Cardiac event recorders yield more diagnoses and are more cost-effective than 48-hour Holter monitoring in patients with palpitations. A controlled clinical trial

Symptom burden guiding invasive electrophysiological study in paroxysmal supraventricular tachycardia: The believe SVT registry

BACKGROUND AND OBJECTIVE

Patients with palpitations clinically suggestive of paroxysmal supraventricular tachycardia (PSVT) are often managed conservatively until ECG-documentation of the tachycardia, leading to high impact on life quality and healthcare resource utilization. We evaluated results of electrophysiological study (EPS), and ablation when appropriate, among these patients, with special focus on gender differences in management.

METHODS

BELIEVE SVT is a European multicenter, retrospective registry in tertiary hospitals performing EPS in patients with palpitations, without ECG-documentation of tachycardia or preexcitation, and considered highly suggestive of PSVT by a cardiologist or cardiac electrophysiologist. We analyzed clinical characteristics, results of EPS and ablation, complications, and clinical outcomes during follow-up.

RESULTS

Six-hundred eighty patients from 20 centers were included. EPS showed sustained tachycardia in 60.9% of patients, and substrate potentially enabling AVNRT in 14.7%. No major/permanent complications occurred. Minor/transient complications were reported in 0.84% of patients undergoing diagnostic-only EPS and 1.8% when followed by ablation. During a 3.4-year follow-up, 76.2% of patients remained free of palpitations recurrence. Ablation (OR: 0.34, P < .01) and male gender (OR: 0.58, P = .01) predicted no recurrence. Despite a higher female proportion among patients with recurrence, (77.2% vs 63.5% among those asymptomatic during follow-up, P < .01), 73% of women in this study reported no recurrence of palpitations after EPS.

CONCLUSIONS

EPS and ablation are safe and effective in preventing recurrence of nondocumented palpitations clinically suggestive of PSVT. Despite a lower efficacy, this strategy is also highly effective among women and warrants no gender differences in management.

An overview of the electrocardiographic monitoring devices in sports cardiology: Between present and future

BACKGROUND

Athletes represent a mainly healthy population, which however could be considered at risk of major arrhythmic events, especially in case of undiagnosed cardiomyopathies. For this reason, the periodical sports medicine examination and the electrocardiography are essential tools in the cardiovascular screening, even though they do not always succeed in identifying rhythm disturbances, particularly when asymptomatic or rarely symptomatic.

HYPOTHESIS

Prolonged cardiac monitoring often enables clinicians to stratify the arrhythmic risk and reach the diagnosis. The technological progress of the last decades has produced an always-increasing number of heart rhythm monitoring devices, starting from the 24-hour electrocardiogram Holter monitoring and ending with the wide world of wearable devices.

METHODS

In the literature, the extreme utility of this equipment in the patients affected by cardiovascular diseases and in the general population is well established. On the contrary, athletes-based randomized trials or large-scale epidemiological studies targeting the frequency of cardiac symptoms and the use of cardiac monitoring are missing, while an ever-growing number of case series and small observational studies are flourishing in recent years.

RESULTS

The present review showcases the available electrocardiographic monitoring options, principally in the medical setting, listing their characteristics, their indications, their supporting evidence, and their general pros and cons.

CONCLUSIONS

The ultimate goal of this review is guiding physicians through the wide variety of heart rhythm monitoring options in the specific subfield of sports cardiology, when an arrhythmia is suspected in an athlete, to tailor the diagnostic process and favor the best diagnostic accuracy.

Palpitations in athletes: diagnosis, workup and treatment

Palpitations are a common reason for athletes to seek medical care. Although often benign, palpitations may serve as a harbinger for underling cardiac pathology. Given the unique challenges in this population, this review will serve to discuss the basic underlying pathophysiology, which may predispose athletes to palpitations. In addition, we will review the aetiologies, diagnostic evaluation, management and counselling strategies for some of the most common diagnoses seen in athletes.

The Relationship between Holter Electrocardiography and Atrial Fibrillation Diagnosis Using Real-World Data in Japan

The relationship between Holter electrocardiography (ECG) and atrial fibrillation (AF) diagnosis in the real world has not been widely evaluated in Japan.This is a claims-based retrospective study using a health insurance claims database provided by DeSC Healthcare Corporation. We identified patients with at least one Holter for any purpose during the data period from April 2015 to November 2020 and without diagnosis of AF before the tests (n = 19,739). We obtained a whole picture of Holter and AF diagnosis after correcting for population distribution bias in the dataset. Based on this picture and the assumption that the patient had AF at the 1^st Holter whose AF was detected for the first time at the second or subsequent Holter, we estimated the number of diagnosis with AF and overlooked AF by initial Holter. We conducted sensitivity analyses changing the definition of AF, the potential detection period, and the washout period (a period required to avoid including patients who have already been diagnosed with AF or who have already undergone several Holters) to confirm the validity of the base scenario.Among patients for analysis, 88.4% had only one Holter. The percentage of AF diagnosis by initial Holter was 7.6%. The percentage of AF overlooked by initial Holter was estimated to be 31.4% and this value did not change much by sensitivity analyses.It was estimated that approximately 30% of AF patients were overlooked by initial Holter, and reducing the overlooked rate will be a clinical challenge.

NExUS-Heart: Novel examinations using smart technologies for heart health-Data sharing from commercial wearable devices and telehealth engagement in participants with or at risk of atrial fibrillation

Background

Telemedicine and commercial wearable devices capable of detecting atrial fibrillation (AF) have revolutionized arrhythmia care during coronavirus disease 2019. However, not much is known about virtual patient-provider interactions or device sharing behaviors.

