1
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Freund O, Caspi I, Alcalay I, Brezis MR, Frydman S, Bornstein G. An old diagnostic tool for new indications: inpatient Holter ECG for conditions other than syncope or stroke. Sci Rep 2023; 13:12510. [PMID: 37532808 PMCID: PMC10397303 DOI: 10.1038/s41598-023-39803-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 07/31/2023] [Indexed: 08/04/2023] Open
Abstract
Holter electrocardiography (ECG) assists in the diagnosis of arrhythmias. Its use in the inpatient setting has been described solely for the evaluation of stroke and syncope. Our aim was to assess its diagnostic value for other conditions in the internal medicine department. We included all hospitalized patients between 2018 and 2021 in a tertiary referral center. The primary outcome was a diagnostic Holter recording a new arrhythmia that led to a change in treatment. Overall, 289 patients completed a 24-h inpatient Holter ECG for conditions other than syncope or stroke, with 39 (13%) diagnostic findings. The highest diagnostic value was found in patients admitted for pre-syncope (19%), palpitations (18%), and unexplained heart failure exacerbation/dyspnea (17%). A low diagnostic yield was found for the evaluation of chest pain (5%). Heart failure with preserved ejection fraction (adjusted OR 2.3, 95% CI 1.1-5.4, p = 0.04), and baseline ECG with either a bundle branch block (AOR 4.2, 95% CI 1.9-9.2, p < 0.01) or atrioventricular block (first or second degree, AOR 5, 95% CI 2.04-12.3, p < 0.01) were among the independent predictors for a diagnostic test. Inpatient Holter ECG monitoring may have value as a diagnostic tool for selected patients with conditions other than syncope or stroke.
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Affiliation(s)
- Ophir Freund
- Internal Medicine B, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Wizman 6, Tel Aviv, Israel.
| | - Inbar Caspi
- Internal Medicine B, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Wizman 6, Tel Aviv, Israel
| | - Idan Alcalay
- Internal Medicine B, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Wizman 6, Tel Aviv, Israel
| | - Miriam R Brezis
- Internal Medicine B, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Wizman 6, Tel Aviv, Israel
| | - Shir Frydman
- Internal Medicine B, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Wizman 6, Tel Aviv, Israel
| | - Gil Bornstein
- Internal Medicine B, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Wizman 6, Tel Aviv, Israel
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2
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Carrington M, Providência R, Chahal CAA, Ricci F, Epstein AE, Gallina S, Fedorowski A, Sutton R, Khanji MY. Clinical applications of heart rhythm monitoring tools in symptomatic patients and for screening in high-risk groups. Europace 2022; 24:1721-1729. [PMID: 35983729 DOI: 10.1093/europace/euac088] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 05/12/2022] [Indexed: 12/15/2022] Open
Abstract
Recent technological advances have facilitated and diversified the options available for the diagnosis of cardiac arrhythmias. Ranging from simple resting or exercise electrocardiograms to more sophisticated and expensive smartphones and implantable cardiac monitors. These tests and devices may be used for varying periods of time depending on symptom frequency. The choice of the most appropriate heart rhythm test should be guided by clinical evaluation and optimized following accurate characterization of underlying symptoms, 'red flags', risk factors, and consideration of cost-effectiveness of the different tests. This review provides evidence-based guidance for assessing suspected arrhythmia in patients who present with symptoms or in the context of screening, such as atrial fibrillation or advanced conduction disturbances following transcatheter aortic valve implantation in high-risk groups. This is intended to help clinicians choose the most appropriate diagnostic tool to facilitate the management of patients with suspected arrhythmias.
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Affiliation(s)
- Mafalda Carrington
- Department of Cardiology, Hospital do Espírito Santo de Évora, Évora, Portugal
| | - Rui Providência
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK.,Department of Cardiology, Newham University Hospital, BartsHealth NHS Trust, London, UK.,Institute of Health Informatics Research, University College London, London, UK
| | - C Anwar A Chahal
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK.,Cardiovascular Division, University of Pennsylvania, Philadelphia, PA, USA.,Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, "G.d'Annunzio" University of Chieti-Pescara, 66100 Chieti, Italy.,Department of Cardiology, Casa di Cura Villa Serena, Città Sant'Angelo, Italy.,Department of Clinical Sciences, Lund University, 205 02 Malmö, Sweden
| | - Andrew E Epstein
- Cardiovascular Division, University of Pennsylvania, Philadelphia, PA, USA
| | - Sabina Gallina
- Department of Neuroscience, Imaging and Clinical Sciences, "G.d'Annunzio" University of Chieti-Pescara, 66100 Chieti, Italy
| | - Artur Fedorowski
- Department of Cardiology, Casa di Cura Villa Serena, Città Sant'Angelo, Italy.,Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Richard Sutton
- Department of Clinical Sciences, Lund University, 205 02 Malmö, Sweden.,Department of Cardiology, Hammersmith Hospital Campus, Imperial College, London, UK
| | - Mohammed Y Khanji
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK.,Department of Cardiology, Newham University Hospital, BartsHealth NHS Trust, London, UK.,NIHR Biomedical Research Unit, William Harvey Research Institute, Queen Mary University of London, London, UK
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3
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Carrington M, Providência R, Chahal CAA, Ricci F, Epstein AE, Gallina S, Fedorowski A, Sutton R, Khanji MY. Monitoring and diagnosis of intermittent arrhythmias: evidence-based guidance and role of novel monitoring strategies. EUROPEAN HEART JOURNAL OPEN 2022; 2:oeac072. [PMID: 36440351 PMCID: PMC9683599 DOI: 10.1093/ehjopen/oeac072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 07/13/2022] [Accepted: 10/26/2022] [Indexed: 11/14/2022]
Abstract
Technological advances have made diagnosis of heart rhythm disturbances much easier, with a wide variety of options, including single-lead portable devices, smartphones/watches to sophisticated implantable cardiac monitors, allowing accurate data to be collected over different time periods depending on symptoms frequency. This review provides an overview of the novel and existing heart rhythm testing options, including a description of the supporting evidence for their use. A description of each of the tests is provided, along with discussion of their advantages and limitations. This is intended to help clinicians towards choosing the most appropriate test, thus improving diagnostic yield management of patients with suspected arrhythmias.
