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Il loop recorder esterno Roberto Maggi
Il loop recorder esterno
Roberto Maggi
ECG monitoring and syncope
• In-hospital monitoring• Holter Monitoring • Event recorder• External loop recorder• Remote (at home) telemetry• Implantable loop recorder
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
Event recorder
ELR: available devices
• MCOT, Cardionet• 3300 BT, Vitaphone• King of the Heart, Instromedics• SpiderFlash, Sorin• Cardiocall, Reynolds‐Esaote• Cardio PAL, Medicomp• etc….
ELR remote data trasmission:Intermittent patient-activated (symptoms)
Cardiology Department,Arrhythmologic Centre
Data stored in the device are sent on demand trough an analogic telephone transmission to physician. Local software for analysis
CALL CENTER
Cardiology Department,Arrhythmologic Centre
Automatic ECG transmission of predefined events via Bluetooth wireless link. Physician accesses data via Internet with a secure log-in
ELR remote data trasmission:Automatic intermittent trasmission
(+ patient activated events)
V-Patch
ELR remote data trasmission:continuous automatic (remote telemetry)
CALL CENTER
Cardiology Department,Arrhythmologic Centre
Continuous or 24 hour loop memory,wireless (real-time) to personal data manager and then trans-telephonic to service center
ELR remote data trasmission:continuous automatic (remote telemetry)
ELR remote data trasmission:continuous automatic (remote telemetry)
ELR models
At present, no system is proven to be superior to the other
Gula L et al. Am Heart J 2004; 147:644-648
Predictors of ELR diagnosis
ECG monitoring and syncope
• In-hospital monitoring• Holter Monitoring • External loop recorder• Remote (at home) telemetry• Implantable loop recorder
Same
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 2nd or 3rd degree AV block
during waking state- rapid paroxysmal atrial/ventricular tachycardia
• Correlation between syncope and sinus rhythmexcludes arrhythmic syncope
Positivity criteriaECG monitoring and syncope
ECG monitoring and syncope
Diagnostic power
In-hospital monitoring 1-7
Holter Monitoring 1-7
External loop recorder 30
Implantable loop recorder 500
External loop recorder
Linzer M et al. Am J Cardiol 1990; 66: 214-9Sivakumaran et al. AJM 2003; 115:1-5Gula L et al. Am Heart J 2004; 147:644-648
Linzer et alAJC 1996
Sivakumaran et alAJM 2003
Gula et alAm 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 orSyncope
Pre-syncope orSyncope
Monitoring duration 4 weeks 4 weeks 4 weeks
Diagnostic value 25% 56% 59%
External loop recorder
Linzer M et al. Am J Cardiol 1990; 66: 214-9Schuchert A et al . PACE 2003; 26: 1837-1840
Linzer et alAJC 1996
Schuchert et alPACE 2003
Symptom frequency
Median 10/year(>1/month in 70%)
<1/month(3±4 last 6 mos)
End-point Pre-syncope or syncope
Syncope
Monitoring duration
4 weeks 6 weeks
Diagnostic value
25% 4%
Mobile cardiac outpatient telemetry (MCOT)
Rothman SA et al. JCE 2007; 18: 241-7Olson JA et al. JCE 2007; March
Rothman SA et al JCE 2007
Olson JA et alJCE 2007
End-point Syncope or presyncope
Syncope or presyncope
Monitoring duration Up to 30 days Up to 30 days
Diagnostic value 89% 59%
Mobile cardiac outpatient telemetry (MCOT) A prospective multi-center randomized study comparing mobile
cardiac outpatient telemetry versus standard loop event monitoring
Rothman SA et al. JCE 2007; 18: 241-7
MCOT External Loop p
End-point Syncope or presyncope
Syncope or presyncope
Monitoring duration 4 weeks 4 weeks
Diagnostic value 89% 69% 0.008
Arrhythmias 41% 15% 0.001
Mobile cardiac outpatient telemetry (MCOT)
Olson JA et al.J Cardiovasc Electrophysiol 2007
Patients 17 18 21
End-point Syncope or presyncope Palpitations Drug titration
Monitoring duration 4 weeks 4 weeks 4 weeks
Diagnostic value 59% 73% 33%
External loop recorder: palpitations
Fogel et al. Am J Card 1997; 79:207-208Schmidt et al. Am J Med Sci 1988;296:299–302Bhandari et al. Am Heart J 1992;124:381–386Martinez et al. Int J Cardiol 2004; 97:495-498
End-point Diagnostic value
Fogel et al Symptom/ECGcorrelation 66%
Schmidt et al Symptom/ECGcorrelation 71 %
Bhandari et al Symptom/ECGcorrelation 63% - 69%
Martinez et al Symptom/ECGcorrelation 75%
External loop recorder: comparative resultsSyncope Unit, Lavagna, 1/2005 – 7/2007
125 pts
55 (44%)
80 (64%)
25 (20%)
125 pts
Inclusion: symptom frequency >1/month
ECG-symptomcorrelation
Arrhythmias
FU 30±16 days
No arrhythmias
VPB/SVPB #18AF/AFLU #18SVT #12VT #4Pauses #3
Palpitations
SyncopePre-syncope
The e-Journal of Cardiology Practice, Volume 7, n° 5, 2008 www.escardio.org
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-symptominterval ≤ 4 weeks
ESC Guidelines on Management of Syncope – Update 2004
Holter Event Recorders
LRE LRI
Syncope 0 0 + +++
Palpitations + ++ +++ +++
ECG trace quality
++ + ++ +++
Patient compliance
++ ++ ++ +
Automaticarrhythmiasdetection
++ 0 ++ ++
Costs +++ +++ ++ +
ECG monitoring and syncope
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
