Author: Andrew Webb

I am the Managing Director of PMS (Instruments) Ltd a successful UK based medical distribution, service and sales company specialising in cardiovascular equipment.

CardXplore your mini cardiology lab

The Meditech CardXplore is a combined 24hr ABPM and Holter ECG recorder.

It is a multifunctional device and can be used just as an ABPM, an ECG Holter monitor or ABPM and ECG combined. It features automatic beat by beat analysis and automatic report generation. CardXplore provides an analysis of the relationship between hypertension and cardiovascular disease.

As hypertension is the most common risk factor for cardiovascular diseases, it is important to assess blood pressure and ECG data at the same time. CardXplore combines 24-hour blood pressure monitoring with Holter ECG recording and actigraphy.

Hokanson Rapid Inflation System

Unfortunately Hokanson recently chose not to renew the CE mark and end distribution of Class I electronic instruments to the European Market. The list of instruments that are no longer available for sale to the EU are:

  • AG101 Air Source
  • AI6 Arterial Inflow System
  • EC6 Strain Gauge & Photo Plethysmograph
  • E20 Rapid Cuff Inflator
  • MD6RP Photo Plethysmograph
  • MD6VR Chart Recorder

Regrettably due to this action we are no longer able to sell the above products in the UK although service and support remains available for the expected lifetime of each product. Replacement parts such as transducers, hoses and batteries will also remain available. Vascular cuffs and aneroid sphygmomanometers are still available for purchase and distribution for UK customers so orders for those products will be processed as usual.

Ideal Professional BP Package

Up until now many Hospitals and GP Practices have purchased low cost digital blood pressure monitors designed originally for home or retail use. As good as some of these monitors are they are not necessarily designed for repeated use on a daily basis or designed to stand up to the rigours of Hospital or Primary Care use.

Monitors in these environments can be subjected to drops and knocks associated with a busy ward or unit.

Expensive vital signs type monitors are available but with extra features not necessarily needed by all.

The A&D Medical UM-201 aims to sit somewhere between these two camps and is aimed at the clinician looking for simple one button operation, accurate readings, cost effectiveness whilst anticipating heavy daily use. It concentrates on features customers actually want, like a large LCD display, long cuff tube, fast measurement times and simple one button operation.

The durable and chemical resistant body and cuffs are easy to clean and disinfect with common antiseptic agents and the low whole life running costs make this suitable for the Hospital environment. The UM-201 features A&D’s latest Electronic Constant Exhaust Valve (ECEV) for enhanced measurement accuracy as well as Irregular Heartbeat Detection (IHB) technology.

We recently introduced a UM-201 Pro package which includes a small (16-24 cm), adult (22-32cm) and large (31-45cm) cuffs as well as a mains adaptor. At £99 it is proving a popular package and for most the complete professional blood pressure solution.

 

What’s the future for manual blood pressure measurement devices?

Since 10 April 2014 and the implementation of EU Commission regulation no 847/2012 the sale of new Mercury sphygmomanometers to the healthcare sector has been banned.

The alternative? Electronic manual sphygmomanometers like the A&D UM-102A mimic the Mercury sphygmomanometer but have none of the inherent disadvantages. These devices blend the best of modern, reliable vertical LCD technology, with the traditional advantage and reassurance of a manual measurement whilst listening to Korotkoff sounds with a stethoscope.

Unlike Mercury sphygmomanometers, devices like the A&D UM-102A sphygmomanometer don’t require routine cleaning or maintenance and can be used at any angle with a wide range of cuffs sizes and on patients with arrhythmias.

There is no oxidisation of the LCD which could alter the dynamic response and readings can be read to a single digit mm/Hg. Most importantly, if a product like the A&D UM-102A gets dropped you won’t end up with a contaminated treatment room and an expensive and time consuming mercury spill to clean up!

Alternative clinically validated Mercury free sphygmomanometers are available, so clinicians do still have a choice as to whether they use a manual method to record blood pressure with a stethoscope or an automatic device.

Manual devices, like the A&D UM-102A, are more tactile to use and can provide the clinician with additional useful information, like regularity or strength of pulse, provided they are used correctly and users have proper training.

Latest AliveCor Kardia Mobile ECG Clinical Paper

Use of the Kardia Mobile may permit patients with palpitations to be evaluated in primary care.

The Kardia Mobile from AliveCor provides convenient patient driven electrocardiogram (ECG) recording over extended periods. That’s one of the key findings from a recently published clinical paper in the UK at Hammersmith Hospital.

The widespread uptake of smartphones makes the Kardia Mobile an appealing method for investigating intermittent palpitations in the absence of syncope.

In the researcher’s experience, the vast majority of patients were able to use the device at the time of symptoms, and a symptom-rhythm correlation was possible for all patients who submitted recordings.