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Affiliation(s)
- Mafalda Carrington
- Cardiology Department, Hospital do Espírito Santo de Évora, Largo do Sr. da Pobreza, 7000-811 Évora, Portugal
| | - Rui Providência
- Barts Heart Centre, Barts Health NHS Trust, W Smithfield, London EC1A 7BE, UK
- Department of Cardiology, Newham University Hospital, Barts Health NHS Trust, Glen Road, London E13 8SL, UK
- Institute of Health Informatics Research, University College London, 222 Euston Road London, NW1 2DA, UK
| | - C Anwar A Chahal
- Barts Heart Centre, Barts Health NHS Trust, W Smithfield, London EC1A 7BE, UK
- Cardiovascular Division, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, “G.d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
- Department of Cardiology, Fondazione Villaserena per la Ricerca, Viale L. Petruzzi n. 42, 65013, Città S. Angelo, Italy
- Department of Clinical Sciences, Lund University, 205 02 Malmö, Sweden
| | - Andrew E Epstein
- Cardiovascular Division, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Sabina Gallina
- Department of Neuroscience, Imaging and Clinical Sciences, “G.d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, 205 02 Malmö, Sweden
- Department of Cardiology, Karolinska University Hospital, and Department of Medicine, Karolinska Institute, 171 64 Solna, Stockholm, Sweden
| | - Richard Sutton
- Department of Clinical Sciences, Lund University, 205 02 Malmö, Sweden
- Department of Cardiology, Hammersmith Hospital Campus, Imperial College, Du Cane Road, London W12 0HS, England, United Kingdom of Great Britain and Northern Ireland
| | - Mohammed Y Khanji
- Barts Heart Centre, Barts Health NHS Trust, W Smithfield, London EC1A 7BE, UK
- Department of Cardiology, Newham University Hospital, Barts Health NHS Trust, Glen Road, London E13 8SL, UK
- NIHR Biomedical Research Unit, William Harvey Research Institute, Queen Mary University of London, Mile End Road, London E1 4NS, UK
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4
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Holter ECG for Syncope Evaluation in the Internal Medicine Department-Choosing the Right Patients. J Clin Med 2022; 11:jcm11164781. [PMID: 36013018 PMCID: PMC9409720 DOI: 10.3390/jcm11164781] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/10/2022] [Accepted: 08/14/2022] [Indexed: 11/23/2022] Open
Abstract
Physicians use Holter electrocardiography (ECG) monitoring to evaluate some patients with syncope in the internal medicine department. We questioned whether Holter ECG should be used in the presented setting. Included were all consecutive patients admitted with syncope to one of our nine internal medicine departments who had completed a 24 h Holter ECG between 2018 and 2021. A diagnostic Holter was defined as one which altered the patient’s treatment and met ESC/ACC/AHA diagnostic criteria. A total of 478 Holter tests were performed for syncope evaluation during admission to an internal medicine department in the study period. Of them, 25 patients (5.2%) had a diagnostic Holter finding. Sinus node dysfunction was the most frequent diagnostic recording (13 patients, 52%). In multivariant analysis, predictors for diagnostic Holter were older age (OR 1.35, 95% CI 1.08−1.68), heart failure with preserved ejection fraction (OR 4.1, 95% CI 1.43−11.72), and shorter duration to Holter initiation (OR 0.73, 95% CI 0.56−0.96). There was a positive correlation between time from admission to Holter and hospital stay, r(479) = 0.342, p < 0.001. Our results suggest that completing a 24 h Holter monitoring during admission to the internal medicine department should be restricted to patients with a high pre-test probability to avoid overuse and possible harm.
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Abstract
INTRODUCTION Suspected transient loss of consciousness (T-LOC) and syncope are common causes of hospitalization in older patients. Arrhythmias are the most common cardiac causes of syncope. Although a number of instrumental diagnostic procedures are usually routinely performed in patients with suspected syncope, a 12 leads electrocardiogram (ECG) is the only instrumental test recommended for the initial evaluation of these patients. EVIDENCE ACQUISITION In this paper current literature on this topic will be reviewed, including ECG diagnostic criteria and findings suggestive of cardiac syncope. EVIDENCE SYNTHESIS The ECG may disclose an arrhythmia associated with a high likelihood of syncope, avoiding further evaluations and permitting institution of specific treatment in 7% of patients referred to emergency department. When the cause of syncope remains uncertain after initial evaluation the next step is to assess the risk of major cardiovascular events or sudden cardiac death. An abnormal ECG selected patients with high probabiliry of cardiac syncope. ECG diagnostic criteria and ECG findings suggesting arrhythmic syncope are presented. Indications and potential clinical implications of ECG monitoring will be discussed too. CONCLUSIONS A careful, well-conducted medical history focused on the suspected syncopal event is crucial for the diagnosis. In this setting, the ECG is a mandatory diagnostic tool which, although normal in the majority of patients of syncope, has the potential to identify patients with high likelihood of cardiac syncope due to arrhythmic or cardiopulmonary disorder.
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Affiliation(s)
- Mario Bo
- Section of Geriatrics, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Attilio Del Rosso
- Cardiology Division, San Giuseppe Hospital, Empoli, Firenze, Italy -
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6
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Abstract
Palpitations are a common presenting symptom in primary care, yet their cause can be difficult to diagnose due to their intermittent and sometimes infrequent nature. All patients presenting with a chief complaint of palpitations should undergo a detailed history, physical examination, and electrocardiogram (ECG). This alone can yield a probable diagnosis. Limited laboratory testing, ambulatory ECG monitoring, and cardiology referral are sometimes indicated. This article reviews current data and guidelines on how to evaluate palpitations in the primary care setting.
