Transcript ADVANCED EKG MONITORING

INTRODUCTION
 Reliable EKG monitoring is the backbone
of arrhythmia diagnosis and management
 Accurate diagnosis (or exclusion) of
arrhythmias responsible for symptoms is
critical for effective patient care
 Outpatient EKG monitoring has the
potential to shape clinical practice
THE EVOLUTION OF OUTPATIENT
Evolution of Outpatient
Cardiac Ambulatory
Monitoring
AMBULATORY
CARDIAC
MONITORING
Holter
Monitor
Event
Monitor:
Non-Looping
Memory
Event
Monitor:
Looping
Memory
AF
Auto-Trigger
Monitor
Implantable
Loop
Recorder
Outpatient
Telemetry:
Patient
Homebound
Mobile
Cardiac
Outpatient
Telemetry
(MCOT)
HOLTER MONITOR
 Technology
– 5 electrodes
– 2-3 leads
– Derived 12 lead available
– Digital or analog recording
– Digital transmission to analyzer
– Requires removal of Holter monitor to
scan recording
HOLTER MONITOR
 Uses:
– Patients experiencing daily symptoms
– Precise quantification of arrhythmias
 Positives:
– 24-48 hours full disclosure available
– Heart rate and AF burden graphs
– Arrhythmia counts (ex., 10 PVCs per
hour)
HOLTER MONITOR
 Negatives:
– 24 -48 hour-short duration
– May be days after test completion
before MD has results
– Artifact may not be discovered until test
analyzed
 Diagnostic yields:
– Yields low for intermittent symptoms or
syncope: <5%1 to 13%2
1.
Gibson TC, Heitzma MR. Diagnostic efficacy of 24-hour electrocardiographic monitoring for
syncope. AM J Cardiol 1984;53:1013-1017.
2. Zeldis SM, Levine BJ, Michelson EL, Morganroth J. Cardiovascular complaints. Correlation with
cardiac arrhythmias on 24-hour electrocardiographic monitoring. Chest 1980;78:456-461.
EVENT MONITOR:
NON-LOOPING MEMORY
 Technology:
– Electrodes not attached to skin, located on
monitor
– Chest plate, “wrist watch” monitors
– Single lead transmission
– Patient feels symptoms, places monitor and
pushes record button
– Recorded event must be transmitted via
phone. Patient required to dial number and
play back event then erase memory
– May have 1-6 events, approximately 6
minutes of memory
EVENT MONITOR:
NON-LOOPING MEMORY
 Uses:
– Infrequent symptoms
• Patients with allergy to electrode patches
• Patients unable to manage electrode
patches
 Positives:
– Patient is not attached to electrodes
EVENT MONITOR:
NON-LOOPING MEMORY
 Negatives:
– Delay in documenting symptoms: Patient senses
symptoms and then places monitor and pushes
button on monitor to record symptoms
– Requires patient intervention to transmit: Patient
needs to go to telephone, dial number and
transmit ECG data
– No trending data (heart rate, AF)
– Compliance: Patient must remember to have
monitor at all times, patients forget how to use
technology due to infrequent use, etc.
– Single lead ECG rhythm strip
EVENT MONITOR: LOOPING MEMORY
 Technology:
– Patient must press record button to capture symptomatic
event
– Continuous loop of pre-memory that is programmable.
Patient pushes button for symptoms and pre-memory is
captured with post symptom ECG. Usually 45 seconds pre
and 15 seconds post symptoms.
– 2 electrodes attached to skin
– Routinely transmits 1 lead but may transmit 2 leads
– Recorded event must be transmitted via phone. Patient
required to dial number and play back event then erase
memory
– May have 1-6 events, approximately 6-10 minutes of
memory
EVENT MONITOR: LOOPING MEMORY
 Uses:
– Infrequent symptoms
– Drug management
 Positives:
– Looping memory
EVENT MONITOR: LOOPING MEMORY
Negatives:
– Requires patient to have symptoms
– Requires patient intervention to transmit
– Diagnostic yield 6% - 68% (syncope, palpitations)
– No trend data (heart rate or AF burden)
– Electrode irritation
– Non-compliance 23%-44% 1,2: failure to activate,
human error, intimidated by technology,
inconvenient, difficulty with electrodes
1. Sivakumaran S, Krahn AD, Klein GJ, Finan J, Yee R, Renner S, Skanes AC. A prospective randomized
comparison of loop recorders versus Holter monitors in patients with syncope or presyncope. AM J
Med 2003;115:1-5.
