Cost-Effectiveness of Extended Electrocardiogram Monitoring for Atrial Fibrillation After Stroke: A Systematic Review.

BACKGROUND AND PURPOSE: Management of cryptogenic stroke involves the identification of modifiable risk factors, such as atrial fibrillation (AF). Extended rhythm monitoring increases AF detection rates but at an increased device cost compared with conventional Holter monitoring. The objective of the study was to identify and synthesize the existing literature on the cost-effectiveness of prolonged rhythm monitoring devices for AF detection in cryptogenic stroke. METHODS: We conducted a systematic review of available economic evaluations of prolonged ECG monitoring for AF detection following cryptogenic stroke compared with standard care. RESULTS: Of the 530 unique citations, 8 studies assessed the cost-utility of prolonged ECG monitoring compared with standard care following cryptogenic stroke. The prolonged ECG monitoring strategies included 7-day ambulatory monitoring, 30-day external loop recorders or intermittent ECG monitoring, and implantable loop recorders. The majority of cost-utility analyses reported incremental cost-effectiveness ratios below $50 000 per QALY gained; and two studies reported a cost-savings. CONCLUSIONS: There is limited economic literature on the cost-effectiveness of extended ECG monitoring devices for detection of atrial fibrillation in cryptogenic stroke. In patients with cryptogenic stroke, extended ECG monitoring for AF detection may be economically attractive when traditional willingness-to-pay thresholds are adopted. However, there was substantial variation in the reported ICERs. The direct comparison of cost-effectiveness across technologies is limited by heterogeneity in modeling assumptions.

Assessment of Remote Heart Rhythm Sampling Using the AliveCor Heart Monitor to Screen for Atrial Fibrillation: The REHEARSE-AF Study.

BACKGROUND: Asymptomatic atrial fibrillation (AF) is increasingly common in the aging population and implicated in many ischemic strokes. Earlier identification of AF with appropriate anticoagulation may decrease stroke morbidity and mortality. METHODS: We conducted a randomized controlled trial of AF screening using an AliveCor Kardia monitor attached to a WiFi-enabled iPod to obtain ECGs (iECGs) in ambulatory patients. Patients ≥65 years of age with a CHADS-VASc score ≥2 free from AF were randomized to the iECG arm or routine care (RC). iECG participants acquired iECGs twice weekly over 12 months (plus additional iECGs if symptomatic) onto a secure study server with overread by an automated AF detection algorithm and by a cardiac physiologist and/or consultant cardiologist. Time to diagnosis of AF was the primary outcome measure. The overall cost of the devices, ECG interpretation, and patient management were captured and used to generate the cost per AF diagnosis in iECG patients. Clinical events and patient attitudes/experience were also evaluated. RESULTS: We studied 1001 patients (500 iECG, 501 RC) who were 72.6±5.4 years of age; 534 were female. Mean CHADS-VASc score was 3.0 (heart failure, 1.4%; hypertension, 54%; diabetes mellitus, 30%; prior stroke/transient ischemic attack, 6.5%; arterial disease, 15.9%; all CHADS-VASc risk factors were evenly distributed between groups). Nineteen patients in the iECG group were diagnosed with AF over the 12-month study period versus 5 in the RC arm (hazard ratio, 3.9; 95% confidence interval=1.4-10.4; P=0.007) at a cost per AF diagnosis of $10 780 (£8255). There was a similar number of stroke/transient ischemic attack/systemic embolic events (6 versus 10, iECG versus RC; hazard ratio=0.61; 95% confidence interval=0.22-1.69; P=0.34). The majority of iECG patients were satisfied with the device, finding it easy to use without restricting activities or causing anxiety. CONCLUSIONS: Screening with twice-weekly single-lead iECG with remote interpretation in ambulatory patients ≥65 years of age at increased risk of stroke is significantly more likely to identify incident AF than RC over a 12-month period. This approach is also highly acceptable to this group of patients, supporting further evaluation in an appropriately powered, event-driven clinical trial. CLINICAL TRIAL REGISTRATION: URL: https://www.isrctn.com. Unique identifier: ISRCTN10709813.

Atrial fibrillation detected by continuous electrocardiographic monitoring using implantable loop recorder to prevent stroke in individuals at risk (the LOOP study): Rationale and design of a large randomized controlled trial.

