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ECG Report
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Introduction
Included in a Holter ECG recording are the following ECG
testing modalities.
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Topics of Discussion
The following slides will describe:
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High Quality Reports
You will be using a 5, 7, or 10
electrode Holter digital recorder.
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High Quality Reports
This 10-electrode lead placement
is for standard 12-Lead ECG
recordings for the entire 48-hour
recording time period.
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How to Read the Holter Reports
It starts with Full
Disclosure. Each report
includes the 24 page FD
print-out. This is your
quality control that the
report is accurate. You
see 100% of the 24-hour
data, so we have to
report accurately.
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Holter ECG Report Summary
You also have a demo copy of the Holter ECG
report. It will be easier for you to read. The
first page is the Holter ECG Report Summary.
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24-Hour Trends Report
This is the 2nd page to the basic Holter ECG
Report. It shows 24-hour trends of Heart Rate,
ST, HRV-SDNN, HRV-Power, VE beats, and SVE
beats.
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Delta ST Analysis
ST depressions of 1mm or more are a strong
indication of blockage in the coronary arteries.
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ECG Strips
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Heart Rate Variability
Time Domain and Frequency
Heart Rate Variability is a strong
predictor of patients with bad
outcomes over a 5-year period.
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Heart Rate Variability
Time Domain and Frequency
The general concept of HRV is that the more the heart
rate variability, the healthier the heart, because it more
readily responds to its various stimuli. A young child has
very rapid and significant changes in heart rate, indicating
that the heart muscle is well and good.
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Heart Rate Variability
Time Domain and Frequency
The top section of this HRV report shows the Frequency Power
Spectrum for all 24-hours, for Awake hours, and for Asleep hours.
Normal power numbers are usually recommended by expert
physicians as follows: Total > 800, VLF > 450, LF > 350, HF > 60.
The next section shows the time correlation for HR, SDNN,
rMSSD, and pNN50. This is for research.
A 24-hour R-R graph can be printed to show that the entire HRV
file has been purged of arrhythmias and artifacts. This is a HRV
Full Disclosure print-out of 4-hours per page print.
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SAECG Late Potentials
The SAECG Late Potentials is a
special high frequency ECG test
for the purpose of predicting
patients at high risk for a future
Ventricular Tachycardia event.
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SAECG Late Potentials
CPT Codes exist for the SAECG Late Potential test.
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12-Lead Enhanced ST
The early detection of ischemia is of prime
importance to the diagnosing physician.
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12-Lead Enhanced ST
The exercise stress test is the test of
choice for detecting ischemia. However,
in several cases Holter is a better choice.
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12-Lead Enhanced ST
This is a 3D 12-Lead ST print-out.
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12-Lead Enhanced ST
This ST report print-out shows ST
Episode data for each lead.
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QT, QTc, and QTd
QT analysis has been absent
in Holter ECG because of its
difficulty. However, QT is
the key to some very serious
and life-threatening events.
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QT, QTc, and QTd
This is a histogram of QTc
during the 24-hour Holter.
The horizontal is the QTc in
ms and the vertical is the
quantity of QTc for each ms.
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QT, QTc, and QTd
This program is the unique solution
for detecting this very serious event.
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QT, QTc, and QTd
In addition to the validated ECG strips that show
the elongated QTc problem, you will also receive
this report print.
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QT, QTc, QTd
QT dispersion
QT dispersion measures
the difference between the
lead with the min QT and
max QT intervals. A QTd
> 90 ms is of concern.
The QT dispersion is
measured for 3 successive
beats, and the average of
the 3 beats is the QTd.
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VCG (Vectorcardiogram)
The VCG converts the PQRST
into spatial loops. It requires
the 7-electrode recorder, with
the XYZ (Frank) leads.
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Sleep Apnea
This Sleep Apnea report is not meant to
compete with the over-night polysomnography
test. A much more user-friendly and cost
effective test is required to find the vast
number of patients who suffer this disease.