Objective

The purpose of this study was to characterize how participants with or at risk of AF are engaging with their providers in the context of telemedicine and using commercially wearable devices to manage their health.

Methods

We developed a survey to describe participant behaviors around telemedicine encounters and commercial wearable device use. The survey was distributed to participants diagnosed with AF or those at risk of AF (as determined by being at least 65 years old and having a CHA₂DS₂-VASc stroke risk score of >2) in the University of Massachusetts Memorial Health Care system.

Results

The survey was distributed to 23,530 patients, and there were 1222 (5.19%) participant responses. Among the participants, 327 (26.8%) had AF and 895 (73.2%) were at risk of AF. Neither device ownership nor device type use differed by AF status. After adjusting for covariates that may influence surveyed participant communication patterns, we found that participants with AF were more likely to share their wearable device-derived data with providers (adjusted odds ratio 1.87; 95% confidence interval 1.02-3.41). Rates of sharing physical activity or sleep data were low for both groups and did not differ by AF status.

Conclusion

Compared with participants at risk of developing AF, those with AF were more likely to share heart rate and rhythm data from their commercial wearable devices with providers. However, both groups had similar rates of sharing physical activity and sleep data, telemedicine engagement, and technology use and ownership.

The Role of External Loop Recorders in Arrhythmia-Related Symptoms in Children: A Single Center Experience

In this study, we report our experience with the use of external loop recorders (ELRs), in terms of diagnostic efficiency according to symptoms and symptom-rhythm correlation in pediatric patients. We evaluated ELRs applied to 178 patients between April 2017 and November 2020 at our center. The mean age of 172 patients included in the study was 13.6 ± 3.8 years, and 69.8% were female. ELR indications were palpitations in 98 (56.9%) cases, chest pain and palpitations in 43 (25%) cases, presyncope/syncope in 28 (16.2%) cases, and pacemaker/ implantable cardioverter-defibrillator (ICD) problems in 3 (0.2%) cases. ELR recording times were 14.2 ± 9.7 days on average, ranging from 2 to 67 days. While the symptom-rhythm correlation was 29.1% in total, when the indications were evaluated one by one, this correlation was found to be 30.2% in palpitations, 34.7% in chest pain and palpitations, and 10.7% in presyncope/syncope. The total diagnostic efficiency was 68.1%. In the follow-up of ELR cases, a total of 139 (80.8%) patients received clinical follow-up without medication, 15 (8.8%) patients received medical treatment, and 18 (10.4%) patients underwent EPS. The cardiac ELR system is useful in detecting underlying arrhythmias. Demonstrating sinus tachycardia at the time of the symptom may be seen as negative finding, but while experiencing symptoms, it is diagnostically valuable and may help avoid further investigation with costly and invasive diagnostic procedures. For diagnostic efficiency and cost effectiveness, the optimal recording time is 2 weeks, but it should be extended to 4 weeks in cases such as of presyncope/syncope that cannot be explained with a 2-week ELR use.

MsFLASH analysis of diurnal salivary cortisol and palpitations in peri- and postmenopausal women

OBJECTIVE

To evaluate the relationship between diurnal salivary cortisol patterns and distress from heart palpitations in midlife women.

METHODS

We analyzed baseline data from 293 women who were eligible for a 3 × 2 factorial trial of exercise or yoga versus routine activity, and omega-3 fish oil versus placebo for vasomotor symptoms. Women self-collected salivary cortisol using swabs at four time points over 2 consecutive days and reported distress from heart racing or pounding during the past 2 weeks using a single item. Sample description and covariate data included demographics, clinical data, vasomotor symptom frequency from daily diaries, medication use, and validated questionnaires on depression, stress, and insomnia (Patient Health Questionnaire-8, Perceived Stress Scale, and Insomnia Severity index). Data were analyzed using descriptive statistics, chi-square and t tests, and repeated measure linear regression models.

RESULTS

Participants were on average 54.6 (SD = 3.6) years old, most were White (67%) postmenopausal (84%), and 26% reported distress related to palpitations. In adjusted models, the morning (wake plus 30-min) geometric mean daily salivary cortisol concentrations were significantly more blunted in those with distress from palpitations compared with those without distress (P ≤ 0.03). When all covariates were controlled, distress from palpitations was the sole significant predictor of wake plus 30-minute cortisol (-0.25 [-0.45 to -0.04], P = 0.02).

CONCLUSIONS

Palpitations among midlife women may be associated with blunted morning cortisol, and this relationship is not explained by demographics, clinical variables, vasomotor symptoms, medications, depression, stress, or insomnia.

Cardiac monitoring for patients with palpitations

Palpitations are one of the most common reasons for medical consultation. They tend to worry patients and can affect their quality of life. They are often a symptom associated with cardiac rhythm disorders, although there are other etiologies. For diagnosis, it is essential to be able to reliably correlate the symptoms with an electrocardiographic record allowing the identification or ruling out of a possible rhythm disorder. However, reaching a diagnosis is not always simple, given that they tend to be transitory symptoms and the patient is frequently asymptomatic at the time of assessment. In recent years, electrocardiographic monitoring systems have incorporated many technical improvements that solve several of the 24-h Holter monitor limitations. The objective of this review is to provide an update on the different monitoring methods currently available, remarking their indications and limitations, to help healthcare professionals to appropriately select and use them in the work-up of patients with palpitations.

