Ambulatory Cardiac Monitoring Research Articles

A WELL KNOWN CARDIOMYOPATHY BEHIND A FAMILY DRAMA: A CASE REPORT

Abstract We report a case of a 55–year–old woman who came to our regional reference center for cardiomyopathies. Her cardiovascular risk factors were systemic arterial hypertension, dyslipidemia, family history of sudden cardiac death. Her first son –20 years old– had died of sudden cardiac death during a football match, at the peak of the exertion, one year before. The autopsy had showed biventricular, diffuse fibro–fatty replacement areas diagnostic for arrhythmogenic cardiomyopathy. DNA extraction in tissue was evaluated for genetic testing. According to 2022 ESC Guidelines, familial evaluation of descendents of patients died of sudden cardiac death should include: genetic testing, gathering of medical history and performing physical examination, standard and high precordial leads ECG, echocardiography and exercise testing, CMR and ambulatory cardiac rhythm monitoring. All of these were normal, except for cardio RM which revealed: aneurysmatic bulging of the right ventricular wall, most prominent at the apex and free wall with normal contractility. Absence of both left and right ventricular dilatation. Left ventricular and right ventricular ejection fraction measured 58% and 55% respectively. According to Padua’s criteria the woman had borderline arrhythmogenic cardiomyopathy. Instead, her 18 years old little son used to practice sports and used anabolics. His cardio–RMN demonstrated: reduced function of the right ventricle with mild dilation and biventricular bulging areas. The patient met the criteria for definite Arrhythmogenic Cardiomyopathy since he had two major criteria. In the meantime of the results of genetic testing, suspension of the smoking habit and reduction of strenuous physical activity were advised. Conclusions Arrhythmogenic displasia of right ventricle is characterized histopathologically by the extensive replacement of right ventricular myocardium with fibro–fatty tissue (dysplasia triangle). Involvement of the left ventricle has been documented on a lesser frequency and has a higher mortality. Different from other conditions, in arrhythmogenic cardiomyopathy, sports practice not only conveys arrhythmic risk to that specific moment (as it happens to the little patient) but also accelerates disease progression.

Comparing the outcomes and costs of cardiac monitoring with implantable loop recorders and mobile cardiac outpatient telemetry following stroke using real-world evidence.

Aim: Patients with ischemic stroke (IS) commonly undergo monitoring to identify atrial fibrillation with mobile cardiac outpatient telemetry (MCOT) or implantable loop recorders (ILRs). The authors compared readmission, healthcare cost and survival in patients monitored post-stroke with either MCOT or ILR. Materials & methods: The authors used claims data from Optum's de-identified Clinformatics® Data Mart Database to identify patients with IS hospitalized from January 2017 to December 2020 who were prescribed ambulatory cardiac monitoring via MCOT or ILR. They compared the costs associated with the initial inpatient visit as well as the rate and causes of readmission, survival and healthcare costs over the following 18months. Datasets were balanced using patient baseline and hospitalization characteristics. Multivariable generalized linear gamma regression was used for cost comparisons. Cox proportional hazard regression was used for survival and readmission analysis. Sub-cohorts were analyzed based on the severity of the index IS. Results: In 2244 patients, readmissions were significantly lower in the MCOT monitored group (30.2%) compared with the ILR group (35.4%) (hazard ratio [HR] 1.23; 95% CI: 1.04-1.46). Average cost over 18months starting with the index IS was $27,429 (USD) lower in the MCOT group (95% CI: $22,353-$32,633). Survival difference bordered on statistical significance and trended to lower mortality in MCOT (8.9%) versus ILR (11.3%) (HR 1.30; 95% CI: 1:00-1.69), led by significance in patients with complications or comorbidities with the index event (MCOT 7.5%, ILR 11.5%; HR 1.62; 95% CI: 1.11-2.36). Conclusion: The use of MCOT versus ILR as the primary monitor following IS was associated with significant decreases in readmission, lower costs for the initial IS and total care over the next 18months, significantly lower mortality for patients with complications and comorbidities at the index stroke, and a trend toward improved survival across all patients.

Adherence to adhesive patch electrocardiographic monitoring among adults with disabilities.

