STARS Healthcare Pioneers Report

Showcasing Best Practice In Syncope

Novel use of a heart-rate monitor and alarm system in the management of symptomatic bradycardia episodes

Dr Beth Taylor and Dr Brian Gordon
Peterborough City Hospital, Peterborough, UK

Introduction

Episodic symptomatic bradycardia can occur because of neck masses compressing local structures regulating autonomic function. Here we describe a case in which novel use of a heart rate monitoring system prior to decompressive surgery was utilised to avoid permanent pacemaker insertion.

Case study

A 54-year-old male with no previous cardiac history presented upon multiple occasions with increasingly frequent nocturnal syncope episodes characterised by bradycardia and hypotension. He was admitted to our cardiology department and a 24-hour electrocardiogram (ECG) was conducted, identifying 125 episodes of nocturnal bradycardia, with the longest episode lasting for 28 beats and a slowest recorded heart rate of 39 beats per minute (Figure 1A and 1B). These episodes were accompanied by a history of progressive voice weakening and swallowing difficulty, with examination demonstrating multiple left lower cranial nerve palsies and a left-sided neck mass. MRI imaging revealed the mass to be an enlarged lymph node with histology and PET-CT imaging confirming metastatic spread from a primary squamous cell carcinoma in the left tonsil.

Given the underlying cause of the bradycardic episodes, permanent pacemaker insertion was contraindicated by the low likelihood of success in resolving the bradycardia and potential reversibility following treatment to reduce mass effect.

Instead, novel use of a “PulseGuard” heart-rate monitoring system was trialled with success; the system was originally designed for use in epilepsy management. The two-component system consists of a lightweight infrared sensor and tablet that communicate via Bluetooth within a 2m range (Figure 1C). A target heart rate can be programmed, outside of which an alarm will sound. By instigating awakening upon detection of bradycardia, prior to onset of syncopal symptoms, use of the system provided symptomatic relief for the patient whilst awaiting definitive management of the neck mass with tonsillectomy and adjuvant therapy.

Conclusion

Autonomic disturbance from compressive neck masses has previously been described, with signs including bradycardia and hypotension resulting from mass effect upon local structures including the carotid sinus and vagus nerve. They are potentially modifiable causes of episodic sinus bradycardia that may be reversible following surgical decompression. Identification of therapeutic methods to manage symptomatic bradycardia obviates the need for permanent pacemaker implantation in patients awaiting decompressive surgery. This case study illustrates the novel use of a heart-rate monitoring alarm device as a low-cost temporary alternative to permanent pacing in the management of these patients.

Novel use of a heart-rate monitor and alarm system in the management of symptomatic bradycardia episodes

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