As cardiac monitoring technology has developed, mobile cardiac telemetry (MCT) has proven to be the most effective method for identifying and managing patients with asymptomatic arrhythmias, complete syncope, medication titration, post CABG, and post ablation. But are all MCT devices the same? The short answer is no.
The next generation of MCT
The Telerhythmics TCAT3 is a mobile cardiac telemetry device that incorporates the most industry advanced features and is supported by a staff of seasoned clinical experts. The device includes onboard patient compliance technology, is flexible, single component, and easy to use. The clinical features include Beat-to-Beat Analysis and Full Disclosure.
The TCAT3 Advantage
While there are many MCT systems available, the TCAT 3 has several advantages, including:
- A higher diagnostic yield, particularly when compared to holter or event monitoring.
- Improved outcomes when managing patients on antiarrhythmic drugs.
- Substantial cost savings in the hospital for ablation, CABG, heart/pericardium, and valve/septa procedures.
- Immediate access to potentially dangerous cardiac rhythms.
- The accurate and continuous capture of ECG information and the relay of critical data to the physician promptly and without the need for patient participation.
A Closer Look at MCT Features
Mobile cardiac telemetry devices and providers offer widely different features, and it’s important to know what type of MCT is being used before making a decision. Items such as Beat-to-Beat Analysis percentage, type of disclosure, and patient compliance requirements will all affect the net results. The chart below compares four types of MCT solutions and highlights the options you have.
Both Holter monitors and mobile cardiac telemetry (MCT) provide ways to monitor a patient’s electrocardiogram for an extended period of time. Their main purpose is to determine the cause of a transient event by recording a patient’s heart rate and rhythm during normal activity. Although similar, Holter monitors and MCT devices have distinctive differences and meet different needs, which impacts the physician’s choice of monitoring method. We’ve outlined some of the differences below:
A Holter monitor typically records cardiac activity for an uninterrupted 24-48 hours, although some are prescribed for up to 14 days. It is ideal for the patient who is experiencing symptoms on a more frequent or regular basis and whose condition does not require continuous monitoring.
Mobile cardiac telemetry is prescribed for a period up to 30 days. It is typically prescribed for patients with rare or intermittent episodes, or those who may be asymptomatic. The extended wear time allows for the opportunity to capture an arrhythmia that may not occur during a shortened wear time and is also helpful in identifying a silent pattern of irregular cardiac activity.
Holter monitors are designed to continuously record data. While their limited wear time reduces the inconvenience for patients, it’s also one of the reasons a Holter may be returned as non-diagnostic, or benign. Most often, this is because symptoms may not reappear during the time in which the Holter is monitoring the patient’s heart rhythm.
Telemetry devices offer a variety of recording methods. Many MCT devices are continually listening, recording every heartbeat for up to 30 days, and provide atrial fibrillation burden assessment.
Devices can store their data either locally or in the cloud. The data collected from a Holter monitor is stored on an internal chip and is limited in terms of space, but sufficient for the prescribed wear time.
Telemetry device storage varies. It can be stored locally or transmit the information to the cloud, as long as there is a strong cell signal present. This feature is significant because the data can be read in real time and irregularities can be addressed immediately. This difference is especially prominent when compared to the 7-14 day Holter monitors. Any irregularity identified with a Holter monitor will not be read until the monitor is returned and analyzed at the end of the prescribed wear time, which could potentially be up to 20 days later.
Both Holter monitors and telemetry devices require leads that are attached to the patient. Holter monitors typically require more leads and tend to be more bulky. As a result of the technology it uses, a telemetry device is smaller, sleeker and easier to wear.
There are also differences in the ways the devices are powered. Based on the amount of wear time, Holter monitors may have batteries that need to be changed. Newer telemetry device models are rechargeable. They typically include two batteries, one to wear while the other is charging.
Depending upon your symptoms, or lack thereof, your physician will prescribe the appropriate monitoring device. Both are completely painless and are considered highly effective ways to identify potential heart issues and to help determine the appropriate treatment.
While there are many variables to consider when partnering with a cardiac monitoring service, the reading expertise of the clinical staff is one of the most important.
Cardiac monitoring services that employ registered nurses offer an undeniably higher level of readiness to their customers and their patients. Their expertise allows them to serve as an extension of the physician as they ask critical questions, provide comprehensive care, and a more holistic approach.
In many cases, seasoned registered nurses, leveraging their experience, has been instrumental in identifying subtle but serious signs that may have easily been overlooked.