Individuals with developmental and/or intellectual disabilities (I/DD) are at a greater risk for atrial fibrillation (AF), the most common type of cardiac arrhythmia. AF is associated with heart failure, stroke, poor mental health, and reduced quality of life. Management and treatment decisions are based on the ability to detect AF; however, noninvasive, remote cardiac monitoring may not be tolerated by individuals with I/DD. To examine adherence to the placement of an ambulatory cardiac rhythm monitoring patch device by adult patients with I/DD. Investigators extracted chart data from a consecutive series of adult patients (18 years+) who received the patch device as part of standard treatment at an adult health center between November 1, 2015 and October 31, 2019. A total of 95 patients were included in data analysis. Average age of subjects was 53.8±13.9 years (range: 20.2-88.5); 66.7% were male. All subjects had intellectual disabilities as follows: mild, 37.9%; moderate, 29.5%; severe, 21.0%; and, profound, 11.6%. With a prescribed duration of 14 days, subjects wore the device a median (interquartile range [IQR]) of 12.2days (4.1-14.0); total analysis time was a median of 9.5 days (3.4-13.5). A total of 29 subjects (30.5%) received cardiac diagnoses not previously identified (median=1 new diagnosis; range: 1-5). This pilot study suggests the possible utility of an ambulatory monitoring patch device in an adult population with I/DD. Investigators recommend larger studies to confirm such preliminary findings to ultimately improve clinical management and patient quality of life.

A Residual U-Net Neural Network for Seismocardiogram Denoising and Analysis During Physical Activity.

Seismocardiogram (SCG) signals are noninvasively obtained cardiomechanical signals containing important features for cardiovascular health monitoring. However, these signals are prone to contamination by motion noise, which can significantly impact accuracy and robustness of the measurements. A deep learning model based on the U-Net architecture is proposed to recover SCG signals contaminated by motion noise induced by walking. The model performance was evaluated through qualitative visualization, as well as quantitative analyses. Quantitative analyses included distance-based comparisons before and after applying our model. Analyses also included assessments of the model's efficacy in improving the performance of downstream tasks related to health parameter estimation during walking. Experimental findings revealed that the denoising model improved similarity to clean signals by approximately 90%. The performance of the model in enhancing heart rate estimation demonstrated a mean absolute error of 1.21 BPM and a root-mean-squared error (RMSE) of 1.97 BPM during walking after denoising with 9.16 BPM and 10.38 BPM improvements, respectively, compared to without denoising. Furthermore, the RMSEs of aortic opening and aortic closing time estimation after denoising for one dataset with catheter ground truth were 7.29 ms and 19.71 ms during walking, respectively, with 50.33 ms and 51.91 ms RMSE improvements compared to without denoising. And for another dataset with ICG-derived PEP ground truth, the RMSE of aortic opening time estimation after denoising was 10.21 ms during walking, with 38.74 ms RMSE improvement compared to without denoising. The proposed model attenuates motion noise from corrupted SCG signals while preserving cardiac information. This development paves the way for improved ambulatory cardiac health monitoring using wearable accelerometers during daily activities.

Utility of smart watches for identifying arrhythmias in children

BackgroundArrhythmia symptoms are frequent complaints in children and often require a pediatric cardiology evaluation. Data regarding the clinical utility of wearable technologies are limited in children. We hypothesize that an Apple Watch can capture arrhythmias in children.MethodsWe present an analysis of patients ≤18 years-of-age who had signs of an arrhythmia documented by an Apple Watch. We include patients evaluated at our center over a 4-year-period and highlight those receiving a formal arrhythmia diagnosis. We evaluate the role of the Apple Watch in arrhythmia diagnosis, the results of other ambulatory cardiac monitoring studies, and findings of any EP studies.ResultsWe identify 145 electronic-medical-record identifications of Apple Watch, and find arrhythmias confirmed in 41 patients (28%) [mean age 13.8 ± 3.2 years]. The arrythmias include: 36 SVT (88%), 3 VT (7%), 1 heart block (2.5%) and wide 1 complex tachycardia (2.5%). We show that invasive EP study confirmed diagnosis in 34 of the 36 patients (94%) with SVT (2 non-inducible). We find that the Apple Watch helped prompt a workup resulting in a new arrhythmia diagnosis for 29 patients (71%). We note traditional ambulatory cardiac monitors were worn by 35 patients (85%), which did not detect arrhythmias in 10 patients (29%). In 73 patients who used an Apple Watch for recreational or self-directed heart rate monitoring, 18 (25%) sought care due to device findings without any arrhythmias identified.ConclusionWe demonstrate that the Apple Watch can record arrhythmia events in children, including events not identified on traditionally used ambulatory monitors.