2. Linzer M, Pritchett EL, Pontinen M, et al. Incremental diagnostic yield of loop electrocardiographic
recorders in unexplained syncope. AM J of Cardiol 1990;66:214-219.
EVENT MONITOR: LOOPING MEMORY
Diagnostic yields:
– Palpitations/Symptoms: Yields of 39%168%2,3 reported
– Syncope/presyncope: Yields of 6%-25%3,4,5
1. Fechter P. Advantage of ECG self-recording by the patient. Schw Medi Wochenschr J suisse Med
1991;121:1488-1492.
2. Kinlay S, Leitch JW, Neil A, et al. Cardiac event recorders yield more diagnoses and are more costeffective than 48-hour Holter monitoring in patients with palpitations: A controlled clinical trial. Ann
Intern Med 1996;124:16-20.
3. Fogel RI, Evans JJ, Prystowsky EN: Utility and cost of event recorders in the diagnosis of
palpitations, presyncope, and syncope.
4. Linzer M, Prichett EL, Pontinem M, et al. Incremental diagnostic yield of loop electrocardiographic
recorders in unexplained syncope. Am J Cardiol 1997;79:207-208.
5. Ximetbaum P, Kim KY, Ho KKL, et al. Utility of patient-activated cardiac event recorders in general
clinical practice. Am J Cardiol. 1997;79:371-372
AF AUTO-TRIGGER EVENT MONITOR
 Technology:
– Algorithm located in monitor:
• Irregular irregularity
• High and low heart rates
• May have “pause”
– Programmable memory, 10-20 minutes in duration
– Memory partitioned for auto-trigger and patient
triggered events
– Recorded events must be transmitted via telephone
Patient required to dial number and play back events
then erase memory
– Patient wears 2-5 electrodes, transmits 1-2 leads
 Uses:
– Patients with symptoms suggestive of AF, a history of
AF, or being treated for AF
– Infrequent symptoms
AF AUTO-TRIGGER EVENT MONITOR
 Positives:
– Algorithm captures arrhythmias on asymptomatic
patients
 Negatives:
– Limited monitor memory-events may not be captured
– False negatives due to limited monitor memory
– Artifact causes inappropriate algorithm triggering
– No trend data (heart rate or AF burden)
– Recorded events must be transmitted via phone.
Patient required to dial number and play back events
then erase memory
– Electrode irritation
– Compliance with monitoring
AF AUTO-TRIGGER EVENT MONITOR
Diagnostic yields:
– Retrospective database analysis
• 600 patients reviewed for diagnostic events
• 36% yield1
1. Reiffel, JA, Schwartzberg R, Murray M. Comparison of autotriggered memory loop recorders versus
standard loop recorders versus 24-hour Holter monitors for arrhythmia detection. Am J Cardiol.
2005;95:1055-1059.
IMPLANTABLE LOOP RECORDER
 Technology:
– Continuous monitoring via algorithm embedded in
recorder
• High and low rates
• Pauses
– Automatic and patient activation of events
– Battery life 14-24 months depending on time on shelf
and patient variability of use
– 21-42 minutes of memory
– Events downloaded via pacemaker programmer
– Patient activated mode, looping memory (5-6 events)
– No remote transmission capabilities
– Minimally invasive procedure to implant
IMPLANTABLE LOOP RECORDER
 Uses
– Very infrequent symptoms with suspected arrhythmia
– Syncope when non invasive testing is negative
 Positives:
– Algorithm recognizes arrhythmia without patient
needing to intervene
– Extending monitoring period
– Improved ability to correlate infrequent symptoms with
ECG rhythm
IMPLANTABLE LOOP RECORDER
Negatives
– Invasive procedure
– Over/undersensing causing false positives
– No ability to transmit remotely
– Limited memory
Diagnostic yields:
– ECG correlation with symptoms 45-88%1,2,3
1. Krahn AD, Klein GJ, Yee R. Et al. Randomized Assessment of Syncope Trial: Conventional
diagnostic testing versus a prolonged monitoring strategy. Circulation 2001; 104:46-51.