Preventing unnecessary procedures
For example, a particular case reported a patient was presenting a complete heart block, which was clearly cause to notify the physician. The patient was immediately directed to the emergency room in anticipation of surgery to implant a pacemaker.
A monitoring staff nurse who was familiar with this particular patient noticed that he had taken a double dose of a calcium channel blocker that works by relaxing the muscles of the heart and blood vessels. She notified the physician, who cancelled his prior instruction for the patient to head to the emergency room and instead, discontinued the medication. The next day, the patient returned to normal sinus rhythm.
This example was a situation where the nurse was able to provide information that helped prevent unnecessary treatment. In other instances, registered nurses are able to identify arrhythmias and triage patients who required an implantable device or other treatment, potentially eliminating an emergency response. Their expertise works both ways and across the full spectrum of care.
A full spectrum of benefits
In addition to the health considerations, the nurse who noticed the double dose of medication prevented a costly hospital visit for the patient. Even with health insurance, the patient would have most likely incurred a copayment, and the healthcare system would have incurred an unnecessary cost as well.
Most of the interactions between patients and the monitoring service take place over the phone. Cardiac trained nurses are experts at listening for shortness of breath, difficulty talking, wheezing, rales and other signs that are not instantly visible on an electrocardiogram. Combining what they can see on an EKG with the information they gain while talking to a patient can make all the difference.
All notifications from a monitoring service are potentially life saving. Given the critical nature of the data, a registered nurse who can more easily piece together a patient’s story, process it, and act quickly on that data is the highest level of care a monitoring service can provide.
Cardiac monitoring providers offer physicians a way to measure a patient’s heart rhythm over a defined period of time. It is considered standard practice in diagnosing cardiac arrhythmias and is also helpful in evaluating and managing medications and their effect on a patient’s condition.
Many cardiology practices choose to partner with a monitoring service center that provides equipment, supplies, and reviews EKG data. These companies actively monitor patients that are enrolled in the service and report the results to the doctor for a diagnosis. Patients enrolled in the service are typically experiencing palpitations, atrial fibrillation, atrial flutter, syncope, or a host of other heart rhythm abnormalities
When a patient is wearing a mobile cardiac telemetry device, the monitoring service continuously receives and observes the patient’s electrocardiogram. If any abnormality presents itself, the monitoring clinician will alert the physician in accordance with the signed notification criteria. A signed notification criteria is a physician-signed notification statement that details the type and level of irregularity and the protocol used to address it.
When a patient has an episode that meets the notification criteria, whether the patient records it or it is automatically recorded via the auto trigger feature of the device, a clinician immediately processes the information and contacts the physician for further instruction. Those further instructions may include heading to the emergency room, the doctor’s office, or a simple adjustment to the patient’s medication.
Holter monitors typically store recorded electrocardiogram data within the device and are not evaluated until the prescribed wear-time has expired. Patients return the Holter monitor to the clinic or the doctor’s office, where the information is downloaded to a secure server, analyzed, interpreted by the monitoring service and reported back to the physician for the diagnosis.
As with event monitoring, if at any point an arrhythmia is identified, the physician is notified. However, a Holter monitor’s activity has already occurred and is being evaluated after the fact, while an event monitor’s activity is currently happening and can be addressed without delay.
An event monitor, also called an ambulatory electrocardiographic monitor, is a battery powered, portable medical device that monitors cardiac activity as a patient goes about an ordinary day. The main purpose of an event monitor is to determine the cause of a transient event by recording a patient’s heart rate and rhythm during a period of time.
In contrast to an EKG, which captures cardiac activity at one point in time, or a Holter monitor, which continuously records over a period of 24-48 hours, an event monitor records intermittently for a period of a few weeks, typically up to 30 days. It is typically prescribed because a prior method of monitoring failed to obtain necessary data, likely because the patient’s symptoms are unpredictable or infrequent, generally occurring less than daily. An event monitor allows for longer monitoring time and a greater chance of capturing an irregularity.
Types of event monitors
Event monitors typically include wired sensors that are attached to the patient’s chest which are then connected to a small recording device. There are two types of event monitors:
- A looping memory monitor, the most common type of event monitor, can be programmed to record ECG activity for a given period of time. When the patient experiences symptoms, he pushes a button to activate the device, which triggers the monitor to record the 60 seconds prior to the event, the event, and up to 40 seconds following.