Comparative effectiveness and healthcare utilization for ambulatory cardiac monitoring strategies in Medicare beneficiaries

Objective data comparing the diagnostic performance of different ambulatory cardiac monitors (ACMs) are lacking. To assess variation in monitoring strategy, clinical outcomes and healthcare utilization in patients undergoing ambulatory monitoring without a pre-existing arrhythmia diagnosis. Using the full sample (100%) of Medicare claims data, we performed a retrospective cohort study of diagnostic-naïve patients who received first-time ACM in 2017 to 2018 and evaluated arrhythmia encounter diagnosis at 3-months, repeat ACM testing at 6 months, all-cause 90-day emergency department (ED) and inpatient utilization, and cost of different strategies: Holter; long-term continuous monitor (LTCM); non-continuous, event-based external ambulatory event monitor (AEM); and mobile cardiac telemetry (MCT). We secondarily performed a device-specific analysis by manufacturer, identified from unique claim modifier codes. ACMs were used in 287,789 patients (AEM=10.3%; Holter=53.8%; LTCM=13.3%; MCT=22.5%). Device-specific analysis showed that compared to Holter, AEM, MCT, or other LTCM manufacturers, a specific LTCM (ZioⓇ XT 14-day patch, iRhythm Technologies, San Francisco, CA) had the highest adjusted odds of diagnosis and lowest adjusted odds of ACM retesting. Findings were consistent for specific arrhythmia diagnoses of ventricular tachycardia, atrioventricular block, and paroxysmal atrial fibrillation. As a category, LTCM was associated with the lowest 1-year incremental health care expenditures (mean Δ$10,159), followed by Holter ($10,755), AEM ($11,462), and MCT ($12,532). There was large variation in diagnostic monitoring strategy. A specific LTCM was associated with the highest adjusted odds of a new arrhythmia diagnosis and lowest adjusted odds of repeat ACM testing. LTCM as a category had the lowest incremental acute care utilization. Different monitoring strategies may produce different results with respect to diagnosis and care.

AI remote ECG monitoring improves arrhythmia detection

Abstract Background Ambulatory ECG monitoring is needed to investigate intermittent heart rhythm symptoms. Traditional monitoring approaches are resource intensive, requiring multiple patient hospital visits and time-consuming analysis, using fixed capacity monitoring equipment. Low diagnostic yield means tests are often repeated. Purpose We carried out a large pilot to compare ambulatory cardiac monitoring with an AI-led remote ECG monitoring service (Zio XT) with Holter monitoring. Patients were fitted with single-use Zio monitoring patches, which they wore for 14 days of continuous monitoring and then returned it by Freepost for outsourced analysis and reporting. Methods Over the course of 12 months, 3505 patients were involved in evaluation of Zio. Of these, we reviewed the detailed rhythm data of 200 consecutive patients, and compared this with a retrospective cohort of 200 consecutive standard Holter monitored patients, fitted prior to the evaluation period. All patients had been referred to cardiology for investigation of heart rhythm symptoms. Results The total Zio group had a mean age of 63.8 years. The 400 participants used in the analysis groups matched this (Table) and there was no significant difference in the age ranges between the two groups. Holter duration was for: 24-hr (45%), 48-hr (8%), 72-hr (20%), 5-day (2%), 7-day (26%). Significant arrhythmias (defined as SVT ≥ 30s, VT ≥ 8bts, AV Block Mob 2⁰ or 3⁰, Pause ≥ 3s, Paroxysmal AF) were detected in 49 (25.8%) Zio patients compared with 18 (9.0%) Holter patients (P<0.00001). Total number of arrhythmia findings was greater in Zio compared with Holter; P<0.05 (Table). The arrhythmia findings in Zio were comparable with those in the pilot’s total cohort. In Holter, 41% of significant arrhythmias were detected in patients monitored for 24 hrs, comparable with Zio where 46% of arrhythmias were detected within the first 24 hours of wear-time. In Zio, 15% of significant arrhythmias were detected post 7 days of the wear-time. Conclusions Arrhythmia detection with Zio was significantly greater compared with Holter; detecting significant arrhythmias in nearly 3 times as many patients. Longer detection enabled greater arrhythmia detection, with 3 in every 20 patients having episodes occurring after 7 days. Even when adjusting for wear time, arrhythmia detection within 7 days was superior in the Zio group. Over half (59%) of arrhythmias were detected in patients monitored for 48 hours or longer, suggesting that for an efficient service longer monitoring is needed, particularly when symptoms are intermittent. For Holter monitoring this has considerable resource utilisation implications, relating to staff (cardiac physiologist) time and capital equipment (Holter monitoring stock). Also, greater detection of arrhythmia across the wear time suggests a higher sensitivity than Holter for detecting cardiac arrhythmias.

