ECG monitoring in syncope

Drop attacks: a practical guide

'Drop attacks' encompass both falls and transient loss of consciousness, but the term is not clearly defined. We offer our definition and explore the differential diagnoses. The most common causes are cardiovascular. We discuss clinical and electrographic criteria that suggest underlying arrhythmia or other serious cardiac disorders that require further investigation, and the potential diagnoses that may underlie these 'worrying syncopes'. Vestibular dysfunction also commonly causes collapses, sometimes without typical vertigo. These two common conditions may coexist especially in the elderly. Falls in elderly people often require assessment through a lens of frailty and multifactorial risk factors, rather than seeking a unitary diagnosis. Some drop attacks may be due to longstanding epilepsy and we discuss how to approach these cases. Functional neurological disorder is a common cause in younger people, for which there may also be clinical clues. We review the rarer causes of collapse that may be described as drop attacks, including cataplexy and hydrocephalic attacks.

Review of the Requirements for a Wearable, Low-Cost External Cardiac Loop Recorder with WBAN in Resource-Constrained Settings

Cardiovascular disease (CVD) has become the most serious health concern in India and globally. The cost of treatment for CVD is very high and in a country like India, where most of the population belongs to rural area, affording treatment is not possible. Diagnosis and treatment are further hampered due to shortage of medical expertise as well as the unavailability of the wearable device. This makes the condition worst in rural areas. As a result of delay in diagnosis, patients do not receive appropriate treatment on time, thus risking lives. Hence, early detection of physiological abnormalities in patients is the best solution to avoid sudden death. In India, the majority of ECG diagnosis is done using a standard ECG machine or Holter monitor, which are not adequate to detect transient or infrequent arrhythmia as the window of detection is 30 s or up to 48 h. So, for arrhythmia diagnosis or syncope and palpitation, external cardiac loop recorder (ECLR) is preferred. ECLR is a monitoring device which records cardiac activities and detects infrequent arrhythmias with syncope and palpitation of a subject for longer period continuously. Due to recent improvements in technology, such as flexible electronics and wireless body area network (WBAN), wearable medical devices are progressively assisting people to monitor their health status while doing their day-to-day activities and furnishing more information to clinicians for early diagnosis and treatment. Flexible electronics allows to develop an electronic circuit on a flexible substrate hence making the device bendable and stretchable. WBAN is a wireless communication between different nodes like sensors and processors that are located at different points on the body. By incorporating technologies such as miniaturization of electronics, making flexible electronics and WBAN concept in ECLR, the device can be made wearable so as to not interfere with the patient's day-to-day activities. This review paper discusses the limitations of existing standard ECG machines as well as how to make the existing ECLR devices more robust, more advanced, more comfortable and also affordable.

El Kassabi H, Ismail H, Nujum Navaz A. ECG Monitoring Systems: Review, Architecture, Processes, and Key Challenges

Health monitoring and its related technologies is an attractive research area. The electrocardiogram (ECG) has always been a popular measurement scheme to assess and diagnose cardiovascular diseases (CVDs). The number of ECG monitoring systems in the literature is expanding exponentially. Hence, it is very hard for researchers and healthcare experts to choose, compare, and evaluate systems that serve their needs and fulfill the monitoring requirements. This accentuates the need for a verified reference guiding the design, classification, and analysis of ECG monitoring systems, serving both researchers and professionals in the field. In this paper, we propose a comprehensive, expert-verified taxonomy of ECG monitoring systems and conduct an extensive, systematic review of the literature. This provides evidence-based support for critically understanding ECG monitoring systems' components, contexts, features, and challenges. Hence, a generic architectural model for ECG monitoring systems is proposed, an extensive analysis of ECG monitoring systems' value chain is conducted, and a thorough review of the relevant literature, classified against the experts' taxonomy, is presented, highlighting challenges and current trends. Finally, we identify key challenges and emphasize the importance of smart monitoring systems that leverage new technologies, including deep learning, artificial intelligence (AI), Big Data and Internet of Things (IoT), to provide efficient, cost-aware, and fully connected monitoring systems.

Syncope in the Young Adult and in the Athlete: Causes and Clinical Work-up to Exclude a Life-Threatening Cardiac Disease

Syncope is defined as a transient loss of consciousness due to cerebral hypoperfusion, characterized by a rapid onset, short duration, and spontaneous complete recovery. It is usually a benign event, but sometimes it may represent the initial presentation of several cardiac disorders associated with sudden cardiac death during physical activity. A careful evaluation is essential particularly in young adults and in competitive athletes in order to exclude the presence of an underlying life-threatening cardiovascular disease. The present review analyzes the main non-cardiac and cardiac causes of syncope and the contribution of the available tools for differential diagnosis. Clinical work-up of the athlete with syncope occurring in extreme environments and management in terms of sports eligibility and disqualification are also discussed.

