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De Ciancio G, Sadoul N, Hammache N, Pace N, Echivard M, Freysz L, Blangy H, Sellal JM, Olivier A. Bradycardia risk stratification with implantable loop recorder after unexplained syncope. Arch Cardiovasc Dis 2024; 117:186-194. [PMID: 38326152 DOI: 10.1016/j.acvd.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 12/05/2023] [Accepted: 12/12/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND An implantable loop recorder is an effective tool for diagnosing unexplained syncope. However, after a first episode in non-high-risk patients, the usefulness of implantable loop recorder implantation remains unclear. AIMS To analyse relevant risk factors for significant bradycardia in order to identify patients who do or do not benefit from implantable loop recorder implantation. Also, to study whether implantable loop recorder implantation with remote monitoring is associated with less recurrence of traumatic syncope. METHODS This was a retrospective monocentric study including patients with implantable loop recorder implantation after unexplained syncope, using remote monitoring and iterative consultations. RESULTS Two hundred and thirty-seven patients were implanted for unexplained syncope. Significant bradycardia occurred in 53 patients (22.4%): 23 (43.4%) caused by paroxysmal atrioventricular block and 30 (56.6%) caused by sinus node dysfunction, leading to permanent pacemaker implantation in 48 patients. Compared with younger patients, there was a 3.46-fold increase (95% confidence interval 1.92-6.23; P<0.0001) in the risk of significant bradycardia in patients aged≥60 years. Based on multivariable analysis, only "typical syncope" was associated with significant bradycardia occurrence (hazard ratio 3.14, 95% confidence interval 1.75-5.65; P=0.0001). There was no recurrence of significant bradycardia with traumatic complications among patients implanted for traumatic syncope. CONCLUSIONS This study shows that: (1) implantable loop recorders identify more significant bradycardia in patients aged≥60 presenting with a first non-high-risk typical syncope, suggesting that an implantable loop recorder should be implanted after a first episode of unexplained syncope in such conditions; and (2) after traumatic syncope, implantable loop recorder implantation is safe, and is associated with little or no recurrence of traumatic syncope.
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Affiliation(s)
- Guillaume De Ciancio
- Department of Cardiology, Nancy University Hospital, 54511 Vandœuvre-lès-Nancy, France.
| | - Nicolas Sadoul
- Department of Cardiology, Nancy University Hospital, 54511 Vandœuvre-lès-Nancy, France; Université de Lorraine, Nancy Medical School, 54505 Vandœuvre-lès-Nancy, France
| | - Nefissa Hammache
- Department of Cardiology, Nancy University Hospital, 54511 Vandœuvre-lès-Nancy, France
| | - Nathalie Pace
- Department of Cardiology, Nancy University Hospital, 54511 Vandœuvre-lès-Nancy, France
| | - Mathieu Echivard
- Department of Cardiology, Nancy University Hospital, 54511 Vandœuvre-lès-Nancy, France
| | - Luc Freysz
- Department of Cardiology, Nancy University Hospital, 54511 Vandœuvre-lès-Nancy, France
| | - Hugues Blangy
- Department of Cardiology, Nancy University Hospital, 54511 Vandœuvre-lès-Nancy, France
| | - Jean Marc Sellal
- Department of Cardiology, Nancy University Hospital, 54511 Vandœuvre-lès-Nancy, France; Université de Lorraine, Nancy Medical School, 54505 Vandœuvre-lès-Nancy, France
| | - Arnaud Olivier
- Department of Cardiology, Nancy University Hospital, 54511 Vandœuvre-lès-Nancy, France
