Cardiac monitoring

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Cardiac monitoring
Holter monitor.JPG
Holter monitor.

Cardiac monitoring generally refers to continuous or intermittent monitoring of heart activity to assess a patient's condition relative to their cardiac rhythm. Cardiac monitoring is usually carried out using electrocardiography, which is a noninvasive process that records the heart's electrical activity and displays it in an electrocardiogram. [1] It is different from hemodynamic monitoring, which monitors the pressure and flow of blood within the cardiovascular system. The two may be performed simultaneously on critical heart patients. Cardiac monitoring for ambulatory patients (those well enough to walk around) is known as ambulatory electrocardiography and uses a small, wearable device, such as a Holter monitor, wireless ambulatory ECG, or an implantable loop recorder. Data from a cardiac monitor can be transmitted to a distant monitoring station in a process known as telemetry or biotelemetry.

Contents

Cardiac monitoring in an emergency department setting focuses primarily on the monitoring of arrhythmia, myocardial infarction, and QT interval monitoring. [2] It is categorized into one of three classes using a rating system developed by the American College of Cardiology Emergency Cardiac Care Committee:

Class I: Cardiac monitoring is indicated in all or most patients.

Class II: Cardiac monitoring may be beneficial, but it is not essential.

Class III: Cardiac monitoring is not indicated because the patient's serious event risk is low. Monitoring will not have therapeutic benefit. [3]

Emergency medical services

In the setting of out-of-hospital acute medical care, ambulance services and other emergency medical services providers utilize heart monitors to assess the patient's cardiac rhythm. Providers licensed or certified at the Paramedic level are qualified to interpret ECGs. Information obtained from ECGs can then be used to direct the patient's treatment at a care facility, particularly in catheterization labs. [4]

In the emergency department

In the emergency department, cardiac monitoring is a part of the monitoring of vital signs in emergency medicine, and generally includes electrocardiography. [2]

Monitor/defibrillators

Some digital patient monitors, especially those used by EMS services, often incorporate a defibrillator into the patient monitor itself. These monitor/defibrillators usually have the normal capabilities of an ICU monitor, but have manual (and usually semi-automatic AED) defibrillation capabilities. This is particularly good for EMS services, who need a compact, easy to use monitor and defibrillator, as well as for patient transport. Most monitor defibrillators also have transcutaneous pacing capability via large AED like adhesive pads (which often can be used for monitoring, defibrillation and pacing) that are applied to the patient in an anterior-posterior configuration. The monitor defibrillator units often have specialized monitoring parameters such as waveform capnography, invasive BP, and, in some monitors, Masimo Rainbow SET pulse oximetry, which can also monitor carbon monoxide and methemoglobin levels. Most modern monitors also allow for transmission of an ECG sample to an emergency department for interpretation; this process may be used to speed up patient care in certain situations, such as bypassing the ED and proceeding to a cath lab.

Examples of monitor defibrillators are the Lifepak 12, 15 and 20 made by Physio Control, the Philips Heartstart MRx, and the E, R, and X Series by ZOLL Medical.

A Welch Allyn PIC 50 monitor/defibrillator from an Austrian EMS service. Defibrillator Monitor.jpg
A Welch Allyn PIC 50 monitor/defibrillator from an Austrian EMS service.
A closeup view of the screen of the PIC 50. Defibrillator Monitor Closeup.jpg
A closeup view of the screen of the PIC 50.
ZOLL R Series Plus external monitor/defibrillator Semi-automated-external-monitor-defibrillator.jpg
ZOLL R Series Plus external monitor/defibrillator

Long-term ambulatory monitors

There are two broad classifications for cardiac event monitors: manual (or dumb) and automatic. Automatic ECG event monitors have the ability to monitor the patient's ECG and make recordings of abnormal events without requiring patient intervention. Manual ECG event recorders require the patient to be symptomatic and to activate the device to record an event; this makes these devices useless whilst, for example, the patient is sleeping. A third classification, the implantable loop recorder, provides both automatic and manual abilities.

An example of automatic monitoring is the transtelephonic cardiac event monitor. This monitor contacts ECG technicians, via telephone, on a regular basis, transmitting ECG rhythms for ongoing monitoring. The transtelephonic cardiac event monitor can normally store approximately five "cardiac events" usually lasting 30–60 seconds.

Heart rate monitoring

Monitoring of the heart rate can be performed as part of electrocardiography, but it can also be measured conveniently with specific heart rate monitors. Such heart rate monitors are largely used by performers of various types of physical exercise.