Abstract 12649: Harnessing Ambulatory Monitoring Data to Improve Prediction of Heart Failure

Introduction: Despite growing evidence that atrial fibrillation (AF) burden impacts clinical outcomes, few clinical risk scores incorporate individual-level arrhythmia characteristics. We analyzed predictors of hospitalization for heart failure (HF) in patients using both clinical history and ambulatory cardiac monitoring data. Methods: We evaluated patients who underwent Zio XT ambulatory monitoring in the US (2014-2020). The monitoring data were linked with clinical data from Centers for Medicare and Medicaid Services. Patients on anticoagulation or anti-arrhythmic therapy and those with evidence of sustained VT, known ventricular fibrillation/flutter, prior ablation, prior left atrial appendage occlusion, or cardiac arrest in the prior year were excluded. We randomly divided our dataset into a 70% training dataset and 30% testing dataset. Predictive models were generated using LASSO Cox regression for variable selection in the training dataset and evaluated on testing dataset among ambulatory ECG variables and the components of CHA 2 DS 2 -VASC. Results: Among 224,682 patients in the training dataset, 4,021 (1.8%) were hospitalized for HF within 1 year. A model that included components of the CHA 2 DS 2 -VASC and all ECG variables (excluding multicollinear variables) had greater discrimination and calibration for HF hospitalization (C-statistic 0.85 [0.84-0.86]), compared with the CHA 2 DS 2 -VASC score alone (C-statistic 0.73 [0.72-0.74], Figure ). ECG findings with the greatest predictive value were the presence of premature ventricular couplets (HR 1.54 [1.43-1.65]) and presence of AF (HR 1.53 [1.35-1.72]). Conclusion: A model that incorporates both ECG variables from ambulatory monitoring data and the components of the CHA 2 DS 2 -VASC provides better discrimination for the risk of HF hospitalization compared with the CHA 2 DS 2 -VASC risk score alone. Premature ventricular couplets and AF are highly associated with HF hospitalization.

Abstract 14201: Double the Trouble: Extremely Rare Incidental Finding of a Double Interatrial Septum With Atrial Septal Aneurysm and Coexisting Patent Foramen Ovale

Case: A 59-year-old female with a past medical history of hypothyroidism and IgG deficiency presents to cardiology clinic due to palpitations and premature ventricular complexes (PVCs) noted at a recent urgent care visit. In-office vitals, physical exam, labs, and EKG were unremarkable. Ambulatory cardiac monitoring showed predominantly sinus rhythm with a PVC burden of 1.4%. Echocardiogram revealed an extremely rare structural anomaly – a double interatrial septum (DIAS) with atrial septal aneurysm. Cardiac MRI (cMRI) further confirmed the presence of a DIAS enclosing an interatrial space, along with blood flow within the interatrial space and a discontinuity in the anterior right lateral atrial septum suggestive of a patent foramen ovale (PFO). There was no evidence of thrombus within the interatrial or intracardiac spaces. Mild right atrial enlargement was seen. The patient was initiated on aspirin for cardioembolic stroke prophylaxis. Discussion: DIAS is a highly rare congenital cardiac anomaly with limited number of cases in literature. It has been described as a midline third atrium resulting in a “tri-atrial heart”. As of 2018, less than 20 cases have been cited. DIAS is characterized by two parallel interatrial septa along with a clear echo lucent midline space that expands in systole and collapses in diastole. This case is unique as it is one of the few to include additional characterization with cMRI. Patients with DIAS are usually asymptomatic but can experience cardioembolic events as the interatrial space is at risk for thrombus formation. Communication across the DIAS makes these events more likely. Unlike with atrial fibrillation/flutter, no current criteria for anticoagulation (AC) initiation exists for DIAS given the scarcity of cases. While some sources advocate for use of anti-platelet agents, others have indicated a preference for oral AC. Our patient had an interatrial space and a PFO but lacked communication across the DIAS, had low bleeding risk, and no other classic risk factors of Virchow’s triad. We determined her risk for thrombus formation to be relatively low, and thus initiated her on aspirin over oral AC. Percutaneous closure of the interatrial space was deferred as it has been dismissed as a viable treatment option in the literature.

Mobile electrocardiographic devices and healthcare utilization in post-atrial fibrillation ablation patients.

The use of mobile electrocardiogram (mECG) devices is becoming more prevalent. mECG devices allow instant access to recording arrhythmias and enable automatic rhythm interpretation. Providers can remotely evaluate patients and this may reduce in-person healthcare utilization. We sought to evaluate the utility of mECG devices in reducing healthcare utilization among patients who underwent atrial fibrillation (AF) ablation. We identified a population of patients with paroxysmal or persistent AF presenting for their first AF ablation. Patients were divided into two groups: KardiaMobile (AliveCor, Mountain View, CA) mECG users and non-KardiaMobile users. Healthcare utilization was compared between the two groups for one year post-ablation. 184 patients were studied (76 KardiaMobile users, 108 non-KardiaMobile users). There was no difference in the number of office visits (p=0.59), cardiac-specific emergency department visits (p=0.26), cardiac-specific hospital admissions (p=0.13), ablations or cardioversions completed (p=0.24), telephone encounters (p=0.05), patient electronic health record messages (p=0.40), or cardiac imaging (transthoracic or transesophageal echocardiograms) tests ordered (p=0.36). Exposure to the device was associated with a reduction in ambulatory cardiac monitor use (p=0.04). There was no difference in sinus rhythm maintenance over 12months by Kaplan-Meier survival analysis (log rank test p=0.05) between groups. Mobile technology is available for heart rhythm monitoring and can give instant feedback to the user. mECG use is associated with a significant reduction in ambulatory cardiac monitor use in the post-ablation period. There was no difference in other AF-related healthcare utilization.