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Affiliation(s)
- Clara Weinstock
- University of Connecticut School of Medicine, 263 Farmington Avenue, Outpatient Pavilion- 2nd Floor East, Farmington, CT 06030, USA.
| | - Hilary Wagner
- University of Connecticut School of Medicine, 263 Farmington Avenue, Outpatient Pavilion- 2nd Floor East, Farmington, CT 06030, USA
| | - Meghan Snuckel
- University of Connecticut School of Medicine, 263 Farmington Avenue, Outpatient Pavilion- 2nd Floor East, Farmington, CT 06030, USA
| | - Marilyn Katz
- University of Connecticut School of Medicine, 263 Farmington Avenue, Outpatient Pavilion- 2nd Floor East, Farmington, CT 06030, USA
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Rajanna RREDDY, Natarajan S, Prakash V, Vittala PR, Arun U, Sahoo S. External Cardiac Loop Recorders: Functionalities, Diagnostic Efficacy, Challenges and Opportunities. IEEE Rev Biomed Eng 2021; 15:273-292. [DOI: 10.1109/rbme.2021.3055219] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Çinier G, Haseeb S, Bazoukis G, Yeung C, Gül EE. Evaluation and Management of Asymptomatic Bradyarrhythmias. Curr Cardiol Rev 2021; 17:60-67. [PMID: 32693770 PMCID: PMC8142361 DOI: 10.2174/1573403x16666200721154143] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 05/30/2020] [Accepted: 06/15/2020] [Indexed: 12/26/2022] Open
Abstract
Asymptomatic bradyarrhythmias involving sinus node dysfunction and atrioventicular blocks are frequently noted in clinical practice. Its prevalence is expected to rise as devices that are developed for monitoring cardiac rhythm for longer duration become more widely available. Episodes of bradyarrhythmia that are asymptomatic are considered to have a benign course compared with those that cause symptoms and do not necessitate further treatment. However, in certain cases, they can be a harbinger of future symptoms or cardiac manifestations of systemic diseases. The evaluation and risk stratification of individuals presenting with asymptomatic bradyarrhythmias is important not only for preventing implantation of unnecessary permanent pacing devices but also for reducing significant morbidity by implementing proper treatment as required. In this article, we will review the current evidence on the pathophysiology, diagnosis, evaluation and management of patients with asymptomatic bradyarrhythmias.
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Affiliation(s)
- Göksel Çinier
- Department of Cardiology, Kaçkar State Hospital, Rize, Turkey
| | - Sohaib Haseeb
- Department of Cardiology, Queen’s University, Kingston, ON K7L 3N6, Canada
| | - Giorgos Bazoukis
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, Athens, Greece
| | - Cynthia Yeung
- Department of Cardiology, Queen’s University, Kingston, ON K7L 3N6, Canada
| | - E. Elvin Gül
- Division of Cardiac Electrophysiology, Madinah Cardiac Centre, Medina, Saudi Arabia
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9
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Seewöster T, Lindemann F, Hindricks G. [Differential diagnostics of unclear syncope]. Herz 2019; 44:759-768. [PMID: 31620824 DOI: 10.1007/s00059-019-04852-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The clarification of syncope is a diagnostic challenge as possible causes often occur only intermittently. Therefore, a detailed and standardized anamnesis is essential as it 1) differentiates syncope from other transient losses of consciousness (TLOC) and 2) directly clarifies possible causes of syncope. The risk stratification plays a central and very important role in order to avoid unnecessary examinations in patients with benign syncope and to provide patients with life-threatening, mostly cardiac syncopal episodes with timely diagnostics and treatment. In cases where the cause of syncope is still unclear, a standardized approach is indicated using extended diagnostics, such as a tilt table examination, a carotid sinus pressure test, prolonged telemetric monitoring or clarification with an implantable loop recorder (ILR).
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Affiliation(s)
- T Seewöster
- Department of Electrophysiology, Heart Center Leipzig, Strümpellstr. 39, 04289, Leipzig, Deutschland.
| | - F Lindemann
- Department of Electrophysiology, Heart Center Leipzig, Strümpellstr. 39, 04289, Leipzig, Deutschland
| | - G Hindricks
- Department of Electrophysiology, Heart Center Leipzig, Strümpellstr. 39, 04289, Leipzig, Deutschland
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10
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Diagnostic challenges in supraventricular tachycardia: anticipating value of natriuretic peptides. Cardiovasc Endocrinol Metab 2018; 7:34-36. [PMID: 31646277 DOI: 10.1097/xce.0000000000000148] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 12/21/2017] [Indexed: 12/30/2022]
Abstract
It is important not to overlook supraventricular tachycardia (SVT) in patients complaining of palpitation or tachycardia-related symptoms but with normal ECG and heart rate in emergency department or outpatient clinics. The severity and presentation of symptoms is highly variable and depends on features including heart rate, duration of tachycardia, underlying heart disease, and individual patient perception. Early measurement of natriuretic peptides in patients presenting with palpitation and/or tachycardia-related symptoms would guide the clinician to rule out tachycardia and/or SVT. High levels of natriuretic peptides within 30 min of postattack period would certainly increase the likelihood of SVT.
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Brignole M, Moya A, de Lange FJ, Deharo JC, Elliott PM, Fanciulli A, Fedorowski A, Furlan R, Kenny RA, Martín A, Probst V, Reed MJ, Rice CP, Sutton R, Ungar A, van Dijk JG. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J 2018; 39:1883-1948. [PMID: 29562304 DOI: 10.1093/eurheartj/ehy037] [Citation(s) in RCA: 976] [Impact Index Per Article: 162.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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12
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Cheung CC, Krahn AD. Loop recorders for syncope evaluation: what is the evidence? Expert Rev Med Devices 2016; 13:1021-1027. [DOI: 10.1080/17434440.2016.1243463] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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13
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Galli A, Ambrosini F, Lombardi F. Holter Monitoring and Loop Recorders: From Research to Clinical Practice. Arrhythm Electrophysiol Rev 2016; 5:136-43. [PMID: 27617093 DOI: 10.15420/aer.2016.17.2] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Holter monitors are tools of proven efficacy in diagnosing and monitoring cardiac arrhythmias. Despite the fact their use is widely prescribed by general practitioners, little is known about their evolving role in the management of patients with cryptogenic stroke, paroxysmal atrial fibrillation, unexplained recurrent syncope and risk stratification in implantable cardioverter defibrillator or pacemaker candidates. New Holter monitoring technologies and loop recorders allow prolonged monitoring of heart rhythm for periods from a few days to several months, making it possible to detect infrequent arrhythmias in patients of all ages. This review discusses the advances in this area of arrhythmology and how Holter monitors have improved the clinical management of patients with suspected cardiac rhythm diseases.
