How we think about cardiac rhythm monitoring...

 Let’s start with defining the clinical needs. Here is a list of patients in whom I might want to use a monitor:

1. Regular and frequent symptoms (skipping, palpitations, syncope, etc)
2. Infrequent symptoms (~ 1/week)
3. Rare symptoms (months)
4. No symptoms but clinical suspicion for arrhythmia high. Think real syncope, crypotogenic stroke as examples (event or presumed arrhythmia frequency high)
5. Infrequent #4
6. Rare #4
7. Clinical suspicion low or screening (information actionable)
8. Screening (not actionable)

I’m sure there are more but this is a start. So what devices do we currently have?

1. Ziopatch equivalent
2. 1st gen AliveCor (Kardia device)
3. ILR
4. Apple Watch (just watch)
5. Apple Watch with Kardia band

So for clinical scenarios 1, 2, 4, & 5, I use A to start. In 2 and 4, I may repeat the A even more than once. For 3, I will start with A usually and then have been using B where possible or serial A if B not possible and eventually C if needed.

In scenarios 4 & 5 where A is unrevealing, I consider C and have used with great results, but if E works, it could be fantastic here. 

I consider scenario 7 mostly a research question. I think it is an interesting one. Say take people with very high CHADS2-VASc score (<5) or people with cryptogenic stroke and in this case one would use C, but E. Has promise. 

Scenario 8 is pure research question and I’m not sure there is much here other than “learning what is normal”. I suppose this is a good place for D or E.