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HRDx Clinical Pathways

Cardiac Monitoring Post Cryptogenic Stroke

  • Approximately one-third of all ischemic strokes are labeled “cryptogenic” or “embolic stroke of undetermined source,” and occult paroxysmal AF is believed to be the cause for a significant number of these strokes.
  • Subclinical (silent) atrial fibrillation (AF) should be considered in all survivors of an ischemic stroke, especially those of undetermined source (i.e., cryptogenic stoke). Documentation of AF in these patient is necessary for initiation of appropriate anticoagulation, which is the cornerstone for stroke prevention in these patients.
  • Mobile cardiac telemetry (MCT) facilitates prompt detection of silent AF and allows for near-real-time notification of first documentation of AF, which enables early initiation of anticoagulation therapy.
  • Additionally, AF detection on MCT facilitates early enrollment of patient in cardiology/electrophysiology clinic for comprehensive evaluation and management of AF in these patients.
  • In addition to improving patient outcome, this clinical pathway for MCT reduces the cost of care. Early AF detection on MCT obviates the need for implantation of a loop recorder in a significant proportion of patients.

Example: Cardiac Monitoring Post Cryptogenic Stroke

  • In this example, a patient who presented with acute cryptogenic stroke was discharged from the hospital with MCT monitor for 30 days.
  • AF was detected on the 3rd day of monitoring. The AF episode was asymptomatic and lasted for more than 4 hours.
  • Detection of AF for the first time on MCT prompted notification of the managing medical practice within the same business day. The patient was subsequently started on oral anticoagulation and was referred to cardiac electrophysiology clinic for further management of AF.
  • If the patient was monitored using only a long-term Holter, the physician would have been alerted to the detection of AF only after the completion of the monitoring period and professional report interpretation. This could result in delay of initiation of anticoagulation therapy for weeks, which could be detrimental to patient outcome.
  • Also, implantation of a loop recorder is no longer necessary in this patient, since the diagnosis of AF has already been established on MCT.

Cardiac Monitoring Post TAVR

  • The risk of high-grade atrioventricular (AV) block requiring pacemaker implantation post transcatheter aortic valve replacement (TAVR) is estimated at 4–20%. Median time to develop AV block post-procedure is 6 days (range, 3-24 days).
  • While AV block requiring pacemaker implantation often develops within the first 24-48 hours of the procedure, delayed high-degree AV block (occurring later than 2 days after the procedure or after hospital discharge) has been reported in approximately 10% of patients post TAVR. The development of advanced AV block after hospital discharge can result in significant morbidity and mortality.
  • Although certain patient and procedural factors can predict an increased risk for delayed high-degree AV block, they do not reach sufficient sensitivity to identify those appropriate for preemptive pacing devices. Accordingly, different management strategies are often employed, ranging from invasive electrophysiological (EP) evaluation of the conduction system to prolonged inpatient and/or outpatient ambulatory cardiac monitoring.
  • In patients with new or worsened conduction disturbance post TAVR (>10% prolongation of the PR interval or QRS duration), early discharge after TAVR is less likely to be safe. Therefore, in-patient telemetry monitoring for at least 2 days is recommended and, if the rhythm disturbance does not progress, ambulatory cardiac monitoring (with urgent notification available for new AV block) for at least 14 days post discharge should be considered. If ambulatory cardiac monitoring is not going to be employed, in-patient telemetry monitoring for up to 7 days should be considered.
  • In this patient population, mobile cardiac telemetry (MCT) monitoring with near-real-time notification of clinically significant AV block can help
  • Shorten hospital length-of-stay.
  • Avoid invasive EP study.
  • Avoid unnecessary pacemaker implantations.
  • Reduce risk of sudden death caused by unattended AV block.

Example: Cardiac Monitoring Post TAVR

  • In this example, a patient developed mild prolongation of the PR interval immediately post TAVR, but no advanced AV block. He was discharged from the hospital the 2nd postoperative with MCT monitor for 14 days.
  • Intermittent 3rd–degree AV block with long ventricular pauses (lasting 7.4 seconds) were detected on day #4 of monitoring. The managing practice was immediately notified, and the patient was called and sent to emergency room. The patient subsequently underwent implantation of a permanent pacemaker.
  • If the patient was monitored using only a long-term Holter, AV block would have been addressed only after the completion of the monitoring period and professional report interpretation. This could result in delay of pacing therapy for days or weeks, which could be detrimental to patient outcome.

Cardiac Monitoring in Patients with AF

  • Patient with atrial fibrillation (AF) require careful management for rate and rhythm control, which often necessitates frequent adjustments of drug therapy and recurring visit to out-patient clinic. Suboptimal treatment can result in clinical deterioration leading to frequent emergency room visits and hospitalizations.
  • In patients with AF requiring on-going titration of drug therapy, mobile cardiac telemetry (MCT) allows continuous remote monitoring of AF burden and adequacy of rate control, which enables the provider to adjust drug therapy as needed to optimize management, while ensuring the absence of adverse effects caused by antiarrhythmic drug therapy, such as sinus bradycardia or ventricular arrhythmias.
  • In this setting, MCT can improve physician’s efficiency and timely intervention, which are critical for risk mitigation, prevention of hospitalization and readmission, as well as improved clinical outcome.

Example: Cardiac Monitoring in Patients with AF

  • In this example, a patient with was hospitalized with paroxysmal AF and rapid ventricular response. After initiation of drug therapy for rate and rhythm control, the patient was discharged from the hospital with MCT monitor for 30 days.
  • On-demand interim and daily summary reports during ongoing monitoring provided detailed data on the occurrence, frequency, and total burden of AF (blue arrows), data on adequacy of ventricular rate control during the episodes of AF (green arrows), as well as data on sinus node function and ventricular arrhythmias that can potentially caused by drug therapy.
  • These data enabled the physician to adjust drug therapy to optimize rate control and suppress AF while the patient was at home, obviating the need for frequent clinic visits, and prevented deterioration of the arrhythmia that would have otherwise resulted in emergency room visit and hospitalization.
  • Additionally, MCT monitoring facilitated expedited treatment decisions. Documentation of high-burden of symptomatic AF by MCT empowered the physician with data-driven management recommendations regarding the need for catheter ablation of AF.
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