Prevalence and prognostic implications of ST-segment deviations from ambulatory Holter monitoring after ST-segment elevation myocardial infarction treated with either fibrinolysis or primary percutaneous coronary intervention (a Danish Trial in Acute Myocardial Infarction-2 Substudy)

Wireless continuous single-lead ST-segment monitoring to detect new-onset myocardial injury at the general ward-An exploratory subanalysis

Patients admitted for acute medical conditions and major noncardiac surgery are at risk of myocardial injury. This is frequently asymptomatic, especially in the context of concomitant pain and analgesics, and detection thus relies on cardiac biomarkers. Continuous single-lead ST-segment monitoring from wireless electrocardiogram (ECG) may enable more timely intervention, but criteria for alerts need to be defined to reduce false alerts. This study aimed to determine optimal ST-deviation thresholds from wireless single-lead ECG for detection of myocardial injury following major abdominal cancer surgery and during acute exacerbation of chronic obstructive pulmonary disease. Patients were monitored with a wireless single-lead ECG patch for up to 4 days and had daily troponin measurements. Single-lead ST-segment deviations of <0.255 mV and/or >0.245 mV (based on previous study comparison with 0.1 mV 12-lead ECG and variation in single-lead ECG) were analyzed for relation to myocardial injury defined as hsTnT elevation of 20-64 ng/L with an absolute change of ≥5 ng/L, or a hsTnT level ≥ 65 ng/L. In total, 528 patients were included for analysis, of which 15.5% had myocardial injury. For corrected ST-thresholds lasting ≥10 and ≥ 20 min, we found specificities of 91% and 94% and sensitivities of 17% and 13% with odds ratios of 2.0 (95% CI: 1.1; 3.9) and 2.4 (95% CI: 1.1; 5.1) for myocardial injury. In conclusion, wireless single-lead ECG monitoring with corrected ST thresholds detected patients developing myocardial injury with specificities >90% and sensitivities <20%, suggesting increased focus on sensitivity improvement.

Ambulatory External Electrocardiography Monitoring: Holter, Extended Holter, Mobile Cardiac Telemetry Monitoring

Ambulatory external electrocardiography (AECG) monitoring is effective as an evidence-based diagnostic tool when suspicion for cardiac arrhythmia is high. Multiple modalities of AECG monitoring exist, with unique advantages and limitations that predict effectiveness in a variety of clinical settings. Knowledge of these characteristics allows appropriate use of AECG, maximizing patient adherence, diagnostic yield, and cost-effectiveness. In addition, new technology has allowed the development of a modern generation of devices that offer increased efficacy and functionality compared with Holter monitors.

Patient management and care after primary percutaneous coronary intervention: reinforcing a continuum of care after primary percutaneous coronary intervention

Primary percutaneous coronary interventions (PPCIs) improve outcomes in patients with ST-elevation myocardial infarction and facilitate the hospitalization course. In most cases, the patient can be discharged within 3 to 5 days after the PPCI, provided that careful triage is applied. Bleeding--often associated with excessive antithrombotic drug dosing--is a major concern. Transfusion has been documented to be a strong and independent predictor of mortality; for this reason, recent guidelines recommend that bleeding be managed using a conservative strategy that limits transfusions and the discontinuation of antithrombotic drugs to major bleeding events and only when local hemostatic interventions are not effective. Primary percutaneous coronary intervention is often performed without previous assessment of renal function, and the amount of contrast medium should be kept to a minimum, because contrast-induced nephropathy occurs frequently and is associated with higher early and late mortality. The risk of major arrhythmias should also be addressed correctly. The prognostic implication of ventricular arrhythmias is extremely dependent on the timing of presentation: midterm mortality is much higher among subjects experiencing a new arrhythmic event after PPCI compared with patients with existing arrhythmias at PPCI or those without arrhythmias. The Zwolle risk score is useful for identifying subjects who may be safely discharged early. Secondary prevention starts at the end of PPCI. Hospital discharge and the planning of follow-up visits are critical for therapeutic recommendations. After an ST-elevation myocardial infarction, patients are at increased risk of recurrences, even when the PPCI is timely; a rehabilitation program and all measures that increase adherence to medications should be implemented, starting at discharge.