common monitoring outpatient cardiac rhythm monitoring

Ambulatory Cardiac Monitoring: What’s New?

SPEAKERAngelo Biviano, MD, MPH

4:15 – 5:00pm Presenter Disclosure Information

►Angelo Biviano, MD, MPH is an advisory board member for Biosense-Webster.

The following relationships exist related to this presentation:

Off-Label/Investigational Discussion

► In accordance with pmiCME policy, faculty have been asked to disclose discussion of unlabeled or unapproved use(s) of drugs or devices during the course of their presentations.

1. Diagnose a potentially serious condition

• Ventricular tachycardia (VT)

• Asystole

• Atrial Fibrillation ‐> stroke

• Syncope/trauma due to arrhythmias

2. Diagnose treatable conditions

• Supraventricular tachycardia (SVT)

3. Reassurance

• PACs/PVCs/NSVT in the setting of a normal heart

Why Pursue Cardiac Rhythm Monitoring? Why Pursue Cardiac Rhythm Monitoring?

Palpitations

PACs or PVCs

Atrial fibrillation

SVT

VT

Loss of Consciousness

Falls

Syncope

Seizures

Stroke

Cryptogenic

1. Diagnose a potentially serious condition

• Ventricular tachycardia (VT)

• Asystole

• Atrial Fibrillation ‐> stroke

• Syncope/trauma due to arrhythmias

2. Diagnose treatable conditions

• Supraventricular tachycardia (SVT)

3. Reassurance

• PACs/PVCs/NSVT in the setting of a normal heart

• Clinical Importance‐ Assess the symptoms

• Etiologies‐ Evaluate for high‐risk features

• Initial Evaluation‐ e.g., physical, ECG, ECHO

• Further Work‐Up and Referral‐ Don’t be the only person who is worrying about the patient!

A Common Pre‐Monitoring Sequence

ECG

24-48 hour Holter monitor

2 week patch monitor4 week

wearable monitor:

Event vs. Continuous

2-3 year subcutaneous implantable

monitor

“Smart” monitors

Outpatient Cardiac Rhythm Monitoring: The Options

ECG



wearable monitor:



monitor



ECG

24-48 hour Holter

monitor


wearable monitor:



monitor



ECG:• Easy• Readily available• Noninvasive• Cheap

• Diagnose ongoing arrhythmias

• Clues to other arrhythmias• Pre‐excitation• Sinus bradycardia• Advanced AV block

Complete Heart block

Long QT + Torsades

Atrial Fibrillation

PVC/NSVT

ECG

24-48 hour Holter

monitor


wearable monitor:



monitor



24‐48 Hour Holter:• Relatively easy• Readily available (since 1960s)• Noninvasive• Relatively cheap

• Diagnose intermittent butfrequent arrhythmias or treatment course of ongoing arrhythmias

• Retrospective/not in real‐time

https://en.wikipedia.org/wiki/Holter_monitor#/media/File:HolterAFT1000.jpg

AF onset/offset

PVCs

ECG



wearable monitor:



monitor



Patch monitors:• Relatively easy• Sometimes available (insurance)• Noninvasive• Not as cheap

• Diagnose intermittent, less frequentarrhythmias

• Some retrospective/not in real‐timeand others prospective/in real‐time

• Able to track symptomatic events

AF onset/offset

PVCs

http://www.medtronicdiagnostics.com/us/cardiac-monitors/seeq-mct-system/seeq-mct-device/index.htm

ECG

24-48 hour Holter

monitor


wearable monitor:



monitor



4 week monitors(Mobile Cardiac Outpatient Telemetry‐MCOT):• Less easy• Often available (insurance)• Noninvasive• Not as cheap

• Diagnose intermittent, even lessfrequent arrhythmias or treatment progress

• Most are prospective/in real‐time

‐ Event (symptomatic) vs. continuous(automatic) options available

https://en.wikipedia.org/wiki/Holter_monitor#/media/File:HolterAFT1000.jpg

ECG

24-48 hour Holter

monitor


wearable monitor:



monitor



Implantable monitors• Require a procedure• Trained personnel• Invasive• More expensive

• Diagnose intermittent, leastfrequent arrhythmias

• Proactive/in near real‐time

‐ Automatic vs. symptomaticrecording

Medtronic.com

• 3‐year longevity• Atrial fibrillation monitoring• Wireless connectivity• MRI conditional

ECG

24-48 hour Holter

monitor


wearable monitor:



monitor



“Smart” Monitors• Noninvasive• Requires a smartphone/‐watch• Cases < $100 if you have the phone• Non‐reimbursable• Some FDA‐approved

• Diagnose intermittent, leastfrequent arrhythmias ORMonitors progress after/on treatment

• Prospective/near real‐time: results can be e‐mailed/faxed to MD

‐ Symptomatic prn recording

www.alivecor.com

Palpitations

PACs or PVCs

Atrial fibrillation

SVT

VT


Falls

Syncope

Seizures

Stroke

Cryptogenic

Palpitations and Rhythm Monitoring

• Palpitations are a symptom of another process.

• The challenge is to find the etiology!

– Cardiac ~ 40%

– Psychiatric ~ 30%

– Other ~ 10%

– ? ~ 20%

• Work‐up required prior to diagnosing with a non‐cardiac cause.

Etiology of Palpitations

Weber BE, Wishwa K. Evaluation and outcomes of patients with palpitations. Am J Med 1996;100:138.