A generic cardiac monitor has the following functions:

There are many different types of cardiac monitors. In personal use, the Holter monitor is an external monitor which uses wires with patches that attach to the skin to continuously measure and record heart activity for 1–2 days. [5] An Event Recorder can be worn on the body for up to 30 days. [6] A Mobile Cardiac Telemetry unit is a wearable monitor that detects, records, and transmits heart rhythms for up to 30 days. For long term use, an Insertable Cardiac Monitor is placed under the skin and automatically detects and records abnormal heart rhythms for up to 5 years. [7]

Fetal heart rate monitoring

Monitoring the fetal heart rate is becoming increasingly prevalent in the standard care of antepartum pregnant patients. [8] As of 2002, 85% of pregnancies in the United States were monitored using electronic fetal monitoring. Electronic fetal monitoring generally uses Doppler ultrasound technology to provide real-time feedback on the fetus's cardiac activity during both gestation and labor, [9] however other technologies such as analyzing the voltage generated by the contracting uterine muscle measured at the skin surface or recording both the fetal ECG and mother's ECG and filtering out the mother's ECG are emerging. [10]

Wearable heart rate monitors for exercise

The new wearable heart rate monitors indirectly measure the heart rate with reflectance photoplethysmography. The monitor illuminates the skin tissue with light emitting diode (LED) and detects the intensity of light reflected with the photodetector. [11] Wearable optical heart rate monitors are less reliable than electrode-based heart rate monitors. The accuracy of the wearable optical heart rate monitors varies with the type of exercise. Skin tone and motion artifacts contributes to this error. [11] [12]

Related Research Articles

The diagnostic tests in cardiology are methods of identifying heart conditions associated with healthy vs. unhealthy, pathologic heart function.

<span class="mw-page-title-main">Cardiac arrest</span> Sudden stop in effective blood flow due to the failure of the heart to beat

Cardiac arrest, also known as sudden cardiac arrest, is when the heart suddenly and unexpectedly stops beating. As a result, blood cannot properly circulate around the body and there is diminished blood flow to the brain and other organs. When the brain does not receive enough blood, this can cause a person to pass out and become unresponsive. Cardiac arrest is also identified by a lack of central pulses and abnormal or absent breathing.

<span class="mw-page-title-main">Electrocardiography</span> Examination of the hearts electrical activity

Electrocardiography is the process of producing an electrocardiogram, a recording of the heart's electrical activity through repeated cardiac cycles. It is an electrogram of the heart which is a graph of voltage versus time of the electrical activity of the heart using electrodes placed on the skin. These electrodes detect the small electrical changes that are a consequence of cardiac muscle depolarization followed by repolarization during each cardiac cycle (heartbeat). Changes in the normal ECG pattern occur in numerous cardiac abnormalities, including:

<span class="mw-page-title-main">Artificial cardiac pacemaker</span> Medical device

An artificial cardiac pacemaker is a medical device, currently always implanted, that generates electrical pulses delivered by electrodes to one or more of the chambers of the heart, the upper atria or lower ventricles. Each pulse causes the targeted chamber(s) to contract and pump blood, thus regulating the function of the electrical conduction system of the heart.

<span class="mw-page-title-main">Cardioversion</span> Conversion of a cardiac arrhythmia to a normal rhythm using an electrical shock or medications

Cardioversion is a medical procedure by which an abnormally fast heart rate (tachycardia) or other cardiac arrhythmia is converted to a normal rhythm using electricity or drugs. Synchronized electrical cardioversion uses a therapeutic dose of electric current to the heart at a specific moment in the cardiac cycle, restoring the activity of the electrical conduction system of the heart. Pharmacologic cardioversion, also called chemical cardioversion, uses antiarrhythmia medication instead of an electrical shock.

<span class="mw-page-title-main">Defibrillation</span> Treatment for life-threatening cardiac arrhythmias

Defibrillation is a treatment for life-threatening cardiac arrhythmias, specifically ventricular fibrillation (V-Fib) and non-perfusing ventricular tachycardia (V-Tach). A defibrillator delivers a dose of electric current to the heart. Although not fully understood, this process depolarizes a large amount of the heart muscle, ending the arrhythmia. Subsequently, the body's natural pacemaker in the sinoatrial node of the heart is able to re-establish normal sinus rhythm. A heart which is in asystole (flatline) cannot be restarted by a defibrillator; it would be treated only by cardiopulmonary resuscitation (CPR) and medication, and then by cardioversion or defibrillation if it converts into a shockable rhythm.