Atrial fibrillation (AF) increases the rate of stroke 5-fold, and AF-related strokes have a poorer prognosis compared with non-AF-related strokes. Atrial fibrillation and stroke constitute an intensifying challenge, and health care organizations are calling for awareness on the topic. Previous studies have demonstrated that AF is often asymptomatic and consequently undiagnosed. The implantable loop recorder (ILR) allows for continuous, long-term electrocardiographic monitoring with daily transmission of arrhythmia information, potentially leading to improvement in AF detection and stroke prevention. METHODS: The LOOP study is an investigator-initiated, randomized controlled trial with 6,000 participants randomized 3:1 to a control group or to receive an ILR with continuous electrocardiographic monitoring. Participants are identified from Danish registries and are eligible for inclusion if 70years or older and previously diagnosed as having at least one of the following conditions: hypertension, diabetes mellitus, heart failure, or previous stroke. Exclusion criteria include history of AF and current oral anticoagulation treatment. When an AF episode lasting ≥6minutes is detected, oral anticoagulation will be initiated according to guidelines. Expected follow-up is 4years. The primary end point is time to stroke or systemic embolism, whereas secondary end points include time to AF diagnosis and death. CONCLUSION: The LOOP study will evaluate health benefits and cost-effectiveness of ILR as a screening tool for AF to prevent stroke in patients at risk. Secondary objectives include identification of risk factors for the development of AF and characterization of arrhythmias in the population. The trial holds the potential to influence the future of stroke prevention.

Potential Cost-Effectiveness of Ambulatory Cardiac Rhythm Monitoring After Cryptogenic Stroke.

BACKGROUND AND PURPOSE: Prolonged ambulatory ECG monitoring after cryptogenic stroke improves detection of covert atrial fibrillation, but its long-term cost-effectiveness is uncertain. METHODS: We estimated the cost-effectiveness of noninvasive ECG monitoring in patients aged ≥55 years after a recent cryptogenic stroke and negative 24-hour ECG. A Markov model used observed rates of atrial fibrillation detection and anticoagulation from a randomized controlled trial (EMBRACE) and the published literature to predict lifetime costs and effectiveness (ischemic strokes, hemorrhages, life-years, and quality-adjusted life-years [QALYs]) for 30-day ECG (primary analysis) and 7-day or 14-day ECG (secondary analysis), when compared with a repeat 24-hour ECG. RESULTS: Prolonged ECG monitoring (7, 14, or 30 days) was predicted to prevent more ischemic strokes, decrease mortality, and improve QALYs. If anticoagulation reduced stroke risk by 50%, 30-day ECG (at a cost of USD $447) would be highly cost-effective ($2000 per QALY gained) for patients with a 4.5% annual ischemic stroke recurrence risk. Cost-effectiveness was sensitive to stroke recurrence risk and anticoagulant effectiveness, which remain uncertain, especially at higher costs of monitoring. Shorter duration (7 or 14 days) monitoring was cost saving and more effective than an additional 24-hour ECG; its cost-effectiveness was less sensitive to changes in ischemic stroke risk and treatment effect. CONCLUSIONS: After a cryptogenic stroke, 30-day ECG monitoring is likely cost-effective for preventing recurrent strokes; 14-day monitoring is an attractive value alternative, especially for lower risk patients. These results strengthen emerging recommendations for prolonged ECG monitoring in secondary stroke prevention. Cost-effectiveness in practice will depend on careful patient selection.

Cost comparison of two implantable cardiac monitors in two different settings: Reveal XT in a catheterization laboratory vs. Reveal LINQ in a procedure room.

AIMS: Implantable cardiac monitors (ICMs) are used for long-term heart rhythm monitoring, e.g. to diagnose unexplained syncope or for detection of suspected atrial and ventricular arrhythmias. The newest ICM, Reveal LINQ™ (Medtronic Inc.), is miniaturized and inserted with a specific insertion tool kit. The procedure is therefore minimally invasive and can be moved from catheterization laboratory (cath lab) to a less resource intensive setting. This study aims to assess the change in procedure costs when performed outside the cath lab. METHODS AND RESULTS: A bottom-up costing methodology was used. Data were collected from interviews with physicians, cath lab managers, and financial controllers. Hospitals in the Netherlands, France, and the UK were included in this study. The cost comparison of a Reveal XT implantation in a cath lab setting vs. a Reveal LINQ insertion outside a cath lab resulted in an estimated reduction of €662 for the UK, €682 for the Netherlands, and €781 for France. These cost savings were primarily realized through fewer staff, less equipment, and overhead costs. The net effect on savings depends on the price differential between these two technologies. The patient care pathway can be improved due to the possibility to move the procedure out of the cath lab. CONCLUSION: Inserting the miniaturized version of the ICM is simpler and faster, and the procedure can take place outside the cath lab in a less resource intensive environment. Hospitals save resources when the higher price of the Reveal LINQ does not outweigh these savings.