- A post-event monitor is typically a handheld device or one that can be worn on the patient’s wrist, similar to a bracelet. The small metal discs that are located on the back of the device function as electrodes When the patient experiences symptoms, the monitor is placed on the chest and the patient activates the recording button. This records the current ECG activity. Unlike the looping memory monitor, however, a symptom event monitor will not store any ECG activity that occurs in the minutes prior to its activation.
Both devices are able to send the ECG by telephone to a receiving center or a doctor’s office for review. Any emergency treatment, further testing or monitoring will be addressed as needed.
There are many variables to consider when selecting a cardiac monitoring service. Each provider has their own mix of technology, process, and service. While the type of technology used to capture patient data is critical, it’s even more important to know who is reading the data.
Readers can range from an automated computer system to a seasoned RN with years of critical care experience. Each category of readers provides a graduated level of service- from the bare minimum to the most advanced. It’s important to understand what level of reading technician each provider employs and, in turn, how that will impact the burden you and your staff absorb. Three high-level categories of monitoring include:
This basic level of monitoring is managed by the reliance on algorithms. It is an automated system that alerts the monitoring company of any abnormality based on specific criteria. Generally, a raw, unedited report is sent to the physician for evaluation and interpretation. With this method, the physician’s office retains the responsibility in terms of analyzing the data in a timely manner.
Many monitoring services are staffed with Certified Rhythm Analysis Technicians (CRATs) and/or Certified Cardiac Technicians (CCTs). These technicians have experience with administering EKGs, and reading and troubleshooting reports. Comparable levels of technicians include those who may have attended a monitored technician course in order to learn how to interpret EKGs or those who may have been hired by the monitoring service and are provided with on-the-job training.
Registered Nurse Monitored
The highest level of cardiac monitoring reading expertise includes a combined staff of registered cardiac nurses and technicians. Registered nurses are college educated, state board certified and, in many cases, certified in additional specific areas of expertise.
Registered nurses generally bring with them years of valuable critical care experience. Their ability to leverage that experience while watching and analyzing EKG results and evaluating their patients’ signs and symptoms adds significant value to the overall monitoring service. Their expertise allows them to serve as an extension of the physician as they ask critical questions and provide comprehensive care and comfort by way of a more holistic approach.
Making the Choice
Cardiac monitoring providers offer distinctly different levels of service when it comes to who reads the data. When evaluating these providers, determining who is caring for the patient is a critical component in the decision-making process. Any monitoring partner you utilize is an extension of your patient care, so it’s important to choose one that not only meets your outsourcing needs, but also your standards and level of patient care.
One-third of stroke and transient ischemic attacks are categorized as having no known cause, or cryptogenic. Recent studies have suggested that atrial fibrillation (AF) could be a possible cause for these cryptogenic strokes. If atrial fibrillation is known or suspected, early detection and monitoring is key.
In a study reported in The New England Journal of Medicine, patients without known atrial fibrillation, who had had a cryptogenic ischemic stroke, were monitored by mobile telemetry for 30 days. The study concluded that 12-15% of strokes were possibly caused by atrial fibrillation and raised the importance of early detection.
In addition to MCT, implantable loops are a new alternative that have also proven effective. These implantable cardiac monitoring systems are particularly useful either when symptoms are infrequent or when long-term data is required.
Based on the NEJM study, the use of mobile cardiac monitoring to detect and manage atrial fibrillation can also reduce a patient’s risk for stroke. Early detection is critical to identifying preventive treatment before an AF-related stroke occurs.
When a patient reports symptoms of an irregular cardiac event, physicians can choose to monitor cardiac activity using a Holter monitor, cardiac event monitor, or mobile cardiac telemetry.
Holter monitors are often a physician’s first line of defense when a patient reports symptoms of a cardiac irregularity. They are a non-invasive, wearable device that records the patient’s heart rhythm for a prescribed period of time during which the patient assumes normal, daily activities. Although it may be a low-cost, low-risk option, many physicians report non-diagnostic rates as high as 85%. Most often, this is because symptoms may not reappear in the 24 to 48 hours during which the Holter is monitoring the patient’s heart rhythm.
A cardiac event monitor is another option and is often the next line of defense. Typically worn for 30 days, it is prescribed for patients whose symptoms occur infrequently. When the patient experiences an abnormality, he manually presses a button to record the preceding and following five minutes of the event. There may also be an auto-capture feature where the device records the information even if the patient is unaware of the activity. Advances in the technology now allow for the wireless transmission of the data via the cellular network. These newer devices also have enhanced programming and expanded storage capabilities. Cardiac event monitors store the recorded data, which is ultimately transmitted either to a physician’s office or to a central recording station.