• Most patients undergoing monitoring who are diagnosed with a cardiac cause of their palpitations are diagnosed with:

•Non‐threatening atrial or ventricular ectopy

•Sinus rhythm

Initial Evaluation of Palpitations

- Kinlay, S, Leitch, JW, Neil, A, et al. Cardiac event recorders yield more diagnoses and are more cost-effective than 48-hour Holter monitoring in patients with palpitations. A controlled clinical trial. Ann Intern Med 1996; 124:16.- Zimetbaum, PJ, Kim, KY, Josephson, ME, et al. Diagnostic yield and optimal duration of continuous-loop event monitoring for the diagnosis of palpitations. A cost-effectiveness analysis. Ann Intern Med 1998; 128:890.- Zimetbaum, P, Kim, KY, Ho, KK, et al. Utility of patient-activated cardiac event recorders in general clinical practice. Am J Cardiol 1997; 79:371.

Initial Evaluation of Palpitations

• Independent predictors of a cardiac etiology in 190 patients presenting with palpitations:

– Male gender

– Irregular heart beat

– History of cardiac disease

– Greater than 5 minute duration

# Predictors:0 ‐ 0%1‐ 26%2‐ 48%3‐ 71%

Weber BE, Wishwa K. Evaluation and outcomes of patients with palpitations. Am J Med 1996;100:138.

Some examples…

Palpitations

PACs or PVCs

Atrial fibrillation

SVT

VT


Falls

Syncope

Seizures

Stroke

Cryptogenic

History of seizures beginning in 1987, with multiple episodes every year.

Events typically begin with a epigastric distress, then anxiety, and finally a “rush” to his head.

Episodes continue despite treatment with multiple anti‐seizure medications.

Case: 48 year‐old man with a history of seizures. HPI (continued):

During these episodes, he denies losing awareness, except for “a few” episodes that resulted in loss of consciousness.

In 2005, he had an episode of loss of consciousness resulting in a cervical spine fracture.

Past Medical/Surgical History: As Noted

Medications: Keppra 500 mg po qam/1000 mg po qpm

Physical Examination:

VS:

130/80 ‐ 70s lying

120/80 ‐ 70 standing

Gen: AAO; vertical scar on back of neck from prior fall

HEENT: Bilateral CSM –

Lungs: CTA b/l

Cardiac: RRR; Apex non‐displaced and without heave; S1S2 physiologically split; no clicks/rubs/gallops

Abdomen: soft, non‐tender

Extremities: no edema

ECG:

Echocardiogram: Normal chamber sizes/function

Plan?

1. Refer back to Neurology

2. Tilt table3. Holter monitor

4. EEG

5. Exercise stress test6. EP study

7. Nothing else8. Something else

ECG

24-48 hour Holter

monitor


wearable monitor:



monitor


Outpatient rhythm monitoring:

Follow‐Up:

Dual‐chamber permanent pacemaker placed.

No seizures to date.

Case: Cardiac Transplant and Syncope

66 year‐old man s/p heart transplant 5 years prior for ischemic disease.

Loss of consciousness without prodrome x 2.

“I don’t think I’m going to survive more of these episodes.”

ECG/telemetry unremarkable.

ECHO with normal LV function.

Right and left heart catheterization/biopsy unremarkable.

Electrophysiology study‐ normal conduction intervals and no inducible VT.

Tilt table test‐ negative.

Outpatient rhythm monitoring x 6 weeks‐unremarkable.

Plan?

1. EEG/Neurology consultation

2. Exercise stress test3. Nothing else

4. Something else

ECG

24-48 hour Holter

monitor


wearable monitor:



monitor


Implantable rhythm monitor placed. Implantable rhythm monitor placed.

Implantable rhythm monitor placed.

Palpitations

PACs or PVCs

Atrial fibrillation

SVT

VT


Falls

Syncope

Seizures

Stroke

Cryptogenic

Stroke and Rhythm Monitoring

Cryptogenic Stroke: How Aggressively Should We Be Screening for AF?

Gladstone DJ et al. Atrial fibrillation in patients with cryptogenic stroke . N Engl J Med 2014 Jun 26; 370:2464.Sanna T et al. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med 2014 Jun 26; 370: 2478

EMBRACE study:

Randomized 572 patients > 55 years with cryptogenic stroke to 30‐day event monitor vs. 24‐hour monitor.

Primary Outcome: Newly detected AF >= 30 seconds within 90 days of study entry.

‐ 16.1% of the prolonged monitoring group vs. 3.2% in the control group (p<0.001)

CRYSTAL AF:

Randomized 441 patients >= 40 years with cryptogenic stroke to insertable cardiac monitor (ICM) vs. conventional follow up.

Primary Outcome: AF > 30 seconds.

‐ 8.9 % of the ICM patients vs 1.4% of the control group by 6 months

‐ 20% vs. 12% by 12 months (P<0.001).

Median time to detection of AF was 84 days with ICM and 53 days with conventional follow‐up.

1. Cardiac rhythm monitoring is helpful for diagnosing many conditions, and leading to improved outcomes.

2. Technological improvements are transforming the availability and duration of cardiac rhythm monitoring.

3. Awareness of cardiac rhythm monitoring options and a coordinated approach/team are essential.

Cardiac Rhythm Monitoring: Conclusions

Palpitations

PACs or PVCs

Atrial fibrillation

SVT

VT


Falls

Syncope

Seizures

Stroke

Cryptogenic

ECG

24‐48 hour Holter monitor


wearable monitor:


2‐3 year subcutaneous implantable monitor


common monitoring outpatient cardiac rhythm monitoring

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