Skin‐Adherent Elastomer‐Hydrogel Patch for Continuous 12‐Lead Cardiac Ambulatory Monitoring during Physical Activities (Adv. Mater. Technol. 18/2023)

Skin‐Adherent Elastomer‐Hydrogel Patch for Continuous 12‐Lead Cardiac Ambulatory Monitoring during Physical Activities (Adv. Mater. Technol. 18/2023)

Atrial Fibrillation Burden and Atrial Shunt Therapy in Heart Failure With Preserved Ejection Fraction

BackgroundAtrial fibrillation (AF) is a common comorbidity in patients with heart failure with preserved ejection fraction (HFpEF) and in heart failure with mildly reduced ejection fraction (HFmrEF). ObjectivesThis study sought to describe AF burden and its clinical impact among individuals with HFpEF and HFmrEF who participated in a randomized clinical trial of atrial shunt therapy (REDUCE LAP-HF II [A Study to Evaluate the Corvia Medical, Inc IASD System II to Reduce Elevated Left Atrial Pressure in Patients with Heart Failure]) and to evaluate the effect of atrial shunt therapy on AF burden. MethodsStudy investigators characterized AF burden among patients in the REDUCE LAP-HF II trial by using ambulatory cardiac patch monitoring at baseline (median patch wear time, 6 days) and over a 12-month follow-up (median patch wear time, 125 days). The investigators determined the association of baseline AF burden with long-term clinical events and examined the effect of atrial shunt therapy on AF burden over time. ResultsAmong 367 patients with cardiac monitoring data at baseline and follow-up, 194 (53%) had a history of AF or atrial flutter (AFL), and median baseline AF burden was 0.012% (IQR: 0%-1.3%). After multivariable adjustment, baseline AF burden ≥0.012% was significantly associated with heart failure (HF) events (HR: 2.00; 95% CI: 1.17-3.44; P = 0.01) both with and without a history of AF or AFL (P for interaction = 0.68). Adjustment for left atrial reservoir strain attenuated the baseline AF burden-HF event association (HR: 1.71; 95% CI: 0.93-3.14; P = 0.08). Of the 367 patients, 141 (38%) had patch-detected AF during follow-up without a history of AF or AFL. Atrial shunt therapy did not change AF incidence or burden during follow-up. ConclusionsIn HFpEF and HFmrEF, nearly 40% of patients have subclinical AF by 1 year. Baseline AF burden, even at low levels, is associated with HF events. Atrial shunt therapy does not affect AF incidence or burden. (A Study to Evaluate the Corvia Medical, Inc IASD System II to Reduce Elevated Left Atrial Pressure in Patients with Heart Failure [REDUCE LAP-HF II]; NCT03088033)

Skin‐Adherent Elastomer‐Hydrogel Patch for Continuous 12‐Lead Cardiac Ambulatory Monitoring during Physical Activities

AbstractContinuous electrocardiography (ECG) monitoring is a necessity to prevent the sudden occurrence of cardiac events and premature death. Wearable bioelectronics provides the opportunity to realize noninvasive 12‐lead ambulatory monitoring for cardiovascular disease (CVD) detection and diagnosis. This work introduces a 12‐lead ECG patch that eliminates the issues associated with compliance, skin damage, and user‐discomfort encountered in conventional ECG sensors. The patch is safe, stretchable, and skin‐adherent with an adaptable design that allows for user‐friendly ECG monitoring. These can be attributed to the unique 3‐bridge patch structure, embedded liquid metal circuitry, and the wet‐adhesive polyacrylamide‐polydopamine‐tannic acid (PAM‐PDA‐TA) hydrogel. The hydrogel displays improved wet adhesiveness and biosafety for long‐term usage on deforming skin. The patch can acquire clean and consistent ECG signals with a higher signal‐to‐noise (SNR) ratio compared to commercial electrodes during both static and dynamic monitoring. The outstanding performance of the patch ascertains its potential for daily continuous ECG monitoring and remote diagnosis.