<span class="mw-page-title-main">Ventricular fibrillation</span> Rapid quivering of the ventricles of the heart

Ventricular fibrillation is an abnormal heart rhythm in which the ventricles of the heart quiver. It is due to disorganized electrical activity. Ventricular fibrillation results in cardiac arrest with loss of consciousness and no pulse. This is followed by sudden cardiac death in the absence of treatment. Ventricular fibrillation is initially found in about 10% of people with cardiac arrest.

<span class="mw-page-title-main">Palpitations</span> Perceived cardiac abnormality in which ones heartbeat can be felt

Palpitations are perceived abnormalities of the heartbeat characterized by awareness of cardiac muscle contractions in the chest, which is further characterized by the hard, fast and/or irregular beatings of the heart.

<span class="mw-page-title-main">Holter monitor</span> Portable device for cardiac monitoring

In medicine, a Holter monitor is a type of ambulatory electrocardiography device, a portable device for cardiac monitoring for at least 24 hours.

<span class="mw-page-title-main">T wave alternans</span>

T wave alternans (TWA) is a periodic beat-to-beat variation in the amplitude or shape of the T wave in an electrocardiogram TWA was first described in 1908. At that time, only large variations could be detected. Those large TWAs were associated with increased susceptibility to lethal ventricular tachycardias.

Clinical cardiac electrophysiology, is a branch of the medical specialty of cardiology concerned with the study and treatment of rhythm disorders of the heart. Cardiologists with expertise in this area are usually referred to as electrophysiologists. Electrophysiologists are trained in the mechanism, function, and performance of the electrical activities of the heart. Electrophysiologists work closely with other cardiologists and cardiac surgeons to assist or guide therapy for heart rhythm disturbances (arrhythmias). They are trained to perform interventional and surgical procedures to treat cardiac arrhythmia.

<span class="mw-page-title-main">Transcutaneous pacing</span> Method of temporary stabilizing an individuals heartbeat

Transcutaneous pacing (TCP), also called external pacing, is a temporary means of pacing a patient's heart during a medical emergency. It should not be confused with defibrillation using a manual or automatic defibrillator, though some newer defibrillators can do both, and pads and an electrical stimulus to the heart are used in transcutaneous pacing and defibrillation. Transcutaneous pacing is accomplished by delivering pulses of electric current through the patient's chest, which stimulates the heart to contract.

The chain of survival refers to a series of actions that, properly executed, reduce the mortality associated with sudden cardiac arrest. Like any chain, the chain of survival is only as strong as its weakest link. The six interdependent links in the chain of survival are early recognition of sudden cardiac arrest and access to emergency medical care, early CPR, early defibrillation, early advanced cardiac life support, and physical and emotional recovery. The first three links in the chain can be performed by lay bystanders, while the second three links are designated to medical professionals. Currently, between 70 and 90% of cardiac arrest patients die before they reach the hospital. However, a cardiac arrest does not have to be lethal if bystanders can take the right steps immediately.

Pediatric advanced life support (PALS) is a course offered by the American Heart Association (AHA) for health care providers who take care of children and infants in the emergency room, critical care and intensive care units in the hospital, and out of hospital. The course teaches healthcare providers how to assess injured and sick children and recognize and treat respiratory distress/failure, shock, cardiac arrest, and arrhythmias.

A wearable cardioverter defibrillator (WCD) is a non-invasive, external device for patients at risk of sudden cardiac arrest (SCA). It allows physicians time to assess their patient's arrhythmic risk and see if their ejection fraction improves before determining the next steps in patient care. It is a leased device. A summary of the device, its technology and indications was published in 2017 and reviewed by the EHRA Scientific Documents Committee.

<span class="mw-page-title-main">Automated ECG interpretation</span>

Automated ECG interpretation is the use of artificial intelligence and pattern recognition software and knowledge bases to carry out automatically the interpretation, test reporting, and computer-aided diagnosis of electrocardiogram tracings obtained usually from a patient.

<span class="mw-page-title-main">Arrhythmia</span> Group of medical conditions characterized by irregular heartbeat

Arrhythmias, also known as cardiac arrhythmias, heart arrhythmias, or dysrhythmias, are irregularities in the heartbeat, including when it is too fast or too slow. A resting heart rate that is too fast – above 100 beats per minute in adults – is called tachycardia, and a resting heart rate that is too slow – below 60 beats per minute – is called bradycardia. Some types of arrhythmias have no symptoms. Symptoms, when present, may include palpitations or feeling a pause between heartbeats. In more serious cases, there may be lightheadedness, passing out, shortness of breath, chest pain, or decreased level of consciousness. While most cases of arrhythmia are not serious, some predispose a person to complications such as stroke or heart failure. Others may result in sudden death.