Syncope and electrocardiogram

INTRODUCTION

Suspected transient loss of consciousness (T-LOC) and syncope are common causes of hospitalization in older patients. Arrhythmias are the most common cardiac causes of syncope. Although a number of instrumental diagnostic procedures are usually routinely performed in patients with suspected syncope, a 12 leads electrocardiogram (ECG) is the only instrumental test recommended for the initial evaluation of these patients.

EVIDENCE ACQUISITION

In this paper current literature on this topic will be reviewed, including ECG diagnostic criteria and findings suggestive of cardiac syncope.

EVIDENCE SYNTHESIS

The ECG may disclose an arrhythmia associated with a high likelihood of syncope, avoiding further evaluations and permitting institution of specific treatment in 7% of patients referred to emergency department. When the cause of syncope remains uncertain after initial evaluation the next step is to assess the risk of major cardiovascular events or sudden cardiac death. An abnormal ECG selected patients with high probabiliry of cardiac syncope. ECG diagnostic criteria and ECG findings suggesting arrhythmic syncope are presented. Indications and potential clinical implications of ECG monitoring will be discussed too.

CONCLUSIONS

A careful, well-conducted medical history focused on the suspected syncopal event is crucial for the diagnosis. In this setting, the ECG is a mandatory diagnostic tool which, although normal in the majority of patients of syncope, has the potential to identify patients with high likelihood of cardiac syncope due to arrhythmic or cardiopulmonary disorder.

Supervised SVM Transfer Learning for Modality-Specific Artefact Detection in ECG

The electrocardiogram (ECG) is an important diagnostic tool for identifying cardiac problems. Nowadays, new ways to record ECG signals outside of the hospital are being investigated. A promising technique is capacitively coupled ECG (ccECG), which allows ECG signals to be recorded through insulating materials. However, as the ECG is no longer recorded in a controlled environment, this inevitably implies the presence of more artefacts. Artefact detection algorithms are used to detect and remove these. Typically, the training of a new algorithm requires a lot of ground truth data, which is costly to obtain. As many labelled contact ECG datasets exist, we could avoid the use of labelling new ccECG signals by making use of previous knowledge. Transfer learning can be used for this purpose. Here, we applied transfer learning to optimise the performance of an artefact detection model, trained on contact ECG, towards ccECG. We used ECG recordings from three different datasets, recorded with three recording devices. We showed that the accuracy of a contact-ECG classifier improved between 5 and 8% by means of transfer learning when tested on a ccECG dataset. Furthermore, we showed that only 20 segments of the ccECG dataset are sufficient to significantly increase the accuracy.

A New Scoring System Detecting the Supraventricular Tachycardia Inducibility and Radiofrequency Ablation With High Specificity in Electrophysiological Study

Aim

The relationship between arrhythmia induction and ablation with palpitation characteristics has been demonstrated in electrophysiological study (EPS) patients. However, there is insufficient data on palpitation characteristics and their sensitivity and specificity. We aimed to identify the relationship between scoring composed of palpitation characteristics with the supraventricular tachycardia (SVT) induction and the success rate of the procedure.

Method

A total of 119 patients, diagnosed as paroxysmal supraventricular tachycardia (PSVT) by electrocardiography, rhythm Holter or symptoms, and underwent EPS, were enrolled in the study. A psychiatrist administered the Hospital Anxiety and Depression Score (HADS) questionnaire.

Results

In SVT induced group, palpitation duration (p = 0.048), palpitation spread to neck (p 0.004), responsiveness to medication (p = 0.008), induction with stress (p = 0.007), admission to emergency (p = 0.021) and documented PSVT (p = 0.017) were more common. Atropine administration (p = 0.001) was higher, and the Wenckebach cycle length (p < 0.001) was longer in the non-induced arrhythmia group. The presence of dual AV pathways was higher in SVT induced group (p = 0.002). There were no differences between groups in terms of anxiety score (p = 0.192), depression score (p = 0.730), and total psychiatric results (p = 0.280) in the HADS questionnaire. In scoring designed by the palpitation characteristics, the score of four and over predicted SVT induction with 63.6% sensitivity and 92.5% specificity. Radio-frequency ablation (RFA) was performed succesfully in 82.1% of patients with a score of ≥4.

Conclusion

Supraventricular tachycardia induction score obtained from the palpitations characteristics and arrhythmia documentation can be useful in predicting the induction of SVT and the success of RFA.

Physiological Changes and Cardiovascular Investigations in Pregnancy

Profound physiological changes in the maternal cardiovascular system occur shortly after conception. These changes may impact upon the investigation of healthy and complicated pregnancies. Additionally, concerns regarding fetal exposure to ionising radiation are important considerations in maternal testing. This manuscript reviews the important physiological changes pertinent to the investigation of maternal cardiovascular disease in pregnancy.

Clinical Approach to Patients with Palpitations

Palpitations are among the most common symptoms that prompt patients to consult a physician. In the diagnostic workup of patients with palpitations, the initial evaluation involves history, physical examination, and 12-lead electrocardiogram. These investigations yield a prognostic stratification of the patients, and a definitive suspected diagnosis of the cause of symptoms in a good proportion of cases. When the initial evaluation results are negative and the patient is suffering from heart disease, or if the palpitations are frequent or poorly tolerated and with a high probability of an arrhythmic origin, ambulatory electrocardiogram monitoring and/or electrophysiological study should be undertaken.

