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(554) Patient Centered Diagnostic Yield of Ambulatory Cardiac Monitoring After Discharge From the Emergency Department


Authors:

Madison House, n/a – Student, Mayo Clinic, Rochester

James L. Homme, n/a – Program Director Mayo Emergency Medicine Residency, College of Medicine Mayo Clinic (Rochester)

James L. Homme, n/a – Program Director Mayo Emergency Medicine Residency, College of Medicine Mayo Clinic (Rochester)

Abstract:

Background and Objectives: Heart disease related complaints result in 5.9% of Emergency Department (ED) visits annually. Patients presenting to the ED with potentially cardiac related issues and determined to be low risk may be discharged with ambulatory cardiac monitoring to assess for arrhythmia as causative of symptoms. Limited data on utility of this practice exists. The goal of this study was to evaluate the practice of ambulatory Holter monitoring after ED discharge for diagnostic yield and safety.

Methods: We performed a retrospective review of ED patients discharged with a 24 or 48-hour Holter monitor between Jan 2, 2017 & Apr 30, 2018, from an academic quaternary-care ED with over 80,000 visits per year. The primary outcome of the study was diagnostic yield of monitoring defined by the patient centered outcomes of 1) reported symptoms with no arrhythmias detected, 2) reported symptoms with detected arrhythmia, or 3) no reported symptoms with detected arrhythmia (i.e silent arrhythmia). Secondary outcomes were safety of the practice and unscheduled return rates.

Results: A total of 540 patients were discharged on a monitor; 493 (91.3%) met inclusion criteria. Completion rate was 99.6% (491/493) and no patients died within 30 days after use. Average age was 52.4 ± 21.3 years (range 3-95) with 46.0% men. Palpitations (N=154; 31.4%), syncope (N=58; 11.8%), chest pain (N=43; 8.8%), and dizziness/lightheadedness (N=41; 8.4%) were the most common presenting complaints. There were 257 (52.3%) patients with a history of cardiac disease and 42 (8.6%) were discharged after suspected transient ischemic attack. Overall diagnostic yield was 68.2% with no significant difference between 24 & 48-hour monitoring (66.9% vs 70.7%, respectively; p=0.39). Diagnostic yield increased significantly with increasing age (p<0.001) (3-18 (40.7%), 19-40 (62.7%), 41-60 (65.7%), and 61-95 (77.6%)). In total, 79 patients (16%) had additional cardiac testing and 63 patients (12.8%) had a follow-up consultation with a primary care provider, cardiologist, or neurologist as a consequence of monitor results.

Conclusion: The practice of discharging selected ED patients with a Holter monitor is safe and resulted in high diagnostic yield (68%) when utilizing patient centered outcomes. Holter monitors provide useful information in discharged patients presenting with a variety of complaints to the ED and are useful in determining the next steps in evaluation.

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