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European Journal of Heart Failure 2000 2(3):281-285; doi:10.1016/S1388-9842(00)00057-X
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© 2000 European Society of Cardiology

Does in-patient ECG monitoring have an impact on medical care in chronic heart failure patients?

Cristina Opasicha,*, Soccorso Capomollab, P. Giorgio Riccardib, Oreste Febob, Giovanni Fornia, Franco Cobellib and Luigi Tavazzic

a S. Maugeri Foundation, Institute of Care and Scientific Research, Department of Cardiology Pavia, Italy
b S. Maugeri Foundation, Institute of Care and Research, Heart Failure Unit Montescano (PV), Italy
c Policlinico S. Matteo, Institute of Care and Scientific Research, Department of Cardiology Pavia, Italy

* Corresponding author. Tel.: +39-0382-592-1; fax: +39-0382-592-099. E-mail address: copasich{at}fsm.it


   Abstract
Top
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 References
 
Background: Heart failure patients' management in non-intensive care units might be improved by telemetry monitoring. However, telemetry adds the cost and evidence of this effectiveness is not available.

Aim: To evaluate the utility of the ECG monitoring in chronic heart failure patients admitted to a non-intensive care unit.

Methods: A prospective analysis of the utility of telemetry in 711 patients admitted to a Heart Failure Unit from March 1996 to September 1997.

Results: One hundred and ninety-nine patients underwent telemetry; 108 telemetry findings were recorded, in 35% of NYHA class II, in 46% in NYHA class III–IV and 43% in unstable patients. Reasons for telemetry were: known arrhythmia (n = 82), electrolytes disturbances (n = 20), atrial fibrillation (n = 12), symptoms (n = 48), i.v. dobutamine (n = 13), drugs control (n = 16), devices control (n = 8). Crossing reasons for telemetry and detected events we had, respectively, 63, 11, 2, 17, 5, 6, and 0 telemetry findings. Treatment was guided by telemetry results in only 33 cases (respectively in 18, 0, 4, 5, 5, 1, and 0 cases). Physicians perceived telemetry as unhelpful in 30% of cases; as helpful in 70%. The percentage of inutility, usefulness with and without related medical intervention were similar between stable and unstable patients (30, 18, 51% and 31, 15, 54%, respectively).

Conclusion: In a heart failure unit ECG monitoring is mostly used in severe and unstable patients. However, medical decisions are rarely guided by the telemetry findings. The usefulness of telemetry might be underestimated because one of the uncounted results might be the avoidance of inappropriate intervention.

Key Words: Heart failure • Telemetry • Non-intensive care unit

Received August 5, 1999; Revised December 22, 1999; Accepted January 7, 2000


   1. Introduction
Top
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 References
 
Admittance to an intensive care unit is recommended for patients with hemodynamic instability (Class I recommendation) [1]. Thus, information that can be drawn by a continuous nursing observation and cardiac monitoring is presumed to improve medical care. In clinical practice, however, less than half of the unstable HF patients are admitted in intensive units [2,3]. The EARISA Italian survey [4] showed that among the 18% of HF patients admitted to cardiological units, only 40% were admitted to coronary care units, while 60% were admitted in non-intensive cardiological wards. Out of the 82% of patients admitted to non-cardiological wards, presumably very few are graphically monitored by ECG. Cardiac monitoring in a non-intensive unit is not frequently used and it adds to the cost of healthcare. That telemetry monitoring was effective in HF patient’s management in non-intensive care units, should be more than simply assumed. To our knowledge, only few studies have been previously published on the efficacy of ECG monitoring in guiding the decisional making of patients admitted to the non-intensive unit [5–8]. Among them, the study of Estrada et al. [6] on more than 2000 patients, 277 with HF, concluded about an overestimate of the role of ECG monitoring because significant arrhythmias which modified the therapeutic strategy or induced an urgent treatment occurred only in a small subset of patients.

Accordingly, we planned a prospective, evidence-based analysis on the utility of the ECG monitoring in patients admitted to a heart failure unit. We sought: (1) to analyse telemetry indications and findings, subsequent decisional making, physicians’ perception of telemetry utility; and (2) to examine the impact of telemetry on patients management.


   2. Methods
Top
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 References
 
The heart failure unit consists of 21-bed telemetry units and six beds with telemetry monitoring. Heart rate and rhythm are recorded continuously with a Marquette 7500 system TTX 9500; this system allows automatic recognition of arrhythmia. Nurses trained in arrhythmia recognition watch the monitor 24 h/day and routinely report to the medical staff. The monitor is in the nursing room, in order to give surveillance and to respect patient’s privacy.