In the cohort of patients with intermittent palpitations, use of the Kardia Mobile enabled the correlation of symptoms with heart rhythm in the bulk (76%) of individuals. This compares favourably to the reported diagnostic yield of 24-hour Holter recordings.

They demonstrated the utility of the Kardia Mobile in the diagnosis of intermittent palpitations in a low-risk population. Based on their findings they propose that many patients presenting with intermittent palpitations could be investigated in primary care as a first line investigation of palpitations.

The minority of patients diagnosed with an arrhythmia can then be triaged appropriately allowing cardiologists to target patients who need their expertise.

The Kardia Mobile is cost effective and helps reduce delays in the diagnosis of arrhythmia or gives reassurance where heart rhythm is normal and will improve the patient experience.

The paper Diagnostic utility of real-time smartphone ECG in the initial investigation of palpitations can be viewed here 10.5837/bjc.2018.006

PMS Instruments Awarded Feefo Gold Trusted Service Award 2018

I am pleased to report that PMS Instruments has again been awarded the Feefo Gold Service award, an independent seal of excellence that recognises businesses for delivering exceptional experiences, as rated by real customers.

Created by Feefo, Trusted Service is awarded only to those businesses that use Feefo to collect genuine ratings and reviews. Those that meet the high standard, based on the number of reviews they have collected, and their average rating, are awarded. A badge of honour, this accreditation remains unique, as it is based purely on the interactions with verified customers.

As all reviews are verified as genuine, the accreditation is a true reflection of a business’ commitment to outstanding service.

PMS Instruments met the criteria of collecting at least 50 reviews between January 1st 2017 and December 31st 2017, with a Feefo service rating of between 4.5 and 5.0.

I am proud of the team at PMS and it’s a real honour to receive this award from Feefo. To be recognised for delivering exceptional experiences to our customers is a great achievement. We’ve been working hard to ensure our customers receive the best service possible, and being able to listen, understand and respond to their needs has enabled us to improve our offering. We’re looking forward to another successful year ahead.

Could AliveCor SmartRhythm Monitoring Revolutionise AF Detection?

The latest App version 5.0.2 from AliveCor introduces a new premium feature “SmartRhythm” monitoring.

What is SmartRhythm monitoring?

SmartRhythm monitoring from AliveCor is a system that takes heart rate and activity data gathered from an Apple Watch, and evaluates it using a deep neural network to predict heart rate patterns. If  heart rate differs from the neural network prediction, SmartRhythm will notify you to record an ECG either on your phone with Kardia Mobile or for convenience and if you have one with the KardiaBand.

Taking frequent ECGs can help you better manage your heart health, and capturing an ECG specifically during times when heart rate does not match activity levels may be useful.

SmartRhythm monitoring uses the Apple Watch Photoplethysmogram (PPG) sensor to evaluate heart rate approximately every 5 seconds. Your heart rate itself depends on many factors such as activity, stress, time of day and more. So at times your heart rate pattern should be high (during exercise), sometimes, it should be low (at rest) and sometimes it may signify a heart problem.

Patented AliveCor SmartRhythm monitoring technology uses an autoregressive, deep neural network that can learn the normal relationship between heart rate and activity, and notify you when it sees an unexpected pattern. It notifies you when the actual data from the Apple Watch doesn’t match what the SmartRhythm model expects to see.

Receiving a SmartRhythm notification does not necessarily mean that something is wrong. There are many perfectly normal situations that can cause a SmartRhythm notification, including exercise the Apple Watch can’t detect, stress or anxiety, consumption of caffeine or alcohol, and even motion artifact from wearing the watch band too loosely.

Conversely, not getting a SmartRhythm notification does not necessarily mean that everything is normal, since the Apple Watch sensor is only measuring your heart rate and does not capture the full complexity of your heart. SmartRhythm monitoring should be used as an additional means to capture frequent ECGs.

Does SmartRhythm monitoring affect Apple Watch battery life?

Yes. SmartRhythm causes a higher battery usage and you will need to charge your Apple Watch more frequently. This is because SmartRhythm requires the Apple Watch to be in Workout mode as it is evaluating heart rate data continually which increases battery usage.

AliveCor internal testing has shown that with a series 2 or newer watch you can expect around 16 hours of battery life. It can still be worn over night just top up the charge for an hour or so.

The first generation Apple Watch is not supported because it has a smaller battery and will only last 5 hours.

What’s Next?

Kardia for Apple Watch is just the first step in bridging the gap between consumer wearable devices and the science of clinically validated ECG healthcare devices.

The availability of a wearable, mobile ECG device like the Kardia has the potential to dramatically improve early detection of arrhythmias. Many arrhythmias start as occasional, intermittent problems that usually don’t show up in a doctor’s office and are notoriously difficult to diagnose.

AliveCor products including the Kardia Mobile and Kardia Band are available directly from UK Distributor PMS Instruments.

