Introduction. Keywords: Ambulatory electrocardiography, cardiac arrhythmias, syncope
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1 Hong Kong Journal of Emergency Medicine The use of ambulatory electrocardiography in the emergency medicine ward to assess patients with symptoms possibly related to cardiac arrhythmia: a sharing of experience in a local hospital CKK Chu, EFT Lee, CS Leung, ACH Lit Ambulatory electrocardiography (AECG) or Holter has a long history of use in patients with suspected symptomatic arrhythmia. In Hong Kong, patients with AECG monitoring were entirely under the care of internal medicine in the past. This report described a pioneer trial on the use of AECG in a local emergency setting under the supervision of emergency physicians. A departmental guideline for AECG use on suitable patients was drawn up and patients underwent AECG monitoring in the emergency medicine ward. The AECG results were reported preliminarily by emergency physicians and then confirmed with additional comments by cardiologists. This report presented the clinical features, AECG results and clinical outcomes of all patients recruited from the start of the protocol in May 2008 to July (Hong Kong j.emerg.med. 2010;17: ) Keywords: Ambulatory electrocardiography, cardiac arrhythmias, syncope Correspondence to: Chu Kwok Keung, Clarence, MBChB, MRCSEd Princess Margaret Hospital, Accident and Emergency Department, 2-10 Princess Margaret Hospital Road, Lai Chi Kok, Kowloon, Hong Kong chuclarence@gmail.com Lee Fu Tat, Eric, MRCP(UK), FRCSEd, FHKAM(Emergency Medicine) Leung Chin San, MRCSEd, FHKCEM, FHKAM(Emergency Medicine) Lit Chau Hung, Albert, MRCP(UK), FRCSEd, FHKAM(Emergency Medicine) Introduction Ambulatory electrocardiography (AECG/Holter monitoring) was first developed in the 1960s by Holter, as a method for continuous ECG monitoring. Under this method, a portable recorder is attached to the patient via chest electrodes, in which one to three ECG leads could be recorded throughout the day, while the patient carries out his/her usual daily activities. In
2 Chu et al./ambulatory electrocardiography 317 contrast to standard 12 leads ECG which provides a wider-view of the electrocardial activity with a short duration (usually shorter than 30 seconds), AECG provides a narrower view of data but can facilitate the diurnal ECG examination of a patient in response to the change in environmental factors over 24 hours. Clinical indications of AECG have been recommended by the American Heart Association (AHA). 1 The major use of AECG is to assess symptoms which are possibly related to cardiac rhythm disturbances (e.g. episodic dizziness, syncope, near syncope, unexplained/recurrent palpitation etc.). As most of the time, the symptoms or the underlying suspected cardiac arrhythmia is nonsustained and of short duration, the standard ECG can be entirely normal when such patients present to the accident and emergency department (A&E). AECG thus serves as an investigation, aiming for a higher yield of detection of possible cardiac arrhythmia, and its clinical efficacy in this aspect has been well established. 1 Compared to other forms of investigation such as electrophysiological study, the Holter study has been shown in a large prospective randomised trial the ESVEM trial to have equivalent predictive accuracy on the long term prognostic outcome in patients with malignant ventricular tachycardia. 2 Holter is well accepted as a cost-effective and non-invasive investigation with a reasonable yield. Besides detection of arrhythmia, the Holter study is also used in monitoring patients receiving antiarrhythmic therapy and those on pace-maker/ implanted defibrillator, and it can also be used in risk stratification of future cardiac events and prognostic assessment. However, we should bear in mind that the Holter study is not a screening test, and its use should be justified by the occurrence of symptoms and the whole clinical picture. In the setting of emergency medicine, the focus of using Holter is for early detection of possible life-threatening cardiac arrhythmia as a cause of symptoms such as sinus pause in syncope. For the other uses of AECG such as risk and prognostic assessment in those patients having history of significant cardiac event, we would try to refer the cases to cardiologists and medical colleagues for more detailed assessment. For the definition of "suspected arrhythmia-related symptoms" which warrants Holter assessment, there is so far no international consensus. Older studies tended to include palpitations as an arrhythmia-related symptom while recent studies emphasized on the symptoms associated with haemodynamic instability (i.e. syncope/dizziness/presyncope) in order to have a higher yield. 3 Besides, the predictive outcomes were highly variable among different studies. 