The proportion of asymptomatic recurrence after catheter ablation of atrial fibrillation in patients with a pacemaker for sick sinus syndrome

Background

Catheter ablation (CA) of paroxysmal atrial fibrillation (PAF) is an effective treatment. However, the frequency of asymptomatic AF recurrence after CA in patients with PAF and sick sinus syndrome (SSS) is not clear. The aim of this study was to elucidate the real AF recurrence after CA in patients with PAF and a pacemaker for SSS.

Methods and results

Fifty-one consecutive patients (mean age 66.6 ± 7.0 years, male 34) with PAF and SSS and pacemakers underwent CA. All patients were followed at 1, 3, 6, 9, and 12 months after the CA using a 12-lead ECG, Holter-ECG, and 1-month event recorder as a conventional follow-up. In addition, the pacemakers were interrogated every 12 months. During a 5-year follow-up after the final CA procedure, AF recurrences were observed in 7 patients (13.7%) with a conventional follow-up, including 1 (2.0%) asymptomatic patient. Pacemaker-interrogation revealed another 10 patients (19.6%) with asymptomatic AF recurrences. Ultimately, the conventional follow-up plus pacemaker-interrogation provided a higher incidence of AF recurrences (P = 0.009). Multiple CA procedures contributed to a significant increase in the AF-free survival rate at 5 years: 58.6% after a single CA and 86.0% after multiple CA procedures with a conventional follow-up, but which decreased to 40.6% and 60.9% with a conventional follow-up plus a pacemaker interrogation, respectively.

Conclusions

One-third of PAF patients with SSS and pacemakers recurred after multiple CA sessions. However, 65% of them were asymptomatic and difficult to be identified with conventional follow-up. Pacemaker interrogation significantly increased the detection rate of AF-recurrence.

Screening strategies for atrial fibrillation: a systematic review and cost-effectiveness analysis

Background

Atrial fibrillation (AF) is a common cardiac arrhythmia that increases the risk of thromboembolic events. Anticoagulation therapy to prevent AF-related stroke has been shown to be cost-effective. A national screening programme for AF may prevent AF-related events, but would involve a substantial investment of NHS resources.

Objectives

To conduct a systematic review of the diagnostic test accuracy (DTA) of screening tests for AF, update a systematic review of comparative studies evaluating screening strategies for AF, develop an economic model to compare the cost-effectiveness of different screening strategies and review observational studies of AF screening to provide inputs to the model.

Design

Systematic review, meta-analysis and cost-effectiveness analysis.

Setting

Primary care.

Participants

Adults.

Intervention

Screening strategies, defined by screening test, age at initial and final screens, screening interval and format of screening {systematic opportunistic screening [individuals offered screening if they consult with their general practitioner (GP)] or systematic population screening (when all eligible individuals are invited to screening)}.

Main outcome measures

Sensitivity, specificity and diagnostic odds ratios; the odds ratio of detecting new AF cases compared with no screening; and the mean incremental net benefit compared with no screening.

Review methods

Two reviewers screened the search results, extracted data and assessed the risk of bias. A DTA meta-analysis was perfomed, and a decision tree and Markov model was used to evaluate the cost-effectiveness of the screening strategies.

Results

Diagnostic test accuracy depended on the screening test and how it was interpreted. In general, the screening tests identified in our review had high sensitivity (> 0.9). Systematic population and systematic opportunistic screening strategies were found to be similarly effective, with an estimated 170 individuals needed to be screened to detect one additional AF case compared with no screening. Systematic opportunistic screening was more likely to be cost-effective than systematic population screening, as long as the uptake of opportunistic screening observed in randomised controlled trials translates to practice. Modified blood pressure monitors, photoplethysmography or nurse pulse palpation were more likely to be cost-effective than other screening tests. A screening strategy with an initial screening age of 65 years and repeated screens every 5 years until age 80 years was likely to be cost-effective, provided that compliance with treatment does not decline with increasing age.

Conclusions

A national screening programme for AF is likely to represent a cost-effective use of resources. Systematic opportunistic screening is more likely to be cost-effective than systematic population screening. Nurse pulse palpation or modified blood pressure monitors would be appropriate screening tests, with confirmation by diagnostic 12-lead electrocardiography interpreted by a trained GP, with referral to a specialist in the case of an unclear diagnosis. Implementation strategies to operationalise uptake of systematic opportunistic screening in primary care should accompany any screening recommendations.

Limitations

Many inputs for the economic model relied on a single trial [the Screening for Atrial Fibrillation in the Elderly (SAFE) study] and DTA results were based on a few studies at high risk of bias/of low applicability.

Future work

Comparative studies measuring long-term outcomes of screening strategies and DTA studies for new, emerging technologies and to replicate the results for photoplethysmography and GP interpretation of 12-lead electrocardiography in a screening population.

Study registration

This study is registered as PROSPERO CRD42014013739.

Funding

The National Institute for Health Research Health Technology Assessment programme.

Clinical Logistics in 24-Hour Ambulatory Electrocardiographic Monitoring

In total, 493 ambulatory ECG recordings were studied. Women were preponderant (62.3% vs 37.7%). The average age of women and men patients was 66.9 and 64.7 years, respectively. Of the ECGs studied, 71.4% showed abnormalities and 28.6% appeared completely normal. Urgent abnormalities were noted in 1.4% of the recordings and significant abnormalities were present in 14.6%. Subjective complaints were noted in their logbooks by 18.8% of patients, but correlation of complaints with the electrocardiographic abnormalities was noted in only 1.2% of cases. The attending cardiologist concluded that 23.9% of the tests supported reasons of valid necessity for performance. Two hundred seventy-three recordings were clas sified as electrocardiographically abnormal (55.4%) but were clinically insignificant. General practitioners requested 59.8% of the tests versus 40.2% by specialists. Preponderant abnor malities included premature atrial and ventricular contractions, supraventricular tachycardia, and atrial fibrillation. Less frequent abnormalities included ventricular tachycardia (4.6%), atrial flutter, atrioventricular block, artificial pacemaker rhythm, nodal rhythm, and intermit tent bundle branch block.