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Affiliation(s)
- Alessio Galli
- Cardiovascular Diseases Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Clinical and Community Sciences, University of Milan, Milan, Italy
| | - Francesco Ambrosini
- Cardiovascular Diseases Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Clinical and Community Sciences, University of Milan, Milan, Italy
| | - Federico Lombardi
- Cardiovascular Diseases Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Clinical and Community Sciences, University of Milan, Milan, Italy
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Abstract
Syncope is a common clinical problem that carries a high socioeconomic burden. A structured approach in the evaluation of syncope with special emphasis on a detailed history, comprehensive physical examination that includes orthostatic vital signs, and an electrocardiogram, proves to be the most cost-effective approach. The need for additional testing and hospital admission should be based on the results of the initial evaluation and use of risk-stratification tools that help identify those syncope patients at highest risk for poor outcomes.
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Affiliation(s)
- Steven Angus
- Department of Medicine, University of Connecticut School of Medicine, 263 Farmington Avenue, Farmington, CT 06030, USA.
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15
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Abstract
Syncope is a common problem encountered by both emergency and internal medicine physicians. This review focuses on not only the assessment, risk stratification and management of the syncope patient, but also the latest thinking on diagnostic testing including more novel tools such as biomarkers and ambulatory patch monitor recording.
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Affiliation(s)
- Catriona Williamson
- Emergency Medicine Research Group Edinburgh (EMERGE), Emergency Department, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - Matthew James Reed
- Emergency Medicine Research Group Edinburgh (EMERGE), Emergency Department, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK.
- College of Medicine and Veterinary Medicine, University of Edinburgh, The Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK.
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Sciaraffia E, Chen J, Hocini M, Larsen TB, Potpara T, Blomström-Lundqvist C. Use of event recorders and loop recorders in clinical practice: results of the European Heart Rhythm Association Survey. Europace 2015; 16:1384-6. [PMID: 25172620 DOI: 10.1093/europace/euu222] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Several kinds of electrocardiogram monitoring systems are now available in the clinical practice. The aim of this European Heart Rhythm Association (EHRA) survey was to assess the use of different monitoring techniques in the evaluation of patients with unexplained syncope, palpitations, and in those with established diagnosis of atrial fibrillation. Forty-five centres in Europe answered the questionnaire and the majority (78%) were university hospitals. The answers showed a discrepancy between the recommended use of implantable loop recorders (ILRs) in patients with unexplained syncope and the use of this device in clinical practice. In most of the cases only a minority of patients (<20%) seemed to actually receive an ILR as a part of the diagnostic process in accordance to the current guidelines. Holter monitoring systems and external loop recorders seemed to be the preferred monitoring techniques both in patients with recurrent palpitations and in those with established diagnosis of atrial fibrillation.
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Affiliation(s)
- Elena Sciaraffia
- Department of Cardiology, Institution of Medical Science, Uppsala University, 75185 Uppsala, Sweden
| | - Jian Chen
- Department of Heart Disease, Haukeland University Hospital, N-5021 Bergen, Norway Department of Clinical Science, University of Bergen, N-5021 Bergen, Norway
| | - Meleze Hocini
- Institut LIRYC, Hôpital Cardiologique du Haut Lévêque, Université Victor Segalen Bordeaux II 33604, Bordeaux, Pessac, France
| | - Torben Bierregaard Larsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg DK-9100 University, Aalborg, Denmark
| | - Tatjana Potpara
- Cardiology Clinic, Clinical Centre of Serbia, School of Medicine, University of Belgrade, 11000 Belgrade, Serbia
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PérezRodon J, FranciscoPascual J, RivasGándara N, RocaLuque I, Bellera N, MoyaMitjans À. Cryptogenic Stroke And Role Of Loop Recorder. J Atr Fibrillation 2014; 7:1178. [PMID: 27957141 DOI: 10.4022/jafib.1178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 12/12/2014] [Accepted: 12/21/2014] [Indexed: 12/29/2022]
Abstract
Ischemic stroke is an important cause of morbidity and mortality when untreated. Identifying atrial fibrillation is important because atrial fibrillation ischemic related strokes are associated with an increased risk of disability and death compared with strokes of other etiologies and tend to recur without anticoagulation. However, atrial fibrillation detection can be difficult when it is asymptomatic and paroxistic and may be the underlying cause of some cryptogenic strokes or strokes of unknown origin. In this review, the different methods of cardiac monitoring to detect atrial fibrillation in patients with cryptogenic stroke are summarized, with a focus on loop recorder monitoring.
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Affiliation(s)
- Jordi PérezRodon
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
| | - Jaume FranciscoPascual
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
| | - Nuria RivasGándara
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
| | - Ivo RocaLuque
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
| | - Neus Bellera
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
| | - Àngel MoyaMitjans
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
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18
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Ward F, McGovern R, Cotter PE. Troponin-I is a predictor of a delayed diagnosis of atrial fibrillation in acute ischemic stroke and transient ischemic attack. J Stroke Cerebrovasc Dis 2014; 24:66-72. [PMID: 25440352 DOI: 10.1016/j.jstrokecerebrovasdis.2014.07.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 07/28/2014] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Prolonged cardiac monitoring detects higher rates of atrial fibrillation (AF) in ischemic stroke and transient ischemic attack (TIA) but is costly and has practical implications. The use of admission troponin-I (TnI) level to identify patients at high risk of delayed AF detection was investigated. METHODS Consecutive ischemic stroke and TIA cases presenting to our institute over a 13-month period were identified from the Irish Stroke and TIA Register. Electronic databases and case notes were examined. "Delayed" AF was diagnosed after a sinus rhythm admission electrocardiogram and no documented history. Group comparisons were made by AF status. The association between TnI and AF was investigated using a multivariate regression model. RESULTS A total of 185 cases (130 ischemic stroke) were analyzed. Mean age (standard deviation) was 73.3 (13.9) years, 47% female. Sixty-two cases (33.5%) had AF. The first documented presentation of AF was found in 21 cases, on admission electrocardiogram (n = 11) or inpatient telemetry (delayed, n = 10). TnI was higher in those with delayed AF than in those without AF (W = 194; P = .036). A higher proportion of those with an elevated TnI (30%) than those with a normal TnI (6.1%) had delayed diagnosis of AF (χ(2) = 6.41, P = .011). Having an abnormal TnI was a significant independent predictor of delayed AF detection (odds ratio, 5.8; P = .037). CONCLUSIONS TnI elevation is associated with a higher likelihood of subsequent AF diagnosis. Identification of these higher risk stroke and TIA cases for more intensive cardiac monitoring may improve stroke secondary prevention practices.