AliveCor®, KardiaBand™ and SmartRhythm™ are trademarks of AliveCor, Inc. Apple Watch® is a trademark of Apple Inc.

Meditech CardiUP!3 24 Hour Holter ECG introduced

January 2018 sees the official UK launch of the new Meditech CardiUP!3 Holter ECG.

Continuous full disclosure Holter ECG monitors were first used in the 1970s and typically operate for 24-48 hours recording every single heartbeat during this period. This can mean that upwards of 100,000 beats are recorded over a 24 hour period. They are especially useful if the wearer does not feel or is not aware of the ECG abnormality.

Holter ECG recorders are generally used to investigate suspected symptoms of arrhythmia including palpitations, light-headedness or syncope (partial or complete loss of consciousness), which has not been detected during a shorter 12 lead, surgery based ECG.

Is there still a need for Holter ECG recorders?

NICE clinical guideline Clinical guideline CG180  on Atrial Fibrillation management recommends the use of a 24‑hour ambulatory ECG monitor in patients with suspected asymptomatic episodes or symptomatic episodes less than 24 hours apart  or with suspected paroxysmal atrial fibrillation undetected by standard ECG recording.

What’s different with the CardiUP!3 Holter?

The latest generation CardiUp!3 from Meditech has a large internal memory which means it can record continuous digital full disclosure ECG from 24 hours or for up to 7 days using just 1 AA battery!

The large LCD screen displays real-time ECG which lets you verify ECG quality, ensuring accurate hook up in real time. Connection is by a new standard mini USB connection.

The CardiUP!3 has a manual programming option which means it can be programmed without connection to a PC. This can be useful if a PC is not available or a treatment room is occupied.

The Meditech CardioVisions analysis software supplied with the CardiUP!3 provides automatic beat-by-beat ECG, ST, PQ, QT and HRV analysis and includes pacemaker beat detection. The QRS detection algorithm of the software is 99.9% accurate according to the IEC 60601-2-47 International Standard and AHA and MIT databases and gives rapid automatic ECG annotation and analysis in minutes.

Running costs are minimised thanks to the latest low power electronic design techniques. The CardiUp!3 Holter uses just 1 AA Alkaline or rechargeable battery.

To find out more or to arrange a demonstration just call us on 01628 773233.

Published Clinical Research Demonstrates The Effectiveness Of Key Products

At PMS Instruments we are always looking to share published clinical research that demonstrates the effectiveness of key products we distribute.

At the European Society of Cardiology Congress in Barcelona recently there were a number of clinical studies, papers, posters and presentations focusing on the Kardia Mobile ECG and its effectiveness in AFib detection.

This is important as the research helps validate the accuracy of AliveCors medical grade algorithm giving users’ confidence in Kardia Mobile ECG technology and potentially saving lives.

In one recent Study Professor Julian Halcox of Swansea University Hospital in Wales presented The REHEARSE-AF Study with simultaneous publication in Circulation and the The Journal of the American Heart Association. This randomized study provided AliveCor Kardia units to 500 patients, who used them to record two ECGs per week for a year and compared the results to 500 patients who received conventional care from their General Practitioner. At the end of the year, the Kardia group had a 4-fold increase in AFib diagnosis compared to the control group, thereby enabling the initiation of potentially life-saving anticoagulant therapy.

A Cleveland clinic study showed Kardia Mobile AFib detection accuracy similar to that of Doctors. Dr Khaldoun Tarakji from the Cleveland Clinic presented the iREAD Study which evaluated the accuracy of the AliveCor automatic AFib algorithm versus expert cardiology over-read of both the Kardia recordings and 12-lead ECGs. Dr Tarakji found that in 52 patients the Kardia algorithm had a 96.6% sensitivity and a 94% specificity compared to a cardiology over-read of the simultaneous 12-lead ECGs for the diagnosis of AFib. Additionally, over 93% of the patients found the Kardia to be easy to use and that it “lessened AFib-diagnosis anxiety.”

Another Study found that the Kardia Mobile was able to detect more patients with AFib that were previously undiagnosed. Dr Bryan Yan of The Chinese University of Hong Kong presented research of over 12,000 patients aged 65 and older. He found that for each 30-second ECG recorded using the Kardia Mobile, his team were able to identify more patients with previously undiagnosed AFib. This demonstrates the empirical value of convenient, inexpensive self-screening using the Kardia Mobile ECG.

Finally at the ECS Dr Ngai Yin Chan of Princess Margaret Hospital in Hong Kong presented the AFinder Study which used community volunteers to perform opportunistic screening for AFib using AliveCor’ s Kardia Mobile in over 10,000 Hong Kong citizens age 50 and older. 244 participants were found to have AFib, with 74 of those previously undiagnosed. This study verifies that by using Kardia Mobile senior citizens who were not medical professionals could perform medical screening of their peers with successful identification of a serious medical condition.

