Solomon Sager, MD

How do I use insertable cardiac monitors in my practice? I’ve been using insertable cardiac monitors in my practice for 8 years. Over the past 3 years, we’ve been implanting them in our office at Chicago Cardiology Institute. We were 1 of the first in the city of Chicago, Illinois to implant insertable cardiac monitors in the office, and we have robust practice in this regard. I use them frequently for my patients with A-Fib [atrial fibrillation]. I find them to be a powerful tool to help guide my decision-making with regard to patient care. I take pride in treating each patient as an individual, and I try to tailor the therapy that they may need based on their individual needs and their individual circumstances. The data that I collect from insertable cardiac monitors allows me to do this for my patients.

The vast majority of patients are extremely happy with insertable cardiac monitors as a tool. They like to know that we’re watching over them and collecting data on their heart rhythm, and they like that we can use that data at the point of care in the office and show them exactly how much A-Fib they’re having, when they had it, when it started, when it stopped, if it’s worse than before, if it’s better than before, and how they’ve done since their ablation. All these things are powerful tools that help guide decision-making that they’re very content and satisfied with.

For syncope, which is the second most common reason that I implanted insertable cardiac monitors, patients are very happy that they’re able to be watched for possible high risk or life-threatening arrhythmias that may be causing them to pass out. There are tons of great stories that I have about patients who had undetected arrhythmias, even undetected ventricular arrhythmias that required defibrillators, where we save their life by using the data collected from an insertable cardiac monitor. Another diagnosis I use them for are cryptogenic stroke. It’s a powerful tool to detect A-Fib and help prevent recurrent strokes in patients who’ve had them as well as unexplained palpitations and monitoring for ventricular arrhythmias. It’s probably not used enough for monitoring ventricular arrhythmias, but we have a lot of patients who have nonsustained ventricular tachycardia. And we know they’re at risk for the development of sustained arrhythmias, although they don’t necessarily meet criteria for implantable cardioverter defibrillators. The insertable cardiac monitor can be a powerful tool for those patients to monitor them and to determine their risk.

™and listening to this talk on insertable cardiac monitors. We appreciate your support. I have some final thoughts on insertable cardiac monitors. Insertable cardiac monitors, in my opinion, are a powerful tool and an underutilized tool for patients with heart arrhythmia. They allow for powerful data collection to help take care of each patient on an individual basis. The future is bright for insertable cardiac monitors, and we still haven’t figured out the best way to use them. The data we collect leads to important clinical decision-making regarding catheter ablation, antiarrhythmic therapy, diagnosing patient symptoms, and even anticoagulation treatment in some individual circumstances. At some point, we may be using the amount of A-Fib the patients have to guide us in our medical decision-making and potentially in regard to anticoagulation for some lower- to intermediate-risk patients.

Videos

Solomon Sager, MD, shares his experience using ICMs in clinical practice for patients with atrial fibrillation and syncope.

Using ICMs in Clinical Practice to Manage Afib and Syncope

Where do we stand today? We have wearable monitors—insertable cardiac monitors—as the mainstay of monitoring devices. What’s in the pipeline and what do we see for the future? A lot of what’s going on in the future of cardiac monitoring revolves around patient-centered data collection. The FDA has approved multiple algorithms in wearable devices such as Apple Watches, Fitbits, and the [AliveCor] KardiaMobile app. This technology allows patients to collect their own information and send it to doctors with the push of a button.

There are many benefits to patient-centered data collection, but there are also pitfalls. If a patient is having silent arrhythmias that they don’t know about or that their device is unable to detect, we won’t be able to see those data. The newer insertable cardiac monitors coming out have longer battery lives. In the future, we should be able to get real-time information via Bluetooth connections with patients, phones, and watches. And they’re adding uses to the insertable cardiac monitors. Some of them are able to check body temperature as well as thoracic impedance to determine if patients have extra fluid in their lungs that may be causing shortness of breath.

As I see it, the future for insertable cardiac monitors means more data collection, which will allow for more ways to take care of patients from the comfort of their own home without coming into the office or the hospital. The future for medicine and for cardiology is being able to take care of people without them coming into the office. The COVID-19 pandemic taught us that telemedicine is the future and insertable cardiac monitors are a powerful tool to help us deliver on our promise to patients to be able to take care of them without them coming into the office or the hospital. Most important, being able to take care of people at home means keeping them out of the hospital environment and within the comfort of their homes.

Which insertable cardiac monitor is the best? All of them have their benefits. The main ones on the market are made by Medtronic, Boston Scientific, Abbott, and Biotronik. Each company has its own benefits and pitfalls. Personally, I use Medtronic’s more because I find that the implantation technique is the easiest and the data collection is the most powerful. But the others have their own benefits. Boston Scientific devices are universally connected via Bluetooth to the patient’s phones. Biotronik has multiple ways of collecting other information, such as body temperature, on their devices, and they have a longer battery life. All of them are excellent devices and can be used for appropriate patient monitoring and data collection.

An expert in cardiovascular medicine provides insight on long-term monitoring solutions in the pipeline for the management of atrial fibrillation and syncope.

