Chest
Volume 122, Issue 2, August 2002, Pages 517-523
Journal home page for Chest

Clinical Investigations
CARDIOLOGY
Is Telemetry Monitoring Necessary in Low-Risk Suspected Acute Chest Pain Syndromes?

https://doi.org/10.1378/chest.122.2.517Get rights and content

Background

Non-ICU telemetry monitoring has proven to be a valuable resource for patients suspected of having an acute myocardial infarction. While a significant number of patients are admitted to these units, the actual incidence of events or interventions is low.

Objective

To identify a subset of patients in whom telemetry monitoring does not alter management.

Design

Prospective observational study.

Setting

Large tertiary care facility.

Patients

A total of 414 patients consecutively admitted from the emergency department for suspected acute coronary syndromes were studied. Patients were excluded if they presented with ST-segment elevations, were revascularized on hospital admission, were admitted to a surgical service, were transferred from another floor or unit, or remained in the emergency department for the course of the stay.

Outcomes

Events were defined as development of myocardial infarction, episodes of chest pain, new or rapid atrial arrhythmias, ventricular arrhythmias, any form of AV nodal block, and asystole. Intervention or change in management was any increase, decrease, or change in medication, cardioversion, electrophysiology study, or transfer to the ICU.

Results

Patients who had atypical chest pain and normal ECG findings were significantly less likely to have both intervention and events (4 interventions vs 23 interventions [p < 0.0001], 12 events vs 45 events [p < 0.0001]), compared to those with typical chest pain and abnormal ECG findings. When normal laboratory values were added, only four telemetry events were observed.

Conclusion

Patients with atypical chest pain and normal ECG findings represent a subset of patients with low risk for life-threatening arrhythmia. Use of telemetry monitoring in this subset of patients should be reevaluated.

Section snippets

Practice Setting

North Shore University Hospital is a 755-bed facility. It is a major cardiac referral center in the New York City metropolitan area. Cardiac monitoring occurs in all ICUs as well as two telemetry units (63 beds). Patients monitored on telemetry may be admitted through the emergency department, transferred from ICUs, as well as from general medical floors.

Heart rate and rhythm are transmitted continuously by two leads (aVL and V1) fashion. Technicians trained to recognize rhythm disturbances

Demographics

A total of 414 consecutive patients were evaluated during the course of the study (Table 1). The average (± SD) age was 67.8 ± 28.7 years. Of these, 191 patients (46.1%) were female and 223 patients (53.9%) were male. Two hundred ninety-four patients (71%) were white, and 39 patients (9.4%) were African American.

Cardiac History and Risk Factors

More than one third of patients had a history of coronary artery disease (n = 152, 36.7%): MI angiographically (n = 79) or on myocardial perfusion imaging (n = 56), or history of

Discussion

Based on initial ECG findings and history of presenting illness in patients suspected of acute coronary syndromes, it is possible to identify low-risk patients in whom telemetry monitoring does not appear to alter management. Its role should be reevaluated in these patients.

CCUs were introduced in the United States in the early 1960s in an attempt to lower the high mortality rate among hospitalized patients with AMI.2 Since then, it has been the standard of care in the United States to admit

Conclusion

Patients that present to the hospital with atypical chest pain and normal ECG findings are at low risk for life-threatening arrhythmias. In those who present without associated symptoms and with normal laboratory values, outpatient management can be considered an appropriate alternative to hospitalization.

Cited by (37)

  • Lessons Learned from Efforts to Reduce Overuse of Cardiac Telemetry Monitoring

    2020, Joint Commission Journal on Quality and Patient Safety
  • Emergency department monitor alarms rarely change clinical management: An observational study

    2020, American Journal of Emergency Medicine
    Citation Excerpt :

    Until a combination of hardware and software technologies emerge to produce a highly sensitive and highly specific monitoring system, more selective monitoring may be key to reducing alarm frequency and the resulting alarm fatigue. For example, many patients monitored in the ED or admitted to telemetry beds are low-risk patients with chest pain, and multiple studies have shown little to no benefit of monitoring in this group [19-23]. EDs could implement protocols to restrict continuous monitoring only to patients with significant potential for clinical decline based on the treating clinician's judgement.

  • Over-monitoring and alarm fatigue: For whom do the bells toll?

    2013, Heart and Lung: Journal of Acute and Critical Care
  • Unnecessary arrhythmia monitoring and underutilization of ischemia and QT interval monitoring in current clinical practice: Baseline results of the practical use of the latest standards for electrocardiography trial

    2010, Journal of Electrocardiology
    Citation Excerpt :

    It could be deemed inappropriate to have a patient in the ICU without the bedside ECG monitor on, regardless of the admitting diagnosis. Others have also reported unnecessary monitoring,1,3,4 and guidelines have been implemented to attempt to focus monitoring on patients most likely to benefit.2,5,8 These studies have taken place in single hospitals using guidelines from 19912,5 or hospital-specific protocols.8

View all citing articles on Scopus
View full text