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Affiliation(s)
- Frank Ward
- Department of Geriatric and Stroke Medicine, St Luke's Hospital, Kilkenny, Ireland.
| | - Rory McGovern
- Department of Geriatric and Stroke Medicine, St Luke's Hospital, Kilkenny, Ireland
| | - Paul E Cotter
- Department of Geriatric and Stroke Medicine, St Luke's Hospital, Kilkenny, Ireland
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Epifanio HB, Katz M, Borges MA, Corrêa ADG, Cintra FD, Grinberg RL, Ludovice ACPP, Valdigem BP, Silva NJCD, Fenelon G. The use of external event monitoring (web-loop) in the elucidation of symptoms associated with arrhythmias in a general population. EINSTEIN-SAO PAULO 2014; 12:295-9. [PMID: 25295448 PMCID: PMC4872938 DOI: 10.1590/s1679-45082014ao2939] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 04/16/2014] [Indexed: 11/22/2022] Open
Abstract
Objective To correlate arrhythmic symptoms with the presence of significant arrhythmias through the external event monitoring (web-loop). Methods Between January and December 2011, the web-loop was connected to 112 patients (46% of them were women, mean age 52±21 years old). Specific arrhythmic symptoms were defined as palpitations, pre-syncope and syncope observed during the monitoring. Supraventricular tachycardia, atrial flutter or fibrillation, ventricular tachycardia, pauses greater than 2 seconds or advanced atrioventricular block were classified as significant arrhythmia. The association between symptoms and significant arrhythmias were analyzed. Results The web-loop recorded arrhythmic symptoms in 74 (66%) patients. Of these, in only 14 (19%) patients the association between symptoms and significant cardiac arrhythmia was detected. Moreover, significant arrhythmia was found in 11 (9.8%) asymptomatic patients. There was no association between presence of major symptoms and significant cardiac arrhythmia (OR=0.57, CI95%: 0.21-1.57; p=0.23). Conclusion We found no association between major symptoms and significant cardiac arrhythmia in patients submitted to event recorder monitoring. Event loop recorder was useful to elucidate cases of palpitations and syncope in symptomatic patients.
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Affiliation(s)
| | - Marcelo Katz
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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20
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Ray JC, Kusumoto F, Goldschlager N. Syncope. J Intensive Care Med 2014; 31:79-93. [PMID: 25286917 DOI: 10.1177/0885066614552988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 06/26/2014] [Indexed: 11/17/2022]
Abstract
Syncope is common representing approximately 3% of ED visits and up to 6% of hospital admissions, with a cost close to 2 billion dollars per year. Diagnostic testing is often poorly sensitive and evaluations commonly lack a standardized approach. A mindful and systematic approach can increase sensitivity and improve diagnostic accuracy. A thorough history and physical exam is paramount, as conclusions drawn from the history and exam will guide further assessment. Developing a strategy for the first and, if necessary, subsequent tests will improve the accuracy of identifying the etiology of syncope and reduce cost. Although syncope has a favorable prognosis, identification of patients with structural heart disease is critical, as these patients are at greatest risk for mortality. Several risk scoring systems have been developed to help separate high risk from low risk patients.
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Affiliation(s)
- Jordan C Ray
- Division of Cardiovascular disease, Department of Medicine, Electrophysiology and Pacing Service, Mayo Clinic, Jacksonville, FL, USA
| | - Fred Kusumoto
- Division of Cardiovascular disease, Department of Medicine, Electrophysiology and Pacing Service, Mayo Clinic, Jacksonville, FL, USA
| | - Nora Goldschlager
- Cardiology Division, Department of Medicine, San Francisco General Hospital, San Francisco, CA, USA Department of Medicine, University of California, San Francisco, CA, USA
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21
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Características clínicas de pacientes llevados a monitoría externa de eventos. REVISTA COLOMBIANA DE CARDIOLOGÍA 2014. [DOI: 10.1016/j.rccar.2013.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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22
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Abstract
A rapid change in ageing demographic is taking place worldwide such that healthcare professionals are increasingly treating old and very old patients. Syncope in the elderly is a challenging presentation that is under-recognised, particularly in the acute care setting. The reason for this is that presentation in the older person may be atypical: patients are less likely to have a prodrome, may have amnesia for loss of consciousness and events are frequently unwitnessed. The older patient thus may present with a fall rather than transient loss of consciousness. There is an increased susceptibility to syncope with advancing age attributed to age-related physiological impairments in heart rate and blood pressure, and alterations in cerebral blood flow. Multi-morbidity and polypharmacy in these complex patients increases susceptibility to syncope. Cardiac causes and more than one possible cause are also common. Syncope is a major cause of morbidity and mortality and is associated with enormous personal and wider health economic costs. In view of this, prompt assessment and early targeted intervention are recommended. The purpose of this article is to update the reader regarding the presentation and management of syncope in this rapidly changing demographic.
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Affiliation(s)
- Helen O' Brien
- Department of Medical Gerontology, TCIN, St James's Hospital, Dublin, Ireland
| | - Rose Anne Kenny
- Department of Medical Gerontology, TCIN, St James's Hospital, Dublin, Ireland
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Tsang JP, Mohan S. Benefits of monitoring patients with mobile cardiac telemetry (MCT) compared with the Event or Holter monitors. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2013; 7:1-5. [PMID: 24353449 PMCID: PMC3862588 DOI: 10.2147/mder.s54038] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION This research is meant to establish if a patient monitored with mobile cardiac telemetry (MCT) sees different outcomes regarding diagnostic yield of arrhythmia, therapeutic management through the use of antiarrhythmic drugs, and cardiovascular costs incurred in the hospital setting when compared with more traditional monitoring devices, such as the Holter or the Event monitor. MATERIALS AND METHODS We conducted a retrospective analysis spanning 57 months of claims data from January 2007 to September 2011 pertaining to 200,000+ patients, of whom 14,000 used MCT only, 54,000 an Event monitor only, and 163,000 a Holter monitor only. Those claims came from the Truven database, an employer database that counts 2.8 million cardiovascular patients from an insured population of about 10 million members. We employed a pair-wise pre/post test-control methodology, and ensured that control patients were similar to test patients along the following dimensions: age, geographic location, type of cardiovascular diagnosis both in the inpatient and outpatient settings, and the cardiovascular drug class the patient uses. RESULTS First, the diagnostic yield of patients monitored with MCT is 61%, that is significantly higher than that of patients that use the Event monitor (23%) or the Holter monitor (24%). Second, patients naive to antiarrhythmic drugs initiate drug therapy after monitoring at the following rates: 61% for patients that use MCT compared with 39% for patients that use the Event and 43% for patients that use the Holter. Third, there are very significant inpatient cardiovascular savings (in the tens of thousands of dollars) for patients that undergo ablation, coronary artery bypass graft (CABG) and valve septa. Savings are more modest but nonetheless significant when it comes to the heart/pericardium procedure. CONCLUSION Given the superior outcome of MCT regarding both patient care and hospital savings, hospitals only stand to gain by enforcing protocols that favor the MCT system over the Event or the Holter monitor.
