Inpatient Telemetry Research Articles

Interactive Multimodal Curriculum on Use and Interpretation of Inpatient Telemetry.

Inpatient telemetry monitoring is a commonly used technology designed to detect and monitor life-threatening arrhythmias. However, residents are rarely educated in the proper use and interpretation of telemetry monitoring. We developed a training module containing an educational video, PowerPoint presentation, and hands-on interactive learning session with a telemetry expert. The module highlights proper use of telemetry monitoring, recognition of telemetry artifact, and interrogation of telemetry to identify clinically significant arrhythmias. Learners completed pre- and postcurriculum knowledge-based assessments and a postcurriculum survey on their experience with the module. In total, the educational curriculum had three 60-minute sessions. Thirty-two residents participated in the training module. Residents scored higher on the posttest (77% ± 12%) than on the pretest (70% ± 12%), t(31) = -4.3, p < .001. Wilcoxon signed rank tests indicated PGY-3s performed better on the posttest (Mdn = 0.86) than on the pretest (Mdn = 0.72), z = -2.19, p = .031. PGY-2s also performed better on the posttest (Mdn = 0.86) than on the pretest (Mdn = 0.76), z = -2.04, p = .042. There was no difference between pretest (Mdn = 0.66) and posttest (Mdn = 0.71) scores for PGY-1s, z = -1.50, p = .142. The majority of residents reported that the telemetry curriculum boosted their self-confidence, helped prepare them to analyze telemetry on their patients, and should be a required component of the residency. This module represents a new paradigm for teaching residents how to successfully and confidently interpret and use inpatient telemetry.

Disinfection of Blood Pressure Cuffs and Electrocardiographic Telemetry Leads With 0.5% Hydrogen Peroxide Wipes.

Disinfection of frequently touched surfaces in the hospital is critical for providing safe care. Because of their complex intricate surfaces, blood pressure cuffs and electrocardiographic telemetry leads may be harder than other equipment to disinfect. To determine the effectiveness of 0.5% hydrogen peroxide wipes in cleaning and disinfecting inpatient hospital surfaces, including hook and loop (Velcro) fasteners of blood pressure cuffs and electrocardiographic telemetry leads. A prospective study of an inpatient telemetry unit was designed to measure the persistence of a UV indicator and the presence of bacterial colonization on electrocardiographic telemetry leads and blood pressure cuffs. Call buttons and patient trays were used as control surfaces, because they are often touched but are easy to disinfect via standard practices. A total of 392 samples were collected between July 11 and August 3, 2016, and cultured for microorganisms. Among the cultures, 247 (63%) had at least 1 colony-forming unit. After adjustments in a multivariable analysis, odds of a contaminated surface (≥ 10 colony-forming units) after final cleaning with 0.5% hydrogen peroxide wipes were 3.70 times greater for patient trays than for blood pressure cuffs (P = .03) and 3.80 times greater for telemetry leads than for blood pressure cuffs (P = .04). The UV indicator persisted longer on blood pressure cuffs and telemetry leads than on patient trays or call buttons (P < .001). Wipes with 0.5% hydrogen peroxide adequately disinfect blood pressure cuffs but not telemetry leads.

Effect of Trainee Performance Data on Standard-Setting Judgments Using the Mastery Angoff Method.

Mastery learning in health professions education requires learners to learn and undergo assessment until they demonstrate a high level of competence. Setting defensible standards is key to accurately assessing educational outcomes in mastery learning. The Mastery Angoff method was proposed recently to set a minimum passing standard (MPS) for mastery learning curricula. However, it is unknown whether prior knowledge of trainee performance affects judges' decisions about setting an MPS using the Mastery Angoff method. We sought to determine the effect of introducing baseline data about trainee performance on faculty judges' decisions about the Mastery Angoff MPS for a written examination. We developed a mastery learning curriculum to train internal medicine residents and cardiology fellows about the correct interpretation of inpatient telemetry monitoring. All learners were required to meet or exceed an MPS on a 35-item written examination at the end of training. The MPS was set in 2017 by judges who used the item-based Mastery Angoff method without prior examinee performance information. The judges subsequently reevaluated the test items after receiving baseline data about trainee performance collected during pilot testing. Mastery Angoff MPSs with and without baseline performance data were compared. Twelve judges participated in the standard-setting exercise. The initial MPS was similar to the repeat MPS set after judges received trainee performance data (86.2% versus 86.9%, P = .23). Prior knowledge about medical trainee performance data did not affect MPS as determined by the Mastery Angoff procedure.