When telemetry monitoring was indicated for a patient (see below), the physician was asked to fill in a standardised form. This form included questions regarding identification of the patient, his/her clinical condition at the start of telemetry, questions on the indications for telemetry (codified answers). The medical staff reviewed the telemetry information daily and documented the rhythm in a standardised form. Moreover, when telemetry monitoring was stopped, physicians were asked to state whether the telemetry had helped them to guide either medical therapy (started, stopped, or changed medications) or non-pharmacological therapy (pacemaker, AICD, etc.). It was also requested that the physician noted his perception of the usefulness of telemetry. No ‘a priori’ specific criteria of usefulness of telemetry were required, although the medical staff had previously achieved a consensus about ECG monitoring prescription. These were: recent history of a sustained or symptomatic arrhythmia, severe hypoxia, electrolytes disturbances, acidosis, severe hemodynamic instability, inotropic drug infusion in patients with a history of arrhythmia or never previously treated or/and when dosage were considered higher than usual.

The open-ended responses were grouped into common items independently by two physicians.

From March 1996 to September 1997, 711 patients with moderate-to-severe HF were admitted to the heart failure unit for management of heart failure and/or cardiac transplant evaluation. During the study period no patient died of sudden death. Patients were grouped according to telemetry indications, functional class and stable/unstable clinical condition. Patients were defined unstable when symptoms or signs of pulmonary or peripheral congestion and of low cardiac output were present [1]. Differences between groups were assessed by analysis of variance. A P value of <0.05 was considered significant. The same repeated arrhythmic events were computed only once. Data are expressed as mean±standard deviation and as percentage when appropriate.


   3. Results
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 References
 
Of the 711 admitted patients, 199 (28%) underwent the ECG monitoring, as a result of a clinical indication freely made by physicians. They were predominantly men (82%), with a mean age of 51±9 years; the etiology of the HF was ischemic in 54% of cases, the mean left ventricular ejection fraction was 24.7±8%. On admission cardiac rhythm was sinus rhythm in 66%; chronic atrial fibrillation was present in 31% and a pacemaker rhythm in 3% of cases. A large majority of patients were in functional class III–IV (n=150, 75%), clinical conditions were unstable in 48%.

3.1. Indications
Reasons for ECG-monitoring are reported in Table 1. Unstable myocardial ischemia was never an indication for ECG monitoring in these patients. The most frequent indication was surveillance in patients considered at high arrhythmic risk because of previously documented arrhythmia. This motivation represented one-half and one-third of the indications in stable and unstable patients, respectively. In stable patients the second most frequent indication for telemetry was as a diagnostic tool (when unclear symptoms were referred by the patient), while in unstable patients indications were varied.


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  		Table 1 Telemetry indications grouped according to NYHA class and clinical condition (stability vs. non-stability)a

 
3.2. Length of the ECG-monitoring
ECG monitoring was used for a longer time in high NYHA class and in unstable patients, but the differences were not significant (10.1±15 vs. 5.9±7 days in NYHA class III–IV and II, respectively; 10.9±18 vs. 9.1±11 days in unstable and stable patients, respectively). The most prolonged ECG monitoring was that prescribed for surveillance in patients with a known arrhythmic pattern (11.4±15 days). When telemetry length was compared in patients grouped according to indications, no significant differences were obtained (F=0.97, n.s.).

3.3. Telemetry findings
One hundred and eight telemetry findings were recorded and are reported in Table 2. At least one finding was observed in 83 patients, 17 were in NYHA class II (this represents 35% of patients in functional class II with an indication for telemetry), 25 were in NYHA class III–IV (46% of patients in functional class III–IV in stable condition with an indication for telemetry) and 41 were unstable (43% of unstable patients in functional class III–IV with an indication for telemetry n.s.). The sole case of resuscitated ventricular fibrillation was in an unstable class IV patient. Ventricular ectopic beats >30/h and non-sustained and sustained ventricular tachycardia were significantly more frequent in class III–IV patients, but no differences were noticed between stable and unstable patients. Bradyarrhythmia were less frequent in unstable patients. A high degree of A–V block was never recorded.