<span class="mw-page-title-main">Lifepak</span> Series of vital signs monitors and defibrillators

Lifepak is a series of vital signs monitors and external cardiac defibrillators produced by medical technology company Physio-Control.

<span class="mw-page-title-main">Implantable loop recorder</span>

An implantable loop recorder (ILR), also known as an insertable cardiac monitor (ICM), is a small device that is implanted under the skin of the chest for cardiac monitoring, to record the heart's electrical activity for an extended period.

Wireless ambulatory electrocardiography (ECG) is a type of ambulatory electrocardiography with recording devices that use wireless technology, such as Bluetooth and smartphones, for at-home cardiac monitoring (monitoring of heart rhythms). These devices are generally recommended to people who have been previously diagnosed with arrhythmias and want to have them monitored, or for those who have suspected arrhythmias and need to be monitored over an extended period of time in order to be diagnosed.

References

  1. ↑ Sattar, Y; Chhabra, L (2022), "article-20969", Electrocardiogram, Treasure Island (FL): StatPearls Publishing, PMID   31747210 , retrieved 2022-09-22
  2. 1 2 Zègre-Hemsey, Jessica K.; Garvey, J. Lee; Carey, Mary G. (2016). "Cardiac Monitoring in the Emergency Department". Critical Care Nursing Clinics of North America. Elsevier BV. 28 (3): 331–345. doi:10.1016/j.cnc.2016.04.009. ISSN   0899-5885. PMC   5630152 . PMID   27484661.
  3. ↑ Zègre-Hemsey, Jessica K.; Garvey, J. Lee; Carey, Mary G. (September 2016). "Cardiac Monitoring in the Emergency Department". Critical Care Nursing Clinics of North America. 28 (3): 331–345. doi:10.1016/j.cnc.2016.04.009. ISSN   0899-5885. PMC   5630152 . PMID   27484661.
  4. ↑ Blackwell, Thomas H. (2018). Rosen's Emergency Medicine: Concepts and Clinical Practice. New York City, New York: Elsevier. pp. 2389–2397. ISBN   9780323390170.
  5. ↑ "Holter Monitor". www.heart.org. Retrieved 2019-08-29.
  6. ↑ "Cardiac Event Recorder". www.heart.org. Retrieved 2019-08-29.
  7. ↑ "Insertable Cardiac Monitor; Cardiology & Heart Care". Orange Regional Medical Center. Retrieved 2019-08-29.
  8. ↑ Mehta, Shobha; Sokol, Robert (2019). "Assessment of At-Risk Pregnancy" In: CURRENT Diagnosis & Treatment: Obstetrics & Gynecology. New York, NY: McGraw-Hill.
  9. ↑ Murray, Henry (2017-01-01). "Antenatal foetal heart monitoring". Best Practice & Research Clinical Obstetrics & Gynaecology. Antenatal Fetal Surveillance. 38: 2–11. doi:10.1016/j.bpobgyn.2016.10.008. ISSN   1521-6934. PMID   27866937.
  10. ↑ Adam, J (2012). "The Future of Fetal Monitoring". Obstetrics & Gynaecology. 5 (3–4): e132-6. PMC   3594859 . PMID   23483429.
  11. 1 2 Preejith, S P; Alex, Annamol; Joseph, Jayaraj; Sivaprakasam, Mohanasankar (May 2016). "Design, development and clinical validation of a wrist-based optical heart rate monitor". 2016 IEEE International Symposium on Medical Measurements and Applications (MeMeA). Benevento, Italy: IEEE. pp. 1–6. doi:10.1109/MeMeA.2016.7533786. ISBN   9781467391726. S2CID   2344766.
  12. ↑ Gillinov, Stephen; Etiwy, Muhammad; Wang, Robert; Blackburn, Gordon; Phelan, Dermot; Gillinov, A. Marc; Houghtaling, Penny; Javadikasgari, Hoda; Desai, Milind Y. (August 2017). "Variable Accuracy of Wearable Heart Rate Monitors during Aerobic Exercise". Medicine & Science in Sports & Exercise. 49 (8): 1697–1703. doi:10.1249/MSS.0000000000001284. ISSN   0195-9131. PMID   28709155. S2CID   46847998.
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