Early Detection of Symptomatic Paroxysmal Cardiac Arrhythmias by Trans-Telephonic ECG Monitoring: Impact on Diagnosis and Treatment of Atrial Fibrillation

INTRODUCTION

Diagnosis of infrequent cardiac arrhythmias (CA) is often unsuccessful using resting or Holter ECG. As early detection and treatment of CA, especially atrial fibrillation (AF), has implications on patients' treatment and outcome, we investigated, whether self-guided, trans-telephonic event-recorder monitoring (Tele-ECG) improves diagnosis and influences treatment options.

METHODS

Between 2009 and 2014, 790 patients (54 ± 18 years, 40% male; no history of CA: 582, known AF: 179, other CA: 29) presented with recurrent symptoms suggestive of CA and were screened by Tele-ECG (17.3 ± 26.9 days). A total of 11,775 ECGs were transmitted via a 24-hour telephone hotline including documentation of the respective symptoms.

RESULTS

In 73% of patients, CA was documented at the time of symptoms: sinus tachycardia 23%, premature ventricular beats 19%, AF 14%, supraventricular tachycardia 9%, sinus bradycardia 5%, sinus arrhythmia 2%, and AV block II 1%. The mean time until the first symptomatic episode occurred was 6.9 ± 15.3 days (median 2.5 days). The first documented arrhythmia occurred on average after 7.7 ± 14.1 days (median 3 days). In patients with AF (n = 110), 44% was newly diagnosed. According to the Tele-ECG diagnosis, AF ablation was performed in 27% of these patients, 7% electrical cardioversion, and in 30% antiarrhythmic therapy was initiated. In 65% of the patients with recurrence of known AF, (re-)ablation was performed or recommended and in 16% antiarrhythmic therapy was modified.

CONCLUSIONS

Tele-ECG monitoring is effective in the diagnosis of suspected symptomatic CA. A diagnosis can usually be achieved within 1 week and has implications on patients' care.

Could ivabradine challenge be helpful for the diagnosis of intermittent sinoatrial node dysfunction in suspected patients?

Sinoatrial node dysfunction (SND) is an important cause of syncope in the elderly. Though the diagnosis can be relatively straightforward in the persistent form of SND, it can be elusive when the dysfunction is intermittent. For intermittent SND, the diagnosis may require prolonged electrocardiographic recordings with an external or internal loop recorder, or an invasive electrophysiologic study. Ivabradine, an If inhibitor that slows sinoatrial discharge rate, is widely used for the treatment of chronic angina or heart failure. Though the drug is contraindicated in patients with known SND as it may exacerbate symptoms, we propose that a simple ivabradine suppression test, followed by a 24-h monitorization of heart rhythm, could be valuable to aid diagnosis of intermittent SND. The test we propose could be used prior to prolonged electrocardiographic monitoring in patients with suspected SND, but both the diagnostic accuracy and the safety should be evaluated with studies prior to implementation.

Arrhythmia Detection in Pediatric Patients: ECG Quality and Diagnostic Yield of a Patient-Triggered Einthoven Lead-I Event Recorder (Zenicor EKG-2™)

Symptoms that may be caused by arrhythmia are common in pediatric outpatient departments, though it remains challenging to reveal paroxysmal tachycardia. This investigation evaluated prospectively the quality and diagnostic yield of a newly available handheld patient-activated event recorder (ER) in children. In 226 children (pts) aged 0-17 years with or without congenital heart defects, pacemaker/ICDs or arrhythmia, a lead-I ER ECG was created. ER ECGs were recorded by pressing the patients' thumbs on the device and were analyzed in comparison with a lead-12 ECG, as gold standard. Event recording and data transmission were possible in all cases. ECG quality of the ER showed a high accordance in measuring heart rate (ICC = 0.962), duration of QRS complexes (κ = 0.686), and PR interval (ICC = 0.750) (p < 0.001) although P wave detection remained challenging (p = 0.120). 36 % (n = 82) of the pts had heart rhythm disturbances. The ER yielded 92 % sensitivity in diagnosing supraventricular tachycardia plus 77 % sensitivity and 92 % specificity in identifying abnormal ECGs. In children, the application of the tested ER was suitable. ECGs of good quality could be performed and transmitted easily, and also complex arrhythmia analysis was possible. This ER is an excellent diagnostic device for the detection and exclusion of tachycardia in children.

Using a Cardiac Event Recorder in Children with Potentially Arrhythmia-Related Symptoms

BACKGROUND

In this study, we reported our experience with the use of cardiac event recorders in pediatric patients.

METHODS

We evaluated 583 patients fitted with an event recorder (15-30 days) between March 2010 and November 2014 at our clinic. Excluded from the study were 117 patients with no recorded events and six with records contaminated by electrocardiogram artifacts. All of the patients received electrocardiograms, Holter monitoring, and echocardiography before the cardiac event recording.