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Eftekhari H, He H, Lee JD, Paul G, Zhupaj A, Lachlan T, Kuehl M, Dhanjal T, Panikker S, Yusuf S, Hayat S, Osman F. Safety and outcome of nurse-led syncope clinics and implantable loop recorder implants. Heart Rhythm 2021; 19:443-447. [PMID: 34767989 DOI: 10.1016/j.hrthm.2021.11.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 10/26/2021] [Accepted: 11/02/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Implantable loop recorders (ILRs) are effective in achieving symptom-rhythm correlation. Data on the diagnostic yield of ILRs, on nurse-led syncope clinics, and on nurse-led ILR implants are limited. OBJECTIVE We evaluated the safety and efficacy of our nurse-led syncope clinic and nurse-led ILR implants. METHODS A retrospective study of all consecutive patients undergoing nurse-led ILR implantations was performed between April 2016 and April 2018. Patients were referred from both nurse-led and physician-led clinics. Data were collected on baseline demographic characteristics, referral source, symptom-rhythm correlation, ILR findings, and subsequent changes to management. All ILRs were enrolled into remote monitoring with automatic arrhythmia detection, and all immediate (≤24 hours) ILR implant complications were recorded. Comparisons were made between nurse-led and physician-led clinics and subsequent outcomes. RESULTS A total of 432 patients with an ILR were identified: 164 (38%) from nurse-led and 268 (62%) from physician-led clinics; 200 (46%) were women (mean age 66.5 ± 18.2 years; mean follow-up duration 28.9 ± 9.5 months). Primary ILR indications were syncope (n = 251 [58%]), presyncope (n = 33 [7%]), palpitation (n = 39 [9%]), cryptogenic stroke (n = 78 [18%]), and other reasons (n = 31 [7%]). No immediate ILR implant complications occurred. Overall, 156 patients (36%) had a change in management as a direct result of ILR findings, with no overall differences between nurse-led and physician-led clinics (35% vs 36%; P = .7). More patients had newly diagnosed atrial fibrillation in physician-led clinics (15% vs 7%; P = .01), and more patients had pacemaker implants for bradycardia in nurse-led clinics (23% vs 13%; P < .01). CONCLUSION Nurse-led ILR implantation was safe and effective. Nurse-led syncope clinics achieved good symptom-rhythm correlation with resultant significant changes to management in comparison to physician-led clinics. Larger prospective studies are needed to evaluate their longer-term impact.
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Affiliation(s)
- Helen Eftekhari
- Department of Cardiology, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, United Kingdom; Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Hejie He
- Department of Cardiology, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, United Kingdom; Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - James Doug Lee
- Department of Cardiology, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, United Kingdom
| | - Geeta Paul
- Department of Cardiology, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, United Kingdom
| | - Albiona Zhupaj
- Department of Cardiology, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, United Kingdom
| | - Thomas Lachlan
- Department of Cardiology, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, United Kingdom; Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Michael Kuehl
- Department of Cardiology, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, United Kingdom; Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Tarv Dhanjal
- Department of Cardiology, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, United Kingdom; Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Sandeep Panikker
- Department of Cardiology, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, United Kingdom
| | - Shamil Yusuf
- Department of Cardiology, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, United Kingdom
| | - Sajad Hayat
- Department of Cardiology, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, United Kingdom
| | - Faizel Osman
- Department of Cardiology, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, United Kingdom; Warwick Medical School, University of Warwick, Coventry, United Kingdom.