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Atrial Fibrillation
As cardiac medication is now
doing a great job in prolonging life
for heart diseased patients, we
are now seeing a significant
increase in Atrial Fibrillation in our
aging population.
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Pacemaker
These are the best quality pace-
maker spikes in Holter ECG.
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Pacemaker
The Pacemaker report shows the following:
* Paced Beat Total
* Intrinsic Beat Total
* % Paced
* % Intrinsic
Pacemaker Failures:
* Failures to Capture
* Failures to Sense
* Beats < Lower HR Limit
* Beats > Upper HR Limit
* R-R Intervals > 1.5 seconds
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FCG CADgram
The FCG CADgram was
referred to earlier in the 12
Lead Enhanced ST.
No billing should be
attempted for this test. A
positive test may prompt
the physician to consider a
Stress Test.
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FCG CADgram
The FCG test must use only
the 10-electrode, 12-Lead
Holter digital recorder.
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FCG CADgram
The FCG takes 90 seconds of
12-Lead ECG data during the
Asleep time with a slow and
steady heart rate. Exercise
ECG is of no value for FCG.
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FCG CADgram
You receive a 2-page report for the FCG CADgram.
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Medical Reference Articles
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ACC/AHA Guidelines for Ambulatory
Electrocardiography (Holter ECG)
Crawford et al 1999
demonstrates that the symptoms are not related to
One of the primary and most widely accepted uses of rhythm disturbances. Third, a patient may remain
Holter ECG is the determination of the relation of a asymptomatic during cardiac arrhythmias documented
patients transient symptoms to cardiac arrhythmias. on the recording. This finding has equivocal value.
Some symptoms are commonly caused by transient The recorded arrhythmia may or may not be relevant to
arrhythmias; syncope, near syncope, dizziness, and the symptoms. Fourth, the patient may remain
palpitation. However, other transient symptoms are less asymptomatic during the Holter ECG recording and no
commonly related to rhythm abnormalities: shortness of arrhythmias are documented. This finding is not useful.
breath, chest discomfort, weakness, diaphoresis, or
neurological symptoms such as transient ischemic attack. The day-to-day variability in the frequency of
Vertigo, which is usually not caused by an arrhythmia, arrhythmias is substantial. Most arrhythmia studies use
must be distinguished from dizziness a 24-hour recording period, although the yield may be
increased slightly with longer recordings or repeated
If arrhythmias are thought to be causative in patients with recordings. Major reductions in arrhythmia frequency
transient symptoms, the crucial information needed is the are necessary to prove treatment effect. To ensure
recording of an ECG during the precise time that the that a change is due to the treatment effect and not a
symptom is occurring. With such a recording, one can spontaneous variability, a 65% to 95% reduction in
determine if the symptom is related to the arrhythmia. arrhythmia frequency after an intervention is necessary.
Four outcomes are possible with Holter ECG recordings.
First, typical symptoms may occur with the simultaneous Because most ischemic episodes during routine daily
documentation of a cardiac arrhythmia capable of activities are related to increases in heart rate, it is
producing such symptoms. Such a finding is most useful therefore essential to encourage similar daily activities
and may help to direct therapy. Second, symptoms may at the time of the Holter ECG. The optimal duration of
occur even though a Holter ECG recording shows no recording to detect and quantify ischemia is 48 hours.
arrhythmias. This finding is also useful because it
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ACC/AHA Guidelines for Ambulatory
Electrocardiography (Holter ECG)
Crawford et al continued Indications for Heart Rate Variability
* Post-MI patients with LV dysfunction.
Indications for Symptoms related to Rhythm Disturbances * Congestive Heart Failure.
* Patients with unexplained recurrent palpitations. * Idiopathic hypertrophic cardiomyopathy.
* Patients with unexplained syncope, near syncope, * Post-MI patients with normal LV function.
or episodic dizziness. * Diabetics to evaluate for diabetic neuropathy.