Mobile cardiac telemetry is the newest of the monitoring options. MCT devices are small portable monitors that, when a cardiac anomaly is detected, automatically send data. MCT devices provide even more information such as AFIB burden. The data is transmitted to a 24-hour manned monitoring center via a mobile network, and then interpreted by a qualified, cardiac-trained registered nurse. In contrast to the cardiac event monitor, MCT provides real-time monitoring and analysis.
There are no official guidelines established for deciding which monitoring method is best for your patient; however some insurance companies have specific criteria for the use of Mobile Outpatient Telemetry. MCT devices have proven beneficial in patients with unexplained syncope, Cryptogenic Stroke and post ablation.
When a patient expresses symptoms or exhibits signs of a cardiac irregularity, many cardiologists look to the Holter monitor as their first line of defense. While Holter monitors can be effective, it’s not uncommon for them to be returned as non-diagnostic. In fact, many physicians report non-diagnostic rates as high as 85%. Most often, this is because symptoms may not reappear in the 24 to 48 hours during which the Holter is monitoring the patient’s heart rhythm. Non-diagnostic Holters are also known as a benign Holter or a negative Holter.
Non-diagnostic results… now what?
Cardiac irregularities should not be dismissed even when a cardiologist receives a non-diagnostic Holter. The suspicion of an arrhythmia warrants additional steps. Many cardiologists will prescribe the use of a Holter monitor for a longer period. If the patient’s condition is infrequent, or if the patient is asymptomatic, then a passive recording system could be a more appropriate choice.
Some recording systems can be activated by the patient when he or she becomes symptomatic. Other systems utilize a Mobile Cardiac Telemetry (MCT) device that continually transmits EKG data back to a staffed monitoring center. If an abnormality is detected, the system will create an event and generate a report which documents the irregularity with full onset and offset as well as comprehensive ectopy reporting.
Many physicians who do not own a Mobile Cardiac Telemetry system choose to utilize a service-based cardiac monitoring provider, such as Telerhythmics. A cardiac monitoring service company can allow you to offer the technology without having to purchase the equipment. Plus, if you’ve never used a Mobile Cardiac Telemetry system, they will teach you how it works and train your staff on how to provide the service.
As always, regardless of which technology or service you choose, it’s most important to continue monitoring the patient until a diagnosis can be made.
There are dozens upon dozens of services that a cardiology office may offer. It can be overwhelming for a newly independent cardiologist to decide what technology and services to invest in first. Digirad works with thousands of cardiologists and we’ve compiled the five most essential services for any cardiologist thinking of opening his or her own office.
Perhaps most essential for any cardiology office is an electrocardiogram (EKG) machine in order to test for problems with the electrical activity of a patient’s heart. EKGs are useful for evaluating the possible causes behind unexplained chest pains as well as the efficacy of medicines and medical devices, such as a pacemaker.
Stress tests are essential for determining the amount of stress that a patient’s heart can manage before developing either an abnormal rhythm or evidence of ischemia.
Echocardiography is routinely used in the diagnosis, management, and follow-up of patients with any known or suspected heart diseases. Echocardiography can help detect cardiomyopathies, such as hypertrophic cardiomyopathy, dilated cardiomyopathy, and many others. Currently, it is one of the most widely used diagnostic tests in cardiology. Stress echocardiography is a subset of echocardiography. By utilizing stress tests during patient evaluation, stress echocardiography may help determine whether any chest pain or associated symptoms are related to heart disease by visualizing wall motion differences between stress and rest.
SPECT Myocardial Perfusion Imaging
SPECT myocardial perfusion scan (MPI) is a nuclear cardiology procedure that highlights the function of a patient’s heart muscle. MPI is useful for diagnosing a variety of heart conditions such as coronary artery disease, hypertrophic cardiomyopathy, and heart wall motion abnormalities. Images are usually acquired at both Stress and Rest allowing physicians to evaluate heart muscle perfusion to determine normalcy, ischemic, or infarcted areas.
Full Spectrum Cardiac Rhythm Event Monitoring
Cardiac rhythm event monitoring includes a variety of noninvasive tests necessary for all cardiology offices. Among the types of monitoring tests are Holter monitoring, event monitoring, and mobile telemetry, all of which involve collecting data from the patient over a period of time for suspected cardiac arrhythmias or to measure the efficacy of treatment.