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Altinsoy M, Sutton R, Kohno R, Sakaguchi S, Mears RK, Benditt DG. Ambulatory ECG monitoring for syncope and collapse in United States, Europe, and Japan: The patients' viewpoint. J Arrhythm 2021; 37:1023-1030. [PMID: 34386128 PMCID: PMC8339081 DOI: 10.1002/joa3.12560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 04/13/2021] [Accepted: 05/04/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Practice guidelines provide clinicians direction for the selection of ambulatory ECG (AECG) monitors in the evaluation of syncope/collapse. However, whether patients' understand differences among AECG systems is unknown. METHODS AND RESULTS A survey was conducted of USA (n = 99), United Kingdom (UK)/Germany (D) (n = 75) and Japan (n = 40) syncope/collapse patients who underwent diagnostic AECG monitoring. Responses were quantitated using a Likert-like 7-point scale (mean ± SD) or percent of patients indicating a Top 2 box (T2B) for a particular AECG attribute. Patient ages and diagnosed etiologies of syncope/collapse were similar across geographies. Patients were queried on AECG attributes including the ability to detect arrhythmic/cardiac causes of collapse, instructions received, ease of use, and cost. Patient perception of the diagnostic capabilities and ease of use did not differ significantly among the AECG technologies; however, USA patients had a more favorable overall view of ICM/ILRs (T2B: 42.4%) than did UK/D (T2B: 28%) or Japan (T2B: 17.5%) patients. Similarly, US patient rankings for education received regarding device choice and operation tended to be higher than UK/D or Japan patients; nevertheless, at their best, the Likert scores were low (approximately 4.7-6.0) suggesting need for education improvement. Finally, both US and UK/D patients were similarly concerned with ICM costs (T2B, 31% vs 20% for Japan). CONCLUSIONS Patients across several geographies have a similar but imperfect understanding of AECG technologies. Given more detailed education the patient is likely to be a more effective partner with the clinician in establishing a potential symptom-arrhythmia correlation.
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Affiliation(s)
- Meltem Altinsoy
- Cardiac Arrhythmia CenterCardiovascular DivisionUniversity of Minnesota Medical SchoolMinneapolisMNUSA
- Cardiology ResidencyTurgut Ozal UniversitySchool of MedicineAnkaraTurkey
| | - Richard Sutton
- Cardiology DepartmentNational Heart and Lung InstituteImperial CollegeHammersmith HospitalLondonUK
| | - Ritsuko Kohno
- Cardiac Arrhythmia CenterCardiovascular DivisionUniversity of Minnesota Medical SchoolMinneapolisMNUSA
| | - Scott Sakaguchi
- Cardiac Arrhythmia CenterCardiovascular DivisionUniversity of Minnesota Medical SchoolMinneapolisMNUSA
| | | | - David G. Benditt
- Cardiac Arrhythmia CenterCardiovascular DivisionUniversity of Minnesota Medical SchoolMinneapolisMNUSA
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Abstract
Cardiac arrhythmia is a common cause of syncope. The prompt identification of arrhythmic syncope has diagnostic and prognostic implications. In this article, an approach to identifying and managing arrhythmic syncope is discussed, including key findings from the history, physical examination, electrocardiogram, role of risk stratification, use of supplemental investigations, and treatment.
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Affiliation(s)
- Evan Martow
- Division of Cardiology, University of Alberta, University of Alberta Hospital, Walter Mackenzie Health Sciences Centre, 8440 112 Street, Edmonton, Alberta T6G 2B7, Canada
| | - Roopinder Sandhu
- Division of Cardiology, University of Alberta, Walter Mackenzie Health Sciences Centre, 8440 112 Street, Edmonton, Alberta T6G 2B7, Canada.
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Sandgren E, Rorsman C, Edvardsson N, Engdahl J. Role of baseline 12‑lead ECG in predicting syncope caused by arrhythmia in patients investigated using an implantable loop recorder. INTERNATIONAL JOURNAL OF CARDIOLOGY. HEART & VASCULATURE 2019; 24:100386. [PMID: 31304233 PMCID: PMC6603332 DOI: 10.1016/j.ijcha.2019.100386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 05/30/2019] [Accepted: 06/13/2019] [Indexed: 11/17/2022]
Abstract
AIM To evaluate the role of baseline 12‑lead ECG in predicting the syncope mechanism during continuous monitoring using an implantable loop recorder (ILR). METHODS Consecutive patients with syncope implanted with an ILR were enrolled. Baseline 12‑lead ECG were related to ECG diagnosis derived from ILR tracings recorded at the time of syncope recurrence. RESULTS In total 300 patients with a mean age of 66 ± 16 years were included, 49% (146/300) received an ILR-guided diagnosis during follow-up. Patients with abnormal baseline ECG more frequently received an ILR-guided diagnosis compared to those with normal baseline ECG 59% vs. 44%, p = 0.018. For a diagnosis of arrhythmic syncope, the corresponding frequencies were 45% vs. 26%, p = 0.001.Patients with bifascicular block significantly more common received an ILR-guided diagnosis 76% (25/33) compared to those with normal baseline ECG 44% (90/205), p ≪ 0.001. In this subgroup, 96% (24/25) were diagnosed with arrhythmic syncope, 23 of which were due to bradyarrhythmia. Bifascicular block occurred almost exclusively among those ≥60 years (31/33). After logistic regression the adjusted OR for arrhythmic syncope was significant for bifascicular block 5.5 (95%CI 2.3-13.2), p ≪ 0.001. PPV for bifascicular block in predicting arrhythmic syncope was 73% and NPV 73%. CONCLUSION A baseline 12‑lead ECG with bifascicular block was a strong predictor for syncope during follow-up, most often due to bradyarrhythmia caused by intermittent complete heart block. No other ECG findings were associated with the ILR outcome. We find it reasonable to consider permanent pacing instead of an ILR for patients with bifascicular block and unexplained syncope.
