Sex-Related Differences in Patients With Unexplained Syncope and Bundle Branch Block: Lower Risk of AV Block and Lesser Need for Cardiac Pacing in Women

Objective

To analyze if there are sex-related differences in patients with unexplained syncope and bundle branch block (BBB).

Background

Despite increasing awareness that sex is a major determinant of the incidence, etiology, and the outcomes of different arrhythmias, no studies have examined differences in presentation and outcomes between men and women with syncope and BBB.

Methods

Cohort study of consecutive patients with unexplained syncope and BBB was included from January 2010 to January 2021 with a median follow-up time of 3.4 years [interquartile range (IQR) 1.7–6.0 years]. They were evaluated by a stepwise workup protocol based on electrophysiological study (EPS) and long-term follow-up with an implantable cardiac monitor (ICM).

Results

Of the 443 patients included in the study, 165 (37.2%) were women. Compared with men, women had less diabetes (25.5 vs. 39.9%, p = 0.002) and less history of ischemic heart disease (IHD; 13.3 vs. 25.9%, p = 0.002). Left bundle branch block (LBBB) was more frequent in women (55.2 vs. 27.7%, p < 0.001) while right bundle branch block (RBBB) was more frequent in men (41.5 vs. 67.7%, p < 0.001). His to ventricle (HV) interval in the EPS was shorter in women (58 ms [IQR 52–71] vs. 60 ms [IQR 52–73], p = 0.035) and less women had an HV interval longer than 70 ms (28.5 vs. 38.1%, p = 0.039), however, EPS and ICM offered a similar diagnostic yield in both sexes (40.6 vs. 48.9% and 48.4% vs. 51.1%, respectively). Women had a lower risk of developing atrioventricular block (AVB) (adjusted odds ratio [OR] 0.44–95% CI 0.26–0.74, p = 0.002) and of requiring permanent pacemaker implantation (adjusted hazard ratio [HR] 0.72–95% CI: 0.52–0.99, p = 0.046). The mortality rate was lower in women (4.5 per 100 person-years [95% CI 3.1–6.4 per 100 person-years] vs. 7.3 per 100 person-years [95% CI 5.9–9.1 per 100 person-years]).

Conclusions

Compared to men, women with unexplained syncope and BBB have a lower risk of AVB and of requiring cardiac pacing. A stepwise diagnostic approach has a similar diagnostic yield in both sexes, and it seems appropriate to guide the treatment and avoid unnecessary pacemaker implantation, especially in women.

Decreasing Pediatric PACU Noise Level and Alarm Fatigue: A Quality Improvement Initiative to Improve Safety and Satisfaction

PURPOSE

To describe how a pediatric postanesthesia care unit used a two-phased approach of bundled interventions to reduce unit noise levels and improve staff perceptions of their work environment.

DESIGN

Pre/post design.

METHODS

Postanesthesia care unit sound levels and monitor alarms were measured at baseline and after implementing both project phases. Nursing staff members were surveyed at baseline and after completion of the project.

FINDINGS

Monitor alarms were reduced by more than 50% after Phase I. However, noise measurement data did not reflect a difference in sound levels between baseline and intervention phases. Despite this, staff perceived the unit as much quieter.

CONCLUSIONS

The reduction in monitor alarms did not cause an appreciable change in sound levels as measured by noise dosimeters in either intervention phase. Despite these findings, nurses perceived a quieter and more pleasant workplace. These impressions might have resulted from subjective expectations versus actual volume levels, or they might owe to the reduction in incidence of alarms themselves, which they had viewed as nuisance sounds.

Ultra-early continuous cardiac monitoring improves atrial fibrillation detection and prognosis of patients with cryptogenic stroke

BACKGROUND AND PURPOSE

Subclinical atrial fibrillation (AF) is known to underlie a number of cases of cryptogenic stroke (CrS). However, there is need to define the most effective strategy for AF detection. The diagnostic usefulness was analysed of a strategy based on ultra-early continuous monitoring in patients with CrS in terms of AF detection, oral anticoagulation treatment and stroke recurrence, in comparison to a standard outpatient strategy.

METHODS

Patients with ischaemic stroke of undetermined origin and confirmed to be cryptogenic after extensive work-up were searched for AF with (i) a conventional strategy (historical cohort, n = 101) with serial electrocardiograms and 24-h Holter monitoring or (ii) an ultra-early monitoring strategy with insertable cardiac monitor (ICM) implanted before discharge (prospective cohort, n = 90). AF episodes lasting >1 min, anticoagulant treatment and stroke recurrence were recorded.

RESULTS

During admission, AF was similarly detected in both cohorts (24% of patients). After discharge (mean follow-up 30 ± 10 months), AF detection rates were 17/80 (21.3%) and 38/65 (58.5%) for patients in the conventional versus the ultra-early ICM group (P < 0.001). Up to 41% of AF cases in the ICM cohort were detected within the first month. Oral anticoagulation was initiated in 37.6% versus 65.5% (P < 0.001) and stroke recurrence was recorded in 10.9% versus 3.3% (P 0.04) in the conventional versus the ICM cohort.

CONCLUSIONS

Pre-discharge ICM implant allows detection of AF during follow-up in up to 58% of selected patients with CrS. Compared to a conventional strategy, ultra-early ICM implant results in higher anticoagulation rates and a decrease in stroke recurrence.