PE-454609-2 MARFAN SYNDROME AND VENTRICULAR ARRHYTHMIAS IN PEDIATRICS: MITRAL ANNULAR DISJUNCTION, MITRAL VALVE PROLAPSE OR BOTH – WHICH IS THE REAL CULPRIT?

Mitral Annular Disjunction (MAD) and Mitral Valve Prolapse (MVP) have been associated with sudden death and ventricular arrhythmias (VA) in adults with connective tissue disease (CTD). While rare, there has been a case report of sudden cardiac death due to VA in a pediatric Marfan patient. However, risk factors have not been well described in this population. Our aim is to assess the association of MAD and MVP with VA in pediatric patients with Marfan syndrome. A retrospective single center cohort study was conducted and included all patients (≤ 21yrs) with clinical (based on Ghent’s criteria) and/or genetic diagnosis of Marfan syndrome. Clinical data including ambulatory cardiac monitoring and echocardiograms were reviewed prior to any mitral valve intervention, if applicable. 32 patients (38% female) with Marfan syndrome (66% with fibrillin 1 mutation) were included. The mean age was 13.5 ± 4.5 yrs. The results revealed MAD in 8 pts (25%), isolated MVP in 5 pts (16%) and bileaflet MVP in 14 pts (44%). Anterior MVP was seen in 16 pts (50%) and posterior MVP in 17 pts (53%). The mean MAD distance was 6.7 ± 2.3 mm. There was normal LV systolic function in 31 pts (97%). The median duration of cardiac monitoring was 58 hrs (IQR: 33-191). 26 pts (81%) had isolated ventricular ectopy (VE), 27 pts (84%) had complex VE (defined as couplets, triplets or NSVT), 4 pts (12.5%) had NSVT and none had sustained VT. The median VE per hour was 0.2 (IQR: 0-1). There was no R on T seen but short coupled VE (<350ms) was seen in 46% of isolated, 46% of couplets and 67% of triplets. Monomorphic ectopy was seen in 28% of isolated and 100% of couplets, triplets and NSVT. There were 5 total episodes of NSVT (Figure 1) with a mean HR of 159 ± 29 bpm, an absolute minimum HR of 94 bpm and maximum HR of 222 bpm. MAD was not associated with the presence of, or complexity in, ventricular arrhythmias. Anterior MVP was only associated with complexity in VE (p= 0.043), but posterior MVP and bileaflet MVP were not. MAD was associated with MVP (anterior, posterior and bileaflet; p= 0.026). There was a high incidence of complex VE and NSVT in this cohort of pediatric Marfan patients despite low overall ectopy burden. Anterior MVP but not MAD was associated with complexity in VE. However, MAD was associated with MVP. Larger studies are needed to better characterize MAD, including distance and circumferential extent, and MVP and their association with VA in pediatric patients with CTD.

PO-03-205 ARRHYTHMIA BURDEN REVEALED BY AMBULATORY CARDIAC MONITORING IN A MEDICARE ADVANTAGE POPULATION

Medicare Advantage plans enroll an increasing proportion of Medicare beneficiaries annually. The capitation payment model for Medicare Advantage plans is dependent on prompt and accurate coding of Hierarchical Condition Categories (HCCs) that impact risk-adjusted payments. Reporting of disease is critical for clinics to estimate expenditures of Medicare Advantage populations with significant cardiac comorbidities. To quantify arrhythmia burden and potential risk adjustment impact in a Medicare Advantage population. We reviewed ambulatory electrocardiogram (ECG) monitors of 909 patients insured under a Medicare Advantage plan across 19 states. Each patient was enrolled in 14-day electrocardiogram monitoring according to clinical indication. Specialists evaluated recorded abnormal events and provided final interpretations. Standardized specialist-derived criteria were developed to assess for atrial arrhythmias, heart block, sick sinus syndrome, supraventricular tachycardia, and ventricular arrhythmias. Each patient with atrial fibrillation, supraventricular tachycardia, or sick sinus syndrome was assigned HCC96 (Specified Heart Arrhythmias). An additional monthly Medicare payment was calculated by multiplying the HCC96 coefficient of 0.268 by $750 (the approximate monthly Medicare payment corresponding to one point in risk adjustment). The average age of the sample population was 71.2 +- 0.3 (SE) years and 65.6% of patients were female. Common indications for ambulatory cardiac monitoring included palpitations (21.8%), syncope (15.4%), concern for atrial arrhythmia (9.5%), tachycardia (6.5%), and bradycardia (5.0%). Patients wore the ECG monitor for an average of 13 days. Abnormal findings included supraventricular tachycardia (59.4%), nonsustained ventricular tachycardia (6.7%), atrial fibrillation (3.0%), second- or third-degree heart block (1.2%), and sick sinus syndrome (2.6%). A majority (61.4%) had a diagnosis that could impact risk adjustment, leading to a potential increase of $1.35 million in annual Medicare reimbursement assuming this is the first recorded diagnosis of arrhythmia. Ambulatory ECG monitors reveal a high prevalence of arrhythmias that can have a significant risk adjustment impact for Medicare Advantage capitation plans. Additional clinical correlation is necessary to confirm the expected change in annual Medicare reimbursement.