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Affiliation(s)
- Emma Sandgren
- Department of Medicine, Halland Hospital Varberg, SE-43281 Varberg, Sweden
- Department of Clinical Sciences, Karolinska Institutet, Danderyd's University Hospital, SE-18288 Stockholm, Sweden
| | - Cecilia Rorsman
- Department of Medicine, Halland Hospital Varberg, SE-43281 Varberg, Sweden
| | - Nils Edvardsson
- Sahlgrenska Academy at Sahlgrenska University Hospital, SE-40530 Gothenburg, Sweden
| | - Johan Engdahl
- Department of Clinical Sciences, Karolinska Institutet, Danderyd's University Hospital, SE-18288 Stockholm, Sweden
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Sakhi R, Theuns DAMJ, Szili-Torok T, Yap SC. Insertable cardiac monitors: current indications and devices. Expert Rev Med Devices 2018; 16:45-55. [PMID: 30522350 DOI: 10.1080/17434440.2018.1557046] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Recurrent unexplained syncope is a well-established indication for an insertable cardiac monitor (ICM). Recently, the indications for an ICM have been expanded. AREAS COVERED This review article discusses the current indications for ICMs and gives an overview of the latest generation of commercially available ICMs. EXPERT COMMENTARY The 2018 ESC Syncope guidelines have expanded the indications for an ICM to patients with inherited cardiomyopathy, inherited channelopathy, suspected unproven epilepsy, and unexplained falls. ICMs are also increasingly used for the detection of subclinical atrial fibrillation (AF) in patients with cryptogenic stroke. Whether treatment of subclinical AF (SCAF) with oral anticoagulation prevents recurrent stroke is yet unknown. The current generation of ICMs are smaller, easier to implant, have better diagnostics, and are capable of remote monitoring. The Reveal LINQ (Medtronic) is the smallest ICM and has the most extensive performance and clinical data. The BioMonitor 2 (Biotronik) is the largest ICM but has excellent R-wave amplitudes, longest longevity, and reliable remote monitoring. The Confirm Rx (Abbott) is capable to provide mobile data transmission enabled by a smartphone app. Future generation of ICMs will incorporate heart failures indices to facilitate remote monitoring of heart failure patients.