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  		Table 2 Telemetry arrhythmic findings grouped according to NYHA class (II e III–IV) and to clinical stability or instabilitya

 
3.4. Cardiac interventions guided by telemetry
Crossing telemetry indication, telemetry finding and cardiac intervention, we observed that, among patients in whom telemetry was indicated for surveillance because of previously documented arrhythmia, there was abnormal finding in 63 cases (77%); 1 patient had ventricular fibrillation, 23 patients had ventricular tachycardia, 16 had episodes of ventricular ectopic beats >30/h, 23 had episodes of bradycardia (heart rate <50 b.p.m.). In 18 cases telemetry guided medical therapy (i.e. a drug was started, stopped or the dose changed), and cardiac intervention (e.g. AICD, pacemaker).

Among patients in whom telemetry was indicated because of electrolytes disturbance, abnormal findings were recorded in 55%. The abnormal findings were ventricular tachycardia (3 patients), episodes of ventricular ectopic beats >30/h (7 cases), episode of bradycardia (1 case). In all cases treatment of the electrolyte disturbances was started independently of telemetry finding. No other intervention was guided by telemetry.

During ECG monitoring, 2 of 12 patients with ‘de novo’ atrial fibrillation had episodes of bradyarrhythmia. In 8 of 12 patients sinus rhythm recovered spontaneously; in 4 a cardiac intervention (electrical or pharmacological cardioversion) was undertaken.

When telemetry was used as a diagnostic tool in patients with palpitations or dizziness, it showed abnormalities in 35% of the cases. Abnormal findings consisted of 5 ventricular tachycardia, 6 episodes of ventricular ectopic beats >30/h, 6 episodes of bradycardia. In 5 cases telemetry guided a therapeutic intervention (in 3 cases a pacemaker was implanted).

In 5 of 13 patients in whom dobutamine was started under ECG monitoring, telemetry showed abnormalities (4 patients developed ventricular ectopic beats >30/h and 1 had ventricular tachycardia). Only in 1 patient dobutamine dosage was reduced, in 4 cases it was not up-titrated. Dobutamine was not withdrawn from any patient. When telemetry was used to detect pro-arrhythmic effect of digoxin (11 cases in whom plasma level was >2 ng/ml;) or of other medications (5 cases), there were abnormal telemetry findings in 37% of the cases (3 cases with ventricular ectopic beats >30/h, 1 with ventricular tachycardia, 2 with episodes of bradycardia). Medical interventions were undertaken in 12 cases; only in one of them, however, it was guided by telemetry.

When telemetry was used to monitor the function of a recently inserted pacemaker or automatic internal cardiac defibrillator (8 cases), no abnormal findings were shown.

3.5. Physicians’ perception of utility
Physicians perceived telemetry as unhelpful in 30% of cases. Crossing the indications and physicians’ perception (Table 3), we found that the highest percentages of ‘not useful’ were reported when telemetry was indicated for diagnosis of referred symptoms, for surveillance in electrolyte disturbances (in these two conditions the monitoring was perceived to be not useful in approximately half of the cases), and for surveillance of patients with an already known arrhythmic pattern (32% of cases). Physicians perceived telemetry as helpful, but telemetry did not lead to direct modifications in management in 53% of cases. Telemetry guided the patients management in 17% of patients. At least one arrhythmic event was present in 28% of patients for whom telemetry was perceived as unhelpful, in 45% for whom telemetry was perceived as useful but did not alter management, and in 58% for whom telemetry guided medical therapy or management. The percentage of perceived inutility and usefulness with and without subsequent alteration in patients’ management were similar between stable and unstable patients (respectively, in stable patients: 30, 18, 51%; in unstable patients: 31, 15, 54%; n.s.).


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  		Table 3 Usefulness of telemetry in guiding management of patients as perceived by physiciansa

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
References
 
In this study in which we prospectively examined how much and when the ECG monitoring had influenced decision making about heart failure patients admitted to a heart failure (non-intensive) unit, we found that telemetry had a weaker role than that expected.

