Evaluation of Aha Recommendations for Cardiac Monitoring in a Noncritical Setting

Background:

Cardiac monitoring is often overutilized. The 2004 American Heart Association (AHA) practice standards categorized indications for electrocardiographic monitoring in hospitalized patients based on the potential therapeutic benefit. This study sought to evaluate whether the AHA recommendations could safely guide the selection of patients for cardiac monitoring in a noncritical setting.

Methods:

Clinical data were extracted from the medical records of patients who were admitted to the telemetry unit of a suburban community hospital from January to March 2009. The indications for cardiac monitoring were classified based on the 2004 AHA practice standards: Class 1 includes clinical conditions in which cardiac monitoring is indicated in most if not all patients; class 2 is when it may be of benefit for some patients, but is not considered essential for all; and class 3 is when it is not indicated. The outcome was the occurrence of new significant cardiac events during the period of monitoring, including acute coronary syndrome, symptomatic or malignant arrhythmias, QT prolongation, and sudden cardiac death. Sensitivity, specificity, and predictive values were calculated.

Results:

There were 505 admissions to the telemetry unit, of whom 93 (18%) had indications for intensive care and were excluded from further analysis. Of the remaining 412 patients, 186 (45%) met class 1 indications, 122 (30%) were class 2, and 104 (25%) were class 3. Of the class 1 patients, 82 (44%) had chest pain, and 73 (39%) had acute coronary syndrome (ACS). Overall, the significant cardiac event rate was 1.46% (6 of 412). The presence of a class 1 indication was 67% sensitive (95% CI, 23%–95%) and 55% specific (95% CI, 50%–60%) for predicting an event. Reclassifying syncope from a class 2 to a class 1 indication resulted in a sensitivity of 100% (95% CI, 54%–100%), specificity of 51% (95% CI, 47%–56%), and negative predictive value of 100% (95% CI, 98%–100%). The potential reduction in cardiac monitoring was 51% (95% CI, 46%–56%).

Conclusions:

The overall incidence of significant cardiac events among patients currently placed on electrocardiographic monitoring in a noncritical setting is low. The 2004 AHA practice standards can provide safe and effective guidance on selecting patients who will benefit from monitoring and may be enhanced if syncope is recategorized as class 1. Applying these recommendations in clinical practice may help to substantially reduce the use of cardiac monitoring.