These are examples of just some of the many published research articles from around the world which demonstrate that if the AliveCor Kardia Mobile ECG is trusted by Clinicians you can trust it to!

Hokanson Cuff Changes Are Ahead.

Hokanson whose range of vascular instruments, cuffs and accessories are distributed in the UK and Ireland by PMS Instruments recently announced some changes to their cuffs. All cuffs manufactured after 31st August 2017 will now be supplied with male bayonet connectors.

Hokanson vascular cuffs have been the standard in vascular laboratories and clinics throughout the world for over 40 years and as they have been using “leur” type connectors for many years why the change now?

As ever the idea is to make medical devices safer and in the case of “small bore connectors” which includes blood pressure and vascular cuffs minimize medical device tubing misconnections.

Small-bore connectors are parts used to connect medical devices such as tubing, syringes, IV lines and other accessories that deliver fluids and gases for patient care. Although thankfully rare, tubes using standard luer connectors but with different functions have in the past been mismatched and connected incorrectly.

In the USA the FDA provide several examples of this happening on their website including the case of a blood pressure cuff which was accidentally connected to an IV catheter.

The FDA, and the International Organization for Standardization (ISO), decided to take action and IEC 80369-5:2016 was published in March 2016 to provide specifications for the small-bore connectors used with blood pressure cuffs. Hokanson have standardised on a male bayonet connector.

The following cuffs will be affected.

Hokanson UDC/UPC cuffs, the DP and SC cuffs that currently come with a Luer connector will be changed to a bayonet connector. This includes the SC10, SC12, TMC7 and SC5.

Hokanson cuffs with D rapid version hoses (SC12D, SC12LD, etc.) will remain unchanged. CC thigh cuffs will come with the bayonet connectors, and that connector can be cut off for use with an E20 rapid cuff inflator Y-connector (as with the Luer).

We will be providing Permanent Conversion Kits as well as Adaptor Kits to ensure compatibility and allow you to use legacy leur connector cuffs. Conversion kits are for permanent conversion of cuffs already being used that will change them to the new standard bayonet connector. Adapter kits are for customers who want to use both Luer and bayonet connectors, until all cuffs in use have bayonet connectors.

There is no requirement requiring customers to remove or stop using products currently in use from the market.

European Society of Cardiology. Diagnosis and timeley detection of AF.

 

I have recently been re-reading the 2016 European Society of Cardiology (ESC) Guidelines for the management of atrial fibrillation (European Heart Journal (2016) 37, 2893–2962 doi:10.1093/eurheartj/ehw210.

Of particular interest was the section on “Diagnosis and timely detection of atrial fibrillation” especially in the light of the popularity of the low cost clinically validated Kardia Mobile ECG from AliveCor.

In their latest review, when putting forward proposals to enhance current guidelines the ESC specify 4 different recommendation classes. A Class I recommendation is defined as

“Evidence and/or general agreement that a given treatment or procedure is beneficial, useful, effective”.

Within the section for screening for atrial fibrillation they have issued a class I recommendation that  

“Opportunistic screening for AF is recommended by pulse taking or ECG rhythm strip in patients >65 years of age”

Clearly that is advice worth taking but in a busy GP Practice, where appointment time is limited to 10 or 15 minutes and resources under pressure, is it always practical to carry out a 12 lead ECG to get a rhythm strip?

Fortunately technology has the answer and there is the Kardia Mobile ECG App for that!

For under £99 the Kardia Mobile and App produces a 30 second rhythm strip that has the same diagnostic accuracy as a 12 lead single channel ECG Lau JK, Lowres N, Neubeck L, Brieger DB, Sy RW, Galloway CD, et al. Int J Cardiol. 2013;165(1):193-4.

It is therefore ideal for use in Primary Care to implement the recommendations of the ESC. The ESC go on to say

“There is good evidence that prolonged ECG monitoring enhances the detection of undiagnosed AF, e.g. monitoring for 72 h after a stroke…and daily short-term ECG recordings increase AF detection in populations over 75 years of age”

Again the Kardia Mobile is ideally suited for regular home monitoring, for instance once in the morning and once in the afternoon.

As it records a 30 second rhythm strip in real time, it is ideal for capturing paroxysmal AF for later analysis by a GP or Cardiologist.

It can be used to replace manual pulse checks providing qualitative ECG evidence in 30 seconds.

There is also an association with high blood pressure and AF. The Kardia Mobile ECG can help here as well.

To save time during a consultation, as well as to opportunistically screen for AF, why not use a Kardia Mobile before taking a blood pressure reading?

In the UK NICE have provided guidance on this with NICE Guideline CG127 Hypertension in adults: diagnosis and management on whether to use an automatic or manual blood pressure device.

Clause 1.1.2 states

“Because automated devices may not measure blood pressure accurately if there is pulse irregularity (for example, due to atrial fibrillation), palpate the radial or brachial pulse before measuring blood pressure. If pulse irregularity is present, measure blood pressure manually using direct auscultation over the brachial artery.”