Continuous Ambulatory Wireless Cardiac Monitoring: A Screening Tool for Cardiac Rhythm Disorders

Continuous Ambulatory Wireless Cardiac Monitoring: A Screening Tool for Cardiac Rhythm Disorders

A Capacitive Electrocardiography System With Dedicated Noise-Cancellation Algorithms for Morphological Analysis.

Capacitive electrocardiography (cECG) has been proposed for ambulatory cardiac health monitoring. However, due to the high sensitivity of capacitive electrodes to various noise sources, particularly the power-line interference (PLI) and motion artifacts (MA), the existing capacitive systems are only verified in terms of RR interval. The aim of the present study is to explore the feasibility of using cECG for morphological analysis, and thus to extract clinical meaningful parameters. A capacitive electrode with active guarding is realized. A phase-locked-loop (PLL) based adaptive canceller is employed to remove PLI from the cECG. Wavelet analysis is adopted to cancel other noises. The developed capacitive system and algorithms are evaluated by real ECG measurements on 7 volunteers using 3-lead configuration. The correlation coefficient (CC) between the processed cECG and the wet ECG is calculated in two different conditions: with and without the QRS complex. Several frequently used diagnostic parameters, i.e., RR interval, QRS interval, P segment, T segment, ST segment, are extracted and compared with that obtained from the wet ECG. High CCs are observed between the cECG and the wet ECG in both conditions, i.e., 0.97±0.03 with the QRS complex and 0.92±0.07 without the QRS complex. Besides, RR interval extracted from the two different ECG signals are identical for each subject. Other diagnostic parameters are quite similar. Our results suggest cECG to be reliable for ambulatory heart rate monitoring. The results also indicate the feasibility of using cECG for clinical diagnosis.

Abstract Number ‐ 278: Transient Ischemic Attack Evaluation Pathways: Inpatient Versus Expedited Outpatient Comparative Analysis

Introduction Transient Ischemic Attack (TIA) evaluation requires urgent etiology identification and targeted stroke prevention, traditionally performed via hospital admission. The literature suggests that outpatient evaluation may be safe and cost‐effective. Hence, we implemented an expedited outpatient pathway (OP) for patients presenting to our institution’s Emergency Department (ED) with TIA. To further guide future practice, we compared clinical features and outcomes between expedited OP and our well‐established inpatient pathway (IP). Methods We implemented an algorithm of direct communication between ED providers and Vascular Neurologists for all TIA patients. Certain screening studies (head CT, CT angiogram, basic laboratories) and acute therapies were implemented in the ED, whereas others (brain MRI, echocardiogram, etc) and Vascular Neurology consultations were expedited outpatient within 48–72 hours.We included all patients that underwent OP evaluation from May 2021‐May 2022. Further, we extracted patients with a final diagnosis of TIA and compared them with IP TIA patients hospitalized (2017‐2021), matched by age, gender, and clinical severity (ABCD2). Descriptive statistics were used to summarize patient demographics, clinical data, treatments, and 3‐month outcomes. Continuous variables were summarized with mean and standard deviations while categorical variables were shown as counts and percentages. Chi‐square test was used for categorical variables and Mann‐Whitney U test was used to compare continuous variables. P‐values &lt; 0.05 were considered statistically significant and all tests were two‐sided. Statistical Analysis was completed in R 4.0.3. Results Of 43 patients who underwent expedited OP TIA workup, TIA or minor stroke was diagnosed in 21/43 (48.9%). 18 TIAs underwent comparative analyses. Mean symptom duration was longer in the IP (2.06 hours) than OP (0.99 hours), p = 0.370%. TIA was more likely to be diagnosed in the OP 14/18 (78%) versus IP 12/18 (67%), (p = 0.423). OP had more transesophageal echocardiograms (17% vs 5%, p = 0.630) and longer duration of ambulatory cardiac monitoring (mean 574.3 vs 381.7 hours, p = 0.100). IP patients were more likely to get started on anticoagulation compared to OP (38% vs 11%, p = 0.258) and high‐intensity statin (38% vs 17%, p = 0.260). All laboratories, echocardiograms and brain MR imaging were performed significantly sooner for the IP (p&lt; 0.05 for all). IP had higher rate of return ED visits (22%) and readmissions at 3 months (11%), whereas OP had none. OP had no deaths or recurrent strokes, whereas 11% and 5.6% respectively were noted in the IP at 3 months (p = 0.310, p = 0.310). Conclusions Our study shows that routine IP evaluation for patients presenting with TIA in the ED may not offer diagnostic superiority nor lead to improvement of short‐term clinical outcomes, as compared to the expedited OP evaluation. Careful evaluation of TIA patients in the ED followed by expedited OP evaluation might be a plausible approach to help lower costs and avoid hospitalization without compromising the safety of these patients.

