Cardiac Event Monitors - Heart Monitor Comparison
- Holter - 24-48 hrs
• Continuous monitoring
- Event Monitor- 3-30 days
• Patient Triggered, Auto Triggered
- Mobile Cardiac Telemetry (MCT) - 3-30 days
• Continuous monitoring, Patient Triggered, Auto Triggered
- Patch - 14 days
• Continuous monitoring, Patient Triggered, Auto Triggered
- Implantable Loop Recorder (ILR) - Up to 3 years
• Continuous monitoring, Auto Triggered
- Commercial
• Patient Triggered
- BWH Medicine Chiefs @BrighamChiefs
#Event #Monitors #Comparison #cardiac #cardiology #holter #cardiology #management #selection #heart
Cardiac Event Monitoring Devices - Compared
Ambulatory ECG (Hotter):
• Advantages: Continuous recording, records asx events, all (most) ECG leads
• Disadvantages: Short monitoring period (48hrs), patient needs to keep symptom diary
Event Recorder:
• Advantages: Longer monitoring period, Correlation of rhythm and Xx
• Disadvantages: Does not detect ASx episodes, requires patient participation
Patch Monitor:
• Advantages: Continuous recording (up to 30d), wireless
• Disadvantages: Patient needs to keep symptom diary
Implantable Loop Recorder:
• Advantages: Continuous long term monitoring
• Disadvantages: Expensive, invasive
Commercial Devices:
• Advantages: Commercially available, fun, widespread
• Disadvantages: Limited data on ability to detect various arrhythmias
@NUIM_Chiefs
#Cardiac #Event #Monitoring #Devices #Comparison #cardiology #management #holter #Monitors
Pacemaker Operating Modes
1 - Chamber paced
A (atrium), V (ventricle), D (dual/both)
2 - Chamber sensed
A, V, D, O (if sensing is temporarily disabled)
3 - Response to sensed events
I - Inhibits pulse in response to sensed event
T - Triggers pulse in response to sensed event (A triggered only response has no clinical purpose)
D - Pulses can be either inhibited or triggered
O - No response to sensed events
4 - Rate modulation
R - Paced rate changes based on perceived physiologic need
(4th position is left blank if this function is not present)
Timing:
• Lower rate limit (50-60 bpm) - The lowest rate at which the device will allow the heart to beat
• Maximum tracking rate (a.k.a. upper rate limit) (120-130 bpm) - The fastest rate at which the device will pace the heart
• AV Delay (150-200 bpm) - The period of time the pacemaker waits after a sensed or paced atrial depolarization before pacing the ventricle if intrinsic ventricular conduction is not sensed
• Post-ventricular atrial refractory period (PVARP) (250-300 bpm) - The period of time after ventricular depolarization during which an atrial impulse sensed by the atrial lead will be ignored for timing cycle purposes. (PVARP is a safety feature: prevents sensing and inappropriate tracking of retrograde P waves which would trigger pacemaker-mediated tachycardia)
Additional Settings:
• Sensitivity - The voltage a lead must measure in order to respond to an intrinsic depolarization (i.e. either inhibit or trigger a pacing spike)
• Output - The voltage the pacemaker delivers to the myocardium in order to initiate depolarization (programmed as voltage x pulse width)
• Mode Switching - Mode can automatically change with changes in heart rhythm
- Dr. Eric Strong @DrEricStrong - Strong Medicine https://www.youtube.com/c/EricsMedicalLectures/featured
#Pacemaker #PPM #Operating #Modes #Pacing #settings #cardiology #management
If the patient has a HEART Score of 0-3 and a negative initial troponin, have a discussion with the patient utilizing the Shared Medical Decision-Making document (Figure 2). Inform the patient that based on validated studies, there is a < 2 % chance of an adverse cardiac event within the next 4-6 weeks. This discussion occurs after the first troponin, not after a second troponin.
The patient chooses amongst the three options listed in the Shared Medical Decision-Making document.
The patient can be offered, and may elect to remain for, a second troponin test and ECG obtained at hour three of the ED stay. If that troponin is negative as well, the patient can be informed that the risk of adverse cardiac event has been lowered to < 1% at 4 weeks. If the second troponin is increased by at least 20% and positive, the patient should be hospitalized for further evaluation.
The patient may elect to be admitted to the hospital or observation unit (based on hospital availability) for observation of occurrence of a cardiac event, or for provocative testing. The patient should be given honest information about the resulting length of stay.
The patient may elect to be discharged immediately after having the single troponin value and knowledge of the < 2% risk as described above.
If the patient chooses either the first or third option and is discharged after either one or two negative troponins, establish followup within one week and save a copy of the signed Shared Decision Making
Document in the chart. Our choice to recommend 1-week follow-up was by consensus and not based on published studies. However, we do not mandate a provocative test at that follow-up visit. The decision for further testing for risk stratification is left to the follow-up physician.
Document medical decision-making and HEART Score in the medical record.
Obtain an ECG at the time of arrival, and repeated along with each troponin, or if symptoms change. If evolving changes are noted on the repeat ECGs, the patient is judged higher risk and admitted.
