Il loop recorder esterno. Roberto Maggi

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1 Il loop recorder esterno Roberto Maggi

2 ECG monitoring and syncope In-hospital monitoring Holter Monitoring Event recorder External loop recorder Remote (at home) telemetry Implantable loop recorder

3 External loop recorder (ELR) Retrospective (loop) memory which continuously record and delete patient s ECG: - patient-activation (symptomatic events) - auto-activation (asymptomatic events) Retrospective memory differentiates ELR from event recorders

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5 Event recorder

6 ELR: available devices MCOT, Cardionet 3300 BT, Vitaphone King of the Heart, Instromedics SpiderFlash, Sorin Cardiocall, Reynolds Esaote Cardio PAL, Medicomp etc.

7 ELR remote data trasmission: Intermittent patient-activated (symptoms) Data stored in the device are sent on demand trough an analogic telephone transmission to physician. Local software for analysis Cardiology Department, Arrhythmologic Centre

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12 ELR remote data trasmission: Automatic intermittent trasmission (+ patient activated events) Automatic ECG transmission of predefined events via Bluetooth wireless link. Physician accesses data via Internet with a secure log-in CALL CENTER Cardiology Department, Arrhythmologic Centre

13 V-Patch

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15 ELR remote data trasmission: continuous automatic (remote telemetry) Continuous or 24 hour loop memory,wireless (real-time) to personal data manager and then trans-telephonic to service center CALL CENTER Cardiology Department, Arrhythmologic Centre

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17 ELR remote data trasmission: continuous automatic (remote telemetry)

18 ELR remote data trasmission: continuous automatic (remote telemetry)

19 ELR models At present, no system is proven to be superior to the other

20 Predictors of ELR diagnosis Gula L et al. Am Heart J 2004; 147:

21 ECG monitoring and syncope In-hospital monitoring Holter Monitoring External loop recorder Remote (at home) telemetry Implantable loop recorder Same positivity Criteria

22 ECG monitoring and syncope Positivity criteria Correlation between syncope and an ECG abnormality (brady- or tachyarrhythmia) (In the absence of such a correlation): - ventricular pause >3 sec during waking state - periods of Mobitz II 2 nd or 3 rd degree AV block during waking state - rapid paroxysmal atrial/ventricular tachycardia Correlation between syncope and sinus rhythm excludes arrhythmic syncope

23 ECG monitoring and syncope Diagnostic power In-hospital monitoring 1-7 Holter Monitoring 1-7 External loop recorder 30 Implantable loop recorder 500

24 External loop recorder Linzer et al AJC 1996 Sivakumaran et al AJM 2003 Gula et al Am Heart J 2004 Symptom frequency Median 10/year (>1/month in 70%) 5-10/year 7/month End-point Pre-syncope or syncope Pre-syncope or Syncope Pre-syncope or Syncope Monitoring duration Diagnostic value 4 weeks 4 weeks 4 weeks 25% 56% 59% Linzer M et al. Am J Cardiol 1990; 66: Sivakumaran et al. AJM 2003; 115:1-5 Gula L et al. Am Heart J 2004; 147:

25 External loop recorder Linzer et al AJC 1996 Schuchert et al PACE 2003 Symptom frequency End-point Monitoring duration Diagnostic value Median 10/year (>1/month in 70%) Pre-syncope or syncope <1/month (3±4 last 6 mos) Syncope 4 weeks 6 weeks 25% 4% Linzer M et al. Am J Cardiol 1990; 66: Schuchert A et al. PACE 2003; 26:

26 Mobile cardiac outpatient telemetry (MCOT) End-point Monitoring duration Rothman SA et al JCE 2007 Syncope or presyncope Up to 30 days Olson JA et al JCE 2007 Syncope or presyncope Up to 30 days Diagnostic value 89% 59% Rothman SA et al. JCE 2007; 18: Olson JA et al. JCE 2007; March

27 Mobile cardiac outpatient telemetry (MCOT) A prospective multi-center randomized study comparing mobile cardiac outpatient telemetry versus standard loop event monitoring MCOT External Loop p End-point Monitoring duration Diagnostic value Syncope or presyncope Syncope or presyncope 4 weeks 4 weeks 89% 69% Arrhythmias 41% 15% Rothman SA et al. JCE 2007; 18: 241-7

28 Mobile cardiac outpatient telemetry (MCOT) Olson JA et al. J Cardiovasc Electrophysiol 2007 Patients End-point Syncope or presyncope Palpitations Drug titration Monitoring duration Diagnostic value 4 weeks 4 weeks 4 weeks 59% 73% 33%

29 External loop recorder: palpitations End-point Diagnostic value Fogel et al Schmidt et al Symptom/ECG correlation 66% Symptom/ECG correlation 71 % Bhandari et al Martinez et al Symptom/ECG correlation Symptom/ECG correlation 63% - 69% 75% Fogel et al. Am J Card 1997; 79: Schmidt et al. Am J Med Sci 1988;296: Bhandari et al. Am Heart J 1992;124: Martinez et al. Int J Cardiol 2004; 97:

30 External loop recorder: comparative results Syncope Unit, Lavagna, 1/2005 7/2007 Syncope Pre-syncope Inclusion: symptom frequency >1/month 125 pts Palpitations 55 (44%) Arrhythmias 80 (64%) FU 30±16 days ECG-symptom correlation 25 (20%) No arrhythmias VPB/SVPB #18 AF/AFLU #18 SVT #12 VT #4 Pauses #3 The e-journal of Cardiology Practice, Volume 7, n 5, 2008

31 External Loop Recorder and syncope: Indications Class I None Class II May be useful in patients with recurrent (pre)syncopes who have the clinical or ECG features suggesting an arrhythmic syncope and inter-symptom interval 4 weeks ESC Guidelines on Management of Syncope Update 2004

32 Holter Event Recorders LRE Syncope Palpitations ECG trace quality Patient compliance Automatic arrhythmias detection ECG monitoring and syncope Costs LRI

33 Key points ELRs are much more useful for palpitations than for syncope evaluation ILRs consequently is less frequently indicated Event records are also useful when symptoms last enough to allow the patient to activate the recorder The diagnostic value of loop recorders is higher than Holter

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