lesoutilsde depistagede …©sa-paris...lesoutilsde depistagede lafaparoxystiqueen2014:...
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LES OUTILS DE DEPISTAGE DE LA FA PAROXYSTIQUE EN 2014: DISPOSITIFS NON IMPLANTABLES
DR Cathy BERTRAND
4 rue de la NEVA 75008 PARIS
CMC PARLY 2 Le Chesnay
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FAP: définition
Guidelines, European Heart Rhythm Association. ACC:AHA/ESC 2006. Circulation. 2006; 114; e257-‐e354
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holter ECG recommandé pour détecter FAP
Guidelines, European Heart Rhythm Association. ACC:AHA/ESC 2006. Circulation. 2006; 114; e257-‐e354
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Differents Devices
• Non invasive device ü ECG ü 48 h Telemetry ü 24h holter ECG ü Loop-‐recording monitors
-‐ with memory ( R test) -‐ without memory ( cardiatel®)
ü MCOT
• Invasive ü Implantable cardiac monitor reveal
xt®. Crystal AF Study Pr DW Kriger, Pr RD Passman. Medscape nov2013
The longer you monitor the paMent, the more likely you are to detect AF.
Its depend also the type of monitoring device
(paMent-‐trigger record, autotriggered device, both)
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Différents dispositifs non implantables pour détecter la FAP
q ECG, Cardiatel (enregistrement d’un ecg par un appareil spécial qui transmet à un centre cardiatel de lecture)
q Holter ECG de 24h-‐48h: enregistrement continu de ECG
q Holter longue durée jusqu’à 3 sem: enregistrement continu
q R test, loop recorder, ZIO patch: enregistrement événementiel uniquement, enregistrement de boucles de qq min, déclenché par le patient et par des critères de tachycardie…transmission ecg par téléphone, tracé par mail au cardio directement…
q Cardionet MCOT: 3 éléctrodes, boitier, événementiel, ECG transmis à un centre d’analyse spécial
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Mobile Cardiac OutpaMent Telemetry (MCOT)
• Non invasive device • 3 cutaneous lead sensors • PDA + Internet ( automaMc transmission) • Permanent recording -‐> No limitaMon on storage Mme: 24h*21d
• Autotriggered device : Event detecMon algorithm (RR interval variability and QRS morphology analysis)
• Manual review of the record in 3 seZngs (2 channels strip ECG) 1. PosiMve algorithm arrhythmia detecMon 2. PaMent reporMng symptom on PDA 3. Predetermined physician threshold (e.g. HB> 140) • PaMent can take a shower
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Litterature
N Device
Dura+on
of PAF
% PAF
detected Risk Factor
Tayal et al ,
Neurology 2008
56 MCOT 21 d <30s
>30s
26%
5,3%
Age, Diabetes
Elijovich L et al,
J Stroke Cerebrovasc Dis 2009
20 MCOT 30 d >30s 20%
BhaA et al,
Stroke Res Treat 2011
62 MCOT 28 d >30s 24% MulMples
infarcts
Miller et al,
J Neurol Sci, 2013
156 MCOT 30 d <30s
>30 s
17%
6%
Female, PACs*,
LVEF < 55%**
*PACs: Premature atrial complex ; **LVEF : LeH Ventricular EjecJon FracJon
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cardioPAL SAVI: loop recorder, holter événementiel, pas de tracé continu, smartphone, centre de lecture FAP: 6,7% (monitoring
pdt 24j)
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R test, ZIO patch
Inconvénients • peut louper des événements car faut bien paramétrer l appareil • manque début ou fin de l épisode, • difficile d’estimer la durée de l épisode d arythmie
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Les ancêtres du holter ECG: 1949
Mr Norman Holter 60 min d’enregistrement
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ELA: HOLTER RECORDERS & EVENTS RECORDERS
2448 2 ECG tracks (Tape AM)
1990 1995 2000 2005
Synesis 3 digital ECG tracks PCMCIA card Hook-Up First Digital recorder / flash
Syneflash 3 digital ECG tracks Graphic Int. ECG 1000Hz/ 2,5µV
First Holter with graphic display
Syneflash MMC
same as Syneflash + MMC card wide band pass
Spiderview
1 to 4 days Holter 1 to 8 tracks Extensions 1000Hz/1µV very light Low Man.Cost
1995 1983 1998 2001 2002
Spiderflash-t 7 to 40 days I.R. Com. With PC 1 to2tracks Extensions 1000Hz/10µV Ultra light Low Man.Cost Event recorder
2005
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spider flash: holter ECG longue durée
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holter ECG longue durée
14
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AFT 1000:holter 24h à 25j en continu
HOLTER ECG COURTE ET LONGUE DURÉE
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quand faire holter ECG § le plus prêt possible de l’épisode d’avc § dans les 72h: FAP= 17,5% par holter ECG 24H
Douen AG. Stroke. 2008; 39: 480-‐482
Rizos T. Cerebrovasc Dis 2010; 30: 410-‐417
enregistrer ECG dans les 72H par holter ECG longue durée ou par scope en continu ds les unités
intensives de neurologie
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Guidelines, European Heart Rhythm Association. ACC:AHA/ESC 2006. Circulation. 2006; 114; e257-‐e354
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Etude personnelle du HLD 21J et AVC cryptogénique
(service CHR Versailles, prof PICO)
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Objectives
• Evaluate the detecMon rate of paroxysmal atrial fibrillaMon (PAF) in
paMents with cryptogenic brain infarct or TIA using 21 days long
duraMon ECG holter
• Determine risk factors of PAF detecMon
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Patients and Methods
• PaMents were included from march 2009 to january 2013
ü in Versailles Stroke Center
ü with cryptogenic brain infarct or TIA
ü Complete work up : Clinical, ECG, TTE and TEE, Brain imaging
ü Afer discharge : 21 days AFT 1000 HLD ECG in Parly II Clinic Cardiology
Department
ü Predictors of AF detecMon by HLD were determined
by univariate and mulMvariate analysis (BiostaMcians. CT, ZM)
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Results
171 paMents: 144 Brain infarct (84%); 27 TIA (16%)
• Mean age 63,2 years ; 63 % Men; 40 % of HTN ; 10 % of Diabetes
• NIHSS arrival (BI)= 2,2 ± 3,6 ( Almost minor stroke)
• Brain imaging : all had CT or Brain MRI.
• 144 paMents (84%) with exploitable Brain MRI data
• Cardiovascular Work up :
ü 100% ECG
ü 72% 48h telemetry
ü TTE 100%; TEE: 88%
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Results
DetecMon rate of AF lasMng > 30 sec ( Guidelines AHA 2006)
= 26 paMents (15,2 %)
Median delay between HLD iniMaMon and first PAF episode detected = 7 days
Mean number of PAF episodes/paMent = 1.2± 1.1
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conclusion
§ H24h n est plus le gold standard, ne pas arreter le bilan cardio si H24h négatif
§ HLD 21j est le meilleur moyen de dépister la FAP et c’est non invasif en plus
§ Pb: faut bcp d’appareils de HLD car durée de 1 à 3 semaines
§ bcp de patience pour l’interprétation (long et bcp artéfacts)
§ coût des appareils cher et organisation+++