Using a clinically validated Kardia Mobile by AliveCor before taking a blood pressure reading can save time as well as ensuring the most appropriate (automatic or manual) BP device is used. For up to date independent reviews on the Kardia Mobile ECG or to purchase visit our website.

 

 

 

 

A history of A&D Medical

A History of A&D Medical

At PMS Instruments we’re proud of the fact that we are the UK’s largest distributor of A&D’s innovative blood pressure monitors for both home healthcare & healthcare professionals and have been since 1989!

A&D are an established and trusted blood pressure brand and with our near 30 year experience with them in the UK and Ireland I thought it a great opportunity to provide a little history, as PMS Instruments have been with them all the way!

Who are A&D? A history of innovation.

A multi-national Japanese company established in 1977 A&D are world leaders in measurement technology and launched their first blood pressure model the UA-102, in 1979. They use their unique skills in analog-to-digital and digital-to-analog conversion technology to produce state-of-the-art equipment, including electronic balances, scales, weighing indicators and of course blood pressure monitors.

Success by investing heavily in Research & Development.

In 1984, they introduced their innovative oscillometric blood pressure measurement technology. Over time and backed up by numerous independent clinical studies the oscillometric method went on to become the standard method for digital blood pressure monitoring in both home healthcare and professional healthcare markets throughout the world.

2001 saw the first introduction of their unique Irregular Heartbeat Indicator in blood pressure monitors closely followed in 2003 by another innovation, the World Hypertension Society (WHO) blood pressure classification index. Both technologies are still in use today and found in millions of A&D blood pressure monitors worldwide.

Other innovative products like the iconic TM-2655P waiting room blood pressure monitor followed in 2002 with the Mercury free UM-101 sphygmomanometer arriving in 2005. New updated versions of these models were introduced last year (TM-2657P, UM-102).

Keeping up to date with Telemedicine, Telehealth and Wellness Connected.

In 2015, A&D launched their Wellness Connected app, giving patients the option of syncing their Blood Pressure results to their smartphone or tablet allowing users to manage and monitor their health, in one simple, easy-to-use app.

The latest innovation in A&D’s product range, the UM-201 Blood Pressure Monitor, has just been validated to the International Protocol and offers one-touch Oscillometric measurement, variable cuff sizes & is clinically validated for accuracy.

Why buy an A&D BP monitor and why buy it from PMS Instruments?

If I am asked this question I happily remind potential customers that A&Ds “Honmono” philosophy means they are one of the few manufacturers to focus on the consumer and professional blood pressure markets and as noted above have a proven pedigree and track record of accuracy and reliability.

Whether it is a monitor for home use, 24 hour ABPM or waiting room BP monitor here’s why you should purchase your A&D BP monitor from PMS Instruments.

  • Largest UK Distributor of A&D blood pressure monitors
  • NHS Supply Chain partner
  • ISO-9001 approved service, repair and warranty partner
  • Extensive A&D experience
  • 5* independent customer service approval
  • Latest current models in stock
  • Extensive range of spare parts and accessories from stock
  • Free demonstration and loan on some models

Are we doing enough to diagnose high blood pressure?

How often do you “Think BP”?

Did you know that in the UK alone, according to the British Heart Foundation (BHF), there are an estimated 7 million people with undiagnosed high Blood Pressure who don’t know they are at risk. Over 24% of people in England are estimated to have high Blood Pressure. At least half of all heart attacks and strokes are associated with high BP and it is a major risk factor for chronic kidney disease, heart failure and cognitive decline.

If these are the challenges facing Primary and Secondary Care the question is what can GP Practices, Hospitals and Clinical Commissioning Groups do to diagnose more patients with high blood pressure?

Can we do BP better and “Think BP”?

The BHF Guidance recommends key areas and stresses that clinicians should “Think BP” at every opportunity. I have separated their recommendations into a couple of key areas below where I think existing technology available from PMS Instruments could help.

Think BP in the Waiting Room— Consider giving patients access to a self-test blood pressure station in GP waiting rooms and Hospital Outpatient clinics. Professional, clinically validated monitors like the A&D Medical TM-2657P are designed for high volume use have been popular with GPs for many years and are now being used in Hospitals. They save both time and money in the long run and especially in a Hospital setting like a Renal Unit free up members of staff for other clinical duties.

Think BP during a consultation-Think BP and increase opportunistic screening in your GP Practice or Hospital. Make blood pressure testing routine for all patients attending clinics such as Renal, Sexual Health, Asthma, COPD, Diabetes, weight management, smoking cessation and other clinics. Patients can record their blood pressure in the GP or Hospital waiting room before they attend the clinic. The printed results can then be handed to the clinician during consultation saving time and staff resources.