4-7 Patient selection and methodology Two Holter machines had been introduced to our emergency medicine ward (EMW) since Both of them were from Philips (model 3100A, Digitrak-Plus 24) and consisted of 5 leads. EMW nurses received training from cardiac nurses on the application and technical aspects of the Holter machine. It took about 30 minutes to train a nursing staff to use the device. Any patient with history or symptoms suspicious of arrhythmia in origin, and considered unsafe to wait for an out-patient Holter, would be admitted to the EMW for observation and inpatient Holter investigation. We followed the ACC/ AHA guideline in patient selection. 1 Patients selected were haemodynamically stable, conscious and with a normal standard 12 leads ECG. Inpatient Holter is part of the investigation in our departmental guideline on syncope. Holter studies were usually initiated by consultants, senior medical officers or deputized senior medical officers who were responsible for ward rounds in the EMW. The installation of the Holter machine was done by trained EMW nurses. After 24 hours of monitoring, the Holter machines were sent to the Electronic Diagnostic Unit (EDU) for decoding. The patients would be discharged from the EMW if their clinical conditions were stable and the symptoms subsided. The preliminary Holter reports would be prepared by the emergency physicians who ordered the investigation, within one week. If any dangerous or significant arrhythmia (Table 1) was spotted, the patients would be called back immediately for assessment. Otherwise, the patients would be followed up at the A&E in two weeks time. The cases would be discharged if the A&E follow-up was uneventful. Formal Holter report would
3 318 Hong Kong j. emerg. med. Vol. 17(4) Sep 2010 be prepared by cardiologists within four weeks to confirm the findings of the preliminary Holter reports. The work-flow of arranging the Holter studies was shown in Figure 1. The work-flow of the followup and management of these cases was virtually the same as the current practice of the cardiac team in the Medical and Geriatric department of our hospital. Results Holter studies were done in 41 cases in the period from May 2008 to July 2009; 27 of them were males and 14 were females. Their age ranged from 18 to 86 years with a mean of 59. Nineteen out of the 41 cases have known history of one or more of the following diseases: diabetes mellitus, hypertension, stroke or ischaemic heart disease. All 41 cases were discharged from the EMW uneventfully without adverse event. The Table 1. Examples of dangerous/significant arrhythmias which require immediate call back 1. Sinus pause >3 seconds 2. Type II second degree atrio-ventricular block 3. Ventricular tachycardia 4. Tachy-bradycardia syndrome associated with symptoms 5. Paroxysmal supraventricular tachycardia 6. Paroxysmal atrial fibrillation 7. Multifocal premature ventricular ectopics Figure 1. Workflow of the Holter study.
4 Chu et al./ambulatory electrocardiography 319 presenting symptoms of the patients are shown in Figure 2. The percentages of positive findings (arrhythmia detected) in different presenting symptoms are shown in Table 2. All Holter studies were done during the EMW stay. There was one Holter study which failed reporting due to the presence of artifact noticed upon decoding, and the Holter study was not repeated afterwards. Most of the preliminary Holter reports were finished by emergency physicians within one week and confirmed by cardiologists within four weeks as shown in Table 3. In general, the comments made by emergency physicians in the preliminary Holter reports were comparable to those made by cardiologists. No dangerous arrhythmia was missed in all the preliminary reports. One case reported by the emergency physician as paroxysmal atrial fibrillation was interpreted by the cardiologist as sinus rhythm with premature atrial ectopics. Three cases of prolonged QTc and one case of ST segment depression found by our emergency physician were commented by the responsible cardiologists as "insignificant". The types and outcomes of arrhythmia found in the eight cases with positive Holter findings are listed in Table 4. Figure 3 shows the AECG rhythm strip of one of the cases as an example. None of the cases with abnormal findings required immediate hospital admission after the preliminary Holter report. For the first case in Table 4 which was found to have sinus pause, the patient had already been urgently referred to the medical out-patient clinic on the day of EMW discharge. Her Holter was reported just before her medical OPD appointment, so the patient was not called back for urgent admission. Discussion The number of positive Holter findings was quite significant in our series. Almost one-fifth (19.5%) of the patients were found to have significant cardiac Table 2. The percentage of cases with positive findings Presenting symptom Positive findings in Holter (%) Dizziness 2/5 (40.0%) Syncope/loss of consciousness 4/21 (19.0%) Palpitations 1/6 (16.7%) Combination of symptoms 0/8 (0%) Unexplained fall 1/1 (100%) Total 8/41(19.5%) Figure 2. Presenting symptoms of patients for the Holter study.