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Affiliation(s)
- Rafi Sakhi
- a Department of Cardiology, Thoraxcenter , Erasmus Medical Center , Rotterdam , The Netherlands
| | - Dominic A M J Theuns
- a Department of Cardiology, Thoraxcenter , Erasmus Medical Center , Rotterdam , The Netherlands
| | - Tamas Szili-Torok
- a Department of Cardiology, Thoraxcenter , Erasmus Medical Center , Rotterdam , The Netherlands
| | - Sing-Chien Yap
- a Department of Cardiology, Thoraxcenter , Erasmus Medical Center , Rotterdam , The Netherlands
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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: 935] [Impact Index Per Article: 155.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Benditt DG, Adkisson WO, Sutton R, Mears RK, Sakaguchi S. Ambulatory diagnostic ECG monitoring for syncope and collapse: An assessment of clinical practice in the United States. Pacing Clin Electrophysiol 2018; 41:203-209. [PMID: 29314105 DOI: 10.1111/pace.13265] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 10/19/2017] [Accepted: 11/04/2017] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Diagnostic ambulatory electrocardiogram (AECG) monitoring is widely used for evaluating syncope and collapse, and practice guidelines provide recommendations regarding optimal AECG device selection. However, whether physicians utilize AECGs in accordance with the pertinent guidelines is unclear. This study assessed utilization of AECG monitoring systems for syncope and collapse diagnosis by physicians in the United States. METHODS AND RESULTS A quantitative survey was undertaken of physicians comprising multiple specialties (emergency department, n = 35; primary care, n = 35; hospitalists, n = 30; neurologists, n = 30; nonimplanting, n = 34, and implanting-cardiologists, n = 35). Depending on specialty, respondents reported that neural-reflex and orthostatic causes accounted for 17-23%, cardiac causes for 12-20%, and "neurological causes" (specifically psychogenic pseudo-syncope/pseudo-seizures and acute cerebrovascular conditions) for 7-12% of their syncope/collapse cases. The choice of AECG technology varied by specialty. Thus, despite patients having daily symptoms, 25% of respondents chose an AECG technology other than a Holter-type monitor. Conversely, when monitoring for infrequent events (e.g., less than monthly), 12-18% indicated that they would choose a 24- to 48-hour Holter, 20-34% would choose either a conventional event recorder or a mobile cardiac telemetry system, and only 53-65% would select an insertable cardiac monitor. CONCLUSIONS In evaluation of syncope/collapse, most U.S. clinicians across specialties use AECGs appropriately, but in a substantial minority there remains discordance between choice of AECG technology and guideline-based recommendations.
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Affiliation(s)
- David G Benditt
- Cardiac Arrhythmia Center, Cardiovascular Division, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Wayne O Adkisson
- Cardiac Arrhythmia Center, Cardiovascular Division, University of Minnesota Medical School, Minneapolis, MN, USA
| | | | | | - Scott Sakaguchi
- Cardiac Arrhythmia Center, Cardiovascular Division, University of Minnesota Medical School, Minneapolis, MN, USA
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Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2017; 136:e60-e122. [DOI: 10.1161/cir.0000000000000499] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Win-Kuang Shen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | | | - David G. Benditt
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mitchell I. Cohen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Daniel E. Forman
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Zachary D. Goldberger
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Blair P. Grubb
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mohamed H. Hamdan
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Andrew D. Krahn
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mark S. Link
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Brian Olshansky
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Satish R. Raj
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Roopinder Kaur Sandhu
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Dan Sorajja
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Benjamin C. Sun
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Clyde W. Yancy
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
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11
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2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: Executive summary. Heart Rhythm 2017; 14:e218-e254. [DOI: 10.1016/j.hrthm.2017.03.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Indexed: 01/05/2023]
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Kohno R, Abe H, Benditt DG. Ambulatory electrocardiogram monitoring devices for evaluating transient loss of consciousness or other related symptoms. J Arrhythm 2017; 33:583-589. [PMID: 29255505 PMCID: PMC5728709 DOI: 10.1016/j.joa.2017.04.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Revised: 04/08/2017] [Accepted: 04/25/2017] [Indexed: 11/25/2022] Open
Abstract
Capturing electrocardiograms (ECGs) during spontaneous events is the most powerful available tool to identify or exclude an arrhythmic cause of symptoms, and often can elucidate the definite diagnosis for different conditions, such as transient loss of consciousness (T-LOC), lightheadedness, or palpitations. Current ambulatory ECG monitoring technologies include 24-hour Holter, wearable event recorder, external loop recorder (ELR), and insertable cardiac monitoring (ICM). Of them, Holter ECG is most frequently used in daily practice in Japan, while ELR and ICM are less frequently used. However, the appropriate monitor choice should be based on the expected frequency of symptoms. Frequent events may be adequately detected by Holter ECG, but less frequent symptoms are more effectively assessed by longer-term monitoring (i.e., ELR or ICM). In this report, based on our clinical experience, we review the usefulness of ambulatory ECG monitoring devices, especially of ELR, for evaluating T-LOC and other potentially arrhythmia-related symptoms. Specifically, we focus on the use of ELR and ICM for evaluating Japanese patients with T-LOC.