Telemetry was indicated for 28% of admitted patients. Being a free clinical indication, we do not know the reasons why the other patients were not observed by telemetric device. We can only speculate that any of the conditions which constituted the indications to telemetry were present. Clearly, the availability of telemetry plays a role in the degree of utilization. The great majority of those observed were severely ill and unstable; in these patients telemetry monitoring lasted a long time. The duration of telemetry, longer than that usual in an intensive care unit, may be explained by the peculiar configuration of a heart failure unit specific for chronically severely ill patients with long recovery times and a high occurrence of complications. In stable patients one-half of the indications were for control of an already known arrhythmic pattern and the other half for diagnosis of unclear symptoms. In unstable patients the more frequent indications were again for control of a risk pattern and for surveillance of a prescribed treatment (pharmacological or not), thus revealing greater care in these patients about therapeutic efficacy and safety. Arrhythmic events occurred predominantly in unstable patients; ventricular ectopic beats >30/h and non-sustained ventricular tachycardia were more frequent in NYHA class III–IV patients. However, comparing stable and unstable patients no differences were observed either in the percentage of patients with arrhythmic events or in the characteristic of their arrhythmic findings. This is a very unexpected result: in such patients, in whom hemodynamic treatment was in fact on going, instability was not associated with a greater occurrence of tachy- or brady-arrhythmias. In only 15% of unstable patients (and in 17% of all patients) telemetry was followed by a therapeutic intervention. However, in approximately half of the cases the ECG-monitoring was useful in reassuring the physician or in confirming a therapeutic strategy. Many of the ‘not useful’ perceptions were motivated by the absence of an arrhythmic finding or of a subsequent medical interventions. For instance when electrolyte disturbances were the indication for the telemetry, electrolyte disturbances would have been treated in any case; when telemetry was prescribed for unclear symptoms, ECG monitoring was inconclusive in assessing the cause of symptoms (intermittent nature, transient duration, low prevalence of arrhythmias potentially responsible for symptoms), as in previous experiences [6–8]. In any case, the relevant but not clearly demonstrable role in reassuring physicians and patients, and in offering availability of a potential intervention should be taken into account. Moreover, the usefulness of telemetry might be underestimated because one of the uncounted results might be the avoidance of inappropriate intervention.

Our results confirm the limited role of heart rhythm monitoring in improving patients’ care in the setting up of a heart failure unit. This result was previously reported by Estrada et al. [5,6] in a general practice telemetry unit and by other authors in a community hospital [7,8]. Thus, the assumption that telemetry was really effective in HF patients management in non-intensive care units is challenged.

In conclusion, from this study it can be derived that, in a heart failure unit ECG monitoring has been predominantly used in severe and unstable in patients with heart failure, thus showing a tendency to a stricter control of therapeutic efficacy and safety in such patients. A negative finding during ECG monitoring has a reassuring effect in more than half of the cases. However, medical decisions are rarely guided by the telemetry findings. The main telemetry effect seems to be that of reassuring physicians and patients. These issues are important because the costs of telemetry can be substantial while the cost-effectiveness might not be worthwhile in many chronic heart failure patients.

In the context of heart failure care, the potential role of telemetry monitoring in the outpatient setting, i.e. home telemetry, should be pointed out.


   Acknowledgements
 
The Authors thank Graziella Garbarini and the whole nursing staff of the Heart Failure Unit of Montescano for their friendly assistance in collecting data.


   References
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 References
 

  1. ACC/AHA Task Force Report. Guidelines for the evaluation and management of heart failure. J Am Coll Cardiol (1995) 26:1376–1398.[Web of Science][Medline]
  2. McMurray J., McDonagh T., Morrison E., Dargie H.J. Trends in hospitalization for heart failure in Scotland — 1990. Eur Heart J (1993) 14:1158–1162.[Abstract/Free Full Text]
  3. Reitsam J.B., Mosterd A., de Craen A.J.M., et al. Increase in hospital admission rates for heart failure in Netherlands. Heart (1996) 76:388–392.[Abstract/Free Full Text]
  4. EARISA Studio sull’Epidemiologia e sull’Assorbimento di Risorse di ischemia, scompenso e aritmia. G Ital Cardiol 1997;27(suppl 2):1–54.
  5. Estrada C.A., Prasad N., Rosman H.S., Young M.J. Outcomes of patients hospitalized to a telemetry unit. Am J Cardiol (1994) 74:357–362.[CrossRef][Web of Science][Medline]
  6. Estrada C.A., Rosman H.S., Prasad N.K., et al. Role of telemetry monitoring in the non-intensive care unit. Am J Cardiol (1995) 76:960–965.[CrossRef][Web of Science][Medline]
  7. Lipskis D.J., Dannehl K.N., Silverman M.E. Value of radiotelemetry in a community hospital. Am J Cardiol (1984) 53:1284–1287.[CrossRef][Web of Science][Medline]
  8. Sivaram C.A., Summers J.H., Ahmed N. Telemetry outside critical care units: patterns of utilization and influence on management decisions. Clin Cardiol (1998) 21:503–505.[Web of Science][Medline]

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