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Health

Diagnostic tools important part of detecting trouble

| Monday, May 20, 2002

As he lay in a Latrobe Area Hospital bed in 1992, Chester "Chet" Leonard dreamt he was going to die.

"It's a funny story now," he said, laughing, but it certainly wasn't at the time.

Suffering from atrial fibrillation — rapid, uncontrolled contractions of the upper chambers of the heart — Leonard was being monitored continuously at the nurses' station when his heart stopped.

"I dreamt I came to the hospital to die," the 81-year-old Latrobe resident recalled. "I woke up the next morning, and the nurse came in and said, 'Hey, do you know your heart stopped beating last night?' I said, 'Well, it must have started again, because I'm still here.'"

The next day, Leonard underwent surgery to implant a pacemaker, designed to reproduce or regulate the rhythms of the heart using electrical impulses.

Emma Lesko of Blairsville can identify with Leonard's experience.

She was at home making lunch for her husband last November when she doubled over.

"The pain was excruciating," she remembered. "It felt like my heart was coming right out of my chest."

Lesko was taken by ambulance from her doctor's office to LAH, where she was monitored in the coronary care unit.

"They put me in bed, and gave me medication to slow my heart down," she said. "And my heart just stopped. I saw heaven - and then everything was black. There was nothing. I was gone."

Doctors revived the 79-year-old patient. Once her condition was stable, a pacemaker was implanted.

"The doctor said to me, 'Boy, you scared us. You were gone for 10 seconds,'" she said.

Both Lesko and Leonard were lucky. They were attached to a hospital heart monitor when things went wrong.

Yet, many heart rhythm abnormalities can go undetected. And, more often than not, they do not occur while the patient is being examined in the doctor's office.

Holter monitors, cardiac event recorders and insertable loop recorders have become extremely important diagnostic tools because these techniques can be used on an out-patient basis.

A holter monitor is generally worn for 24 hours, but can also be used for 48- or 72-hour monitoring if needed. Electrode leads are attached to the patient's chest and are attached by wires to a small recording device, which is worn like a Walkman. The patient is then sent home to resume normal activities while the holter monitor records a continuous electrocardiogram, or ECG. The patient is also asked to keep a diary, noting time and activity when cardiac symptoms occur.

"Holter monitoring techniques have been around for quite some time," said Dr. Richard Seecof, a cardiologist with Latrobe Heart Associates-UPMC. "Once the tape of all the patient's heartbeats is analyzed, the idea is to try to correlate the patient's symptoms with some particular arrhythmia or heart rhythm problem."

The holter monitors can be worn by "just about anybody who is bothered by the sensation of palpitations, episodes where they feel as though they're going to pass out, or if they're frequently dizzy or light-headed," according to Seecof, who is on staff at LAH's pacemaker clinic.

Reyne Mazzarese, a diagnostic cardiology technician at LAH, has been reading holter monitors for over 20 years. She has seen firsthand how holters help "diagnose a lot of different problems in a lot of different people."

When the tape and diary are returned to the hospital for analysis, "I can go to what is called a 'super page' and see 10 minutes of a patient's heart rhythm," she explained.

What she finds can range from a normal, or sinus rhythm to a variety of arrhythmias, some of which require immediate attention.

"I was reading the tape of one particular lady who, at times, was feeling like she was going to faint," Mazzarese said. "I'm looking at her heartbeat, and it's beating very regularly. Then, all of a sudden, it's not beating at all" for a few seconds.

When these pauses in heart rhythm continued — some for as long as five seconds — Mazzarese "got this information to a cardiologist immediately."

The patient was brought into the hospital, and "a pacemaker was put in right away," she said.

The use of ambulatory monitoring devices is not limited entirely to elderly patients. Mazzarese has fitted "a fair number" of children, some as young as 2 years old, with the holter monitor due to dizziness, shortness of breath or irregular heartbeat.

To date, holter monitors have contained an analog tape, much like a cassette tape, to record the patient's heart beats.

However, to keep pace with technology, several hospitals now offer a new state-of-the-art holter monitoring system.

According to Chuck Hilty, group manager of Cardiopulmonary Services at Westmoreland Health System, Frick Hospital in Mt. Pleasant has already upgraded to the high-resolution holters, while Westmoreland Regional Hospital in Greensburg is in the process of changing over to the new system.

"This is digital technology which replaces the audio tapes with solid-state cards," he said. "It's like a flash card that slides into the monitor, and it digitally records cardiac problems."

When the prescribed monitoring time is completed, the card is taken from the monitor, downloaded onto a computer, and then scanned by a technician.

Patients still wear a holter monitor, but it is now smaller and lighter.

"They're about the size of a deck of cards," Hilty noted. "And very light, very easy to attach and very easy to wear."

Additionally, all three local hospitals have 30-day event monitoring capability, a contracted service which has also "gone digital" at Frick and Westmoreland.

Event monitors are traditionally used on patients whose symptoms occur rarely, making diagnosis difficult over a short period of time. The device is similar to a holter, but can be kept on for weeks at a time. It continuously records the heart rhythm into a temporary memory.

The patient is instructed to press a button on the device when symptoms occur. When the button is pressed, the recording for the preceding few seconds, as well as the subsequent few seconds, is placed into a permanent memory. The permanently-stored recordings can then be transmitted back to the doctor's office over standard telephone lines for instant analysis. And, if necessary, trained emergency personnel can be summoned immediately

"We've switched companies and upgraded to digital technology with our 30-day event recorders," Hilty said. "The patient pushes a button if he or she is having symptoms, and this information is transmitted to a scanning company, which then sends us a copy."

For symptoms that occur even more rarely, such as every six months, the insertable loop recorder is implanted under the skin in the chest using a local anesthetic. A relatively new diagnostic tool, this recorder functions just like the event monitor, except that is can be left in indefinitely. The patient uses a hand-help activator to tell the device to permanently store the heart rhythm when symptoms occur.

"The Westmoreland (heart catheterization) lab handles the implantable look recorders," said Hilty.

According to Seecof, LAH also has implantable loop recorder capability, using the device to "increase the amount of time doctors have to find a problem."

"Implantable loop recorders are a fairly new diagnostic tool," he explained. "We put in our first one in two years ago. The Pacemaker Clinic then follows the patient, interrogating (monitoring) the device in case of an event or arrhythmia."

Seecof added all three monitoring devices are widely used techniques due to the "growing number of patients who have heart rhythm problems."

Mazzarese agreed, noting she used to read 30 holters a month. Now, she now reads up to 30 a week.

"I've had weeks where I've read seven or eight in one day," she said. "I'm usually reading 80 or 90 in a month - sometimes more than that. This is a very common way to diagnose these heart arrhythmias."

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