Establishing a Smartphone Ambulatory ECG Service for Patients Presenting to the Emergency Department with Pre-Syncope and Palpitations

Background and Objectives: The Investigation of Palpitations in the ED (IPED) study showed that a smartphone-based event recorder increased the number of patients in whom an electrocardiogram (ECG) was captured during symptoms over five-fold to more than 55% at 90 days compared to standard care and concluded that this safe, non-invasive and easy-to-use device should be considered part of on-going care to all patients presenting acutely with unexplained palpitations or pre-syncope. This study reports the process of establishing a smartphone palpitation and pre-syncope ambulatory care Clinic (SPACC) service. Materials and Methods: A clinical standard operating procedure (SOP) was devised, and funding was secured through a business case for the purchase of 40 AliveCor devices in the first instance. The clinic was launched on 22 July 2019. Results: Between 22 July 2019 and 31 October 2019, 68 patients seen in the emergency departments (EDs) with palpitations or pre-syncope were referred to SPACC. Of those, 30 were male and 38 were female, and the mean age was 45.8 years old (SD 15.1) with a range from 18 years old to 80 years old. A total of 50 (74%) patients underwent full investigation. On the first assessment, seven (10%) patients were deemed to have non-cardiac palpitations and were not fitted with the device. All patients who underwent full investigation achieved symptomatic rhythm correlation most with sinus rhythm, ventricular ectopics, or bigeminy. A symptomatic cardiac dysrhythmia was detected in six (8.8%) patients. Three patients had supraventricular tachycardia (4%), two had atrial fibrillation (3%), and one had atrial flutter (2%). Qualitative feedback from the SPACC team suggested several areas where improvement to the clinic could be made. Conclusion: We believe a smartphone palpitation service based on ambulatory care is simple to implement and is effective at detecting cardiac dysrhythmia in ED palpitation patients.

Establishing a Smartphone Ambulatory ECG Service for Patients Presenting to the Emergency Department with Pre-Syncope and Palpitations

Background and Objectives: The IPED study showed that a smartphone-based event recorder increased the number of patients in whom an ECG was captured during symptoms over five-fold to more than 55% at 90 days compared to standard care [1] and concluded that this safe, non-invasive and easy to use device should be considered part of on-going care to all patients presenting acutely with unexplained palpitations or pre-syncope. This study reports the process of establishing a smartphone palpitation and pre-syncope service. Materials and Methods: A clinical Standard Operating Procedure (SOP) was devised, and funding was secured through a business case for the purchase of 40 AliveCor devices in the first instance. The clinic was launched on 22nd July 2019. Results: Between 22nd July 2019 and 31st October 2019, 68 patients seen in the ED with palpitations or pre-syncope were referred to SPACC. 30 were male and 38 female and mean age was 45.8 (SD 15.1) with a range from 18 to 80 years. 50 (74%) patients underwent full investigation. 7 (11%) patients were deemed on first assessment to have non-cardiac palpitations and were not fitted with the device. All patients who underwent full investigation achieved symptomatic rhythm correlation most with sinus rhythm, ventricular ectopics or bigeminy. A symptomatic cardiac dysrhythmia was detected in 6 (8.8%) patients. 3 patients had supraventricular tachycardia; SVT (4%), 2 had atrial fibrillation (3%) and 1 atrial flutter (2%). Qualitative feedback from the SPACC team suggested several areas where improvement to the clinic could be made. Conclusion: We believe a smartphone palpitation service based in ambulatory care is simple to implement and is effective at detecting cardiac dysrhythmia in ED palpitation patients.

Prospective case finding for patients at risk of future one-year incident cardiac dysrhythmia in the State of Maine (Preprint)

BACKGROUND Cardiac dysrhythmia is an extremely common disease among people today. While severe arrhythmias often cause a series of complications including congestive heart failure, fainting or syncope, stroke, and sudden death. OBJECTIVE The aim of this study was to predict incident arrhythmia prospectively within the next one year to provide early warning of impending arrhythmia. METHODS Retrospective (1,033,856 subjects registered between October 1, 2016 and October 1, 2017) and prospective (1,040,767 subjects registered between October 1, 2017 and October 1, 2018) cohorts were constructed from electronic health records integrated in the state of Maine. An ensemble learning workflow was built through multiple machine learning algorithms. Differentiated features including acute and chronic diseases, procedures, health status, laboratory tests, prescriptions, clinical utilization indicators, and social-economic determinants were compiled for incident arrhythmia assessment. The predictive model was retrospectively trained and calibrated using an isotonic regression method, and prospectively validated. RESULTS The cardiac dysrhythmia case finding algorithm (the areas under the receiver operating characteristic curve ROC AUC is: retrospective 0.854; prospective 0.819) divided the validation population into five risk subgroups: 53.348%, 44.832%, 1.757%, 0.060% and 0.003% cases in the very low-risk, the low-risk, the medium-risk, the high-risk, and the very high-risk subgroups. 51.85% patients in the very high-risk subgroup were confirmed with a new incident cardiac dysrhythmia within the next one year. CONCLUSIONS With the promise to predict future one-year incident cardiac dysrhythmias in a general population, we believe that our case finding algorithm can serve as early warning system to allow statewide population-level screening and surveillance to improve cardiac dysrhythmia care.

Implantable loop recorders for cardiac dysrhythmia monitoring

Incorporation of technological advances in healthcare delivery has played a foundational role in development of modern healthcare. With the use of wireless transmission in conjunction with digitization of electrocardiography, continuous monitoring strategies have redefined our approach to dysrhythmia. These devices show promising results in evolving implantable loop recorder technology. In this review, we summarize the history of remote monitoring, indications for loop recorders, devices available, evidence for specific devices and anticipated studies.