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Locati ET, Vecchi AM, Vargiu S, Cattafi G, Lunati M. Role of extended external loop recorders for the diagnosis of unexplained syncope, pre-syncope, and sustained palpitations. Europace 2013; 16:914-22. [PMID: 24158255 DOI: 10.1093/europace/eut337] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS To assess the diagnostic yield of new external loop recorders (ELRs) in patients with history of syncope, pre-syncope, and sustained palpitations. METHODS AND RESULTS Since 2005, we have established a registry including patients who consecutively received ELR monitoring for unexplained syncope or pre-syncope/palpitations. The registry included 307 patients (61% females, age 58 ± 19 years, range 8-94 years) monitored by high-capacity memory ELR of two subsequent generations: SpiderFlash-A(®) (SFA(®), Sorin CRM), storing two-lead electrocardiogram (ECG) patient-activated recordings by loop-recording technique (191 patients, 54 patients with syncope, years 2005-09), and SpiderFlash-T(®) (SFT(®)), adding auto-trigger detection for pauses, bradycardia, and supraventricular/ventricular arrhythmias (116 patients, 38 patients with syncope, years 2009-12). All the patients previously underwent routine workup for syncope or palpitation, including one or more 24 h Holter, not conclusive for diagnosis. Mean monitoring duration was 24.1 ± 8.9 days. Among 215 patients with palpitations, a conclusive diagnosis was obtained in 184 patients (86% diagnostic yield for palpitation). Among 92 patients with syncope, a conclusive diagnosis was obtained in 16 patients (17% clinical diagnostic yield for syncope), with recording during syncope of significant arrhythmias in 9 patients, and sinus rhythm in 7 patients. Furthermore, asymptomatic arrhythmias were de novo detected in 12 patients (13%), mainly by auto-trigger detection, suggesting an arrhythmic origin of the syncope. CONCLUSIONS The diagnostic yield of ELR in patients with syncope, pre-syncope, or palpitation of unknown origin after routine workup was similar to implantable loop recorder (ILR) within the same timeframe, therefore, ELR could be considered for patients candidate for long-term ECG monitoring, stepwise before ILR.
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Affiliation(s)
- Emanuela T Locati
- Department of Cardiovascular, Cardiology Unit 3 - Electrophysiology, Niguarda Hospital, Milan, Italy
| | - Anna Maria Vecchi
- Department of Cardiovascular, Cardiology Unit 3 - Electrophysiology, Niguarda Hospital, Milan, Italy
| | - Sara Vargiu
- Department of Cardiovascular, Cardiology Unit 3 - Electrophysiology, Niguarda Hospital, Milan, Italy
| | - Giuseppe Cattafi
- Department of Cardiovascular, Cardiology Unit 3 - Electrophysiology, Niguarda Hospital, Milan, Italy
| | - Maurizio Lunati
- Department of Cardiovascular, Cardiology Unit 3 - Electrophysiology, Niguarda Hospital, Milan, Italy
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Abstract
Electrocardiographic (ECG) monitoring is a well-established procedure in the work-up of patients with syncope or for diagnosing arrhythmias. The investigation of syncope remains, however, challenging and physicians have an increasing armamentarium of diagnostic tools available and with advances in technology the role of these tools has to be continuously evaluated. The gold standard for the diagnosis of syncope is a symptom-ECG correlation, and while many studies have investigated the use and indications of both short-term and long-term monitoring; there is still some uncertainty in their clinical utility and practical approach. The use of ECG monitoring and other diagnostic tools is often subject to a "shot-gun approach" rather than a strict guideline algorithm. A systematic approach and selection of ECG monitoring tools helps permit an effective usage of the limited health care resources available for the management of unexplained syncope. In this review we aim to focus and clarify the role of short-term (Holter and external loop recorders) and long-term (implantable loop recorders) ECG monitoring in the diagnosis and management of patients with unexplained syncope.
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Affiliation(s)
- Martin H Ruwald
- Cardiology Division, Heart Research Follow-up Program, University of Rochester Medical Center, Rochester, NY, USA.
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Sparkes J, Valaitis R, McKibbon A. A usability study of patients setting up a cardiac event loop recorder and BlackBerry gateway for remote monitoring at home. Telemed J E Health 2012; 18:484-90. [PMID: 22676379 DOI: 10.1089/tmj.2011.0230] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This article reports on a usability study of remote noninvasive cardiac testing in homes. We studied the Vitaphone 3100BT (Bluetooth®) event loop recorder (Vitaphone GmbH, Mannheim, Germany) and paired BlackBerry® Curve™ 8520 smartphone (Research In Motion, Ltd., Waterloo, ON, Canada). This application requires independent device set-up by patients in their own homes following receipt by mail out of the kit (instructions plus the event loop recorder and smartphone). The case studies of five participants, each with varying experience with technology, were documented as they interacted with the devices. Participants were videotaped following written instructions as they performed a "think aloud" procedure while completing 20 device set-up tasks. Interviews provided insight into how the independent device set-up and processes could be improved. This study concluded that gender, age, and familiarity with technology seemed to influence the participants' abilities to successfully set up these devices and that sending the kit by mail appeared to be an acceptable strategy to provide remote noninvasive cardiac diagnostic services. This study provides a foundation for future research assessing usability of mobile healthcare technology.