Screening of Cardiac Rhythm Disorders in Women Working at Information Technology Sector Using Continuous Ambulatory Wireless Cardiac Monitoring – A Community-Based Study

Objectives: The role of screening cardiac arrhythmias provides continuum of care to rediscover the causes and prevention strategies. This study was taken up to screen women working in the information and technology sector for cardiac rhythm disorders using continuous ambulatory cardiac monitoring and asses various risk factors along with work-related stress. Materials and Methods: A cross-sectional study was taken up at the workplace to screen women for cardiac rhythm disorders using wireless continuous ambulatory cardiac monitoring. Various risk factors and work-related stress were assessed using a standardized questionnaire. Differences in ECG parameters such as heart rate, heart rate variability (HRV), and frequency corrected QT (QTc) were compared on working and non-working days. Results: A total of 109 women were screened to find a proportion of 4.58% having cardiac arrhythmias. We found two cases of second-degree AV block (type 1), two cases of atrial tachycardia in the age group of 21–30 years, and one case of sinus pauses. Risk factors such as alcohol usage were statistically associated with cardiac arrhythmias. Others included a sedentary lifestyle, being underweight, a lesser number of sleep hours, no physical activity, work-related stress, and the presence of past-COVID-19 infection, but these were not statistically significant. There were significant changes in heart rate, HRV, and QTc prolongation on working day compared to non-working days. Among the domains of work-related stress, the influence at work and perceived stress due to individual demands and commitments contributed the highest mean score. Moreover, those with higher work-related stress scores were at 3.66 times the increased risk of QTc prolongation. Conclusion: The present study implies the combination of the need for the screening tool in younger age groups and lifestyle factors with more elucidation of work-related stress on autonomic cardiac function.

Diagnostic yield of ambulatory cardiac monitoring in pediatric patients with palpitations.

Palpitations are a frequent reason for referral to pediatric cardiology providers and diagnostic workup includes ambulatory cardiac monitoring. While common practice, the diagnostic yield is unknown in the pediatric population. The objective is to evaluate the diagnostic yield of 24-h Holter and extended ambulatory cardiac monitoring in pediatric patients with palpitations. All pediatric patients aged 10-18 years who had ambulatory cardiac monitoring (1-30 days) through the Pocket Electrocardiogram (PocketECG™) system (Medi-Lynx) between January 2016 and July 2020 were included. Patients with an International Classification of Diseases-10 diagnosis code of palpitations (R00.2) during enrollment were evaluated separately. Tachyarrhythmia diagnoses included atrial fibrillation (AF), nonsustained supraventricular tachycardia (nSVT), supraventricular tachycardia (SVT), nonsustained ventricular tachycardia (nVT), and ventricular tachycardia (VT). Age, heart rates, arrhythmia type, and symptomatic transmission data were collected and analyzed. A total of 2388 patients (mean age 11.6 years, 58% F) with the R00.2 code had ambulatory cardiac monitoring (28% 24-h Holter, 72% extended) performed during the study period and there were 6287 total patients (mean age 13.9 years, 54% F) that underwent ambulatory cardiac monitoring (42% 24-h Holter, 58% extended) during that time. Of 2388 patients, 321 (13%) were diagnosed with tachyarrhythmia: AF (9), nSVT (192), SVT (59), and nVT (61). In the overall cohort, 764 (12%) patients were diagnosed with tachyarrhythmia: AF (22), nSVT (478), SVT (85), nVT (177), and VT (2). Symptomatic transmissions with normal cardiac rhythm were common in the R00.2 (n = 1697, 71%) and overall (n = 3848, 61%) groups. No episodes of nSVT, SVT, nVT, or VT were associated with symptomatic transmissions. Ambulatory cardiac monitors are an integral part of the diagnostic workup for pediatric palpitations patients and have demonstrated a high yield of combined positive arrhythmia diagnoses and symptomatic normal transmissions. Further prospective study of this population with the integration of clinical information is warranted.