5 320 Hong Kong j. emerg. med. Vol. 17(4) Sep 2010 Table 3. Time of completion of preliminary and final Holter reports Number of preliminary reports Number of Holter reports done by EMW physician confirmed by cardiologist Within EMW stay 5/41(12.2%) 5/41 (12.2%) Within 2 days after discharge from EMW 20/41(48.8%) 19/41 (46.3%) Within 7 days after discharge from EMW 34/41(82.9%) 32/41 (78.0%) Within 14 days after discharge from EMW 38/41(92.7%) 37/41 (90.2%) Within 21 days after discharge from EMW 40/41(97.6%) 38/41 (92.7%) Within 28 days after discharge from EMW 40/41(97.6%) 38/41 (92.7%) EMW=Emergency Medicine Ward Table 4. Particulars of the cases with arrhythmia detected Age / sex Presenting symptom Arrhythmia detected by ambulatory ECG Outcome 1 81/F Dizziness Sinus pause > 4.7 sec Referred cardiac OPD Paroxysmal AF Pacemaker inserted subsequently PVC with one episode of R on T 2 79/M Dizziness AV block with R-R interval 2.2 sec Referred medical OPD 6 episodes of ST depression 3 62/M Syncope Daytime sinus bradycardia Follow-up in cardiac OPD (average rate 52, lowest 45) EPS may be considered 4 75/M Syncope Paroxysmal AF Referred medical OPD 5 51/F Syncope Episodes of ST depression mm Referred medical OPD suspicious of ischemic heart disease 6 18/M Syncope Sinus bradycardia (19.5/24 hours) Referred medical OPD for workup Lowest heart rate 30/min lasting 5 min 7 22/M Palpitation Frequent PVC (2473 beats in 24 hours) Referred medical OPD Short run of 4 consecutive PVC 8 75/F Unexplained fall Short run of SVT / atrial ectopics Follow-up in medical OPD AF=atrial fibrillation; AV=atrioventricular; EPS=electrophysiological study; OPD=outpatient clinic; PVC=premature ventricular contraction; SVT=supraventricular tachycardia arrhythmias. The percentage of positive Holter findings in our series was comparable to previous international studies. 3 This suggested the importance of the initiation of Holter investigation in EMW patients. Our experience showed that there were difficulties in correlating patient symptoms with the AECG findings. Although our nursing staff had already emphasized to every patient how and when to record their symptom events, none of the 41 patients pressed the "event" button to record any symptom during the 24 hours Holter studies. Without such record, it would be difficult to conclude whether the arrhythmia detected was directly related to the presenting symptom or just the "background casual arrhythmia". Under-reporting of symptom during AECG has been a well known factor largely affecting the accuracy and yield of AECG assessment. 3 In addition, without comparison to a control group, we failed to prove that introducing Holter in the emergency medicine ward could reduce patients' risk or the number
6 Chu et al./ambulatory electrocardiography 321 of unnecessary admission. However, our result did show that the introduction of EMW Holter enabled an earlier detection of arrhythmia, including some potentially serious arrhythmia such as long sinus pause, and speeded up their management. Moreover, we have shown that conducting Holter monitoring was feasible in the EMW and emergency physicians were competent in analysing the result. It could probably shorten the time for identifying arrhythmia in patients who were not known to have underlying cardiac disease. Conclusion Introducing AECG is feasible in the emergency medicine setting. AECG is useful in assessing patients presenting with potentially arrhythmia-related symptoms. Emergency physicians are competent in identifying arrhythmia in Holter. In collaboration with cardiologists, Holter monitoring is a safe investigation in the EMW. Hopefully, it can minimise the risk of patients by shortening the time to diagnosis and reduce Figure 3. Ambulatory ECG strip for Case 1, showing a long sinus pause.
7 322 Hong Kong j. emerg. med. Vol. 17(4) Sep 2010 unnecessary admissions. However, its success depends very much on careful selection of patients, training of nurses and education of patients to record symptom during the period of monitoring. References 1. Crawford MH, Bernstein SJ, Deedwania PC, DiMarco JP, Ferrick KJ, Garson A Jr, et al. ACC/AHA guidelines for ambulatory electrocardiography: executive summary and recommendations. A report of the American College of Cardiology/American Heart Association task force on practice guidelines (committee to revise the guidelines for ambulatory electrocardiography) Circulation 1999;100(8): The ESVEM trial. Electrophysiologic study versus electrocardiographic monitoring for selection of antiarrhythmic therapy of ventricular tachyarrhythmias. The ESVEM Investigators. Circulation 1989;79(6): Kennedy HL. Long-term (Holter) electrocardiogram recordings. In: Zipes DP, Jalife J, editors. Cardiac electrophysiology: from cell to bedside. Philadelphia: WB Saunders; Bass EB, Curtiss EI, Arena VC, Hanusa BH, Cecchetti A, Karpf M, et al. The duration of Holter monitoring in patients with syncope: is 24 hours enough? Arch Intern Med 1990;150(5): Zeldis SM, Levine BJ, Michelson EL, Morganroth J. Cardiovascular complaint: correlation with cardiac arrhythmias on 24 hour electrocardiographic monitoring. Chest 1980;78(3): Gibson TC, Heitzman MR. Diagnostic efficacy of 24 hour electrocardiographic monitoring for syncope. Am J Cardiol 1984;53(8): Johansson BW. Evaluation of alteration of consciousness and palpitations. In: Wenger NK, Mock MB, Ringquist I, editors. Ambulatory electrocardiographic recording. Chicago: Year Book Medical Publishers; 1981: p
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