* Patients with episodic shortness of breath, chest pain, * Rhythm disturbances that preclude HRV analysis.
or fatigue that is not otherwise explained.
* Neurological events when transient atrial fibrillation or Indications to assess Anti-arrhythmic Therapy
flutter is suspected. * To assess anti-arrhythmic drug response in
* Cerebrovascular accidents without other evidence of individuals in whom baseline frequency of
arrhythmias. arrhythmia has been characterized as reproducible
and of sufficient frequency to permit analysis.
Indications for patients without symptoms from arrhythmia * To detect pro-arrhythmic responses to anti-arrhythmic
* Post-MI patients with ejection fraction < 40%. therapy in patients at high risk.
* Congestive Heart Failure. * To assess rate control during atrial fibrillation.
* Idiopathic hypertrophic cardiomyopathy. * To document recurrent or asymptomatic
* Sustained myocardial contusion. non-sustained arrhythmias during therapy in the
* Systemic hypertensive patients with LV hypertrophy. out-patient setting.
* Post-MI patients with normal LV function.
* Pre-operative arrhythmia evaluation. Indications for Pacemaker and ICD
* Patients with Sleep Apnea. * Suspected pacemaker or ICD failures.
* Patients with valvular heart disease. * Post-operative evaluation of pacemaker and ICD
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ACC/AHA Guidelines for Ambulatory
Electrocardiography (Holter ECG)
Crawford, et al continued
Disease, with or without symptoms of arrhythmia. The
During the past decade, Holter ECG has been extensively rationale for this testing is the evolution of disease
used for the detection of myocardial ischemia. It is now processes (such as long QT syndrome or hypertrophic
widely accepted that Holter ECG monitoring provides cardiomyopathy).
accurate and clinically meaningful information about
myocardial ischemia in patients with coronary disease. Indications for Monitoring Pediatric Patients
* Syncope, near syncope, or dizziness.
Indications for Ischemia Monitoring * Evaluation of hypertrophy or dilated cardiomyopathies
* Patients with suspected variant angina. * Documented long QT syndromes.
* Patients with chest pain who cannot exercise. * Palpitation after surgery for congenital heart disease.
* Pre-operative for vascular surgery who cannot exercise * Evaluation of drug efficacy during rapid somatic growth
* Patients with known CAD. * Asymptomatic congenital AV block, nonpaced.
* Patients with atypical chest pain syndrome. * Evaluate cardiac rhythm after anti-arrhythmic therapy.
* Initial evaluation of patients with chest pain who are * Evaluate cardiac rhythm after transient AV block
able to exercise. associated with heart surgery or catheter ablation.
* Evaluate rate-responsive or physiological pacing
The purposes of Holter ECG monitoring in pediatric function in symptomatic patients.
patients include (1) the eveluation of symptoms that may
be arrhythmia related; (2) risk assessment in patients with * Evaluate patient less than 3-years old with a prior
cardiovascular disease, with or without symptoms of an tachy-arrhythmia.
arrhythmia; and (3) the evaluation of cardiac rhythm after * Follow-up of complex ventricular ectopy on ECG or
an intervention such as drug therapy or device exercise stress test.
implantation. Holter ECG monitoring is commonly used in * Evaluate suspected incessant atrial tachycardia.
the periodic evaluation of pediatric patients with heart
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Heart Rate Variability
Standards of Measurement, Physiological Interpretation,
and Clinical Use
The last two decades have witnessed the recognition of a Depressed HRV can be used as a predictor of risk after
significant relationship between the autonomic nervous an acute MI, and as an early warning sign of diabetic
system and cardiovascular mortality, including sudden neuropathy.
cardiac death. The clinical importance of HRV became
appreciated in the late 1980s, when it was confirmed that For prediction of all-cause mortality, the value of HRV is
HRV was a strong and independent predictor of mortality similar to that of left ventricular ejection fraction.
after an acute myocardial infarction. With the availability of However, HRV is superior to left ventricular ejection
new, digital, high frequency, 24-hour, multi-channel ECG fraction in predicting arrhythmic events (sudden cardiac
recorders, HRV has the potential to provide additional death and ventricular tachycardia). The observed
valuable insight into physiological conditions and to depressed cut-off values of 24-hour measures of HRV is
enhance risk stratification. an SDNN < 50 ms.