A cost-effectiveness analysis of screening for silent atrial fibrillation after ischaemic stroke.

AIMS: The purpose of this study was to estimate the cost-effectiveness of two screening methods for detection of silent AF, intermittent electrocardiogram (ECG) recordings using a handheld recording device, at regular time intervals for 30 days, and short-term 24 h continuous Holter ECG, in comparison with a no-screening alternative in 75-year-old patients with a recent ischaemic stroke. METHODS AND RESULTS: The long-term (20-year) costs and effects of all alternatives were estimated with a decision analytic model combining the result of a clinical study and epidemiological data from Sweden. The structure of a cost-effectiveness analysis was used in this study. The short-term decision tree model analysed the screening procedure until the onset of anticoagulant treatment. The second part of the decision model followed a Markov design, simulating the patients' health states for 20 years. Continuous 24 h ECG recording was inferior to intermittent ECG in terms of cost-effectiveness, due to both lower sensitivity and higher costs. The base-case analysis compared intermittent ECG screening with no screening of patients with recent stroke. The implementation of the screening programme on 1000 patients resulted over a 20-year period in 11 avoided strokes and the gain of 29 life-years, or 23 quality-adjusted life years, and cost savings of €55 400. CONCLUSION: Screening of silent AF by intermittent ECG recordings in patients with a recent ischaemic stroke is a cost-effective use of health care resources saving costs and lives and improving the quality of life.

Financial impact of adopting implantable loop recorder diagnostic for unexplained syncope compared with conventional diagnostic pathway in Portugal.

BACKGROUND: To estimate the short- and long-term financial impact of early referral for implantable loop recorder diagnostic (ILR) versus conventional diagnostic pathway (CDP) in the management of unexplained syncope (US) in the Portuguese National Health Service (PNHS). METHODS: A Markov model was developed to estimate the expected number of hospital admissions due to US and its respective financial impact in patients implanted with ILR versus CDP. The average cost of a syncope episode admission was estimated based on Portuguese cost data and landmark papers. The financial impact of ILR adoption was estimated for a total of 197 patients with US, based on the number of syncope admissions per year in the PNHS. Sensitivity analysis was performed to take into account the effect of uncertainty in the input parameters (hazard ratio of death; number of syncope events per year; probabilities and unit costs of each diagnostic test; probability of trauma and yield of diagnosis) over three-year and lifetime horizons. RESULTS: The average cost of a syncope event was estimated to be between 1,760€ and 2,800€. Over a lifetime horizon, the total discounted costs of hospital admissions and syncope diagnosis for the entire cohort were 23% lower amongst patients in the ILR group compared with the CDP group (1,204,621€ for ILR, versus 1,571,332€ for CDP). CONCLUSION: The utilization of ILR leads to an earlier diagnosis and lower number of syncope hospital admissions and investigations, thus allowing significant cost offsets in the Portuguese setting. The result is robust to changes in the input parameter values, and cost savings become more pronounced over time.

The effect of late adoption of Canadian innovations: a case for implantable cardiac monitors.

Syncope is a sudden and generally momentary loss of consciousness, which can have serious adverse events. The outcomes of the syncope episode can vary from a fall to fatal accidents. Syncope has a major negative effect on the patient's health-related quality of life. The economic burden of syncope on healthcare systems is considerable. There are no clear diagnostic pathways for identifying the cause of syncope; patients can be admitted to hospital and undergo expensive and often repeated and inconclusive diagnostic tests. Implantable cardiac monitors have been available for more than a decade to help early diagnosis of syncope in unexplained cases. However, despite being a Canadian invention, the use of the implantable cardiac monitors has been suboptimal in the Canadian healthcare system. This study provides an overview of syncope, its management, and presents the estimated potential cost savings per diagnosis of systematic use of implantable cardiac monitors in Ontario.