Bridging gaps in care: Implementation of a pharmacist-led transitions-of-care program.

The development and implementation of a hospitalwide, pharmacist-led transitions-of-care (TOC) program are described. This 21-week quality improvement initiative was conducted from October 1, 2015, to February 26, 2016, at Memorial Hospital Pembroke. A TOC team was comprised of pharmacists, a pharmacy resident, pharmacy students, a physician, case managers, and nurses. All patients over the age of 18 admitted to the inpatient telemetry unit were included in this initiative. The primary endpoint was a sustained improvement in Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores for "Communication About Medications" and "Care Transitions: Understood the Purpose of Taking Medications." Secondary outcomes included 90% of admission and 80% of discharge medication reconciliations reviewed by a pharmacist. A total of 661 patients were included. The HCAHPS scores for "Communication About Medications" and "Care Transitions: Understood the Purpose of Taking Medications" had a sustained improvement during the study period. A pharmacist completed 94% and 75% of admission and discharge medication reviews, respectively, and a total of 1,579 interventions were made. Discharge education was completed at a rate of 73%. After a quality improvement initiative developed by pharmacists was implemented, HCAHPS scores showed improvement and more patients received medication reconciliation.

Video ambulatory EEG: A good alternative to inpatient video telemetry?

PurposeVideo ambulatory EEG (V-AEEG) is a new technique which could add increased capacity for long term EEG monitoring to overstretched inpatient video telemetry (IPVT) services. We compare V-AEEG and IPVT for diagnostic efficacy, recording quality, patient acceptability and technologist time required. MethodsForty-one V-AEEG and 64 IPVT adult patients were included. Patients were investigated to diagnose attacks or to obtain polysomnography (PSG) prior to multiple sleep latency test (MSLT). Number of attacks recorded, whether the diagnostic question was answered, quality of video and EEG recording and patients’ preference for investigation at home or in hospital were noted. For V-AEEG patients, ease of procedure and extra technologist time required were recorded. ResultsOf patients investigated for diagnosis of attacks, 74% V-AEEG patients and 62% IPVT had typical attacks during the investigation. All PSGs were useful in interpreting the MSLTs. Diagnostic questions were answered by 73% V-AEEGs and 73% IPVTs.Quality of EEG and video recording was similar using V-AEEG and IPVT.Four patients had difficulty using V-AEEG equipment but diagnostic information was lost in only one. 5% of V-AEEG patients would have preferred hospital investigation but 45% of IPVT patients would have preferred home investigation. Extra technologist time for home visits (mean 2h) was required only for the first 7 patients. ConclusionVideo EEG recording quality and diagnostic efficacy from V-AEEG are similar to IPVT. V-AEEG is acceptable to most patients and does not require additional technical time. Hence, V-AEEG offers a convenient, economical alternative to IPVT.

Decrease in Inpatient Telemetry Utilization Through a System-Wide Electronic Health Record Change and a Multifaceted Hospitalist Intervention.