RESULTS

The patient sample consisted of 460 patients (64% female). The mean age was 12.8 ± 4.1 years. The median number of recorded events was 7. The indications included palpitations in 336 (73%) patients, syncope in 27 (6%) patients, and chest pain and palpitations in 97 (21%) patients. Whereas 64 patients (14%) had structural heart disease according to echocardiographic examination, the remaining patients had normal echocardiographic examination results. The most frequent cardiac comorbidities were mitral valve prolapse (6%), operated tetralogy of Fallot (1.5%), and complicated congenital heart diseases with single ventricle physiology (1%). The recorded events were sinus tachycardia in 113 (25%) patients, supraventricular tachycardia in 35 (8%) patients, ventricular extrasystole in 20 (4%) patients, supraventricular extrasystole in nine (2%) patients, and ventricular tachycardia in two (0.4%) patients. Based on the event recorder and follow-up electrocardiogram findings, 46 patients received an electrophysiology study/ablation. The symptom-rhythm correlation was 39%.

CONCLUSION

In the presence of possible arrhythmia-related symptoms in children, a cardiac event recorder can be considered a useful primary diagnostic method. More research on this topic is needed.

Ambulatory cardiac monitoring for discharged emergency department patients with possible cardiac arrhythmias

Introduction

Many emergency department (ED) patients have symptoms that may be attributed to arrhythmias, necessitating outpatient ambulatory cardiac monitoring. Consensus is lacking on the optimal duration of monitoring. We describe the use of a novel device applied at ED discharge that provides continuous prolonged cardiac monitoring.

Methods

We enrolled discharged adult ED patients with symptoms of possible cardiac arrhythmia. A novel, single use continuous recording patch (Zio®Patch) was applied at ED discharge. Patients wore the device for up to 14 days or until they had symptoms to trigger an event. They then returned the device by mail for interpretation. Significant arrhythmias are defined as: ventricular tachycardia (VT) ≥4 beats, supraventricular tachycardia (SVT) ≥4 beats, atrial fibrillation, ≥3 second pause, 2nd degree Mobitz II, 3rd degree AV Block, or symptomatic bradycardia.

Results

There were 174 patients were enrolled and all mailed back their devices. The average age was 52.2 (± 21.0) years, and 55% were female. The most common indications for device placement were palpitations 44.8%, syncope 24.1% and dizziness 6.3%. Eighty-three patients (47.7%) had ≥1 arrhythmias and 17 (9.8%) were symptomatic at the time of their arrhythmia. Median time to first arrhythmia was 1.0 days (IQR 0.2–2.8) and median time to first symptomatic arrhythmia was 1.5 days (IQR 0.4–6.7). 93 (53.4%) of symptomatic patients did not have any arrhythmia during their triggered events. The overall diagnostic yield was 63.2%

Conclusion

The Zio®Patch cardiac monitoring device can efficiently characterize symptomatic patients without significant arrhythmia and has a higher diagnostic yield for arrhythmias than traditional 24–48 hour Holter monitoring. It allows for longer term monitoring up to 14 days.

Emerging role of digital technology and remote monitoring in the care of cardiac patients

Current available mobile health technologies make possible earlier diagnosis and long-term monitoring of patients with cardiovascular diseases. Remote monitoring of patients with implantable devices and chronic diseases has resulted in better outcomes reducing health care costs and hospital admissions. New care models, which shift point of care to the outpatient setting and the patient's home, necessitate innovations in technology.

Emergency Physicians' Perceptions and Decision-making Processes Regarding Patients Presenting with Palpitations

BACKGROUND

Palpitations are a common emergency department (ED) complaint, yet relatively little research exists on this topic from an emergency care perspective.

OBJECTIVES

We sought to describe the perceptions and clinical decision-making processes of emergency physicians (EP) surrounding patients with palpitations.

METHODS

We conducted 21 semistructured interviews with a convenience sample of EPs. We recruited participants from academic and community practice settings from four regions of the United States. The transcribed interviews were analyzed using a combination of structural coding and grounded theory approaches with ATLAS.ti, a qualitative data analysis software program (version 7; Atlas.ti Scientific Software Development GmbH, Berlin, Germany).

RESULTS

EPs perceive palpitations to be a common but generally benign chief complaint. EPs' clinical approach to palpitations, with regards to testing, treatment, and ED management, can be classified as relating to one or more of the following themes: (1) risk stratification, (2) diagnostic categorization, (3) algorithmic management, and (4) case-specific gestalt. With regard to disposition decisions, four main themes emerged: (1) presence of a serious diagnosis, (2) perceived need for further cardiac testing/monitoring, (3) presence of key associated symptoms, (4) request of other physician or patient desire. The interrater reliability exercise yielded a Fleiss' kappa measure of 0.69, indicating substantial agreement between coders.

CONCLUSION

EPs perceive palpitations to be a common but generally benign chief complaint. EPs rely on one or more of four main clinical approaches to manage these patients. These findings could help guide future efforts at developing risk-stratification tools and clinical algorithms for patients with palpitations.