Impact of an expanded reimbursement policy on utilization of implantable loop recorders in patients with cryptogenic stroke in Korea.

BACKGROUND/AIMS: The reimbursement policy for cryptogenic stroke (CS) was expanded in November 2018 from recurrent strokes to the first stroke episode. No reports have demonstrated whether this policy change has affected trends in implantable loop recorder (ILR) utilization. METHODS: We identified patients who received an ILR implant using the Korea Health Insurance Review and Assessment Service database between July 2016 and October 2021. Patients meeting all the following criteria were considered to have CS indication: 1) prior stroke history, 2) no previous history of atrial fibrillation or flutter (AF/AFL), and 3) no maintenance of oral anticoagulant for ≥4 weeks within a year before ILR implant. AF/AFL diagnosed within 3 years after ILR implant or before ILR removal was considered ILR-driven. RESULTS: Among 3,056 patients, 1,001 (32.8%) had CS indications. The total ILR implant number gradually increased for both CS and non-CS indications and the number of CS indication significantly increased after implementing the expanded reimbursement policy. The detection rate for AF/AFL was 26.3% in CS patients over 3 years, which was significantly higher in patients implanted with an ILR within 2 months after stroke than those implanted later. CONCLUSION: The expanded coverage policy for CS had a significant impact on the number of ILR implantation for CS indication. The diagnostic yield of ILR for AF/AFL detection seems better when ILR is implanted within 2 months than later. Further investigation is needed to demonstrate other clinical benefits and the optimal ILR implantation timing.

Long-term clinical outcomes and cost-effectiveness of catheter vs thoracoscopic surgical ablation in long-standing persistent atrial fibrillation using continuous cardiac monitoring: CASA-AF randomized controlled trial.

BACKGROUND: Long-term clinical outcomes of catheter ablation (CA) compared to thoracoscopic surgical ablation (SA) to treat patients with long-standing persistent atrial fibrillation (LSPAF) are not known. OBJECTIVE: The purpose of this study was to compare the long-term (36-month) clinical efficacy, quality of life, and cost-effectiveness of SA and CA in LSPAF. METHODS: Participants were followed up for 3 years using implantable loop recorders and questionnaires to assess the change in quality of life. Intention-to-treat analyses were used to report the findings. RESULTS: Of the 115 patients with LSPAF treated, 104 (90.4%) completed 36-month follow-up [CA: n = 57 (95%); SA: n = 47 (85%)]. After a single procedure without antiarrhythmic drugs, 7 patients (12%) in the CA arm and 5 (11%) in the SA arm [hazard ratio 1.22; 95% confidence interval (CI) 0.81-1.83; P = .41] were free from atrial fibrillation/tachycardia (AF/AT) ≥30 seconds at 36 months. Thirty-three patients (58%) in the CA arm and 26 (55%) in the SA arm (hazard ratio 1.04; 95% CI 0.57-1.88; P = .91) had their AF/AT burden reduced by ≥75%. The overall impact on health-related quality of life was similar, with mean quality-adjusted life year estimates of 2.45 (95% CI 2.31-2.59) for CA and 2.32 (95% CI 2.13-2.52) for SA. Estimated costs were higher for SA (mean £24,682; 95% CI £21,746-£27,618) than for CA (mean £18,002; 95% CI £15,422-£20,581). CONCLUSION: In symptomatic LSPAF, CA and SA were equally effective at achieving arrhythmia outcomes (freedom from AF/AT ≥30 seconds and ≥75% burden reduction) after a single procedure without antiarrhythmic drugs. However, SA is significantly more costly than CA.

Effectiveness, utilisation and cost associated with implantable loop recorders versus external monitors after ischaemic or cryptogenic stroke.