Unnecessary telemetry monitoring contributes to healthcare waste. To evaluate the impact of 2 interventions to reduce telemetry utilization. A 2-group retrospective, observational pre- to postintervention study of 35,871 nonintensive care unit (ICU) patients admitted to 1 academic medical center. On the hospitalist service, we implemented a telemetry reduction intervention including education, process change, routine feedback, and a financial incentive between January 2015 and June 2015. In July 2015, a system-wide change to the telemetry ordering process was introduced. The primary outcome was telemetry utilization, measured as the percentage of daily room charges for telemetry. Secondary outcomes were mortality, escalation of care, code event rate, and appropriateness of telemetry utilization. Generalized linear models were used to evaluate changes in outcomes while adjusting for patient factors. Among hospitalist service patients, telemetry utilization was reduced by 69% (95% confidence interval [CI], -72% to -64%; P < .001), whereas on other services the reduction was a less marked 22% (95% CI, -27% to -16%; P < .001). There were no significant increases in mortality, code event rates, or care escalation, and there was a trend toward improved utilization appropriateness. Although electronic telemetry ordering changes can produce decreases in hospital-wide telemetry monitoring, a multifaceted intervention may lead to an even larger decline in utilization rates. Whether these changes are durable cannot be ascertained from our study.

Abstract WP235: Rates of Diagnostic Testing for Embolic Sources in a Nationally Representative Cohort of Patients With Ischemic Stroke

Introduction: Many strokes arise from a distant embolic source such as the heart or large arteries. It has recently been proposed that a minimum evaluation to identify such sources should include imaging of the intracranial and extracranial arteries, an echocardiogram, and continuous heart-rhythm monitoring for ≥24 hours. We sought to evaluate the utilization rates of these tests in a nationally representative cohort of U.S. patients with ischemic stroke. Methods: We analyzed inpatient and outpatient claims data from 2009-2014 in a 5% sample of Medicare beneficiaries ≥66 years of age. Using validated ICD-9-CM codes, we identified all patients with inpatient admission for ischemic stroke. Our outcomes were the following recommended diagnostic evaluations: intracranial arterial imaging (CTA, MRA, or TCD), extracranial imaging (CTA, MRA, or Doppler ultrasound), echocardiography (transthoracic or transesophageal), and heart-rhythm monitoring (Holter or loop recorder). We used CPT codes to identify whether these tests were performed within 3 months prior to and 6 months after the stroke. Results: We identified 23,475 patients with ischemic stroke. Extracranial vascular imaging was performed in 20,600 patients (87.8%; 95% confidence interval [CI], 87.3-88.2%), intracranial vascular imaging in 11,726 patients (50.0%; 95% CI, 49.3-50.6%), echocardiography in 19,278 patients (82.1%; 95% CI, 81.6-82.6%), and heart-rhythm monitoring in 2,063 patients (8.8%; 95% CI, 8.4-9.2%). Only 49 (0.2%) underwent the complete recommended diagnostic battery for the detection of embolic sources. These rates were not substantially different even after excluding patients with known atrial fibrillation, the most common source of embolic stroke. Limitations: We could not capture inpatient cardiac telemetry that was not formally interpreted by a physician. Conclusions: Among Medicare beneficiaries with acute ischemic stroke, the majority did not receive a full diagnostic evaluation for potential embolic sources of stroke. Promoting the widespread adoption of a more systematic interrogation of potential etiologies of stroke may allow for the implementation of more personalized secondary stroke prevention strategies.