For a trial, demonstration or to find out more about the TM-2657P call us today on 01628 773233.

Quality, customer service Feefo Gold Trusted Award

I am pleased to announce that PMS Instruments have won a Feefo Gold Service award, an independent seal of excellence that recognises businesses for delivering exceptional experiences, rated by real customers.

Created by Feefo, Trusted Service is awarded to businesses that use Feefo to collect genuine ratings and reviews. A badge of honour, this accreditation remains unique as all the awards are based purely on the interactions with verified customers. This feedback has been collated by the Feefo review platform, with the accolades being awarded based upon performance.

PMS Instruments have met the criteria of achieving a Feefo service rating of between 4.5 and 5.0 between January 1st 2016 and December 31st 2016.

It’s a real honour to receive this award from Feefo. To be recognised for delivering exceptional experiences to our customers is a great achievement. We’ve been working hard to ensure our customers receive the best service possible, and being able to listen, understand and respond to their needs has enabled us to improve our offering in 2016. We have been working closely with all our customers to build trust and transparency online, and ultimately helping shoppers buy with confidence and make better decisions.

Feefo ensures that all feedback is authentic, by matching it to a legitimate transaction which combats the rising issue of fake reviews.

Our stand out product is the AliveCor Kardia mobile ECG with a rating of 4.7 out of 5 over the last year.

We’re looking forward to another successful year ahead. You can look at our latest reviews here.

AliveCor Kardia ECG Technology. Bringing Wearable Medtech and innovation to the NHS.

It’s not hard to get excited about the difference that innovations like the AliveCor Kardia mobile and Kardia Band ECG Watch could make to the NHS and its patients.

Both devices bring low cost wearable medtech to the NHS and capture medical grade ECG recordings using algorithms to monitor and manage heart arrhythmias. They can automatically detect atrial fibrillation (AF) which if undiagnosed can lead to strokes.

In the UK strokes kill 100,000 a year. Each one is estimated to cost the NHS between £9,500 and £14,000.

The financial impact of Atrial Fibrillation (AF), the most common type of arrhythmia, becomes more apparent when considering the cost to the UK economy as a whole which has been estimated to be £2.4 million.

That’s apart from the human impact strokes have on patients quality of life and their carers. Early detection then is crucial.

So how does the NHS currently identify these at risk patients?

As a busy GP at the moment when patients visit you, depending on their age and medical profile they may receive a simple manual pulse check. If you have time you count their pulse over 60 seconds. If you don’t you count to 30 and multiple the figure by 2!

The problem with a manual pulse check is that it remains a ‘one off’ check. An assessment of an irregular heart rhythm with this method is a snap shot in time and in part relies on chance to identify at risk patients, especially those with asymptomatic paroxysmal atrial fibrillation.

Depending on the result you may or may not then refer to secondary care for a 24 hour or 7 day Holter ECG to confirm the findings. The CCG will remind you there is a cost for this oh and probably a waiting list!

The existing pathway takes the time and resources of both you, your patients and the NHS.

What can AliveCor technology and innovation do to help?

The AliveCor Kardia Mobile and Kardia Band ECG devices offers huge benefits in early diagnosis of AF as they allow simple validated, quantitative and qualitative assessment of a patient’s ECG and heart health using a smart phone App.

 

With AliveCor ECG technology patients can record a 30 second medical grade ECG unobtrusively at any time helping reduce appointment times and detect AF.

At a time when Primary Care resources are under real pressure it means less time and money is wasted on nurse appointments, resources and follow ups for the NHS and patients.

It also means the anxiety some patients feel about their condition can be removed and they can take a proactive role in their heart health.

The wider adoption of AliveCor technology by the NHS and Primary Care will be a big step forward. It’s one to watch for sure.

The AliveCor Kardia Mobile costs £94.99 and the Kardia Band for the Apple Watch costs £226. Buy both from our web site.

 

Is 24 Hour ABPM Still An Indispensable Tool In The Management Of Hypertension?

Ambulatory Blood Pressure Measurement (ABPM) has been used increasingly in clinical practice over the last 30 years. With the rise and adoption of low cost home blood pressure monitoring is it still an indispensable tool in the management of hypertensives in General Practice?

I first asked this question in an article I wrote for Practice Management magazine in 2010. I concluded that it was but in the intervening years is this still the case?

In the light of clinical developments and the publication of guidelines like NICE Guideline CG127 on Hypertension in 2011 and latest update in November 2016 is it still relevant?

Some background

In recognition of the importance of ABPM, the British Hypertension Society (now the British and Irish Hypertension Society), the European Society of Hypertension and NICE CG127 have all published guidelines for the use and interpretation of ABPM in clinical practice.

Traditionally, hypertensive patients had been assessed using clinic based blood pressure readings by a Nurse or Doctor. This changed in 2011 and recognition was formally given to the importance of using 24 hour ABPM monitoring.

