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Managing Patients with Heart Arrhythmia - Episode 8

Early ICM Use for Patients With Atrial Fibrillation and Syncope

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

Solomon J. Sager, MD: 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.

Transcript Edited for Clarity