Future of Long-Term Monitoring Solutions for Afib and Syncope

What we talk about a lot is the timing of when we want to implant insertable cardiac monitors [ICMs]. This is an ongoing topic of conversation. In the current health care paradigm, there’s an ongoing dialogue between doctors and insurance companies about what needs to be done before we can recommend an insertable cardiac monitor for patients. Depending on the insurance plan, there are different policies and guidelines for all diagnoses.

There’s a lot of great data that would suggest that the earlier you get an insertable cardiac monitor into patients, the better it is for them. We can avoid many unnecessary health care costs, including unnecessary monitoring and procedures by just getting to the insertable cardiac monitor right away. The longer period of time that you have monitoring on a patient’s beat-by-beat analysis, the more likely you are to find a diagnosis and potentially discover data that can lead to improved clinical care. There are multiple ongoing studies determining when the optimal timing is for using insertable cardiac monitors. In my own practice, with A-Fib [atrial fibrillation] management, the earlier you get an insertable cardiac monitor in, the more likely you are and the sooner you are to get data that’s actionable for patient care.

How do ICMs help reduce health care costs and health care utilization? Multiple studies have shown that over the long term, ICMs in patients with unexplained syncope reduce costs. At 3 years of monitoring in 1 study, hospitalizations in syncope patients were reduced by up to 60%, and there was a 67% cost reduction through fewer tests and hospital stays. Compared with the standard of care, patients who have ICMs are 3.6 times more likely to reach a diagnosis with a 44% diagnostic yield of insertable cardiac monitors. This increases over time to 52% in 3 years. Twenty percent of the syncope diagnoses made in insertable cardiac monitors occur after 2 years. The power of the insertable cardiac monitors in patients with unexplained syncope increases with time, and it clearly, if utilized appropriately, saves the health care system money and saves the patients money.

How do insertable cardiac monitors help reach diagnosis? We use insertable cardiac monitors frequently in patients who have undergone full work-ups but still don’t have a diagnosis, symptoms such as syncope, palpitations, or dizziness. There are 2 different ways we can reach the diagnosis. One, the patients have a button they can push, which will have the ICM store data for a certain period of time before they click that button and afterward. The amount of time before and after is proprietary to each company’s device. The other way is that the devices are automatically set to look for low or high heart rates based on algorithms in each device. Even if a patient doesn’t have the clicker by their side to click when they have symptoms, if something abnormal happened, the device will automatically store that data and then will communicate it via the programmer at the patient’s bedside to the cloud. Most practices and hospitals are checking that data on a daily basis to allow for ongoing communication within 24 hours of symptom onset.

Dr. Solomon Sager assesses the benefit of earlier ICM use on patients and providers for the management of atrial fibrillation and syncope.

Early ICM Use for Patients With Atrial Fibrillation and Syncope

How has the monitoring technology evolved over the years? For 1 thing, size is a big deal. When the first monitors were implanted in the 2000s, they were a surgical procedure that took 25 to 30 minutes to implant. Over time, they’ve become barely bigger than a matchstick, they’re done in the office, and it takes 60 seconds to insert. Another technology that’s evolved is machine learning, which is really important. It’s the newest, latest, and greatest of the insertable cardiac monitor technology. This allows for enhanced detection of arrhythmias and decreased false detection of arrhythmias. Additionally, the ability to detect extra heartbeats such as PVCs [premature ventricular contractions] has become part of the paradigm of insertable cardiac monitors. Although it’s not indicated specifically to quantify PVCs, it is an additional use of the devices, and that’s just in the past year.

What are the best ways to obtain clinically actionable data on patients? There are a lot of ways to obtain data via monitors. Wearable monitors can be useful, and there’s a variety of wearable monitors. The limitations of wearable monitors is No. 1, they can be worn only for a certain amount of time, and No. 2, many of them do not provide real-time data. You place the monitor for 1 week, 2 week, or up to 4 weeks, and you don’t get the data back until after those data are analyzed. The other limitation is that they can be very cumbersome and can cause rashes as well as local reactions.

How do we monitor patients at high risk for syncope? The original studies were done on patients with unexplained syncope. In some of those studies, they randomized patients to routine clinical monitoring vs long-term monitoring with an insertable cardiac monitor to determine the diagnosis of the unexplained syncope. The patients who had the insertable cardiac monitor were 30% more likely to obtain an appropriate diagnosis at 1 year, and the longer they were monitored, the more likely they were to obtain an appropriate diagnosis.

Today we use insertable cardiac monitors all the time in patients with unexplained syncope. Usually we do at least some sort of wearable monitor beforehand. The reason is that if we can detect something within a couple of weeks on a wearable monitor, sometimes we recommend a pacemaker, in which case an insertable cardiac monitor isn’t indicated. But the vast majority of the time, patients who present with multiple episodes of unexplained syncope—and who’ve had a full work-up without clear explanation—meet criteria for insertable cardiac monitoring and benefit from having this. The long-term likelihood of finding a diagnosis with an insertable cardiac monitor in a patient with unexplained syncope is greater than 30%.