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Affiliation(s)
- Jane Sparkes
- eHealth, McMaster University, Hamilton, Ontario, Canada.
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27
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Strotmann C, Rüb N, Wolpert C. [Significance of diagnostic methods in the work-up of syncope]. Herzschrittmacherther Elektrophysiol 2011; 22:72-82. [PMID: 21562861 DOI: 10.1007/s00399-011-0129-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
After the initial evaluation including detailed history, physical examination, electrocardiogram, and orthostatic blood pressure measurements, risk stratification should follow, if the cause of syncope is still unclear in order to define the acuteness and extensiveness of the further diagnostic evaluation. The documentation of arrhythmia during syncope is the gold standard for diagnosis of arrhythmic syncope. The implantable loop recorder should be integrated early in the diagnostic work-up. In patients >40 years with otherwise unexplained syncope, carotid sinus massage is recommended. In suspected reflex-mediated syncope, the tilt test is able to confirm the diagnosis and gives information about the underlying pathomechanisms, while electrophysiological studies have still a proven indication in patients with previous myocardial infarction and preserved left ventricular function. The adenosine triphophate test has no clinical relevance in the diagnostics of syncope. Echocardiography plays an important role in the risk stratification by diagnosing structural cardiac disease. In patients experiencing syncope associated with exertion, exercise stress testing is indicated. Finally, a coronary angiogram should be performed, if ischemia triggered syncope is suspected. A routinely performed neurological evaluation is not recommended.
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Affiliation(s)
- C Strotmann
- Medizinische Klinik II, Klinikum Ludwigsburg, Deutschland.
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28
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Hickey KT, Reiffel J, Sciacca RR, Whang W, Biviano A, Baumeister M, Castillo C, Talathothi J, Garan H. The Utility of Ambulatory Electrocardiographic Monitoring for Detecting Silent Arrhythmias and Clarifying Symptom Mechanism in an Urban Elderly Population with Heart Failure and Hypertension: Clinical Implications. J Atr Fibrillation 2010; 3:193. [PMID: 28496654 PMCID: PMC2928076 DOI: 10.4022/jafib.193] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2009] [Revised: 04/19/2010] [Accepted: 05/14/2010] [Indexed: 11/10/2022]
Abstract
Background: Atrial and ventriclar tachyarrhythmias, as well as bradyarrhythmias, in the elderly with heart failure (HF) and/or hypertension (HTN) have been well documented. However, the frequency of these arrhythmias, whether silent or symptomatic, and their association with subsequent cardiac events has not been well defi ned in patients 65 years or older with HF and other cardiovascular risk factors. Objective: To assess the value of 2 weeks of remote, transtelephonic cardiac monitoring for detecting arrhythmias in an elderly, urban population living with HF. Methods: Fi" y-four patients with a history of systolic HF and/or HTN were consented and enrolled. All wore an auto triggered cardiac loop monitor for 2 weeks that captures EKG data and both silent and symptomatic arrhythmias were recorded. Results: Mean age was 73 ± 6 years with 59% of subjects were females, 74% Hispanic, 22% black, and 4% white/other. All patients had HF and 94% had HTN. From the cardiac monitoring, 72% demonstrated ectopic atrial and ventricular activity, and 1 paroxysmal episode of atrial fi brillation was documented. In addition, 3 subjects had signifi cant non-sustained ventricular tachycardia, and 4 individuals had severe bradycardia recorded on cardiac monitoring. These 7 individuals underwent placement of an implantable cardioverter defi brillator (ICD) or pacemaker based on the documented arrhythmias which may have otherwise gone undetected. Conclusions: A substantial proportion of patients exhibited cardiac arrhythmias. Future morbidity was prevented because of the detection of arrhythmias on monitoring that led to specifi c therapies such as pacemaker or ICD implantation which otherwise may not have been implemented.
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Affiliation(s)
| | - James Reiffel
- Professor of Clinical Medicine, College of Physicians & Surgeons, Columbia University, New York, NY
| | - Robert R Sciacca
- Statistician, College of Physicians & Surgeons, Columbia University, New York, NY
| | - William Whang
- Assistant Professor of Clinical Medicine, College of Physicians & Surgeons, Columbia University, New York, NY
| | - Angelo Biviano
- Esther Aboodi Asst Professor of Clinical Medicine, College of Physicians & Surgeons, Columbia University, New York, NY
| | - Maurita Baumeister
- Acute Care Nurse Practitioner, College of Physicians & Surgeons, Columbia University, New York, NY
| | - Carmen Castillo
- Research Coordinator, College of Physicians & Surgeons, Columbia University, New York, NY
| | - Jyothi Talathothi
- Research Assistant, College of Physicians & Surgeons, Columbia University, New York, NY
| | - Hasan Garan
- Professor of Medicine, College of Physicians & Surgeons, Columbia University, New York, NY
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Kadish AH, Reiffel JA, Clauser J, Prater S, Menard M, Kopelman H. Frequency of serious arrhythmias detected with ambulatory cardiac telemetry. Am J Cardiol 2010; 105:1313-6. [PMID: 20403485 DOI: 10.1016/j.amjcard.2009.12.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2009] [Revised: 12/14/2009] [Accepted: 12/14/2009] [Indexed: 10/19/2022]
Abstract
Ambulatory cardiac telemetry has been shown to be effective in establishing diagnoses in patients with suspected arrhythmias. A critical component of ambulatory telemetry is the immediate transfer of rhythm information to a central monitoring station without requiring patient action. The frequency with which potentially life-threatening events are detected using ambulatory telemetry has not previously been evaluated in a large patient population. All patients (n = 26,438) who underwent monitoring from April to December 2008 at a single service provider formed the patient population of this study. Arrhythmic events noted in these patients were defined as those requiring physician notification and those that represented potentially life-threatening arrhythmias. Of the 26,438 patients included in the study, 5,459 (21%) had arrhythmic events meeting physician notification criteria during a mean monitoring period of 21 days. Of these, 262 patients (1%) had arrhythmic events that could potentially be classified as emergent. These included 120 patients with wide complex tachycardia > or = 15 beats at > or = 120 beats/min, 100 patients with pauses > or = 6 seconds, and 42 patients with sustained heart rates <30 beats/min. An additional 704 patients (3%) had narrow complex tachycardia > or = 180 beats/min at rest. In conclusion, approximately 1% of patients who underwent ambulatory telemetry for routine clinical indications experienced life-threatening arrhythmic events over a 3-week monitoring period. Ambulatory cardiac telemetry could be potentially lifesaving in this group of patients.
