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August 20, 2019 Circulation. 2019;140:e382–e482. DOI: 10.1161/CIR.0000000000000628 e398

CLINICAL STATEMENTS AND GUIDELINES Kusumoto et al 2018 Bradycardia Clinical Practice Guidelines

and, in active individuals, may help identify the presence or absence of chronotropic incompetence.S4.2.3-13 Less frequent symptoms are best evaluated with more prolonged ambulatory electrocardiographic monitoring that can be accomplished with a broad array of modalities. Contemporary options have been recently reviewed in a comprehensive expert consensus statement.S4.2.3-14 The yield of ambulatory monitoring for significant bradyarrhythmias varies according to the population studied but is typically <15%.S4.2.3-13,S4.2.3-15,S4.2.3-16 However, in populations with nonspecific symptoms felt to be potentially arrhythmic, one-third of the population will manifest their presenting symptoms during continuous ambulatory monitoring without associated arrhythmia, a useful observation that often excludes arrhythmia or conduction disorder as the source.S4.2.3-13 Recommendation-Specific Supportive Text

1.	In a prospective study of 95 individuals with syncope of uncertain origin after history, physical examination and ECG, up to 72 hours of continuous ambulatory monitoring uncovered significant bradyarrhythmia in 11%.S4.2.3-15 In patients with less specific symptoms, the diagnostic yield of continuous ambulatory electrocardiographic monitoring for bradyarrhythmias is even lower. A study of 518 consecutive 24-hour Holter monitors performed for a broad range of cardiac symptoms revealed significant bradyarrhythmia in only 4%, and none manifested advanced atrioventricular block.S4.2.3-16 External loop recorders, transtelephonic event recorders, adhesive patch recorders,

Table 6.  Cardiac Rhythm Monitors

Types of Monitor Device Description Patient Selection Nonphysician prescribed smartphone-based systems Commercially available smartphone–based systems

Can record a rhythm strip when the patient has symptoms or continuously depending on the technology Patient access to the technology

Holter monitor 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) A recording device that transmits patient-activated data (live or stored) via an analog telephone 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 incapacitating symptoms

External loop recorder (patient or auto triggered)* 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 telephone, which transmits triggered data automatically over a wireless network to a remote monitoring system Frequent, spontaneous symptoms potentially related to bradycardia or conduction disorder, likely to recur within 2–6 wk

External patch recorders 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 AF 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 telemetry 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 electrocardiographic data through a wireless network to the central monitoring station, which is attended by trained technicians 24 h/d Spontaneous symptoms, potentially related to bradycardia or conduction disorder, that are too brief, too subtle, or too infrequent to be readily documented with patient activated monitors

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

Implantable cardiac monitor Subcutaneously implanted device, with a battery life of 2–3y

Triggered by the patient (oroften 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 symptoms, potentially related to bradycardia or conduction disorder after a nondiagnostic initial workup, with or without structural heart disease

*Higher yield in patients who are able to record a diary to correlate with possible arrhythmia. Adapted with permission from Shen et al.S4.2.3-19 AF indicates atrial fibrillation.

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