Indication and choice of

Remote Monitoring
Dicky A Hanafy, MD
Department of Cardiology and Vascular Medicine
Faculty of Medicine, Universitas Indonesia
Pusat Jantung Nasional Harapan Kita
 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

• Ambulatory ECG (AECG) monitoring has

the potential to shape clinical practice

 Spectrum of AECG Monitoring Modalities

Suboptimal Ideal

J Am Coll Cardiol. 2011;58(17):1741-1749. doi:10.1016/j.jacc.2011.07.026

 Evolution of Outpatient
Cardiac Ambulatory Monitoring

Mobile
Cardiac
Outpatient
Outpatient Telemetry
Telemetry: (MCOT)
Patient
Implantable
Homebound
Loop Recorder
AF
Event Auto-Trigger
Monitor: Monitor
Looping
Event
Memory
Monitor:
Holter Non-Looping
Monitor Memory
 Categories of AECG recorders

Continuous Intermittent Cardiovascular

implantable electronic
recorders Recorders devices (CIEDs)

Event recorders -
Used for 24 to 48 hours, attached by the patient
can be longer and activated after the
onset of symptoms
Implantable cardioverter
defibrillators (ICDs),
permanent pace- makers,
and implantable loop
recorders (ILRs)

Symptoms or that are

Loop recorder - worn
continuously, can activate Continuous cardiac
likely to occur within that
the recorder immediately monitoring
time frame
and stored ECG

J Am Coll Cardiol. 2011;58(17):1741-1749

Types of AECG Monitors Currently Available (1)

(A) Holter, event,

and loop
monitoring

J Am Coll Cardiol. 2011;58(17):1741-1749

Types of AECG Monitors Currently Available (2)

(B) patch-type
extended Holter and
ambulatory telemetry
monitoring

J Am Coll Cardiol. 2011;58(17):1741-1749

 The use of AECG

1. The technical capacity of the available equipment (professional

and technical staff)
2. The diagnostic accuracy of the technique
3. The accuracy of the technique as compared with other diagnostic
procedures
4. The effect of positive or negative results on subsequent clinical
decision making
5. The influence of the technique on health-related out-comes.
 Indications for AECG to Assess Symptoms Possibly
Related to Rhythm Disturbances
Class I
1. Patients with unexplained syncope, near syncope, or episodic dizziness in whom the cause
is not obvious
2. Patients with unexplained recurrent palpitation
Class IIb
1. Patients with episodic shortness of breath, chest pain, or fatigue that is not otherwise
explained
2. Patients with neurological events when transient atrial fibrillation or flutter is suspected
3. Patients with symptoms such as syncope, near syncope, episodic dizziness, or palpitation in
whom a probable cause other than an arrhythmia has been identified but in whom
symptoms persist despite treatment of this other cause
Class III
1. 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
2. Patients with cerebrovascular accidents, without other evidence of arrhythmia

ACC/AHA Guidelines for Ambulatory Electrocardiography, JACC Vol. 34, No. 3, 1999 September 1999:912–48
 Indications for AECG Arrhythmia Detection to Assess Risk for
Future Cardiac Events in Patients Without Symptoms From
Arrhythmia

Class I - None
Class IIb
1. Post-MI patients with LV dysfunction
2. Patients with CHF
3. Patients with idiopathic hypertrophic cardiomyopathy
Class III
1. Patients who have sustained myocardial contusion
2. Systemic hypertensive patients with LV hypertrophy
3. Post-MI patients with normal LV function
4. Preoperative arrhythmia evaluation of patients for noncardiac surgery
5. Patients with sleep apnea
6. Patients with valvular heart disease

ACC/AHA Guidelines for Ambulatory Electrocardiography, JACC Vol. 34, No. 3, 1999 September 1999:912–48
 Types of AECG Monitors

• HOLTER MONITOR
• EVENT MONITOR: NON-LOOPING MEMORY
• EVENT MONITOR: LOOPING MEMORY
• IMPLANTABLE LOOP RECORDER
• OUTPATIENT TELEMETRY - In Home Only
• MOBILE CARDIAC OUTPATIENT TELEMETRY (MCOT)
 HOLTER MONITOR

• Norman J. Holter (1914 –1983)

in the 1940s

• The original Holter monitor was

a 75-lb backpack
• A reel-to-reel FM tape recorder
• Large batteries
 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)

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
• Low for intermittent symptoms or syncope: <5% to 13%
Gibson TC, Heitzma MR. Am J Cardiol 1984;53:1013-1017.
Zeldis SM, Levine BJ, Michelson EL, Morganroth J. Chest 1980;78:456-461.
Holter Monitoring

?
 EVENT MONITOR: NON-LOOPING MEMORY

Technology
• Electrodes not attached to skin, located on monitor
• Chest plate, “wrist watch” monitors
• Single lead transmission
• 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
• Allergy or unable to manage electrode patches

Positives
• Patient is not attached to electrodes

Negatives

• Delay in documenting symptoms

• Requires patient intervention to transmit
• No trending data (heart rate, AF)
• Compliance: must remember to have monitor at all times
• Single lead ECG rhythm strip
 EVENT MONITOR: LOOPING MEMORY

Technology
• Patient must press record button to capture symptomatic event
• Continuous loop of pre-memory. 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
• May have 1-6 events, approximately 6-10 minutes
of memory
 EVENT MONITOR: LOOPING MEMORY

Uses
• Infrequent symptoms
• Drug management

Positives
• 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% : failure to activate, human error, intimidated by
technology, inconvenient, difficulty with electrodes

Diagnostic yields
• Palpitations/Symptoms: Yields of 39%-68% reported
• Syncope/presyncope: Yields of 6%-25%
Kinlay S, Leitch JW, Neil A, et al. Ann Intern Med 1996;124:16-20.
Ximetbaum P, Kim KY, Ho KKL, et al. Am J Cardiol. 1997;79:371-372
 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
 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

Negatives
• Invasive procedure
• Over/undersensing causing false positives
• No ability to transmit remotely
• Limited memory

Diagnostic yields
• ECG correlation with symptoms 45-88%
Krahn AD, Klein GJ, Yee R. Et al. Circulation 2001; 104:46-51
Krahn AD, Klein GJ, Skanes AC, Yee R. Pace 2004;27:657-664
 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

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
• Up to 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)
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
• Post cardiac surgery
• Post ablation
• Drug management

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 and ability to contact patient
• 96 hours of retrievable memory and patient able to be mobile

Negatives
• Electrode irritation
Wireless MCOT
 Analysis

Arrhythmia Analysis
• Each beat is classified as normal, ventricular ectopic, supraventricular ectopic, paced, other,
or unknown
• The system automatically stores strips of significant arrhythmia events detected as well as
patient events
• Bradycardia, tachycardia, pauses

Ischemia Analysis
• The QRS-T morphology - to identify ischemic changes

Heart Rate Variability

T-wave alternans, Q-T interval dispersion, and signal-averaged analysis

J Am Coll Cardiol. 2011;58(17):1741-1749

 Summary Profile of Ambulatory ECG

Zimetbaum P, Goldman A. Circulation. 2010;122:1629-1636

TERIMA KASIH