The old “snapshot” approach to blood pressure measurement could give inconsistencies and over-estimate a patient’s blood pressure by anything up to 30mmHg.

The so called White Coat Hypertension, leading to elevated blood pressure is well documented and can lead to unnecessary prescription of hypertensive medicines. This has a profound clinical and financial relevance to Primary Care and can lead to inappropriate diagnosis and treatment. Ambulatory Blood Pressure Monitors provide much more consistent readings over a 24-hour period and give multiple measurements throughout the day and night.

CardioVisions NICE Software keeps it simple.

Modern ABPM software can produce a plethora of statistics and data which even for experienced clinicians can be overwhelming.

As a response to this and in view of the 2011 NICE guidelines we introduced our CardioVisions NICE software. This provided a meaningful textual analysis ensuring clinicians got reporting continuity to a recognised clinical standard as well as importantly saving Doctor and Nurse time. It’s compatible with the Meditech ABPMs and a typical report may read something like this.

“The ABPM was worn by the patient for 24 hours. During this period the average daytime blood pressure was 169/118 and the pulse rate was 88 beats per minute. According to NICE guidelines the patient exhibits stage 2 hypertension. The examination was divided into day 06:00-22:00, night 22:00-06:00. 64 successful readings were taken during the daytime period and the NICE key quality requirement for 14 has been met. During the daytime there were 64 readings (100.0%) above the NICE guideline figure of 135/85. The highest reading was 202/134 recorded at 9:15 22/05/1997. During the night time period 24 successful readings were taken and the average blood pressure was 135/87.”

The detailed stats, graphs and readings are still there for those that want them but the textual analysis summary can be copied and pasted into the patient notes and also attached to popular clinical management systems like EMIS Web and SystmOne. There is no annual licence fee and multiple copies can be installed.

What about home blood pressure monitoring?

The cost of clinically validated home blood pressure monitors has fallen since 2010 and a number of GP Practices have been loaning monitors like the UA-767S-W to patients. Home monitoring is great for the small number of patients that find ambulatory blood pressure monitoring inconvenient or difficult tolerate but it’s not ideal for everyone and can be difficult to manage in practice.

For home blood pressure monitoring NICE recommend patients should measure their blood pressure twice a day, ideally once in the morning and once in the evening, while sitting down. Each time they do this, they should take two readings, 1 minute apart. They should continue to measure their blood pressure twice daily for at least 4 days and ideally for 7 days. Some patients may find this onerous and patient compliance can vary. A 24 hour monitor is only worn for 24 hours!

All the measurements taken after the first day are used to work out average day time blood pressure but again this can be time consuming and may be subject to error.

Whilst home blood pressure monitoring gives multiple readings, it relies on proper patient technique, patient training and compliance for up to seven days to give meaningful results.

As a complementary technique to 24 hour ABPM it can be useful to monitor patients with long term chronic conditions such as diabetes and coronary heart disease.

On the flip side the detail, automatic analysis and reporting, 24 hour ABPM provides with very little user or patient input just isn’t available with home blood pressure monitoring.

Night time readings cannot be recorded and for many 24 hour ABPM remains the “Gold Standard”.

So why doesn’t everyone use 24 hour ABPM?

For some the initial cost is off putting but the cost of 24 hour ABPM monitors has fallen since 2010.

The latest 24 hour BP monitors like the Meditech ABPM-04 and ABPM-05 are reliable with low running costs, long warranties and a low overall cost of ownership.

PMS Instruments now offer a flexible rental ABPM service which means cost can be spread over several months and for a low monthly fee service and calibration is covered.

“Is 24 Hour ABPM Still An Indispensable Tool In Management Of Hypertension?” my answer would still be yes.

To arrange a free trial of one of our latest ABPM monitors and find out for yourself please contact us on 01628 773233.

PMS Instruments. Expertise, Experience and Trust for service, calibration and support.

These are the key words our customers associate with PMS Instruments as well as being the fundamental foundations of our calibration and service department.

I recently posted on Facebook a picture of an A&D Medical TM-2655P waiting room blood pressure monitor that had recorded a staggering 103366 readings since we originally supplied it in 2004!

Having visited the R&D centre in Japan I know the engineering quality, research and development that A&D Medical put into the design and manufacturer of their products but was intrigued and asked one of our service engineers to give me the service history of the monitor over the last 12 years.

We keep detailed service and calibration records for every item of equipment we service and repair. The monitor had a new cuff mechanism fitted in 2007 which we replaced under warranty but other than that had had no other parts fitted just regular, routine and preventative maintenance.

What’s the secret of this reliability and low cost of ownership?

I am convinced it is regular, preventative and routine servicing by PMS Instruments which extends the in service life of the monitors and prolongs the investment our customers make in their equipment.