An expert in cardiovascular medicine comments on how the technology of ICMs has evolved and evaluates the use of ICMs for patients fibrillation who are at high risk for syncope.

Evolution of ICMs for Afib and Syncope Management

My name is Joey Sager. I’m the director of cardiac electrophysiology and the managing director of Chicago Cardiology Institute in Schaumburg, Illinois. We are a 17-provider group offering the full range of cardiac care. Today I’ll be talking to you about cardiac monitoring, including wearable monitors and insertable cardiac monitors. We’ll probably even touch on some of the patient-centered data collectors, such as the Apple Watch and the [AliveCor] KardiaMobile app.

What are the benefits of insertable cardiac monitors for cardiac monitoring? When we’re managing patients with heart rhythm disorders, the more data we can collect, the better it is for patient care. Insertable cardiac monitors allow us to collect data on a beat-by-beat basis for up to 3 to 4 years. They’re inserted very easily under the skin. It takes about 60 to 120 seconds, and can be done in the office.

The data we collect can guide a variety of clinical decision-making. It helps us guide medical management for patients with atrial fibrillation [A-Fib]. It helps guide what ablations we may want to perform based on whether the A-Fib is paroxysmal, persistent, or even permanent. It helps us decide whether patients have enough A-Fib that would warrant anticoagulation, and it helps guide decisions regarding antiarrhythmic therapy. Sometimes patients have palpitations, and we’re not sure if they have atrial fibrillation. The insertable cardiac monitor can help us diagnose atrial fibrillation in those patients.

Atrial fibrillation is the new paradigm for insertable cardiac monitors. We used to use them only for syncope, for cryptogenic stroke, or for undiagnosed symptoms. But as the usage of insertable cardiac monitors and the technology has improved, we’ve started to use it much more for the management of A-Fib. The data we collect over a period of time can help us determine the best course of treatment for our patients and individualize the care for each patient. It’s a powerful tool, and patients have to do minimal activity to generate the data. The monitor for the device just sits by their bed, and overnight the communicator by the bed sends the data to a web-based portal that doctors and technicians can gather information from every morning to help us guide clinical decision-making.

How can we use insertable cardiac monitors to guide management of our patients with A-Fib? Two important factors for A-Fib are catheter ablation and anticoagulation. Frequently after catheter ablation, we’re able to discontinue some medications depending on the amount of A-Fib that the patients have afterward. Using insertable cardiac monitors after catheter ablation allows us to confirm that they’re not having any more atrial fibrillation and that we can indeed safely stop antiarrhythmic drugs.

Anticoagulation can be a little more of a challenge. As you probably know, we make decisions on anticoagulation based mostly on a score called the CHA2DS2-VASc [congestive heart failure, hypertension, age, diabetes mellitus, stroke, vascular disease, age, sex category] score, which is the best predictor of whether a patient is at increased risk for stroke. However, there are patients who are at the borderline of needing anticoagulation, as well as lower-risk patients who may want to know whether they’re having more A-Fib to help guide their anticoagulation decisions. In these circumstances, it’s not unreasonable to use the data collected from the insertable cardiac monitor to help guide therapy regarding anticoagulation. As many of you probably know from treating patients with A-Fib, many patients are adverse or just adamantly don’t want to take anticoagulation. The insertable cardiac monitor allows us to monitor those patients for any A-Fib recurrence and their overall A-Fib burden to see whether we need to continue to aggressively pursue anticoagulation.

What are the limitations of insertable cardiac monitors? From an implantation perspective, there are very few limitations. The complication rate is less than 1%. The main complication we occasionally see is bleeding at the site of where we insert the monitor. Very rarely you can have an infection, although that’s less than 1 of 1000. Some limitations are that it doesn’t allow us to collect real-time data. The data are transmitted only via the monitor by the bedside. Although some of the newer ICMs [implantable cardiac monitors] are able to connect via the phone using Bluetooth. I always warn my patients that these data aren’t collected in real time and that if they go into A-Fib at, say, at 2 PM, then I may not find out until the next morning.

Some of the other limitations are that it can overdiagnose A-Fib or underdiagnose it. Sometimes atrial flutter can present as a regular rhythm that the device, if the rate is slow enough, may not detect if the rate is regular and resembles normal sinus rhythm. At other times the device may think that it’s seeing pauses or may think it’s seeing fast rates if it’s over- or undersensing. There are new machine-learning algorithms to help prevent this from happening, but they don’t completely eliminate them. Sometimes we think we detect arrhythmias or other things when those aren’t there. Careful analysis of the strips from the device can usually eliminate this, but that adds to the time it takes to manage these patients.

Solomon Sager, MD, reviews the benefits of cardiac monitoring with insertable devices and how it can guide treatment decision-making in patients with atrial fibrillation.

Solomon Sager, MD

Articles

Using ICMs in Clinical Practice to Manage Afib and Syncope

Future of Long-Term Monitoring Solutions for Afib and Syncope

Early ICM Use for Patients With Atrial Fibrillation and Syncope

Evolution of ICMs for Afib and Syncope Management

Atrial Fibrillation: Role of Cardiac Monitoring With Insertable Devices