Changes in HRV Related to Specific Pathologies: Once clinical manifestations of diabetic autonomic
* Myocardial Infarction: Depressed HRV after MI reflects a neuropathy (DAN) supervene, the estimated 5-year
decrease in vagal activity directed to the heart, which leads mortality is approximately 50%. Thus, early subclinical
to the prevalence of sympathetic mechanisms and to detection of autonomic dysfunction is important for risk
cardiac electrical instability. The rationale for trying to stratification and subsequent management. Analyses of
modify HRV after a MI stems from the multiple observations short-term and long-term HRV have been proven useful
indicating that cardiac mortality is higher among those post in detecting DAN.
MI patients who have a more depressed HRV. Intervention
therapies include B-Adrenergic Blockade drugs, Anti-
arrhythmic drugs, Scopolamine, Thrombolysis, and The Framingham Heart Study concluded that HRV offers
Exercise training. prognostic data independent of and beyond that provided
by traditional risk factors.
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Heart Rate Variability
Standards of Measurement, Physiological Inrepretation,
and Clinical Use
Disease Mechanisms: Several primary neurological * Diabetic patient for evaluation of diabetic neuropathy
disorders including Parkinsons disease, multiple sclerosis,
Guillain-Barre syndrome, and orthostatic hypotension of the * Post MI patients with normal and dysfunctional LV
Shy-Drager type are associated with altered autonomic
function. Changes in HRV may be an early manifestation of function.
the condition and may be useful in quantitating the rate of
disease progression and/or the efficacy of therapeutic * Idiopathic hypertrophic cardiomyopathy.
interventions. This same approach may also be useful in the
evaluation of secondary autonomic neurological disorders * Congestive Heart Failure.
that accompany diabetes mellitus, alcoholism, and spinal
cord injuries.
The Malik et al publication set the current standards by
the North American and European Joint Task Force for
The phenomenon that is the focus of this report is the HRV, and lists other indications that you have just read
oscillation in the interval between consecutive heartbeats, as for using the Holter HRV testing modality.
well as the oscillations between consecutive instantaneous
heart rates. This is called Heart Rate Variability (HRV).
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SAECG Late Potentials
Literature Review
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12-Lead Enhanced ST
Literature Review
12-Lead Holter ECG recordings open up new dimensions in to establish the type and efficacy of treatment. However,
detecting ischemia. several studies suggest that many individuals with severe
coronary artery lesions do not have angina pectoris. In
Asymptomatic Cardiac Ischemia Pilot (ACIP) Study: these patients, episodes of transitory myocardial ischemia
may be silent, although abnormal asymptomatic ST
Stone et al changes may be recorded during the Holter ECG. The
The presence of asymptomatic ischemic episodes silent ischemic events considerably outnumber the
identified by Holter ECG during routine daily activities in symptomatic ones, and it is generally accepted that
stable coronary patients is associated with an adverse nearly 75% of the transient ischemic episodes recorded
cardiac outcome. An ischemic episode was defined as during Holter ECG are asymptomatic in patients with
transient ST-segment deviation >1.0 mm that lasted 1.0 stable angina pectoris.
