EKG monitoring : Holter, loop recorder or telemedicine should be relevant DR SOFIAN JOHAR CONSULTANT CARDIOLOGIST AND ELECTROPHYSIOLOGIST RIPAS HOSPITAL AND GLENEAGLES JPMC BRUNEI DARUSSALAM Holter monitoring • • • • Usually 24-48h 2-3 bipolar leads 5-7 electrodes Common channels – Modified V5 – Modified V3 – Modified inferior lead Loop recorder • Can be worn for prolonged periods of time – 2-4 weeks – Record ECGs in a continuous manner but store a brief period when activated by patient – Also auto-trigger – Advantageous when patient is very symptomatic / syncopal during episodes – Can transmit information over telephone lines Event recorder • Can be used for prolonged periods of time – 2-4 weeks to months – Relies on rapid placement of electrodes /device during episodes – May be useful when patients are not too symptomatic during episodes – Can transmit over telephone lines Implantable loop recorders • Implanted subcutaneously – Examples include • Medronic – REVEAL – LINQ • St Jude – Confirm • Batteries last 2-3 years • Useful when symptoms are intermittent or when prolonged monitoring is required Indications for ambulatory monitoring – Palpitations – Syncope – Chest pain – Evaluation of anti-arrhythmic therapy – Unexplained SOB/fatigue – Evaluation in patient with unexplained stroke – Monitoring atrial fibrillation ablation Indications for Ambulatory ECG to assess symptoms possibly related to rhythm disturbances • Class I – Patients with unexplained syncope, near syncope or episodic dizziness in whom the cause is not obvious – Patients with unexplained recurrent palpitations • Class IIb – Patients with episodic shortness of breath, chest pain or fatigue that is not otherwise explained – Patients with neurological events when transient atrial fibrillation or flutter is suspected – Patients with symptoms such as syncope, near syncope, episodic dizziness, or palpitation in whom a probable cause other than arrhythmia has been identified but in whom symptoms persist despite treatment if this other cause • Class III – Patients with symptoms such as syncope, near syncope, episodic dizziness, or palpitation in whom other causes have been identified by history, physical examination or laboratory tests – Patients with CVA, without other evidence of arrhythmia Assessment of risk in patients without symptoms of arrhythmias • After myocardial infarction • Congestive heart failure • Genetic heart disorders – Hypertrophic cardiomyopathies – Arrhythmogenic right ventricular cardiomyopathy – Primary arrhythmia disorders • Brugada Syndrome • Long QT Indications for AECG • Class I – None • Class Iib – Post-MI patients with LV dysfunction – Patients with CHF – Patients with idiopathic hypertrophic cardiomyopathy Diagnostic yield • Syncope (1-26%) • Palpitations (0-44%) Palpitations Peter Zimetbaum, and Alena Goldman Circulation 2010;122:1629-1636 Syncope Peter Zimetbaum, and Alena Goldman Circulation 2010;122:1629-1636 AF and stroke • Atrial fibrillation and flutter (AF) account for ≈10% of all strokes and 50% of cardioembolic strokes • Stroke associated with AF carries a poor prognosis as more than 50% of the survivors remain with a severe deficit, and recurrence may be as high as 12% per year • Because anticoagulant treatment dramatically reduces the recurrence rate, detection of this arrhythmia after stroke is essential • Unfortunately, AF remains underdiagnosed as it is often asymptomatic: up to 30% of patients with AF are unaware of their diagnosis • 25% of those with AF-associated stroke have no prior diagnosis of AF • AF pattern is intermittent in 30% of patients with stroke and may not appear on a single recording AF and stroke • The AF detection rate with 12-lead ECG ranges between and 5% after ischemic stroke or transient ischemic stroke (TIA) • and 6% if a 24-hour Holter device is used EMBRACE CRYSTAL-AF Patients enrolled - n 572 447 Mean age in years ±SD 72.5 ± 8.5 61.5 ± 11.3 Median CHADS2 Score of all patients 3 Hypertension in intervention group - n/n total IG(%) 204/286 (71.3%) 144/221 (65.2%) Diabetes mellitus in intervention group - n/n total IG(%) Monitoring device in intervention group Invasive insertion of device required Primary endpoint 55/286 (19.2%) 34/221 (15.4%) 30 day event-triggered loop recorder from Braemar (ER910AF insertable cardiac monitor from Cardiac Event Monitor) Medtronic (REVEAL XT) No newly detected AF lasting >30s within 90 days after randomisation Yes time to first detection of AF (lasting >30s) within months EMBRACE CRYSTAL-AF CRYSTAL-AF CRYSTAL-AF Follow up months mth mth 12 mth 36 mth AF Detection rate Intervention group - n/n total IG 45/280 (16.1%) 19/221 (8.9%) Control group n/n total CG 9/277 (3.2%) 3/220 (1.4%) 4/220 (2.0%) 5/220 (3.0%) Number needed to screen~ - n 14 10 29/221 (12.4%) 42/221 (30.0%) Phase Phase Phase • The overall atrial fibrillation detection yield after all phases of sequential cardiac monitoring was 23·7% (95% CI 17·2–31·0) • Stopping screening after phase or phase would have resulted in post-stroke atrial fibrillation diagnosis in 50·2% (*7·7 + 4·2+ / 23·7) or 81·9% (*7·7 + 4·2 + 7·5+ / 23·7), respectively, of those who would have been diagnosed after four phases Conclusion • Wide choice of devices to monitor cardiac rhythm • Choice dictated by – Frequency of symptoms – Cost – Invasiveness • Final choice may depend on cost-effectiveness and patient preference ... episodes – Can transmit over telephone lines Implantable loop recorders • Implanted subcutaneously – Examples include • Medronic – REVEAL – LINQ • St Jude – Confirm • Batteries last 2-3 years • Useful... episodic dizziness, or palpitation in whom other causes have been identified by history, physical examination or laboratory tests – Patients with CVA, without other evidence of arrhythmia Assessment