05 for all head-to-head comparisons
in accuracy).
Cardiologists’ interpretation
The cardiologists’ interpretation of Withings leads I
and Apple lead I had sensitivity and specificity of 94–96%
(Table 1). The accuracy of Kardia 6L was significantly
better (sensitivity 99% and specificity 97%; correct classi-
fications 97.9% (95% confidence interval: 96.8–99.0%)),
P = .013 vs Withings, P = .024 vs Apple (Table 1). Re-
sults for the cardiologists’ interpretation of the subset
with an “uninterpretable” ECG by the algorithm are listed
in Table 1. The average proportions of cardiologists’ un-
certainty were 8.5% for Withings, 9.9% for Apple, 10.5%
for lead II, and 4.4% for Kardia (Kardia 6L P ≤ .001 com-
pared to all).
Atrial flutter detection
The differentiation between SR, AF, and AFL is shown
in Table 2 (A–D). Averaged over the 2 cardiologists, their
classification showed a correct diagnosis of AFL in 28%
for Withings lead I and 33% for Apple lead I. The correct
classification was numerically higher when based on lead
II: 54% (P = .076 compared to Withings and P = .246
compared to Apple). Kardia 6L was most accurate in dif-
ferentiating between SR, AF, and AFL, with a correct di-
 American Heart Journal
56 Scholten et al
November 2022

Table II. (A-D) Cardiologists’ differentiation of SR, AF, and AFL

The total number of observations is listed for both cardiologists (on each ECG) and the corresponding gold standard 12L ECG (2
per patient: both before and after ECV). Percentage values are averaged over the 2 cardiologists’ classifications on each device
compared to the 12-lead ECG. Patients were randomly allocated to acquire a single-lead II ECG with either Withings or Apple
in a 1:1 ratio. Both cardiologists were asked to interpret all device ECGs once.
A. Withings lead I, total number of ECG interpretations: N = 823,
B. Apple lead I, total number of ECG interpretations: N = 819,
C. Total lead II, total number of ECG interpretations: N = 822,
D. Kardia 6 leads, total number of ECG interpretations: N = 796.
AF, atrial fibrillation; AFL, atrial flutter; ECG, electrocardiogram; SR, sinus rhythm.