322 A Longitudinal Exploration of In Situ Mock Code Events and the Performance of Cardiac Arrest Skills

In hospital cardiac arrest (IHCA) affects 200,000 adults in the United States each year, and survival is generally low. Performance of key processes of care during resuscitation of patients suffering IHCA often falls short of published guidelines. Evidence suggests that simulation can improve teamwork among IHCA resuscitation teams, translating to improved performance in key processes of care such as cardiopulmonary resuscitation (CPR) fraction (the proportion of time that a pulseless patient receives CPR). The objective of this study was to determine whether a hospital-wide campaign of simulated “mock codes” has lead to improvements in group-level performance of cardiac resuscitation skills over time. The primary outcome of interest was improvement in CPR fraction, and the secondary outcomes of interest were time to first dose of epinephrine and time to first defibrillation. We hypothesized that a sustained program of mock codes would translate to greater than 10% improvement in each of these core metrics over the course of the three years the program has been in place. This was a retrospective analysis of in situ mock codes conducted in an urban teaching hospital between August 23, 2012 and October 12, 2015. Mock codes were held on inpatient telemetry and medical/surgical units on day and night shifts. The codes were managed by unit staff as well as members of the hospital’s “Code Blue” team (physicians, intensive care unit and rapid response Team nurses, pharmacists, respiratory therapists, and patient transporters). Data were recorded by trained observers who were present at each code. The data were analyzed using descriptive statistics, and repeated measures outcomes were calculated using a mixed effects model. During the study period there were 79 mock codes; 55 on medical/surgical units and 17 on telemetry units. 72 codes were included in the analysis, and 7 were excluded due to missing data. Two observers were present for 12 codes (17%), and their interobserver reliability for all outcomes was high (ICC 0.79-0.99 and correlation coefficient 0.82-0.99). Longitudinal mixed model analysis showed a significant improvement in CPR fraction over time (t(44) = 2.07, p = 0.04). CPR fraction increased by 2.9% per time interval unit on telemetry units, and 1.3% per time interval on medical/surgical units. Neither time to first epinephrine dosing nor time to defibrillation changed significantly over the course of the study in terms of main effects of unit type and time trend. While we observed a significant improvement in CPR fraction over the course of this program of mock codes, similar improvements were not observed for other key measures of cardiac arrest performance. Hospitals considering this approach to cardiac arrest training should view it as an adjunct rather than a replacement for other types of focused training. A larger trial with greater power is warranted.

Seek and Ye Shall Find Fibrillations

See related article, p 1982 . Law No. 10 in the satirical book House of God states, “If you don’t take a temperature, you can’t find a fever.”1 In essence, do not go looking for problems. However, what if finding that fever led to ordering a limb ultrasound, discovering a deep vein thrombosis, prescribing anticoagulation, and averting life-threatening pulmonary emboli? Similar logic now applies for atrial fibrillation (AF). It has been known for decades that AF directly causes ischemic stroke as fibrin-rich clots form in the left atrium, flicking off into the brain. However, AF is often paroxysmal and, hence, uncaptured on 12-lead ECG or inpatient telemetry—so what if, just a few days or weeks after stroke, finding that AF led to prescribing anticoagulation and averting massive, debilitating strokes? In a longitudinal cohort study, Edwards et al compiled over a decade of data (2003–2013) from the Ontario Stroke Registry—patients in normal sinus rhythm, without known AF, after ischemic stroke or TIA.2 Outcomes included the proportion who received at least 24-hour Holter cardiac monitoring within 30 and 90 days. They found that after adjusting for potential confounders, the majority of the registry’s 17 398 subjects did not receive even a 24-hour monitor at either time point. Almost none (<1%) underwent prolonged monitoring (over 60 hours). They conclude that this woeful underuse of cardiac monitoring has likely caused a population-wide overdiagnosis of cryptogenic strokes and underdiagnosis of AF.2 AF currently affects ≈5 million Americans and has a lifetime risk of 1:4 over age 40.3 Compared with those without AF, those with AF carry a 5-fold higher future stroke risk,4 and unanticoagulated AF doubles recurrent stroke risk.5 AF represents 15% …

Prevalence and Prognostic Significance of Runs of Premature Atrial Complexes in Ischemic Stroke Patients

