Download All Elderly Patients Who Fall Should Have a 24

All Elderly Patients Who Fall
Should Have a 24-hour ECG
• Jennifer Inglis
• Geriatric Medicine
Training Day
• 27th February 2007
The history of the ECG
• Augustus Waller –
published first human
ECG 1887
• Willem Einthoven –
created PQRST
system 1895,
described ECG
features of CV
disorders
24-hour ECG
• Invented by Dr. Norman J. Holter 1949
• Initially contained within a 75 pound
backpack
• Now a lot more portable…
• …but is it helpful in investigating falls in
the elderly population?
Some evidence
• 24-hour ambulatory electrocardiographic
monitoring is unhelpful in the investigation
of older persons with recurrent falls
• Davison J, Brady S, Kenny RA
• Age and Ageing 2005; 34: 382-6
• Prospective case-control study
Methods
• Recruited patients age >64 presenting to
A&E with fall, having sustained an
additional fall in previous year
• Exclusions – MMSE<24 or >1 previous
syncopal episode or medical explanation
for fall
• Controls matched for age and sex, no falls
in 3 years or any previous syncope
Methods
• Both groups fitted with 24-hour monitors
• Instructed in using a symptom diary
• Type and duration of arrhythmia recorded
– major abnormalities e.g. VT, pauses, HR<30, Mobitz
type II or complete heart block
– minor abnormalities e.g. multiple VEs, paroxysmal
SVT, HR 30-39, Mobitz type I, PAF/flutter
• Symptoms and arrhythmias compared
Results - symptoms
Fallers (n=128)
Average age
76.8
Mild symptoms 10%
Breathlessness 3%
Fatigue
1%
Chest pain
2%
Dizziness
5%
Palpitations
?%
Falls
1 patient
Controls (n=100)
75.3
13%
7%
3%
2%
?%
5%
none
Fallers
Controls
Any abnormality
49%
41%
Pauses > 2s
6%
8%
VT > 2 beats
4%
3%
Mobitz II HB
1%
0%
HR < 30 bpm
0%
1%
Complete HB
0%
0%
HR 30-39 bpm
9%
5%
Paroxysmal SVT
10%
13%
Ventricular ectopy
34%
24%
Paroxysmal AF
5%
4%
Summary of findings
• No significant difference between groups
in prevalence of major or minor ECG
abnormalities, or symptoms during
recording
• Multiple abnormalities present in older
people whether or not they have fallen
• 24-hour ECGs not helpful in investigation
of recurrent falls
Limitations
• Study not powered for small difference in
abnormalities observed
• Fallers were older and more likely to have
hypertension and diabetes
• Patients with more than one syncopal
episode were excluded
• Falls of any nature included… So what is
our definition of a fall?
Definition of a Fall
• “A fall is an event whereby an individual
comes to rest on the ground or another
lower level with or without loss of
consciousness” Oxford Textbook of
Geriatric Medicine
• May be accidental, syncopal, drop attack,
epileptic, metabolic, psychogenic
(although how easy is it to tell?)
All elderly patients with syncope
should have a 24-hour ECG
Jennifer Inglis
Geriatric Medicine Training Day
27th February 2007
Some useful questions
• What causes syncope in the elderly?
• Why is it important to determine the
cause?
• Which of these causes may be detected by
a 24-hour ECG?
• What is the diagnostic yield of a 24-hour
ECG?
Causes of syncope in the elderly
• Neurally-mediated
– vasovagal
– carotid sinus syncope
– situational syncope
• Orthostatic
hypotension
– autonomic failure
– drug-induced
– volume depletion
Causes of syncope in the elderly
• Cardiac arrhythmia
– sinus node dysfunction
– AV conduction system
disease
– paroxysmal SVT/VT
– inherited syndromes
– implanted device
malfunction
– drug-induced
• Structural cardiac or
cardiopulmonary disease
–
–
–
–
–
–
–
valvular disease
MI/ischaemia
HOCM
myxoma
acute aortic dissection
pericardial disease
PE or pulmonary
hypertension
Causes of syncope
•
•
•
•
•
Neurally-mediated
Cardiac syncope
Arrhythmia
Neurological and psychiatric
>1 possible attributable cause
56%
14%
11%
9%
33%
– Beware attributable and associated diagnoses
Framingham data
• Patients with syncope of any cause have a
1.31 increased risk of death
• Patients with cardiac syncope have highest
risk of
– death from any cause– hazard ratio 2.1
– cardiovascular event – hazard ratio 2.66
24-hour tapes
• Non-invasive
• Safe
• Low cost (approx.
£70 per tape)
• Beat to beat
acquisition
• High fidelity
However…
• There may be intolerance to adhesive, or
electrodes may become detached during
recording
• Symptoms may not recur during recording
• Incidental abnormalities may be detected,
unrelated to the fall
Diagnostic yield
• Results from studies vary widely
• For 24-hour tapes of patients with syncope
or dizziness, arrhythmias in 4-64%
• Rhythm-symptom correlation in 4%
• 15% had symptoms but no arrhythmia
(helpful in its own way)
• So yield is low, making cost per diagnosis
higher (NB yield from history and exam)
So which patients should have a
24-hour ECG?
• Patients with clinical or ECG features to
suggest arrhythmic syncope AND
• Frequent syncopes (or pre-syncopes) more than once per week
Clinical features of cardiac
syncope
• Syncope preceded by palpitation
• Syncope occurring during exertion, or
while supine
• Family history of sudden death
• Evidence of structural heart disease
ECG abnormalities suggesting
arrhythmic syncope
•
•
•
•
•
•
•
•
•
Bifascicular block
Intraventricular conduction abnormalities
Mobitz type I AV block
HR <50 bpm, sinus pause >3s
Pre-excited QRS complexes
Prolonged QT interval
RBBB with ST elevation in leads V1-3
Changes of arrhythmogenic RV dysplasia (!)
Q waves suggesting MI
Other considerations
• Bass et al (1990) found that there is an
increase in yield with 48-hour monitoring
in comparison with a 24-hour tape
• Consider role for implantable loop
recorders – up to 24 months battery life,
symptom/ECG correlation 88% at 6
months – more cost effective than 24-hour
ECG
In summary
• Not all elderly patients who fall should
have a 24-hour ECG
• Not all elderly patients with syncope
should have a 24-hour ECG
• Consider 24-48 hour ECG or implantable
loop recorder if high suspicion of cardiac
syncope as per history, examination and 12
lead ECG findings
Discussion points
• Do we order too many 24-hour ECGs?
• If so, how can we change our practice?
• Do we miss important diagnoses by relying
on a normal result?
• Do we over-treat patients with
asymptomatic ECG abnormalities?
• Do we consider requesting implantable
loop recorders where appropriate?