Diagnostic yield of patch ambulatory electrocardiogram monitoring in children (from a national registry)

The diagnostic yield of continuous electrocardiographic (ECG) monitoring in children for periods longer than a Holter monitor is unclear. The aim of this study was to characterize diagnostic yield, arrhythmia type, and time to first arrhythmia using a clinical repository of national ambulatory ECG data in children. A cross-sectional study was performed in 3,209 consecutive children receiving a 14-day adhesive patch monitor (Zio Patch) for clinical indications from January 2011 to December 2013. Of the 3,209 children (56% female, mean age 12.5 ± 4.4 years, range 1 month to 17 years), 390 had arrhythmias detected, making the diagnostic yield 12.2%. Of these, 137 patients (4.3%) had arrhythmias deemed clinically significant to warrant urgent physician notification. The most frequent indications for monitoring were palpitations (n = 1,138 [35.5%]), syncope (n = 450 [14.0%]), unspecified tachycardia (n = 291 [9.1%]), supraventricular tachycardia (n = 264 [8.2%]), and chest pain (n = 261 [8.1%]). Arrhythmias were detected in 10.0% of patients with palpitations, 6.7% of patients with syncope, 14.8% of patients with tachycardia, 22.7% of patients with supraventricular tachycardia, and 6.5% of patients with chest pain. The mean times to first detected and first symptom-triggered arrhythmias were 2.7 ± 3.0 and 3.3 ± 3.3 days, respectively. Forty-four percent of first detected arrhythmias and 50.4% of the first symptom-triggered arrhythmias occurred beyond 48 hours of monitoring. In conclusion, the diagnostic yield of continuous ECG patch monitoring in children was substantial beyond 48 hours and should be considered in children who are candidates for longer term ECG monitoring.

Cost Analysis and Clinical Outcomes of Ambulatory Care Monitoring in Medicare Patients: Describing the Diagnostic Odyssey

Objectives: The diagnostic sequence and costs for arrhythmia detection utilizing Holter ambulatory ECG monitoring have not been well studied. The objective of the current study was to characterize the number of patients and associated costs incurred in the diagnosis, additional monitoring, clinical events and sequelae after an initial Holter monitor in Medicare patients with arrhythmia-the diagnostic odyssey. Methods: We performed a retrospective, longitudinal claims analysis using a 5% random sample of Medicare beneficiaries' claims from the Fee-for-Service (FFS) Standard Analytic Files. The analysis was limited to patients with full benefits for 1 year prior and 2 years post the index 24- or 48-hour Holter event, no prior arrhythmia or Holter. Results: The group of greatest interest was the "No results" category, since these 1,976 patients (11.1% of the total 17,887 patients evaluated) reflected the failure of repeat Holter monitoring to either detect clinical events or diagnose disease. In spite of this failure, there was a total allowed charge of more than $45 million or slightly more than $23,000 per involved patient. When extrapolated over the entire Medicare FFS population, this category was estimated to cost more than $900 million over the 2-year study period. Conclusions: Additional diagnostic paradigms need to be explored to improve upon these patient and system outcomes, where repeat monitoring frequently did not yield a diagnosis and patients continued to experience clinical events.

Validation and clinical use of a novel diagnostic device for screening of atrial fibrillation

AIMS

Patients with asymptomatic and undiagnosed atrial fibrillation (AF) are at increased risk of heart failure and ischaemic stroke. In this study, we validated a new diagnostic device, the MyDiagnostick, for detection of AF by general practitioners and patients. It records and stores a Lead I electrocardiogram (ECG) which is automatically analysed for the presence of AF.

METHODS AND RESULTS

In total, 192 patients (age 69.4 ± 12.6 years) were asked to hold the MyDiagnostick for 1 min, immediately before a routine 12-lead ECG was recorded. Atrial fibrillation detection and ECGs stored by the MyDiagnostick were compared with the cardiac rhythm on the 12-lead ECG. In a second part of the study, the MyDiagnostick was used to screen for AF during influenza vaccination in the general practitioner's office. Atrial fibrillation was present in 53 out of the 192 patients (27.6%). All AF patients were correctly detected by the MyDiagnostick (sensitivity 100%; 95% confidence interval 93-100%). MyDiagnostick AF classification in 6 out of 139 patients in sinus rhythm was considered false positive (specificity 95.9%; 95% confidence interval 91.3-98.1%). During 4 h of influenza vaccination in 676 patients (age 74 ± 7.1 years), the MyDiagnostick correctly diagnosed AF in all 55 patients (prevalence 8.1%). In 11 patients (1.6%), AF was not diagnosed before, all with a CHA2DS2VASc score of >1.

CONCLUSION

The high AF detection performance of the MyDiagnostick, combined with the ease of use of the device, enables large screening programmes for detection of undiagnosed AF.

Clinical validation of a low-power and wearable ECG patch for long term full-disclosure monitoring

BACKGROUND

Detection of intermittent atrial fibrillation (AF) is done using a 24-h Holter. Holter recordings are powerful but lack the comfort and have limited recording times resulting in under diagnosing of intermittent AF.

OBJECTIVE

Within this work we evaluated and compared a novel miniaturized three-channel ECG monitoring patch versus a 24-h Holter system.

METHODS

Both patients with a chronic AF rhythm (n=5) as well as patients with an AF rhythm that underwent electrical reconversion (n = 5) were equipped with both a 24-h Holter and ECG patch.

RESULTS

Alignment of raw data of both ECG systems allowed cross-correlation analysis. Overall good correlations of up to 85% were obtained. RR-interval analysis of both systems resulted in very high correlations of 99% and higher. AF analysis showed correct identification of AF on both ECG systems.

CONCLUSIONS

The performance of our ECG patch matches that of the 24-h Holter and could provide a suitable tool for long-term monitoring applications.

A novel patch for heart rhythm monitoring: is the Holter monitor obsolete?

