Chief Corner: Continuous Electrocardiographic Monitoring

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Background

Continuous electrocardiographic monitoring (telemetry) is often reflexively ordered for patients on admission to the hospital. This practice can lead to unnecessary use of a limited resource, patient limitations, increased cost, and alarm fatigue. Internal medicine physicians should be mindful that there are established indications for continuous electrocardiographic monitoring.

Indications for Telemetry

The American Heart Association (AHA) and American College of Cardiology (ACC) issued guidelines for continuous electrocardiographic monitoring in 2004 and recently updated their recommendations in 2017. Below summarizes some major points.

The goal of continuous ECG monitoring includes:

  • Recognize deteriorating conditions that may lead to life-threatening arrhythmias
  • Facilitate management of arrhythmias
  • Diagnose arrhythmias  or identify etiology of symptoms (palpitations, syncope)
  • Immediately detect cardiac arrest

Important conditions that warrant continuous ECG monitoring on in the hospital:

  • Syncope of truly unknown origin or suspected cardiac origin
  • Stroke – if cryptogenic and/or suspect atrial fibrillation
  • Moderate to severe imbalance of potassium or magnesium
  • Drug overdose – until patient is free of drug influence and clinically stable
  • Risk for QTcB prolongation – QT-prolonging medications, severe hypokalemia or hypomagnesemia
  • Following non-cardiac thoracic surgery – due to risk of new onset atrial fibrillation
  • Primary cardiac diagnoses:
    • Acute coronary syndrome
    • Admission for acute decompensated heart failure until precipitating factor resolved
    • New onset or recurrent atrial arrhythmia or if admission requires rate control
    • Any symptomatic or significant asymptomatic sinus arrhythmia
    • Patients resuscitated from cardiac arrest
    • Infective endocarditis – until clinically stable
    • Recent pacemaker or ICD placement
    • Monitoring after initiation of antiarrhythmic drug
    • After ablation procedure
    • Patients on mechanical circulatory support including ECMO, VAD, intra-aortic balloon pump
    • Following transcatheter interventions including TAVR, closure of atrial/ventricular septal defect

It is important to note several points. First, the choice for telemetry monitoring is at the discretion of the physician. Second, while there are not official guidelines or recommendations, other medical conditions often considered for continuous monitoring are alcohol withdrawal, sepsis, and pulmonary embolism. These can be decided on case-by-case basis, however need for telemetry should be reassessed daily. Third, no studies have supported the use for telemetry as a monitor for “early clinical deterioration.”

Let’s end with a friendly chief reminder – When considering ordering telemetry, consider if the patient meets an indication. If so, make sure that you note this indication when ordering. Go ahead and make the need telemetry a part of your daily rounds discussion.

Learning Points

  • The overuse of continuous electrocardiographic monitoring  may have negative consequences including increased cost and alarm fatigue
  • There are specific guidelines by the AHA and ACC for the indications of continuous electrocardiographic monitoring that should be followed for admitted patients
  • These indications include both cardiac and non-cardiac primary diagnoses
  • Need for continuous electrocardiographic monitoring should be reassessed daily

References

  • Sandau, K et al. “Update to Practice Standards for Electrocardiographic Monitoring in Hospital Settings: A Scientific Statement from the American Heart Association.” Circulation. 2018; 137(25): e273-e344.
  • Weinberg, R. “Standards for Inpatient Electrocardiographic Monitoring.” American College of Cardiology. Oct 4, 2017.
  • Najafi, N. et al. “Use and Outcomes of Telemetry Monitoring on a Medicine Service.” Arch Intern Med. 2012; 172(17): 1349-50.
  • Benjamin, EM et al. “Impact of cardiac telemetry on patient safety and cost.” Am J Manag Care. 2013; 19(6): e225-32.
  • <https://commons.wikimedia.org/wiki/File:EKG_Complex_en.sv>
  • <https://commons.wikimedia.org/wiki/File:Blausen_0339_Electrocardiogram.png>

Authored by: GREGORY WIGGER, MD

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Internal Medicine Chiefs