Dall’Holter al Monitoraggio Mensile: Indicazioni e Risultati Emanuela T. LOCATI, MD, PhD Ospedale Niguarda Dipartimento Cardiovascolare Cardiologia 3 – Elettrofisiologia MILAN, Italy

Sessione AIAC: Nuove Tecnologie in Aritmologia

Institutional Research Grants from

Conflicts of interest

1949 First ECG transmission 1959 First transportable Holter

Norman HOLTER (1914-1983)

G.A., Female, 76 yrs, Hx of TIA

Occurrence of FAP during Multiday Holter

G.A., Female, 76 yrs, Hx of TIA

Occurrence of FAP during Multiday Holter

M.A., Male, 74 yrs totally asyntomatic

during recording

Holter 72 hours

Asymptomatic FAP during Multiday Holter

CG-2206™ “Event Recorder” 30 sec

1-lead ECG

CG-7000™ 12-lead Standard ECG

CG-6106™ “Loop Recorder” 90 sec 1-lead ECG

First Generation Event and Loop Recorders with Transtelefonic Transmission

M.C. Female 75 yrsi

CAD AHT

Unexplained Palpitationis

CG2206 Event monitoring: PAF during palpitations

Optimal Duration of Monitoring

INCIDENZA CUMULATIVA DI EVENTI

94

41

144 4 7

2

0

20

40

60

80

100

1 2 3 4 5 6 7

SETTIMANE

SO

MM

A E

VE

NT

I

INCIDENZA DI EVENTI PER SOGGETTO

0

2

4

6

8

10

12

14

16

1 2 3 4 5 6 7

SETTIMANA

SO

MM

A E

VE

NT

I

TeCH Niguarda: Time to Onset of First Symptom

Low Risk

Frequency of syncope ≤ 4 weeks?

Arrhythmic cause?

no

yes

yes no

Further tests (Tilt Test,...)

Therapy to avoid further syncopes

Risk Stratification in low-risk patients (ESC2009)

Up to 30 days monitoring

3 Recording Modalities

ECG Strips up to 22.5 minutes

Auto-trigger (SFT®)

Hourly time table (SFA®/SFT®)

Patient activation (SFA®/SFT®)

Heart Rate Profile SFA®

SFT®

From External Loop Recorder to Extended Holter monitoring

Europace, 2013

Study population

patients without events

patients with events

Onset of symptoms

Diagnostic yield for syncope/palpitation of SpiderFlash-T with autotrigger

function in symptomatic/asymptomatic patients

Diagnostic yield

60 second asystole

Female, 70 yrs Permanent AF, Hx of syncope 24 Holter negative for pauses

SpiderFlash-T Automatic & patient activation

Day 5

Syncope due to 60 sec asystole during chronic AF

Paper Speed 3.125 mm/sec

60 seconds asystole

Patient sent to Pacemaker implant! Day 5

SpiderFlash-T Automatic & patient activation

Syncope due to 60 sec asystole during chronic AF

Female, 70 yrs Permanent AF, Hx of syncope 24 Holter negative for pauses

Conclusive diagnosis

Day 8

SpiderFlash-T Automatic & patient activation

6 sec Asystole During Nightmare in PAF

Male, 73 yrs PAF, Hx of syncope 24 Holter negative for pauses

Suggestive diagnosis

Atrial fibrillation (paroxysmal or chronic) is not included among ECG features suggesting arrythmic syncope is ESC 2009 guidelines!

Male, 45 yrs, Hx of Recurrent Epysodes of Unexplained TLoC

Simil-Syncope due to Epilectic Seizure (during sleep)

Simil-Syncope due to Epilectic Seizure (during sleep)

Male, 45 yrs, Hx of Recurrent Epysodes of Unexplained TLoC

85% one-month diagnostic yield for unexplained palpitations

ECG findings in patients with a history of pre-syncope or palpitations

M.M. Female

16 yrs Palpitations,

Presyncope and Chest pain

Palpitation and presyncope due to fast PSVT

M.M. Female

16 yrs Palpitations,

Presyncope and Chest pain

Palpitation and Presyncope due to fast PSVT: Onset and Offset

SYNARR-flash Study

SMART Study inlcuded 239 patients

FAP > 5 sec was detected in 29 patients (12%)

FAP > 30 sec was detected in 16 patients (6.7%)

Most events were asymptomatic

Stroke 2012; 43:2788

Zio Patch

Zio Patch

Wireless Sensor Device

• Wireless dynamic ECG can be used in real-time and holter

• Long-duration: 8 GB capacity (removable micro-SD

card, stores up to 2 months in continuous ECG

recording mode)

• ECG in environments with high levels of physical

activity, such as sports

Technical specifications ECG Channels: single-lead // Three-leads Sampling rate: 250 sps Bandwidth: 0.05-100 Hz Class: IIa Type: CF

Bluetooth® v2.0+EDR Class I (50 m) Accelerometer 3-axis HR transmitter (5.5 khz)

Data storage 8GB 54 gr

NUUBO: Wireless Long-Term Holter

BlendFix® Sensor Electrode Technology

• Proprietary biomedical e-textile technology (wearable sensor)

• Cost-effective, continuous and non-invasive

• Excellent ECG signal quality and dynamic control

• Extremely easy-to-use, minimal impact on patient lifestyle

• Available in different sizes .

NUUBO: Wireless Long-Term Holter

AMG, Female

24 yrs Hx of

Palpitation at effort,

Sister with SD

NUUBO: Wireless Long-Term Holter

Patient sent to ICD implant!

AMG, Female

24 yrs Hx of

Palpitation at effort,

Sister with SD

NUUBO: Wireless Long-Term Holter

OMRON: Event Recorder

CardioDefender: SmartPhone Event Recorder

CardioDefender: SmartPhone Event Recorder

Step-wise approach for the diagnosis of syncope and palpitation

Cost-saving approach for the diagnosis of syncope and palpitation

Now available new and different methods for long term ECG monitoring

Distintion between diagnostic and remote monitoring tools

More efficient electrodes system (belt or patch electrodes or vest or wireless non-contact

ECG electrodes) for long-term external ECG monitoring

Continuous long-term Holter ECG recording (>30 days) as first step in most cases

Insertable LR for very prolonged ECG monitoring in selected cases

Need of call-centers for telemetric surveillance of devices

Revision of Clinical Guidelines for management of AF, syncope and palpitations

Need of precise definition for asymptomatic atrial fibrillation (minimum duration?)

Need of reimbursement fee for long-term Holter ECG monitoring and Telecardiology !!!!!

Future of Long-Term ECG Monitoring

A special thanks to

Franca NEGRINI

Adriana MIGLIAVACCA

Anna STRAGLIATI

Andrea PINCIROLI

Acknowledgements