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Höhler H. [A patient with syncope]. MEDIZINISCHE KLINIK (MUNICH, GERMANY : 1983) 2009; 104:780-798. [PMID: 19856152 DOI: 10.1007/s00063-009-1164-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- Helene Höhler
- Ehemals Kliniken St. Antonius gGmbH, Wuppertal, Germany.
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32
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Moya A, Sutton R, Ammirati F, Blanc JJ, Brignole M, Dahm JB, Deharo JC, Gajek J, Gjesdal K, Krahn A, Massin M, Pepi M, Pezawas T, Ruiz Granell R, Sarasin F, Ungar A, van Dijk JG, Walma EP, Wieling W. Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 2009; 30:2631-71. [PMID: 19713422 DOI: 10.1093/eurheartj/ehp298] [Citation(s) in RCA: 1202] [Impact Index Per Article: 80.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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GULA LORNEJ, KLEIN GEORGEJ, ZURAWSKA URSZULA, MASSEL DAVID, YEE RAYMOND, SKANES ALLANC, KRAHN ANDREWD. Does Familiarity with Technology Predict Successful Use of an External Loop Recorder? The Loop Recorder Technology Cognition Study (LOCO). PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2009; 32:466-72. [DOI: 10.1111/j.1540-8159.2009.02306.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Rothman SA, Laughlin JC, Seltzer J, Walia JS, Baman RI, Siouffi SY, Sangrigoli RM, Kowey PR. The diagnosis of cardiac arrhythmias: a prospective multi-center randomized study comparing mobile cardiac outpatient telemetry versus standard loop event monitoring. J Cardiovasc Electrophysiol 2007; 18:241-7. [PMID: 17318994 DOI: 10.1111/j.1540-8167.2006.00729.x] [Citation(s) in RCA: 153] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Ambulatory electrocardiographic monitoring systems are frequently used in the outpatient evaluation of symptoms suggestive of a cardiac arrhythmia; however, they have a low yield in the identification of clinically significant but infrequent, brief, and/or intermittently symptomatic arrhythmias. The purpose of this study was to compare the relative value of a mobile cardiac outpatient telemetry system (MCOT) with a patient-activated external looping event monitor (LOOP) for symptoms thought to be due to an arrhythmia. METHODS AND RESULTS The study was a 17-center prospective clinical trial with patients randomized to either LOOP or MCOT for up to 30 days. Subjects with symptoms of syncope, presyncope, or severe palpitations who had a nondiagnostic 24-hour Holter monitor were randomized. The primary endpoint was the confirmation or exclusion of a probable arrhythmic cause of their symptoms. A total of 266 patients who completed the monitoring period were analyzed. A diagnosis was made in 88% of MCOT subjects compared with 75% of LOOP subjects (P = 0.008). In a subgroup of patients presenting with syncope or presyncope, a diagnosis was made in 89% of MCOT subjects versus 69% of LOOP subjects (P = 0.008). MCOT was superior in confirming the diagnosis of clinical significant arrhythmias, detecting such events in 55 of 134 patients (41%) compared with 19 of 132 patients (15%) in the LOOP group (P < 0.001). CONCLUSIONS MCOT provided a significantly higher yield than standard cardiac loop recorders in patients with symptoms suggestive of a significant cardiac arrhythmia.
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Affiliation(s)
- Steven A Rothman
- Lankenau Hospital and Institute for Medical Research/Main Line Health Heart Center, Wynnewood, PA, USA.
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35
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Current World Literature. Curr Opin Cardiol 2007; 22:49-53. [PMID: 17143045 DOI: 10.1097/hco.0b013e3280126b20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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36
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Hoch JS, Rockx MA, Krahn AD. Using the net benefit regression framework to construct cost-effectiveness acceptability curves: an example using data from a trial of external loop recorders versus Holter monitoring for ambulatory monitoring of "community acquired" syncope. BMC Health Serv Res 2006; 6:68. [PMID: 16756680 PMCID: PMC1543623 DOI: 10.1186/1472-6963-6-68] [Citation(s) in RCA: 112] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2006] [Accepted: 06/06/2006] [Indexed: 11/10/2022] Open
Abstract
Background Cost-effectiveness acceptability curves (CEACs) describe the probability that a new treatment or intervention is cost-effective. The net benefit regression framework (NBRF) allows cost-effectiveness analysis to be done in a simple regression framework. The objective of the paper is to illustrate how net benefit regression can be used to construct a CEAC. Methods One hundred patients referred for ambulatory monitoring with syncope or presyncope were randomized to a one-month external loop recorder (n = 49) or 48-hour Holter monitor (n = 51). The primary endpoint was symptom-rhythm correlation during monitoring. Direct costs were calculated based on the 2003 Ontario Health Insurance Plan (OHIP) fee schedule combined with hospital case costing of labour, materials, service and overhead costs for diagnostic testing and related equipment. Results In the loop recorder group, 63.27% of patients (31/49) had symptom recurrence and successful activation, compared to 23.53% in the Holter group (12/51). The cost in US dollars for loop recording was $648.50 and $212.92 for Holter monitoring. The incremental cost-effectiveness ratio (ICER) of the loop recorder was $1,096 per extra successful diagnosis. The probability that the loop recorder was cost-effective compared to the Holter monitor was estimated using net benefit regression and plotted on a CEAC. In a sensitivity analysis, bootstrapping was used to examine the effect of distributional assumptions. Conclusion The NBRF is straightforward to use and interpret. The resulting uncertainty surrounding the regression coefficient relates to the CEAC. When the link from the regression's p-value to the probability of cost-effectiveness is tentative, bootstrapping may be used.
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Affiliation(s)
- Jeffrey S Hoch
- Centre for Research on Inner City Health, St. Michael's Hospital, Toronto, Canada
- Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | | | - Andrew D Krahn
- Department of Medicine, University of Western Ontario, London Ontario, Canada
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