agnosis of AFL in 63% of all cases (P < .001 compared to
Withings and Apple).
Discussion
This is the first study to compare multiple commer-
cially available devices with different methods of ECG-
acquisition for AF detection. Sensitivity and specificity of
the algorithms by all devices were high (91–99%) com-
pared to the gold standard 12-lead ECG. However, we
excluded uninterpretable results, which led to overesti-
mation of algorithm accuracy in practice. The propor-
tion of uninterpretable ECGs by devices (20–24%) were
in line with most previous studies, although a recent
study reported fewer uninterpretable ECGs by the Ap-
ple watch.3-5 This difference might be explained by more
“high heart rate” classifications in our older study popu-
lation admitted for ECV.5
Our results of the cardiologists’ interpretation revealed
that the six-lead Kardia ECG was superior to both single-
lead smartwatches to detect AF, and accurate in ECGs
that were uninterpretable by the algorithm. We hypothe-
size that the improved AF detection can be explained by
information provided by the multiple leads that improves
p-wave detection to help differentiate between SR and
AF.6 In addition, cardiologists were less uncertain about
their interpretation when analyzing Kardia 6L compared
to the single-lead ECGs, which is relevant in situations
when no simultaneous 12-lead ECG is available. Differ-
ences in hardware and recording electrodes could have
also played a role in the better accuracy of Kardia 6L com-
pared to the single-lead smartwatches.
It is conceivable AF detection algorithms can fur-
ther improve, especially when information from multi-
ple leads is integrated (not the case for the Kardia algo-
rithm during our study). In clinical practice or popula-
tion screening programs, health care provider interpreta-
tion may be needed only to confirm newly detected AF
or evaluate uninterpretable ECGs by the algorithm. Kar-
dia 6L may be preferred due to the combined high sen-
sitivity of the algorithm and accurate cardiologists’ inter-
pretation. Considering the rate of uninterpretable device
ECGs, mass utilization by the general population may
lead to increased health care utilization.7 This study in-
forms high-risk population screening programs, in which
appropriate use may facilitate early AF detection and pre-
vent stroke. Previous studies found that mobile devices
could detect 1–3% of new AF in an elderly high-risk pop-
American Heart Journal
Volume 253
ulation and are cost efficient for this purpose.8 , 9 Long-
term intermittent rhythm monitoring in an at-risk popu-
lation has higher yield than one single screening ECG.10
Another benefit of the six-lead Kardia ECG was the im-
proved differentiation between AFL and AF compared
to the single-lead ECGs. The trend towards better AFL
recognition on lead II suggests that recording an addi-
tional lead II ECG (instead of lead I) by the patient could
be informative when there is doubt about the rhythm
using a single-lead device. Currently, there is little evi-
dence on accuracy of single-lead devices beyond AF de-
tection.11 Our findings suggest Kardia 6L has clinical ben-
efit compared to the single-lead devices, but only when
reviewed by cardiologists. In comparison to single-lead
ECGs, a six-lead device can more accurately diagnose AF
and may lead to less health care utilization when uncer-
tainty remains after cardiologists’ interpretation. Many
cardiologists are reluctant to initiate therapies such as an-
ticoagulant treatment based on a single-lead ECG sugges-
tive of new AF.12 Overall, our findings suggest that mobile
ECGs are sufficient to establish an AF diagnosis when the
rhythm is interpretable to the cardiologist without uncer-
tainty.
Limitations
This was a single-center study including AF patients
scheduled for ECV in a regional hospital with a uniform
protocol and high inclusion rate. In this controlled en-
vironment, devices were compared that can be used
at-home with low AF prevalence in a population with
high AF prevalence, which may influence accuracy, al-
though likely similar in all devices. We did not evaluate
devices used by patients themselves at-home, although
instructions were limited and patients needed to acquire
the ECGs themselves, this could have affected quality.
False classifications may be more prevalent in patients
with symptomatic premature atrial contractions or other
types of SVT’s, who were not included in our study. Be-
cause of our study design we pooled ECGs before and
after ECV into different sections to compare various as-
pects of device ECG accuracy.
In a home setting or during exercise, single-lead smart-
watches can have practical advantages compared to
the six-lead device, which requires 3 contact points to
record. More people own smartwatches for other appli-
cations which could make this a more widely applica-
ble screening tool. Finally, AF detection during follow-up
using photoplethysmography to detect asymptomatic AF
by smartwatches was not evaluated.7
Conclusions
In all devices, sensitivity and specificity for algorithm
AF classification were 91–99% after excluding the 20–
24% of uninterpretable ECGs. When interpreted by cardi-
Scholten et al 57
ologists, the Kardia 6-lead ECG was superior (sensitivity
99%, specificity 97%) to single-lead ECGs.
Author contributions
Jouke P. Bokma: conceived of the study. Jouke
P. Bokma, Ward P.J. Jansen, Aeilko H. Zwin-
derman, Joris R. de Groot: designed the research.
Josca Scholten, Anuska D. Mahes, Madelon Min-
neboo, Jouke P. Bokma, Ward P.J. Jansen, Thomas
Horsthuis: conducted the research and contributed to
data collection. Jan T. Keijer, Aeilko H. Zwinderman,
Michiel M. Winter, Joris R. de Groot: contributed to
the interpretation of the data. Josca Scholten, Jouke P.
Bokma: analyzed the data under supervision of Aeilko
H. Zwinderman. Josca Scholten, Jouke P. Bokma:
wrote the paper. Jouke P. Bokma: is the guarantor of
this research. All authors read and approved the final
manuscript.
Funding
J.P. Bokma was supported by a research grant of Am-
sterdam Cardiovascular Sciences. All devices were pur-
chased by the Cardiology department of Tergooi Hospi-
tal.
Declaration of Competing Interest
None.
Supplementary materials
Supplementary material associated with this article can
be found, in the online version, at doi:10.1016/j.ahj.
2022.06.010.
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