Runs of premature atrial complexes (PACs) are common in stroke patients and perceived to be clinically insignificant, but their prognostic significance is unclear. This study investigated the association between runs of PACs in ischemic stroke patients and the risk of recurrent ischemic strokes/transient ischemic attacks (TIAs) or death. The study included consecutive patients admitted with an ischemic stroke from August 2008 to April 2011. Patients with known and newly detected atrial fibrillation were excluded. Runs of PACs were defined as 3 or more PACs lasting less than 30 seconds during 48 hours of continuous inpatient cardiac telemetry. The patients were followed for 4 years or until death, whichever came first. They were stratified according to stroke severity. The combined primary endpoint was a recurrent ischemic stroke/TIA or death. Of the 565 patients included in the study, 28% had runs of PACs. Patients with runs of PACs were likely to be older, female, and to have experienced more severe strokes. During the follow-up, 210 (37%) patients had a recurrent ischemic stroke/TIA (n = 73) or died (n = 137) respectively. Among the 489 patients who had mild-to-moderate strokes, runs of PACs were associated with recurrent ischemic strokes/TIAs or death (hazard ratio = 1.47; 95% CI 1.06-2.04; P = .023). Runs of PACs were frequent in patients with acute ischemic strokes and sinus rhythm, and they were independently associated with an increased risk of recurrent ischemic strokes/TIAs or death in patients with mild-to-moderate strokes.

Home Video Telemetry vs inpatient telemetry: A comparative study looking at video quality

ObjectiveTo compare the quality of home video recording with inpatient telemetry (IPT) to evaluate our current Home Video Telemetry (HVT) practice. MethodTo assess our HVT practice, a retrospective comparison of the video quality against IPT was conducted with the latter as the gold standard. A pilot study had been conducted in 2008 on 5 patients.Patients (n=28) were included in each group over a period of one year.The data was collected from referral spreadsheets, King’s EPR and telemetry archive.Scoring of the events captured was by consensus using two scorers.The variables compared included: visibility of the body part of interest, visibility of eyes, time of event, illumination, contrast, sound quality and picture clarity when amplified to 200%.Statistical evaluation was carried out using Shapiro–Wilk and Chi-square tests. The P-value of ⩽0.05 was considered statistically significant. ResultsSignificant differences were demonstrated in lighting and contrast between the two groups (HVT performed better in both).Amplified picture quality was slightly better in the HVT group. ConclusionVideo quality of HVT is comparable to IPT, even surpassing IPT in certain aspects such as the level of illumination and contrast. Results were reconfirmed in a larger sample of patients with more variables. SignificanceDespite the user and environmental variability in HVT, it looks promising and can be seriously considered as a preferable alternative for patients who may require investigation at locations remote from an EEG laboratory.

Reducing hospital noise with sound acoustic panels and diffusion: a controlled study

Noise has been identified as a major stressor in hospitals,1 ,2 with ambient noise frequently exceeding recommended levels set by the WHO3 and reportedly as high as alarm clocks.4 ,5...

Telemetry Monitoring: Are Admission Criteria Based on Evidence?

Telemetry Monitoring: Are Admission Criteria Based on Evidence?

Diagnosis of atrial fibrillation after stroke and transient ischaemic attack: a systematic review and meta-analysis

Among patients with atrial fibrillation, the risk of stroke is highest for those with a history of stroke; however, oral anticoagulants can lower the risk of recurrent stroke by two-thirds. No consensus has been reached about how atrial fibrillation should be investigated in patients with stroke, and its prevalence after a stroke remains uncertain. We did a systematic review and meta-analysis to estimate the proportion of patients newly diagnosed with atrial fibrillation after four sequential phases of cardiac monitoring after a stroke or transient ischaemic attack. We searched PubMed, Embase, and Scopus from 1980 to June 30, 2014. We included studies that provided the number of patients with ischaemic stroke or transient ischaemic attack who were newly diagnosed with atrial fibrillation. We stratified cardiac monitoring methods into four sequential phases of screening: phase 1 (emergency room) consisted of admission electrocardiogram (ECG); phase 2 (in hospital) comprised serial ECG, continuous inpatient ECG monitoring, continuous inpatient cardiac telemetry, and in-hospital Holter monitoring; phase 3 (first ambulatory period) consisted of ambulatory Holter; and phase 4 (second ambulatory period) consisted of mobile cardiac outpatient telemetry, external loop recording, and implantable loop recording. The primary endpoint was the proportion of patients newly diagnosed with atrial fibrillation for each method and each phase, and for the sequential combination of phases. For each method and each phase, we estimated the summary proportion of patients diagnosed with post-stroke atrial fibrillation using random-effects meta-analyses. Our systematic review returned 28,290 studies, of which 50 studies (comprising 11,658 patients) met the criteria for inclusion in the meta-analyses. The summary proportion of patients diagnosed with post-stroke atrial fibrillation was 7·7% (95% CI 5·0-10·8) in phase 1, 5·1% (3·8-6·5) in phase 2, 10·7% (5·6-17·2) in phase 3, and 16·9% (13·0-21·2) in phase 4. The overall atrial fibrillation detection yield after all phases of sequential cardiac monitoring was 23·7% (95% CI 17·2-31·0). By sequentially combining cardiac monitoring methods, atrial fibrillation might be newly detected in nearly a quarter of patients with stroke or transient ischaemic attack. The overall proportion of patients with stroke who are known to have atrial fibrillation seems to be higher than previously estimated. Accordingly, more patients could be treated with oral anticoagulants and more stroke recurrences prevented. Heart and Stroke Foundation of Canada, and Natural Science and Engineering Research Council of Canada.