#Management #PatientInfo #Cardiology #ChestPain #LowRisk #Percent3 #DecisionAid #SharedDecisionMaking #UMaryland
Preoperative Risk Evaluation
Major Pre-Op Questions:
1. Does the patient have any modifiable risk factors that could be optimized before surgery?
2. Would delaying the surgery increase the patient’s perioperative risk or morbidity?
3. Does the patient have enough info regarding the risk of the surgery to make an informed decision?
Key Components:
1. Take a thorough history (specific questions to ask)
- Any adverse events or complications from anesthesia in the past - personal or family
- Ever been intubated in the past? If yes, any mention of a difficult airway
- Allergies to medications?
- Any implantable devices?
2. Assess functional status
- Able to perform own ADLs
- Highest metabolic equivalent able to perform?
4 Mets = Climbing a flight of stairs, brisk 4 mph walk
3. Performance thorough physical exam - Key components:
- CV exam (any evidence of fluid overload, irregular rhythm, new murmur 3/6)
- Pulmonary exam
- Skin exam for infection
- Baseline neuroexam
- Oral cavity/Airway exam
Determine Cardiac Risk:
RCRI:
1. Risk of the particular surgery
2. Preop creatinine
3. Medical history of:
a) Ischemic heart disease
b) CHF
c) CVA
4. Insulin dependent DM
ACS NSQIP:
1. Risk for particular surgery
2. Preop creatinine
3. Age
4. Functional status
5. ASA class
If high risk > 1% risk of CV event, follow ACC algorithm to determine if stress test is indicated
• EKG Indicated? Obtain EKG if:
- Known CV disease
- Arrhythmia
- Structural heart disease
• Echo indicated?
- Patients with valvular dysfunction or LV dysfunction
or
a. Change in clinical status or physical exam since last echo
b. Stable patients with no echo in the last year
Risk Stratify Type of Surgery:
• High risk (>5%):
- Aortic
- Peripheral vascular
• Intermediate (1-5%):
- Intrathoracic
- Intraabdominal
- Orthopedic
• Low risk (<1%):
- Endoscopic procedures
- Cataract
Plan for Meds:
1. Anticoagulation - what is the bleeding risk of surgery? What is the type of and indication of AC?
2. ACEi/ARBs - Hold day of surgery
3. Diabetes regimen
4. NSAIDs - Hold 7 days before
5. VITAMINS/supplements - Hold 7 days before
Pulmonary:
• Smoking - quit > 8 weeks before surgery
• Screen for OSA
• Continue CPAP if they have one post op
Cardiology:
1. Recent PCI/stenting
2. Severe Aortic stenosis
3. Unstable Angina
Delay elective surgery if...
• <6mo since elective PCI/DES ( Levine 2016)
• <12mo since ACS ( Levine 2016)
• <6mo since stroke ( Doherty 2017)
• <3mo since VTE
Determine if any labs are needed:
• HgbA1c - if not done in last 3 months
• Creatinine - needed if result will change CV risk
Chest X-ray:
• Not indicated unless prior heart/lung issues
• Older > 50 years and undergoing AAA or upper abdominal/thoracic surgery
Stress Testing:
• Preoperative coronary revascularization does not seem to prevent postoperative cardiac events or death (CARP, DECREASE V trials)
• BUT, preoperative stress testing may inform risk discussions, perioperative medical and surgical management for select patients
#Preop #preoperative #perioperative #Risk #Evaluation #stratification #diagnosis
Perioperative Medications - Which Medications to Hold or Continue?
Aspirin - Continue
• Aspirin should be continued in patients with coronary stents unless the surgery has a very high bleeding risk (many neurosurgical procedures)
Metoprolol - Continue
• Evidence reveals multiple potential benefits (reduces O2 demand, controls arrhythmias) - Even some scenarios in which b-blockers should be initiated preoperatively to reduce cardiac mortality
• Abrupt withdrawal may result in angina, MI (box warning) as well as tachycardia and hypertension. Risks of withdrawal are not as important in patients taking beta blockers for reasons other than HF, CAD, or arrhythmias such as hypertension or migraine prophylaxis.
Lisinopril - Hold morning of surgery
• Data Is inconsistent with some studies revealing risk for prolonged postop hypotension (interestingly, not much mention of AKI)
• When indication is for HF or poorly controlled hypertension, may want to continue → Need to discuss with anesthesiology/surgical team to notify them of your reasoning
Atorvastatin - Continue
• There is evidence that statins may prevent vascular events in the perioperative period
Lasix - Hold morning of surgery
• Again, no consensus, but most recommend holding morning of.
• May consider continuing in patients with HF and difficult to control volume status.
Metformin - Hold morning of surgery
Empagliflozin (SGLT2 Inhibitors) - Hold 3-4 days before surgery
• Risk of UTI and hypovolemia. Also reports of AKI and euglycemic ketoacidosis.
Glargine - Continue
• Consider reducing by 15-20%, especially if patient has a history of low blood glucoses
Apixaban - Hold 2 days before surgery
• General approach is to estimate thromboembolic risk and bleeding risk Of surgery/procedure. Knee/hip surgeries are high bleeding risk.
• Most patients don't require bridging anticoagulation. May be necessary in patients on warfarin at high thromboembolic risk (mechanical heart valve, recent stroke).
Amlodipine - Continue
• Limited data re risks/benefits, but overall they appear to be safe and may even have some benefit on hemodynamic stability
Dr. Lizzy Hastie @LizzyHastie
#Perioperative #Medications #Hold #Continue #preop #preoperative