Cardiac monitoring and the use of a systematic approach in interpreting electrocardiogram rhythms

Attaching a patient to a cardiac monitor and obtaining a clear electrocardiogram (ECG) trace may now be considered basic nursing skills. In line with the UK professional standards and code of conduct, healthcare practitioners are required to practise effectively and preserve patients' safety. Therefore, healthcare practitioners undertaking cardiac monitoring are required to have a basic understanding of normal sinus rhythms and some of the common types of cardiac arrhythmia. This will enable prompt recognition of early warning signs of potential and actual clinical conditions, and the timely initiation of treatment. This article reviews the clinical skill of attaching a patient to a three and five-lead cardiac monitor, discussing appropriate skin preparation and lead selection. It also outlines the identification of several of the common types of cardiac arrhythmia on an ECG rhythm strip using a systematic approach.

Reveal LINQ Versus Reveal XT Implantable Loop Recorders: Intra- and Post-Procedural Comparison

OBJECTIVES

To compare the procedure, recovery, hospitalization times, and costs along with patient/parent satisfaction after newer-generation cardiac implantable loop recorder (Reveal LINQ; Medtronic Inc, Minneapolis, Minnesota) and previous-generation implantable loop recorder (Reveal XT; Medtronic Inc).

STUDY DESIGN

A prospective study of patients undergoing LINQ implantations between April 2014 and October 2015 was performed. Retrospective chart review of patients undergoing XT implantations was performed for comparison.

RESULTS

Thirty-one patients received LINQ and 15 patients received XT. Indications included syncope/palpitations (28/46, 61%), history of arrhythmias (9/46, 20%), arrhythmia burden in congenital heart disease (5/46, 10%), and monitoring in channelopathies (4/46, 9%). The LINQ group underwent more conscious sedation procedures than the XT group (8/31 vs 0/15, P = .04) with shorter procedural time (9 vs 34 minutes, P <.001), room occupation time (38 vs 81 minutes, P <.001), recovery time (21 vs 67 minutes, P <.001), and total hospital time (214 vs 264 minutes, P = .046). The LINQ group also had shorter return to activity time (2 vs 5 days, P = 1). Three device erosions in the LINQ group required reintervention. The LINQ group had fewer body image issues than the XT group (1/26 vs 5/14, P = .01) with both groups scoring 5/5 overall patient/parent satisfaction score at follow-up. Both groups had comparable total direct hospital costs (US $5905 vs $5438, P = .8).

CONCLUSIONS

LINQ offers better procedural and recovery time compared with XT. LINQ implantations under conscious sedation reduce total hospitalization time.

Prolonged Cardiac Monitoring to Detect Atrial Fibrillation after Cryptogenic Stroke or Transient Ischemic Attack: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

The cause of ischemic stroke or transient ischemic attack (TIA) remains unclear after initial cardiac monitoring in approximately one-third of patients. Randomized controlled trials (RCTs) showed that the prolonged cardiac monitoring of patients with cryptogenic stroke or TIA increased detection of atrial fibrillation (AF). We aimed to perform a meta-analysis of all RCTs that evaluated the prolonged monitoring ≥7 days in patients with cryptogenic stroke or TIA.

METHODS

We searched PubMed, EMBASE, Cochrane CENTRAL, and relevant references for RCTs without language restriction (inception through December 2014) and performed meta-analysis using random effects model. Detection of AF, use of anticoagulation at follow-up, recurrent stroke or TIA, and mortality were major outcomes.

RESULTS

Four RCTs with 1149 total patients were included in the meta-analysis. Prolonged cardiac monitoring ≥7 days compared to shorter cardiac monitoring of ≤48 hours duration increased the detection of AF (≥30 seconds duration) in patients after cryptogenic stroke or TIA (13.8% vs. 2.5%; odds ratio [OR], 6.4; 95% confidence interval [CI], 3.50-11.73; P < 0.00001; I(2) , 0%]. It also increased the odds of AF detection of any duration (22.6% vs. 5.2%; 5.68[3.3-9.77]; P < 0.00001; I(2) , 0%). The patients who underwent prolonged monitoring were more likely to be on anticoagulation at follow-up (2.21[1.52-3.21]; P < 0.0001; I(2) , 0%). No differences in recurrent stroke or TIA (0.78[0.40-1.55]; P = 0.48; I(2) , 0%) and mortality (1.33[0.29-6.00]; P = 0.71; I(2) , 0%] were observed between two strategies.

CONCLUSION

Prolonged cardiac monitoring improves detection of atrial fibrillation and anti-coagulation use after cryptogenic stroke or TIA and therefore should be considered instead of shorter duration of cardiac monitoring.

A team-based approach to reducing cardiac monitor alarms

BACKGROUND AND OBJECTIVES

Excessive cardiac monitor alarms lead to desensitization and alarm fatigue. We created and implemented a standardized cardiac monitor care process (CMCP) on a 24-bed pediatric bone marrow transplant unit. The aim of this project was to decrease monitor alarms through the use of team-based standardized care and processes.

METHODS

Using small tests of change, we developed and implemented a standardized CMCP that included: (1) a process for initial ordering of monitor parameters based on age-appropriate standards; (2) pain-free daily replacement of electrodes; (3) daily individualized assessment of cardiac monitor parameters; and (4) a reliable method for appropriate discontinuation of monitor. The Model for Improvement was used to design, test, and implement changes. The changes that were implemented after testing and adaptation were: family/patient engagement in the CMCP; creation of a monitor care log to address parameters, lead changes, and discontinuation; development of a pain-free process for electrode removal; and customized monitor delay and customized threshold parameters.

RESULTS

From January to November 2013, percent compliance with each of the 4 components of the CMCP increased. Overall compliance with the CMCP increased from a median of 38% to 95%. During this time, the median number of alarms per patient-day decreased from 180 to 40.

CONCLUSIONS

Implementation of the standardized CMCP resulted in a significant decrease in cardiac monitor alarms per patient day. We recommend a team-based approach to monitor care, including individualized assessment of monitor parameters, daily lead change, and proper discontinuation of the monitors.