A number of substantial improvements to the 60-year-old concept of the Holter monitor have recently been developed. One promising advance is the Zio(®) Patch (iRhythm Technologies, Inc., CA, USA), a small 2 × 5-inch patch, which can continuously record up to 14 days of a single ECG channel of cardiac rhythm without the need for removal during exercise, sleeping or bathing. Its ease-of-use, which enables optimal long-term monitoring, has been established in the ambulatory setting, although some insurance carriers have been reluctant to reimburse appropriately for this advance, an issue characteristic of other heart monitors, treated as 'loss-leaders.' In this article, in addition to discussing possible reasons for this reluctance, a novel model for direct-to-consumer marketing of heart monitoring, outside of the traditional health insurance reimbursement model, is also presented. Additional current and future advances in heart rhythm recording are also discussed. Such potentially revolutionary opportunities have only recently become possible as a result of technologic advances.

The teenager with palpitations

Palpitations can result from cardiac awareness (increased conscious perception of the heart beating) or from a fast or irregular cardiac rhythm. Most causes for palpitations in the teenager can be diagnosed with minimal testing. Patients with an abnormal ECG, non-sinus tachycardia, abnormal cardiac examination, concerning family history, or palpitations associated with activity or syncope should be referred to a pediatric cardiologist. This article discusses the evaluation, testing, and management of teenagers with palpitations. It also provides a general guideline for referral for subspecialty evaluation.

Minimally invasive approach to the child with palpitations

Palpitations are a common reason for referral to a pediatric cardiologist. Although generally benign, palpitations are a significant cause for concern in the individual and their family. Similarly, palpitations may be the initial presentation of significant heart disease, resulting in heightened concern in the referring physician. Although emphasis is usually placed on excluding arrhythmia as the cause for palpitations, there are a variety of noncardiac causes for palpitations. The patient history and physical examination are the key components of the evaluation and guide subsequent investigations. In many cases, an immediate diagnosis cannot be made and additional testing may be required; this often includes further monitoring for episodes, cardiac imaging and ambulatory monitoring. Current technologies for ambulatory monitoring during symptoms include Holter monitoring and a variety of patient-activated event recorders, including implantable loop recorders. Each presents its own unique advantages and disadvantages to aid diagnosis in the management of a child with palpitations. The primary focus for the clinician is to determine whether the etiology is benign in nature or whether there is underlying heart disease that may carry a more serious prognosis.

Comparison of 24-hour Holter monitoring with 14-day novel adhesive patch electrocardiographic monitoring

BACKGROUND

Cardiac arrhythmias are remarkably common and routinely go undiagnosed because they are often transient and asymptomatic. Effective diagnosis and treatment can substantially reduce the morbidity and mortality associated with cardiac arrhythmias. The Zio Patch (iRhythm Technologies, Inc, San Francisco, Calif) is a novel, single-lead electrocardiographic (ECG), lightweight, Food and Drug Administration-cleared, continuously recording ambulatory adhesive patch monitor suitable for detecting cardiac arrhythmias in patients referred for ambulatory ECG monitoring.

METHODS

A total of 146 patients referred for evaluation of cardiac arrhythmia underwent simultaneous ambulatory ECG recording with a conventional 24-hour Holter monitor and a 14-day adhesive patch monitor. The primary outcome of the study was to compare the detection arrhythmia events over total wear time for both devices. Arrhythmia events were defined as detection of any 1 of 6 arrhythmias, including supraventricular tachycardia, atrial fibrillation/flutter, pause greater than 3 seconds, atrioventricular block, ventricular tachycardia, or polymorphic ventricular tachycardia/ventricular fibrillation. McNemar's tests were used to compare the matched pairs of data from the Holter and the adhesive patch monitor.

RESULTS

Over the total wear time of both devices, the adhesive patch monitor detected 96 arrhythmia events compared with 61 arrhythmia events by the Holter monitor (P < .001).

CONCLUSIONS

Over the total wear time of both devices, the adhesive patch monitor detected more events than the Holter monitor. Prolonged duration monitoring for detection of arrhythmia events using single-lead, less-obtrusive, adhesive-patch monitoring platforms could replace conventional Holter monitoring in patients referred for ambulatory ECG monitoring.

Diagnostic utility of a novel leadless arrhythmia monitoring device

Although extending the duration of ambulatory electrocardiographic monitoring beyond 24 to 48 hours can improve the detection of arrhythmias, lead-based (Holter) monitors might be limited by patient compliance and other factors. We, therefore, evaluated compliance, analyzable signal time, interval to arrhythmia detection, and diagnostic yield of the Zio Patch, a novel leadless, electrocardiographic monitoring device in 26,751 consecutive patients. The mean wear time was 7.6 ± 3.6 days, and the median analyzable time was 99% of the total wear time. Among the patients with detected arrhythmias (60.3% of all patients), 29.9% had their first arrhythmia and 51.1% had their first symptom-triggered arrhythmia occur after the initial 48-hour period. Compared with the first 48 hours of monitoring, the overall diagnostic yield was greater when data from the entire Zio Patch wear duration were included for any arrhythmia (62.2% vs 43.9%, p <0.0001) and for any symptomatic arrhythmia (9.7% vs 4.4%, p <0.0001). For paroxysmal atrial fibrillation (AF), the mean interval to the first detection of AF was inversely proportional to the total AF burden, with an increasing proportion occurring after 48 hours (11.2%, 10.5%, 20.8%, and 38.0% for an AF burden of 51% to 75%, 26% to 50%, 1% to 25%, and <1%, respectively). In conclusion, extended monitoring with the Zio Patch for ≤14 days is feasible, with high patient compliance, a high analyzable signal time, and an incremental diagnostic yield beyond 48 hours for all arrhythmia types. These findings could have significant implications for device selection, monitoring duration, and care pathways for arrhythmia evaluation and AF surveillance.