OBJECTIVE: Implantable loop recorders (ILRs) are increasingly used for long-term rhythm monitoring after ischaemic and cryptogenic stroke, with the goal of detecting atrial fibrillation (AF) and subsequent initiation of oral anticoagulation to reduce risk of adverse clinical outcomes. There is a need to determine the effectiveness of different rhythm monitoring strategies in this context. METHODS: We conducted a retrospective cohort analysis of individuals with commercial and Medicare Advantage insurance in Optum Labs Data Warehouse who had incident ischaemic or cryptogenic stroke and no prior cardiovascular implantable electronic device from 1 January 2016 to 30 June 2021. Patients were stratified by rhythm monitoring strategy: ILR, long-term continuous external cardiac monitor (>48 hours to 30 days) or Holter monitor (≤48 hours). The primary outcome was risk-adjusted all-cause mortality at 12 months. Secondary outcomes included new diagnosis of AF and oral anticoagulation, bleeding, and costs. RESULTS: Among 48 901 patients with ischaemic or cryptogenic stroke, 9235 received an ILR, 29 103 long-term continuous external monitor and 10 563 Holter monitor only. Mean age was 69.9 (SD 11.9) years and 53.5% were female. During the 12-month follow-up period, patients who received ILRs compared with those who received long-term continuous external monitors had a higher odds of new diagnosis of AF and oral anticoagulant initiation (adjusted OR 2.27, 95% CI 2.09 to 2.48). Compared with patients who received long-term continuous external monitors, those who received ILRs had similar 12-month mortality (HR 1.00; 95% CI 0.89 to 1.12), with approximately $13 000 higher costs at baseline (including monitor cost) and $2500 higher costs during 12-month follow-up. CONCLUSIONS: In this large real-world study of patients with ischaemic or cryptogenic stroke, ILR placement resulted in more diagnosis of AF and initiation of oral anticoagulation, but no difference in mortality compared with long-term continuous external monitors.

Cost efficiency and reimbursement of remote monitoring: a US perspective.

Demographic and technological changes are driving increased utilization of cardiac implantable electronic devices (CIEDs) remote monitoring. In the USA, fee-for-service model of healthcare delivery, services rendered are valued based upon time, intensity, and technical or practice expense costs. As a consequence of this perspective, and to contain spending, Medicare has grouped physician services into families. Spending within each family of services must, by law, remain budget neutral. Cardiac implantable electronic devices monitoring services, remote and in-person, are grouped into one family. As the volume of services within this family increases, the individual encounters are destined to be discounted into ever decreasing portions. However, if the value of remote monitoring is demonstrated to extend beyond the previous boundaries of in-person interrogations, a rational request can be made to reconsider the relative value of remote monitoring. Outcome data supporting the value-added benefits of remote monitoring are rapidly accumulating, including (i) patient convenience, with reduced use of office services, (ii) equal safety compared with in-person evaluation, (iii) shorter detection time to actionable events (arrhythmias, cardiovascular disease progression, and device malfunction), (iv) reduced length of stay for hospitalizations, (v) reduced inappropriate shocks, (vi) increased battery longevity, and (vii) a relative reduction in the risk of death. Fully automatic wireless technology, only recently widely implemented, will add considerable clinical efficiencies and further increase the value of remote monitoring. The U.S. challenge will be to appropriately define the relative value of CIEDs remote monitoring now that outcome data have demonstrated its value extends beyond in-person interrogation.

Remote monitoring costs, benefits, and reimbursement: a European perspective.

AIMS: To provide a European perspective on reimbursement issues surrounding remote monitoring of cardiac implantable electronic devices in view of the anticipated costs and benefits. METHODS AND RESULTS: Review of recent literature addressing clinical, economic, sociocultural, and technological factors associated with remote monitoring. When healthcare transformation is urgently needed, remote monitoring offers opportunities to innovate and cope with escalating costs and constrained resources, while improving patient safety, quality, and access to care as reflected in clinical studies. The introduction of remote monitoring into daily practice requires analysis of reimbursement policies to address funding scope, payment method, payer, price and allocation, and alignment with health system objectives and goals to ensure financial and operational sustainability of resources, infrastructure, and processes. Remote monitoring policies should gradually transition from activity-based, added-value services in a care-and-cure setting, to performance and outcome-oriented highlighting prevention, surveillance, and empowerment. By encouraging and rewarding innovation and interoperability, proprietary remote monitoring technologies can open up using standards and connect to support a growing evidence base that guides clinical decision support and planning of future policies. CONCLUSION: Careful planning, sharing of experiences, and gradual adoption of reimbursement models that focus on outcome, performance, and cost-effectiveness are key aspects of containing escalating costs and improving quality and access to healthcare. Despite differences in health systems and payment methods in Europe, policy-makers, professional societies, payers, providers, and the industry need to join forces to transform healthcare and make innovation happen.

