Clinical Applications of Heart Rhythm Monitoring Tools in Symptomatic Patients and for Screening in High-risk Groups

Mafalda Carrington; Rui Providência; C. Anwar A. Chahal; Fabrizio Ricci; Andrew E. Epstein; Sabina Gallina; Artur Fedorowski; Richard Sutton; Mohammed Y. Khanji

Disclosures

Europace. 2022;24(11):1721-1729.

Abstract and Introduction

Abstract

Recent technological advances have facilitated and diversified the options available for the diagnosis of cardiac arrhythmias. Ranging from simple resting or exercise electrocardiograms to more sophisticated and expensive smartphones and implantable cardiac monitors. These tests and devices may be used for varying periods of time depending on symptom frequency. The choice of the most appropriate heart rhythm test should be guided by clinical evaluation and optimized following accurate characterization of underlying symptoms, 'red flags', risk factors, and consideration of cost-effectiveness of the different tests. This review provides evidence-based guidance for assessing suspected arrhythmia in patients who present with symptoms or in the context of screening, such as atrial fibrillation or advanced conduction disturbances following transcatheter aortic valve implantation in high-risk groups. This is intended to help clinicians choose the most appropriate diagnostic tool to facilitate the management of patients with suspected arrhythmias.

Introduction

Heart rhythm monitoring options have expanded beyond the classic 12-lead surface electrocardiogram (ECG), exercise ECGs and Holter monitors, now including smartphones, smartwatches and wristbands using electrodes or photoplethysmographic (PPG) sensors, extended rhythm recording using patches and wearables, external loop recorders (ELRs) and post-event recorders, handheld devices, ambulatory continuous cardiac telemetry monitoring, and implantable cardiac monitors (ICMs).^[1] Prolonged out-of-hospital heart rhythm monitoring is a key component of atrial fibrillation (AF) diagnosis and assessment of its burden. They are also essential to evaluate patients who suffered events potentially related to arrhythmia, such as stroke, or who present with unexplained symptoms such as palpitations or syncope that may be caused by other suspected arrhythmias. In the latter group of patients, the assessment of both frequency and severity of symptoms is crucial for choosing the most adequate method and duration of rhythm monitoring.

In this report, we summarize the current and future clinical applications for heart rhythm testing in patients at increased arrhythmic risk or with symptoms suspected to be due to arrhythmia (Figure 1).

(Enlarge Image)

Figure 1.

Indications for monitoring intermittent arrhythmias with smart electronic devices. Guideline recommendations (arrow); evidence-based indications suggested by the authors (dashed arrow). AC, arrhythmogenic cardiomyopathy; BBB, bundle branch block; CAD, coronary artery disease; CIED, cardiac implantable electronic devices; CMP, cardiomyopathy; CPVT, catecholaminergic polymorphic ventricular tachycardia; ECG, electrocardiogram; EPS, electrophysiological study; HCM, hypertrophic cardiomyopathy; LQTS, long QT syndrome; LV, left ventricle; OSA, obstructive sleep apnoea; SCD, sudden cardiac death; VA, ventricular arrhythmia. **Particularly important in athletes.

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Europace. 2022;24(11):1721-1729. © 2022 Oxford University Press
Copyright 2007 European Heart Rhythm Association of the European Society of Cardiology (ESC). Published by Oxford University Press. All rights reserved.

Abstract and Introduction
Syncope
Palpitations
Suspected Atrial Fibrillation
Rhythm Monitoring Following Transcatheter Aortic Valve Implantation
General Points for Consideration
Conclusions
References

Table 1. High risk clinical and electrocardiographic features in the assessment for cardiac arrhythmias
Red flags (adapted from ESC guidelines for the diagnosis and management of syncope²)
Non-electrocardiographic features
• Presence of structural heart disease
• Syncope during exertion or when supine
• Sudden onset palpitations immediately followed by syncope
• Associated severe symptoms such as chest discomfort and dyspnoea
• Family history of SCD at younger age.
Resting ECG findings
Bradycardia-related findings
• Bifascicular BBB (either left or right BBB combined with left anterior or posterior fascicular block)
• Intraventricular conduction abnormalities with QRS durations ≥120 ms
• AVB, from first degree AVB with markedly prolonged PR interval to third degree
• Sinus bradycardia or slow atrial fibrillation (<50 bpm)
• Sinus pauses >3 s in awake state, in the absence of physical training
• CIED malfunctions (e.g. oversensing, loss of capture)
Tachycardia-related findings
• Non-sustained or sustained VT
• Pre-excited QRS complexes
• Paroxysmal SVT or atrial fibrillation
• Long or short QT intervals
• Early repolarisation
• Type-1 Brugada pattern
• Epsilon Waves suggestive of AC
• Left ventricular hypertrophy suggestive of underlying cardiomyopathy
• ECG changes consistent with acute ischaemia
• CIED malfunctions (e.g. pacemaker-mediated tachycardia)

AC, arrhythmogenic cardiomyopathy; AVB, atrioventricular block; BBB, bundle branch block; CIED, cardiac implantable electronic devices ECG, electrocardiogram; ESC, European Society of Cardiology; SCD, sudden cardiac death; SVT, supraventricular tachycardia; VT, ventricular tachycardia.

Table 2. ISSUE classification for heart rhythm test findings and management options
ISSUE classification	Description	Final diagnosis	Management options
Type 1	Asystole (≥3 s)		Reflex syncope mechanism by clinical history: • Reassurance and counselling about the risk of recurrence and avoidance of triggers. Isometric counter-pressure manoeuvres and tilt training if hypotensive response, especially if positive tilt-test. ³ • Cardiac pacing if symptomatic asystole >3 s or asymptomatic asystole >6 s due to sinus arrest and/or AVB (patients >40 years of age).¹ Unexplained syncope by clinical history • Cardiac pacing if correlation between symptoms and ECG OR if Mobitz II second or three-degree AVB or prolonged asystole (>6 s).^1,3
1A	Sinus bradycardia plus sinus arrest	Reflex syncope probable, intrinsic sinus arrest possible
1B	Sinus bradycardia plus AVB	Reflex syncope probable, intrinsic AVB possible
1C	Sudden AVB	Intrinsic AVB, low-adenosine syncope possible
Type 2	Bradycardia with a decrease in heart rate of >30% or to <40 bpm for >10 s	Reflex syncope probable, intrinsic sinus arrest, or AVB possible
Type 3	No (3A) or slight (3B) rhythm variations occur	Non-cardiac cause probable, reflex syncope possible
Type 4	Tachycardia with an increase in heart rate of >30% or >120 bpm
4A	Progressive sinus tachycardia	Non-cardiac cause probable, orthostatic intolerance possible if accompanied by hypotension	• Reassurance and counselling about the risk of recurrence and avoidance of triggers. Isometric counter-pressure manoeuvres and tilt training if hypotensive response.³
4B	Atrial fibrillation, with rapid ventricular response		• ABC pathway ²³: Anticoagulation/Avoiding stroke, Better symptom control through rate and rhythm modifying therapies, Comorbidities/Cardiovascular risk factor management
4C	Supraventricular tachycardia	AV nodal re-entrant tachycardia, AV re-entrant tachycardia, atrial flutter, or focal atrial tachycardia	• Catheter ablation is the first choice in symptomatic patients. Alternatively, drug therapy.¹³
4D	Ventricular tachycardia	Sustained or non-sustained ventricular tachycardia	• Optimization of medical therapy of the underlying disease. Drug therapy, catheter ablation, or ICD implantation may be indicated.^2,3