Exploring the experiences of individuals with an insertable cardiac monitor: Making the decision for device insertion

BACKGROUND

Little is known about the decision-making process for insertable cardiac monitors (ICM) in those with suspected arrhythmias.

OBJECTIVE

The purpose of this qualitative study was to describe how individuals make a decision to insert an ICM.

METHODS

A qualitative descriptive design was used. Data were analyzed using content analysis and constant comparison. NVivo 10 was used for data grouping and patterns.

RESULTS

Participants (N = 12) ranged in age from 41to 95. Most (n = 7) had the device inserted because of syncope or atrial fibrillation (AF), and others (n = 5) for cryptogenic stroke. Three categories emerged: pre-decision, definitive decision, and deliberated decision. Event symptoms, including physical, cognitive and emotional, and trust emerged as factors in decision-making.

CONCLUSIONS

Those who perceived their experience as life-threatening, trusted the healthcare provider and assented to the ICM insertion. Conversely, those who perceived symptoms as episodic, used other strategies to resolve symptoms prior to making the decision for insertion.

Diagnostic yield of an ambulatory patch monitor in patients with unexplained syncope after initial evaluation in the emergency department: the PATCH-ED study

OBJECTIVES

Diagnosing underlying arrhythmia in ED syncope patients remains problematic. This study investigates diagnostic yield, event prevalence, patient satisfaction and compliance, and influence on resource utilisation of an ambulatory patch monitor in unexplained ED syncope patients.

METHODS

Prospective pilot study conducted in a single tertiary ED in Scotland between 17 November 2015 and 16 June 2017 with a historical unmatched comparator group. Patients 16 years or over presenting within 6 hours of unexplained syncope were fitted in the ED with an ambulatory patch ECG recorder (Zio XT monitor), which continuously records a single-lead ECG for up to 14 days. Patients with an obvious underlying cause were excluded. An unmatched historical group of 603 syncope patients with no obvious diagnosis in ED, recruited to a prior cohort study (2007-2008), were used as a comparator. Primary endpoint was symptomatic significant arrhythmia at 90-day follow-up.

RESULTS

During the prospective study period, 86 patients were recruited. 90-day diagnostic yield for symptomatic significant arrhythmia was 10.5% (95% CI 4.0 to 16.9; 9 of 86) versus 2.0% (95% CI 0.9 to 3.1; 12 of 603) in the comparator group. 24 patients (27.9%) had a significant arrhythmia (five serious); 26 patients (30.2%) had serious outcomes (major adverse cardiac event and/or death). Blinded patch report review suggested the patch would significantly reduce requirement for standard outpatient ambulatory ECG monitoring. 56 of 76 returned patches had a diagnostic finding within±45 s of a triggered/diary event (73.7% diagnostic utility; 95% CI 63.7 to 83.6); 34 of 56 (61%) for sinus rhythm or ectopic beats only.

CONCLUSIONS

Routine, early ambulatory ECG monitoring in ED patients with unexplained syncope is probably warranted. A large-scale trial comparing this approach to standard care with cost-effectiveness and safety analysis is now required.

TRIAL REGISTRATION

NCT02683174.

Use of implantable and external loop recorders in syncope with unknown causes

The gold standard for diagnosing syncope is to elucidate the symptom-electrocardiogram (ECG) correlation. The ECG recordings during syncope allow physicians to either confirm or exclude an arrhythmia as the mechanism of syncope. Many studies have investigated the use of internal loop recorder (ILR), while few studies have used external loop recorder (ELR) for patients with unexplained syncope. The aim of this review is to clarify the clinical usefulness of ILR and ELR in the diagnosis and management of patients with unexplained syncope. Many observational and four randomized control studies have shown that ILR for patients with unknown syncope is a useful tool for early diagnosis and improving diagnosis rate. ILR also provides important information on the mechanism of syncope and treatment strategy. However, there is no evidence of total mortality or quality of life improvements with ILR. The diagnostic yield of ELR in patients with syncope was similar to that with ILR within the same timeframe. Therefore, ELR could be considered for long-term ECG monitoring before a patient switches to using ILR. A systematic approach and selection of ECG monitoring tools reduces health care costs and improves the selection of patients for optimal treatment possibilities.

Cardiovascular Conditions in the Observation Unit: Beyond Chest Pain

The first emergency department observation units (EDOUs) focused on chest pain and potential acute coronary syndromes. However, most EDOUs now cover multiple other conditions that lend themselves to protocolized, aggressive diagnostic and therapeutic regimens. In this article, the authors discuss the management of 4 cardiovascular conditions that have been successfully deployed in EDOUs around the country.