Abstract W P194: Improved Efficacy of ICM Detection of Atrial Fibrillation in Cryptogenic Stroke Patients with MRI-Defined Infarcts: Preliminary Results from the SPIDER Registry

Introduction: Recent trials have demonstrated the efficacy of the implantable cardiac monitor (ICM) in detecting atrial fibrillation (AF) in cryptogenic stroke (CS) patients. However, these trials have included patients with TIAs or no CT or MRI imaging of the brain. We hypothesized that the AF detection rate in CS patients would be improved by requiring the presence of an embolic-appearing infarct on MRI. Methods: All CS patients within the Promedica Stroke Network were considered for inclusion in the SPIDER (Stroke Prevention through the Improved Detection of AF) registry. All patients were monitored by inpatient telemetry for AF for a minimum of 48 hours, and received brain MRI with or without angiography. Patients with no AF, a negative transesophageal echo for ASD/PFO, and an embolic-appearing MRI infarct (wedge infarct, multiple vascular distributions) were offered an ICM (Reveal or Reveal LINQ™) for AF detection (minimum of 10 seconds). Results: 64 patients have been enrolled to date and followed for 223 days. Mean age was 66.9 ± 12.8 years and 40.6% were female with a median NIH stroke score of 5.2 on presentation. AF episodes were detected in 11 patients, resulting in an AF detection rate of 17.2% and a median time to AF detection of 35 days. While both mean follow-up and time to AF detection were comparable to the data from CRYSTAL-AF (6 months, 41 days), AF detection rate was increased nearly two-fold. Conclusions: Here we show that restricting ICM implantation for AF detection in CS patients to those with MRI-defined embolic-appearing infarcts improves efficacy, with an increase of 8.3% in detection at six months, when adjusted for follow-up time. Explanations for this higher detection rate might include a slightly higher age (66.9 vs 61.5 years of age), a more liberal cutoff for AF (10 vs 30 seconds), and, likely, a more highly selected patient population. Such an approach might both improve access to this important technology and help preserve health care resources.

Troponin-I Is a Predictor of a Delayed Diagnosis of Atrial Fibrillation in Acute Ischemic Stroke and Transient Ischemic Attack