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Affiliation(s)
- Ritsuko Kohno
- Department of Heart Rhythm Management, University of Occupational and Environmental Health, 1-1, Iseigaoka, Yahatanishiku, Kitakyushu, 807-8555, Japan
| | - Haruhiko Abe
- Department of Heart Rhythm Management, University of Occupational and Environmental Health, 1-1, Iseigaoka, Yahatanishiku, Kitakyushu, 807-8555, Japan
| | - David G Benditt
- Cardiac Arrhythmia Center, Cardiovascular Division, University of Minnesota, Minneapolis, MN, USA
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Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW. 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm 2017; 14:e155-e217. [PMID: 28286247 DOI: 10.1016/j.hrthm.2017.03.004] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Indexed: 12/26/2022]
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Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2017; 70:620-663. [PMID: 28286222 DOI: 10.1016/j.jacc.2017.03.002] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2017; 136:e25-e59. [PMID: 28280232 DOI: 10.1161/cir.0000000000000498] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Win-Kuang Shen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | | | - David G Benditt
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mitchell I Cohen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Daniel E Forman
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Zachary D Goldberger
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Blair P Grubb
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mohamed H Hamdan
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Andrew D Krahn
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mark S Link
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Brian Olshansky
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Satish R Raj
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Roopinder Kaur Sandhu
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Dan Sorajja
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Benjamin C Sun
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Clyde W Yancy
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison.,Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
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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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Edvardsson N, Wolff C, Tsintzos S, Rieger G, Linker NJ. Costs of unstructured investigation of unexplained syncope: insights from a micro-costing analysis of the observational PICTURE registry. Europace 2015; 17:1141-8. [PMID: 25759408 PMCID: PMC4482287 DOI: 10.1093/europace/euu412] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 12/30/2014] [Indexed: 12/17/2022] Open
Abstract
AIMS The observational PICTURE (Place of Reveal In the Care pathway and Treatment of patients with Unexplained Recurrent Syncope) registry enrolled 570 patients with unexplained syncope, documented their care pathway and the various tests they underwent before the insertion of an implantable loop recorder (ILR). The aims were to describe the extent and cost of diagnostic tests performed before the implant. METHODS AND RESULTS Actual costs of 17 predefined diagnostic tests were characterized based on a combination of data from PICTURE and a micro-costing study performed at a medium-sized UK university hospital in the UK. The median cost of diagnostic tests per patient was £1114 (95% CI £995-£1233). As many patients received more than the median number of tests, the mean expenditure per patient was higher with £1613 (95% CI £1494-£1732), and for 10% of the patients the cost exceeded £3539. Tests were frequently repeated, and early use of specific and expensive tests was common. In the 12% of patients with types of tests entirely within the recommendations for an initial evaluation before ILR implant, the mean cost was £710. CONCLUSION Important opportunities to reduce test-related costs before an ILR implant were identified, e.g. by more appropriate use of tests recommended in the initial evaluation, by decreasing repetition of tests, and by avoiding early use of specialized and expensive tests. A structured multidisciplinary approach would be the best model to achieve an optimal outcome.
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Affiliation(s)
- Nils Edvardsson
- Sahlgrenska Academy at Sahlgrenska University Hospital, S-413 45 Göteborg, Sweden
| | - Claudia Wolff
- Medtronic European Headquarters, Tolochenaz, Switzerland
| | | | - Guido Rieger
- Medtronic Bakken Research Center, Maastricht, The Netherlands
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