Remote monitoring of cardiac implantable devices in the Asia-Pacific.

Remote monitoring of pacemakers and implantable cardioverter defibrillators (ICDs) has emerged as a tool to replace regular follow-up of such devices, and to detect hardware failure, arrhythmias, and heart failure decompensation. The Asia-Pacific region is a geographically diverse area, with widely different cardiac device implant rates and expertise. However, common to all countries, distance and logistic for patients to reach an expert monitoring centre for routine follow up are significant, and in some countries, this will likely be replaced by remote monitoring. Unscheduled visits such as for the treatment of atrial fibrillation and ICD shocks will be expedited. There has been an increase in both pacemaker and ICD implant rates in Asia-Pacific, due to an ageing population and improvement in economic condition. Among the countries, Australia and Japan are the major users of remote monitoring. According to the statistics of the suppliers, in Australia, up to 15% of pacemakers, 40% ICD, and 30% cardiac resynchronization therapy (CRT)/cardiac resynchronization therapy defibrillator (CTRD) are remotely monitored. The corresponding numbers for Japan are 5, 50, and 50% respectively. The monitoring personnel include nurses, technicians, and doctors, either from local centre or from device companies. Cost, lack of reimbursement, and logistic support are major issues in widespread application of remote monitoring technology. In conclusion, remote monitoring is increasing in Asia-Pacific region despite the increase in cost. Implantable cardioverter defibrillators and CRT/CRTDs are more likely than pacemakers to be enabled with remote monitoring.

Home Monitoring technology and integrated follow-up care of ICD patients.

OBJECTIVE: Increasing utilization rates of implantable cardioverter-defibrillators (ICDs) tend to overburden follow-up resources at the implanting electrophysiological centres (ECs). Remote monitoring technology allows physicians from different institutions to simultaneously review ICD data of shared patients. We studied if an integrated follow-up care involving ECs and general cardiologists (GCs) may reduce the frequency of in-office follow-ups at ECs by using remote monitoring data to identify routine checks that may be conducted at GCs. METHODS AND RESULTS: The analysis included 109 patients (aged 63 +/- 11 years, 84.4% male) followed for a cumulative study duration of 155 patient-years. The patients underwent 436 in-office controls after hospital discharge: 143 (33%) at two ECs and 293 (67%) at two GCs (each cooperating with one EC). The mean duration of in-office follow-up sessions was 13.7 min (EC) and 10.3 min (GC). The average distance between patients' homes and follow-up sites was 31.6 km (EC) vs. 16.2 km (GC). Investigators considered a follow-up to be of'high or medium'importance in 78% (EC) vs. 45% (GC) of all in-office follow-ups. At one EC, the integrated follow-up care concept appeared highly successful, with 97% of follow-ups transferred to the corresponding GC and, on average, 103.8 km shorter patient trips per follow-up. CONCLUSIONS: Integrated follow-up care guided by remote monitoring allows to direct the more significant follow-ups towards ECs and routine follow-ups towards GCs.This concept may contribute to the needed adaptations of the health-care system to the rising numbers of patients with implanted devices.

Legal and organizational aspects of remote cardiac monitoring: the example of implantable cardioverter defibrillators.

The remote monitoring of implantable cardioverter defibrillators (ICDs) recently emerged as an attractive technological innovation that proved to be reasonably safe in partially replacing the in-clinic follow-ups of ICD patients with no or only mild symptoms. Apart from the fact that strong evidence about any additional clinical benefits and/or cost-efficiency are still awaited, legal and organizational hurdles remain in place, hampering any possibility for adoption of remote cardiac monitoring. This paper identifies a number of legal and organizational constraints which urgently need to be addressed. An elaboration of the specific juridical guidance for the interpretation and application of the relevant legislation is called for.

First experience of monitoring with cardiac event recorder electrocardiography Omron system in childhood population for sporadic, potentially arrhythmia-related symptoms.

