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Establishing a smartphone ambulatory ECG service for patients presenting to the emergency department with pre-syncope and palpitations
Dr Matthew J Reed, Dr Julia Cullen, Dr Alexandra Muir, Dr Ross Murphy, Dr Valery Pollard, Dr Goran Zangana, Dr Sean Krupej, Sylvia Askham, Patricia Holdsworth, Dr Lauren Davies
Royal Infirmary of Edinburgh Smartphone Palpitation and Pre-Syncope Ambulatory Care Clinic (SPACC) service, Edinburgh, UK
The Investigation of Palpitations in the ED (IPED) study showed that use of a smartphone-based event recorder (AliveCor/Kardia) led to a five-fold increase in the number of patients in whom an electrocardiogram (ECG) was captured during symptoms — to more than 55% at 90 days compared to 9.5% with standard care. Therefore, use of an event recorder was concluded to be a safe, non-invasive, and easyto-use device that should be considered part of ongoing care to all patients presenting acutely with unexplained palpitations or pre-syncope. In this case study, we report the process of establishing a novel Smartphone Palpitation and Pre-Syncope Ambulatory Care Clinic (SPACC) service, enabling Emergency Department (ED) or Acute Medicine Unit (AMU) patients to be referred for assessment and education on use of the device with subsequent review of device recordings in an ambulatory setting.
A clinical Standard Operating Procedure (SOP) was devised, and funding was secured through a business case for the purchase of 40 AliveCor/Kardia single-lead devices in the first instance. The devices can be cleaned and reused multiple times.
From 24 July 2019, when the clinic was launched, all patients aged 16 years or older presenting to the ED or AMU of the Royal Infirmary of Edinburgh (RIE), UK, with palpitations or presyncope, whose ECG was normal, who had a compatible Apple/Android phone, tablet or watch, and in whom an underlying cardiac dysrhythmia was possible, were discharged with a patient advice leaflet and an appointment at the SPACC service (based in Ambulatory Care adjacent to the ED) on the next available day. History of the event was revisited in the clinic and eligible patients were fitted with the smartphone-based event recorder. Electronic Patient Record (EPR) data of sequential clinic attendees over a 12-month period was collected and analysed.
Between 24th July 2019 and 23rd July 2020, 290 patients (aged between 16 and 80 years; mean age 43.3, SD 15.0) were referred; 120 (41.4%) were male. Of the 237 (81.7%) who were fitted with the device, 17 (7.2%) had a cardiac diagnosis (12 atrial fibrillation/ flutter, five supraventricular tachycardias, and one atrial tachycardia). There were also 200 non-cardiac diagnoses (84.3%) and 20 undiagnosed patients (8.4%). Cost per symptomatic rhythm diagnosis was £358 and per cardiac dysrhythmia diagnosis was £4,570.
This is the first clinical implementation of the AliveCor/Kardia in an ED setting for patients presenting with palpitation or pre-syncope and demonstrates similar detection rates to the IPED study. A smartphone-based event recorder clinic like ours should be considered for acute palpitation.