minute or longer. From a total of 802 participants whose
exercise treadmill test (ETT) indicated the presence of
ischemia, 143 had no episodes of ischemia during Holter Right Bundle Branch Block and ST Elevation
ECG, and 659 (82%) had one or more episodes of Holter Brugada et al
ECG ischemia. Patients with Holter ECG ischemia had a Patients with no demonstrable structural heart disease
more marked ischemic response during the ETT than and an abnormal ECG pattern consisting of right bundle
patients without Holter ECG ischemia. Our results indicate branch block and ST-segment elevation in leads V1
that there is a significant, consistent, and direct relation through V3 are at risk of sudden death. An implantable
between indexes of ischemia by exercise testing and the defibrillator is at present the treatment of choice. No
presence and frequency of asymptomatic Holter ECG patient died in the implantable defibrillator group, 4
ischemia. patients died in the pharmacological group, and four
patients died in the no therapy group. All mortality was
Silent Myocardial Ischemia due to sudden death. These results strongly stress the
Chiareiello et al need for careful evaluation of asymptomatic patients with
this ECG pattern and the need for family ECG screening
Chest pain is certainly the predominant symptom of
in survivors of cardiac arrest.
ischemic heart disease and the one most commonly used
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12-Lead Enhanced ST
Literature Review
AHA Scientific Statement: 2000 transient ST-segment changes (>0.05 mV) that develop
Tests for Silent and Inducible Ischemia during a symptomatic episode at rest and that resolve
Smith et al when the patient becomes asymptomatic strongly
suggest acute ischemia and a very high likelihood of
Among asymptomatic individuals, there is evidence that underlying severe CAD. Monitoring for recurrence of ST
development of an ischemic ECG response at low segment shifts provides useful diagnostic and prognostic
workloads of exercise testing is associated with a higher information, although the system of monitoring for ST
incidence of future events such as angina pectoris, segment shifts must include specific methods intended to
myocardial infarction, and sudden death. More specifically provide stable and accurate recordings.
ST depression > 1 mm occurring within 6 minutes on the
Bruce protocol (6-7 METs) has been associated with an
increased relative risk of cardiovascular events in men. A 12-Lead Holter ECG Specifications:
study in which the Ellested protocol was used in * Electrodes:
asymptomatic men with known CHD found that ECG a. 10 electrodes for Wilson 12-Lead ECG (DMS-300-12)
changes and exercise duration < 5 minutes correlated with b. 7-electrodes for Frank XYZ (DMS-300-7)
subsequent CHD in men > 40 years of age. * Recording duration: 24 or 48 hours
* % of time recording the 12-Lead ECG: 100%
ACC/AHA Practice Guidelines: 2000 * ECG digital sample rate: Read-in @ 512 samples/sec.
Management of patients with Unstable Angina * Analysis:
Braunwald et al a. ST analysis of all 12-Leads
Coronary artery disease (CAD) is the leading cause of b. ST measured at J-point and ST (with Slope)
death in the United States. Although imperfect, the 12-
Lead ECG lies at the center of the decision pathway for the c. Most common ST level for each individual lead
evaluation and management of patients with ischemic selected as 0-reference ST baseline
discomfort. A recording made during an episode of the d. All ST Episodes edited, verified, and validated
presenting symptoms is particularly valuable. Importantly,
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QT, QTc, and QTd
Literature Review
Multiple Mechanisms on the Long-QT Syndrome: Policy Conference on Potential for QT Prolongation
SADS Foundation Task Force on LQTS: Haverkamp et al 1999
Roden et al QT interval prolongation, and possibly increased QT
The long-QT syndrome (LQTS) is characterized by dispersion, are risk factors in a number of cardiovascular
prolonged QT intervals, QT interval lability, and as well as non-cardiovascular diseases. A variety of
polymorphic ventricular tachycardia. Most of the life drugs prolong the QT interval. These drugs generally
threatening arrhythmias in LQTS occur during physical or exert their therapeutic effect by affecting potassium ion
emotional stress. Most episodes of sudden death in LQTS channels, thereby reducing the repolarising current, and
almost certainly result from ventricular fibrillation triggered prolonging the action potential duration and the QT