AIMS: To document symptomatic episodes of palpitations with traditional methods such as24 h Holter monitoring (HM) or loop recorders remains a big challenge in clinical practice. Clinical trials with patient-activated electrocardiography (ECG) recorders show increased diagnostic yield in such patients. However, studies in the paediatric population are limited. We want to present a first experience with an event-recording system Omron HeartScan in children with symptomatic palpitations. METHODS AND RESULTS: Thirty paediatric patients (age 4-16 years) were followed with the Omron at our centre. All patients had a normal echocardiogram, a normal baseline 12-lead ECG and a normal 24 h HM. Indications with regard to monitoring were palpitations (n = 30). Two of them also had episodes of pre-syncope. The average of palpitation episodes in the past 3 months was 13.2 ± 8.3. The mean age of the study population was 9.7 ± 2.3 years [17 males (56.7 %)]. In all patients (n = 30) a diagnostic event could be recorded with the studied system. Four patients were diagnosed with supraventricular tachycardia (SVT) and underwent catheter ablation. The remaining patients (n = 26; 87%) were diagnosed with sinus tachycardia. Two patients with SVT additionally had episodes of pre-syncope. None of the patients could be diagnosed with previous 24 h HM. CONCLUSION: This event recorder has a high diagnostic yield in the childhood population. The children enjoyed the ease of using the system under daily-life conditions. In this study the system was able to record a diagnostic event in all patients with palpitations.

Patient information - Holter monitors/event recorders.

A Holter monitor is a portable way of taking an electrical trace of your heartbeat over a period of time (usually 24 hours) while you go about your normal day-to-day activities. The machine records this trace so that a technician and cardiologist (heart doctor) can review your heart rhythm and report back information about your heart to your general practitioner. The test can help pick up if your heartbeat is too fast, too slow or irregular.

Changing patterns of use of implantable cardiac monitors from 2011 to 2018 for a large commercially-insured U.S. population.

ABSTRACT: Implantable cardiac monitors (ICMs) provide long-term electrocardiographic monitoring for a number of indications. However, frequencies of use by indication and temporal changes have not been characterized on a national scale. We sought to characterize overall use and changes between 2011 and 2018. We used generalized linear models to characterize the incidence rate per 1,000,000 patient-quarters at risk and an autoregressive integrated moving average model to account for autocorrelation in this time series data. We studied commercially-insured patients and their insured dependents in the IBM MarketScan Commercial Database who had an ICM placed. We described the characteristics of individuals who received ICMs and the frequency of placements into 3 guideline concordance groups. We estimated the mean change per quarter in ICM placements (mean quarterly change in incidence rate per 1,000,000 patient-quarters at risk) for quarter (Q)1 2011 through Q1 2014, Q1 2014 to Q2 2014, and Q2 2014 through Q4 2018 for each guideline concordance group. The most common indications for categorizable ICM placement were syncope (24%), atrial fibrillation (11%), and stroke (11%). For each of the 3 guideline concordance groups except guideline unaddressed inpatient ICM placements, there was a significant increase in use either during the Q1 2014 to Q2 2014 or the Q2 2014 through Q4 2018 periods. A significant portion of ICM placements were for indications that lack strong evidence, such as established atrial fibrillation. The incidence of ICM placement for most of the indications and settings increased after miniaturization and technical improvements.

Cost-effectiveness of outpatient cardiac monitoring to detect atrial fibrillation after ischemic stroke.

BACKGROUND AND PURPOSE: Extending the duration of continuous electrocardiography after ischemic stroke detects more new cases of atrial fibrillation, which is an important and treatable cause of stroke, but the cost-effectiveness of this approach is unknown. Therefore, we performed a cost-utility analysis of outpatient cardiac monitoring after ischemic stroke. METHODS: Using a Markov model, we determined the lifetime cost and utility of warfarin therapy in a hypothetical cohort of 70-year-old patients with atrial fibrillation, prior stroke, and no contraindication to warfarin therapy. Meta-analysis was used to determine the yield of outpatient cardiac monitoring. RESULTS: Outpatient cardiac monitoring would detect 44 new cases of atrial fibrillation for every 1000 patients monitored. This would result in a gain of 34 quality-adjusted life-years at a net cost of $440,000. Therefore, the cost-utility ratio of outpatient cardiac monitoring would be $13,000 per quality-adjusted life-years gained. Outpatient monitoring remained cost-effective throughout a wide range of model inputs in sensitivity analyses, including changes in the cost and yield of monitoring. CONCLUSIONS: By identifying patients with paroxysmal atrial fibrillation who will benefit from anticoagulation, outpatient cardiac monitoring is cost-effective after ischemic stroke over a wide range of model inputs. The optimal duration and method of monitoring is unknown.