2. Krahn AD, Klein GJ, Skanes AC, Yee R. Insertable loop recorder use for detection of intermittent
arrhythmias. Pace 2004;27:657-664.
3. Assar M, Krahn A, Klein G, Yee R, Skanes A. Optimal duration of monitoring in patients with
unexplained syncope. AM J Cardiol 2003;92:1231-3.
OUTPATIENT TELEMETRY-In Home Only
 Technology:
– Algorithm embedded in computer tower set in home
– Computer tower connected to phone line
– Patient module worn on belt and connected to patient
by electrodes
– Patient module transmits ECG signal to computer
tower
– Automatic and patient activated events
– ECG events transmitted automatically via phone line
OUTPATIENT TELEMETRY-In Home Only
 Uses:
– Post CABG atrial fibrillation
– Infrequent symptoms
– Drug management
 Positives:
– Beat by beat analysis
– 24 hours of stored ECG data
– Heart rate trending
– Physician daily reporting
OUTPATIENT TELEMETRY-In Home Only
 Negatives:
– Patient home bound
– No cellular capabilities, all ECG events
transmitted via land line connected to
computer tower in home
– Unable to monitor patient when patient
separated from computer tower
MOBILE CARDIAC OUTPATIENT
TELEMETRY (MCOT)
 Technology:
– 3 electrode Sensor worn by patient
– Sensor transmits ECG to Monitor
– Beat by beat analysis via embedded algorithm
– Touch screen for patient to report symptoms
– Patient and algorithm triggered events
– Monitor has cellular capability and 2 way text
communication with patient
– Base connected to phone line placed in patient’s
home
– 96 hours of ECG memory capacity-ability to access
ECG data from memory
– Trend reporting for heart rate and AF burden
MOBILE CARDIAC OUTPATIENT
TELEMETRY (MCOT)
 Uses:
– Infrequent symptoms suggestive of
arrhythmia (palpitations, syncope,
presyncope, etc)
– Patient who require monitoring for known,
non-life threatening arrhythmias (AF, PSVT,
etc)
– Post cardiac surgery
– Post ablation
– Drug management
MOBILE CARDIAC OUTPATIENT
TELEMETRY (MCOT)
 Positives:
– Beat by beat analysis, not patient dependent to
capture event
– Symptom correlation via touch screen on Monitor
– Heart rate and AF trending
– High compliance due to daily reporting
– Ability to contact patient
– 96 hours of retrievable memory
– Patient able to be mobile
 Negatives:
– Electrode irritation
First Experience with a Mobile Outpatient Telemetry (MCOT) System
for the Diagnosis and Management of Cardiac Arrhythmia, Joshi A,
Kowey P, etal, AM J Cardiol April 2005; Vol 95,Issue 7
 100 Patients
– 16 of 30 patients with prior negative Holter or
event monitoring diagnosed with MCOT
– Clinically significant arrhythmia found in 51 of
100 patients
– 13 of 17 patients diagnosed with atrial
fibrillation had no symptoms
Outcomes of “First Experience” Study
First 100 Patients on
Service
30 Patients with prior
Holter or Event
Outcomes
 14 Required drug therapy
 5 Pacemaker implants
 4 Ablations
 3 Changed drug therapy
 2 ICD implant
 2 Stopped Coumadin
 2 Alternate diagnosis
 1 Stopped therapy
 1 Pacemaker
replacement
Outcomes
 7 Required drug therapy
 3 Pacemaker implants
 2 2nd Deg AV Block
 1 ICD implant
 1 Ablation
 1 NSVT
 1 Second accessory
pathway
Other MCOT Research
 Symptomatic and Asymptomatic Atrial Fibrillation in Patients
Undergoing Radiofrequency Catheter Ablation, Vasamreddy DD,
Calkins H, Journal of CV Electrophysiology, Feb 2006; Vol 17:2