by torsades de pointes (polymorphic ventricular interval. Anti-arrhythmic drugs which prolong cardiac
tachycardia). In most patients with LQTS, the heart rate repolarization are not harmless, as they may induce a
corrected QT interval (QTc by Bazetts formula) is >0.46 potentially fatal arrhythmia, known as Torsade de
seconds (460 ms). The ECG changes in LQTS include Pointes. Recently, it has become apparent that a variety
considerably more than simple prolongation of the QT of non-anti-arrhythmic agents may aggravate and/or
interval. For example, QT dispersion (QTd), as assessed provoke Torsade de Pointes. As many as 50 clinically
by the difference between the longest and shortest QT available or still investigational drugs have been
intervals on a 12-Lead ECG, is increased in LQTS, implicated (see listing on next slide). Of concern is the
indicating spatial heterogeneity in repolarization. The interval, usually measured in years, from the marketing of
normal range for QTd is 28 to 64 ms, but in patients with these drugs to initial recognition of their association with
LQTS, it is 112 to 154 ms. The mortality of untreated QT interval prolongation. The risk of drug-induced
symptomatic patients with LQTS exceeds 20% in the year Torsade de Pointes (LQTS) arrhythmias raises a
after their first syncopal episode, and approaches 50% dilemma of early detection of the effects of any new
within 10 years. With therapy, this can be reduced to 3% chemical entity on cardiac ventricular repolarization.
to 4% in 5-years. Strong evidence supports the use of
antiadrenergic interventions as mainstays of therapy. Note: The Holter QT, QTc, and QTd report is a specific
testing modality for detecting the transient LQTS events.
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QT, QTc, and QTd
Literature Review
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VCG (Vectorcardiogram)
Literature Review
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Sleep Apnea
Literature Review
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Atrial Fibrillation
Literature Review
Can We Believe in Symptoms for Detection of Atrial Atrial Fibrillation cardioversion fails in 15-30% of patients,
Fibrillation in Clinical Routine? leading to interest in ibutilide, biphasic waveforms, and
Fetsch et al 2002 internal cardioversion. We sought to find the predictors of
About 90% of documented AF recurrences occurred successful cardioversion in a standardized high volume
completely asymptomatic, and have only been detected clinical practice. Conclusion: 1) Use of digoxin is
by daily ECG monitoring. With respect to these findings, associated with improved acute cardioversion success; 2)
it is questionable if associated symptoms are still valid increasing Left Atrial Appendage velocity also appears
parameters for reliable detection of AF in clinical routine. univariately to predict cardioversion success, possibly as it
indicates a more organized rhythm; 3) increasing body
mass index and beta blockers use are associated with
Rate Control and Rhythm Control Improve Quality of Life diminished cardioversion success; and 4) calcium
in Patients with Atrial Fibrillation. blockers and ace inhibitors/A2 blockers do not appear to
Carlsson et al 2002 affect acute cardioversion success.
Quality of life is reduced in patients with atrial fibrillation.
It had been unknown whether a strategy of rhythm control How Do Class 1 Anti-arrhythmic Drugs Terminate AF?
improves quality of life as compared with rate control.
Conclusion: Quality of life in patients with AF can be Kneller et al
significantly improved by either treatment strategy. This Class 1 anti-arrhythmic drugs terminate clinical AF, but
is probably due to more intensive treatment and better the underlying electrophysiological mechanisms are poorly
patient guidance, and seems to be unrelated to actual understood. We conclude that despite the reduction in
heart rhythm. The most important predictor of quality of wavelength by pure blockade, AF conversion occurs
life in these patients is NYHA functional class. because of the effects of reduced excitability on re-entry
dynamics. These data show for the first time that pure
blockade can terminate AF and elucidate the underlying
Predictors of Successful Transthoracic AF Cardioversion mechanisms.
Friedman et al
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FCG CADgram
Literature Review
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