Prolonged cardiac monitoring detects higher rates of atrial fibrillation (AF) in ischemic stroke and transient ischemic attack (TIA) but is costly and has practical implications. The use of admission troponin-I (TnI) level to identify patients at high risk of delayed AF detection was investigated. Consecutive ischemic stroke and TIA cases presenting to our institute over a 13-month period were identified from the Irish Stroke and TIA Register. Electronic databases and case notes were examined. "Delayed" AF was diagnosed after a sinus rhythm admission electrocardiogram and no documented history. Group comparisons were made by AF status. The association between TnI and AF was investigated using a multivariate regression model. A total of 185 cases (130 ischemic stroke) were analyzed. Mean age (standard deviation) was 73.3 (13.9) years, 47% female. Sixty-two cases (33.5%) had AF. The first documented presentation of AF was found in 21 cases, on admission electrocardiogram (n = 11) or inpatient telemetry (delayed, n = 10). TnI was higher in those with delayed AF than in those without AF (W = 194; P = .036). A higher proportion of those with an elevated TnI (30%) than those with a normal TnI (6.1%) had delayed diagnosis of AF (χ(2) = 6.41, P = .011). Having an abnormal TnI was a significant independent predictor of delayed AF detection (odds ratio, 5.8; P = .037). TnI elevation is associated with a higher likelihood of subsequent AF diagnosis. Identification of these higher risk stroke and TIA cases for more intensive cardiac monitoring may improve stroke secondary prevention practices.

SHORT-VIDEO EEG IN DIAGNOSING NON-EPILEPTIC ATTACK DISORDER

<h3>Background</h3> Non-epileptic attack disorder (NEAD) and epileptic seizures are often hard to differentiate clinically. However accurate diagnosis is essential for the optimum outcome for the patient. Diagnosis often requires inpatient video telemetry, which is both time consuming and financially constraining. Short video electroencephalography (SV-EEG) with provocation has been described previously and was shown to be a useful diagnostic tool in other specialist centres in the United Kingdom. <h3>Objective</h3> To determine the usefulness of SV-EEG in the diagnosis of NEAD in a University teaching hospital with no previous SV-EEG experience. <h3>Method</h3> Review of medical notes of 35 patients who underwent SV-EEG in Ninewells Hospital between September 2011 and October 2013. <h3>Results</h3> A positive SV-EEG supporting a diagnosis of NEAD occurred in 57.1% of patients (n=20). No attack or an atypical attack resulting in an inconclusive SV-EEG occurred in 42.9% of patients (n=15). <h3>Conclusion</h3> The positive rates of attacks from SV-EEG were comparable to previously published results and show that SV-EEG is easily implemented in centres with no previous experience of the technique.

The value of long term EEG monitoring in children: A comparison of ambulatory EEG and video telemetry

PurposeOutpatient ambulatory EEG may be followed by inpatient video telemetry EEG when investigating children for possible seizures and for classification of epilepsy. We investigated the value of ambulatory EEG and subsequent video telemetry recording in our centre. MethodThe departmental EEG database was interrogated retrospectively for children undergoing ambulatory recording followed by inpatient video telemetry within an 18-month period. Results30 patients fitted these criteria, 21 females, 9 males, age range 3–16 years. The mean interval between studies was 9 months. For ambulatory recordings 93% of studies were undertaken to ascertain if behaviours were epileptic. 66% of ambulatory recordings studies captured an event of interest and 63% were able to answer the question asked of the test. In video telemetry recording 80% of studies were aimed at ascertaining if events were epileptic or not, 20% were undertaken for classification of seizure type. 70% of recordings captured an ictus and were considered helpful in addressing the clinical question. Pooled together 90% of patients had a paroxysmal event captured and the clinical question answered by the recording techniques. In patients for whom ambulatory recording failed to capture an attack or answer the clinical question, 70% went on to have a successful video telemetry recording. ConclusionBoth ambulatory EEG and inpatient video telemetry are effective tools for diagnosis of seizures. The majority of patients with failed ambulatory recordings go on to have successful video telemetry. Combining the two resources provides useful clinical information in nearly all instances.

