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August 1, 2017 Circulation. 2017;136:e60–e122. DOI: 10.1161/CIR.0000000000000499 e78

4 MANAGEMENT OF

CARDIOVASCULAR CONDITIONS

The writing committee reviewed the evidence to support recommendations in the relevant ACC/AHA guidelines and affirms the ongoing validity of the related recommendations in the context of syncope, thus obviating the need to repeat existing guideline recommendations in the present guideline, except for the specific cardiac conditions in Sections 4.2.4, 4.2.5, and 4.3 for which ACC/AHA guidelines are not available. The relevant guidelines are noted in Table 2.

It is pertinent to note that the principles of evaluation and management of syncope in patients with various cardiac conditions are the same as for other noncardiac conditions. A thorough history, physical examination, and baseline ECG are recommended in all patients. The determination of the immediate cause of syncope may be related, indirectly related, or unrelated to the underlying cardiac condition. Management of

Table 8.  Cardiac Rhythm Monitors

Types of Monitor Device Description Patient Selection Holter monitor151–153 A portable, battery-operated device

Continuous recording for 24–72 h; up to 2 wk with newer models Symptom rhythm correlation can be achieved through a patient event diary and patient-activated annotations Symptoms frequent enough to be detected within a short period (24–72 h) of monitoring*

Patient-activated, transtelephonic monitor (event monitor)150,154,155 A recording device that transmits patient-activated data (live or stored) via an analog phone line to a central remote monitoring station (eg, physician office) Frequent, spontaneous symptoms likely to recur within 2–6 wk

Limited use in patients with frank syncope associated with sudden incapacitation

External loop recorder (patient or auto triggered)†150,154,155 A device that continuously records and stores rhythm data over weeks to months

Patient activated, or auto triggered (eg, to record asymptomatic arrhythmias) to provide a recording of events antecedent to (3–14 min), during, and after (1–4 min) the triggered event Newer models are equipped with a cellular phone, which transmits triggered data automatically over a wireless network to a remote monitoring system Frequent, spontaneous symptoms related to syncope, likely to recur within 2–6 wk

External patch recorders157–159 Patch device that continuously records and stores rhythm data, with patient-trigger capability to allow for symptomrhythm correlation

No leads or wires, and adhesive to chest wall/sternum Various models record from 2–14 d Offers accurate means of assessing burden of atrial fibrillation Patient activated, or auto triggered (eg, to record asymptomatic arrhythmias) to provide a recording of events antecedent to, during, and after the triggered event Can be considered as an alternative to external loop recorder

Given that it is leadless, can be accurately self-applied, and is largely water resistant, it may be more comfortable and less cumbersome than an external loop recorder, potentially improving compliance Unlike Holter monitors and other external monitors, it offers only 1-lead recording

Mobile cardiac outpatient telemetry160,161 Device that records and transmits data (up to 30 d) from preprogrammed arrhythmias or patient activation to a communication hub at the patient’s home

Significant arrhythmias are detected; the monitor automatically transmits the patient’s ECG data through a wireless network to the central monitoring station, which is attended by trained technicians 24 h/d This offers the potential for real-time, immediate feedback to a healthcare provider for evaluation Spontaneous symptoms related to syncope and rhythm correlation

In high-risk patients whose rhythm requires real-time monitoring

Implantable cardiac monitor162,167,179–181 Subcutaneously implanted device, with a battery life of 2–3 y

Triggered by the patient (or often family member witness) to store the event Models allow for transtelephonic transmission, as well as automatic detection of significant arrhythmias with remote monitoring Recurrent, infrequent, unexplained syncope (or suspected atypical reflex syncope) of suspected arrhythmic cause after a nondiagnostic initial workup, with or without structural heart disease

*Includes history, physical examination, and 12-lead ECG; may include nondiagnostic tilt-table test or electrophysiological study. †Higher yield in patients who are able to record a diary to correlate with possible arrhythmia. ECG indicates electrocardiogram.

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