– 82% of atrial fibrillation events were asymptomatic
– 20% of patients considered AF-free based on symptoms reporting
actually had recurrent AF
– Patients in AF frequently triggered symptoms when they were in NSR
 Assessment of Rhythm and Rate Controls in Patients with Atrial
Fibrillation, Prystowsky, EN, Journal of CV Electrophysiology, Sept
2006; Vol 17:9
– Symptoms do not always correlate with AF, most patients have
asymptomatic AF
– Assumption: optimal physiological response during sinus rhythm can be
duplicated by similar rate during AF
Other MCOT Research
 Incidence of Asymptomatic Atrial Fibrillation Recurrence Post
Pulmonary Vein Isolation Using a Novel Continuous Event
Monitoring System, Tarakji KG, Natale A, Heart Rhythm 2005
Scientific Sessions
– Continuous event monitoring (MCOT) seems to help facilitating the
decision to stop anticoagulation treatments.
 Initial Experience with a Novel Cardiac Outpatient Telemetry System
for Pediatric Patients with Suspected Arrhythmia, Saarel EV, Sierba
R, Heart Rhythm 2005 Scientific Sessions
– Looked at yields for patients with palpitations, syncope and presyncope
using MCOT versus event monitoring
– “MCOT is safe and useful for evaluation of children and adolescents
with suspected arrhythmia providing a diagnosis is 64% of subjects.”
MOBILE CARDIAC OUTPATIENT
TELEMETRY (MCOT) CLINICAL TRIAL
 (Recently completed) Rothman, SA, Laughlin
JC, Seltzer J, Walia JS, Baman, RI, Siouffi SY,
Sangrigoli RM, Kowey PR. “The Diagnosis of
Cardiac Arrhythmias: A prospective Multi-Center
Randomized Study Comparing Mobile Cardiac
Outpatient Telemetry versus Standard Loop
Event Monitoring”
 Abstract: American Heart Association Scientific
Sessions 2006. Oral presentation: Nov. 14
11:45-12 PM
MOBILE CARDIAC OUTPATIENT TELEMETRY (MCOT)
CASE STUDY #1
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Patient History
– 71 year old woman with history of
hypertension
– Long history of feeling “shaky” with
associated extreme fatigue
– Multiple Holter and event monitoring,
over 10 years, detected no arrhythmic
events
– Patient treated with anti-anxiety
medications
10/29 Cardiologist enrolls patient in MCOT
baseline indicated Normal Sinus Rhythm
11/2 MCOT triggered automatically, transmitting
a wide QRS complex tachycardia at a rate of
210 BPM - no symptoms reported
Physician notified, patient contacted and
directed to ER
Cardiologist terminated tachycardia with carotid
sinus pressure
EP study induced focal right atrial tachycardia
and patient underwent with successful mapping
and ablation
CardioNet Daily Report-No AF Burden
CardioNet Daily Report-With AF Burden Graph
CardioNet Urgent Report
CardioNet Urgent Report
CardioNet Urgent Report
CardioNet End of Service Summary Report
CardioNet Reporting Options
 Web reporting only
 Editing reports on the web
– Interpretation by Physician
 Physician Notification Criteria changes
 Additional ECG data available
OTHER USES OF MCOT
 Quantify arrhythmia on therapy
 Identify arrhythmias without symptoms
(especially AF)
 Safe drug administration / dose titration
 Exclude arrhythmias with vague symptoms
CONCLUSION
 New technologies are now available for
outpatient EKG monitoring
 Proof of utility must come from wellconceived clinical trials
 MCOT fills a void in patient care
 We can expect extension of this
technology to other aspects of ambulatory
patient monitoring
QUESTIONS?