Slow Sinus Heart Rate as a Potential Predictive Factor of Paroxysmal Atrial Fibrillation in Stroke Patients

Background: Paroxysmal atrial fibrillation (PAF) is a strong independent risk factor for ischemic stroke and is also associated with stroke severity and mortality. However, the detection rate of PAF in patients with ischemic stroke is limited because they are often asymptomatic or present with sinus rhythm on electrocardiograms (ECGs). In the present study, we aimed to identify predictors of PAF in stroke patients by continuous ECG monitoring of the heart rate in sinus rhythm. Methods: We enrolled 741 consecutive patients with acute symptomatic ischemic stroke who were admitted to our hospital. Exclusion criteria were the following: (1) patients with persistent AF, (2) cardiac pacemaker users and (3) incomplete clinical investigations. Each patient was subject to 24-hour Holter ECG, cardiac monitoring by inpatient telemetry and routine transthoracic echocardiography. The minimum and mean sinus heart rates (SHRs) on 24-hour Holter ECGs were recorded. The presence of PAF was judged on the basis of previous history and cardiac studies during hospitalization. Clinical characteristics of the patients with and without PAF were compared, and multiple logistic regression analysis was performed to identify the predictors of PAF. Results: Of all enrolled patients, 606 (mean age 68.2 years, 63.4% male) were eligible for analysis, and the presence of PAF was confirmed in 116 subjects (19.1%). In the univariate analysis, the patients with and without PAF showed significant differences in age (74.3 vs. 66.7 years, p < 0.001), dyslipidemia (32.8 vs. 50.4%, p = 0.001), chronic heart failure (16.4 vs. 4.7%, p < 0.001), admission National Institute of Health Stroke Scale score (8.5 vs. 6, p < 0.001) and absence of vascular etiology (80.2 vs. 54.1%, p < 0.001). Furthermore, the minimum and mean SHRs were slower in the patients with than in those without PAF (46.5 vs. 54.0 bpm, p < 0.001 and 70.7 vs. 73.8 bpm, p = 0.009, respectively). In 501 (82.7%) out of 606 patients, minimum SHRs were detected at night (from 9:00 p.m. to 7:00 a.m.). A minimum SHR was an independent predictive factor of PAF in the multivariate analysis (odds ratio 1.08, 95% confidence interval 1.05 - 1.12, p < 0.001). Conclusions: A slow SHR on monitoring ECG is a potential predictive factor of PAF in patients with ischemic stroke.

Unusual Tachycardia-Bradycardia Syndrome During Atrial Fibrillation

A 60-year-old man with a history of remote myocarditis and residual mild left ventricular dysfunction presented with syncope. Before admission, the patient was not taking any regular medications. Medical history was otherwise unremarkable. Examination at presentation was unremarkable, apart from slow atrial fibrillation (AF). ECG on presentation demonstrated AF with slow ventricular response and a complete left bundle-branch block (Figure 1). Inpatient telemetry demonstrated episodes of nonsustained ventricular tachycardia (VT). Cardiac catheterization with coronary angiography was normal. Echocardiogram demonstrated mild left ventricular dysfunction (ejection fraction 50%) but was otherwise unremarkable. Figure 1. At baseline, the patient presented with persistent atrial fibrillation with complete left bundle-branch block and premature ventricular complexes. Twelve-lead ECG at a sweep speed of 25 mm/s. An electrophysiological study showed a hisioventricular interval of 75 ms during AF at a rate of 75 beats per minute. No spontaneous pauses or infranodal phase 4 atrioventricular (AV) block was spontaneously observed. Programmed stimulation from the right ventricular apex was unremarkable at a 600-ms cycle length. At a 400-ms cycle length, a sustained monomorphic VT at 165 beats per minute with left bundle-branch block morphology and an inferior axis (Figure 2) was induced with a single extrastimulus (S2=270 ms). After 35 seconds, the VT spontaneously terminated. Despite the persistence of AF, the termination of VT was followed by a prolonged complete infrahisian AV block (Figure 3). After 8.5 seconds of ventricular asystole, AV conduction resumed. In addition, spontaneous premature ventricular complexes were observed (Figure 4). Those originating from the left anterior septum were associated with transient infrahisian AV block (Figure 4A). In contrast, those originating from the right ventricular apex were not associated with AV block, despite an identical coupling interval (Figure 4B). A single-chamber cardioverter-defibrillator was successfully implanted, and the patient subsequently remained asymptomatic. Figure 2. A sustained left bundle-branch block morphology ventricular …