Why do I think this? There are any number of medical companies that visit GP surgeries in the UK offering to service and calibrate a wide range of blood pressure monitoring equipment. That may be the case but the TM-2655P and TM-2657P waiting room blood pressure monitors are specialist instruments, requiring specialist knowledge and test equipment.

So what are you actually getting from us and how does our service differ?

With our service and calibration service each monitor is subjected to an approved individual ISO-9001 quality assured Work Instruction. This comprises a series of up to 70 detailed steps our service engineers must follow and which the product must pass in accordance with the manufacturer’s service manuals. You get so much more from PMS Instruments than the basic 10 minute on site functional test some companies offer.

You get what you pay for?

Depending on the model it can take up to 90 minutes for our Service Engineers to adjust, calibrate and service an A&D Medical waiting room blood pressure monitor and we are the experts at it! Rapid turnaround time means minimum downtime and a full service and calibration certificate is issued.

Not convinced and want to use another company?

To ensure you are getting a proper and professional service for your A&D Medical waiting room blood pressure monitor and compare like for like ask your current service provider these questions.

  • Are you authorised by A&D Medical to work on this equipment?
  • Have the service engineers working on your equipment been on an A&D training course?
  • Do you follow a preventative service and maintenance schedule?
  • Do you perform an internal inspection of the equipment?
  • Do you check and replace routine original service parts?
  • Do you use an A&D Medical BP Checker?

Was it yes to all of these?

I was happy for the customer that their A&D Medical waiting room blood pressure monitor had provided so many years of reliable and trouble free service.

Has your TM-2655P monitor reached 100000 + readings during its lifetime yet? If your current service company can’t tell you call us on 01628 773233 and we will.

The secret by the way is Test Mode 41 or is it 42!

The missing 5.5 million with undiagnosed high BP.

A new resource – Blood Pressure – How Can We Do Better? – has just been launched and can be accessed at the British Heart Foundation website.

It has been developed by stakeholders including GPs, nurses and pharmacists working with organizations including NHS England, Public Health England, the British Heart Foundation, the Stroke Association and the Royal College of General Practitioners.

It is well known that high blood pressure affects one in four adults in England and is one of the leading causes of premature death in England. At least half of all heart attacks and strokes are associated with high blood pressure.

Treatment thankfully is very effective – for every 10mmHg reduction in blood pressure, the risk of a life changing heart attack or stroke is reduced by 20%.

What’s the challenge?

Finding undiagnosed hypertensives, around 25000 in the average CCG or 5.5 million in England, unaware of their increased risk and not receiving treatment is the challenge. It’s also worth remembering that of those diagnosed with high BP, one in three, are not treated to target.

GP Practices and Clinical Commissioning Groups (CCGS) need to do things differently to improve detection and increase opportunistic screening.

What practical steps should GP Practices take?

Think BP! Whether in routine consultations, or in nurse led clinics, like COPD, asthma and diabetes. Encourage opportunistic screening and ensure identification of poor BP control is the responsibility of all clinicians.

Think BP! In accordance with NICE CG127 guideline on Hypertension always offer ambulatory 24 hour blood pressure monitoring or when appropriate home blood pressure monitoring to confirm a diagnosis of high BP. Ensure BP equipment is serviced and calibrated regularly by reputable third parties with experience of the devices you use.

Think BP! Use clinically validated waiting room self-test BP monitors like the A&D Medical TM-2657P to make it easier to collect BP data, save appointment time and empower patients to actively use this equipment.

Think BP! Advise patients of the option to buy clinically validated low cost blood pressure monitors like the UA-767S from established suppliers so they can monitor their blood pressure at home.

There is also a role for Clinical Commissioning Groups (CCGs) who need to do things differently to improve detection, support GP Practices and increase opportunistic screening.

They can use the BHF website to see how many people in their CCG have undiagnosed high blood pressure.

How do we diagnose more patients with high blood pressure?

Time pressured consultations and other clinical priorities are a factor and simply mean in many instances there isn’t enough time to record a blood pressure. The answer is the wider adoption of technology like the A&D Medical TM-2657P waiting room BP monitor and doing things differently.

How does it work?

Patient self-measurement of blood pressure using A&D waiting room blood pressure monitors have been used in the UK since PMS Instruments introduced them in 2002. They are an established part of many GP Practices hypertension diagnosis and management pathways. Put simply the patient records their blood pressure which is printed on a paper slip. This is then shown to the clinician during the consultation. The readings can be input to the patient’s clinical record.

What does the future for detection and management of high BP hold?

With no extra capacity at present the situation won’t be improved by GP’s working harder. It may be improved by doing things differently, changing the system and the wider adoption of new technology. If you are a GP Practice, CCG or GP Federation and want to find out more about the latest BP measuring technology contact me.

24/7 ABPM Guidelines Revisited

NICE clinical guideline 127 states that ABPM monitoring is the most accurate method for confirming a diagnosis of hypertension, and its use should reduce unnecessary treatment in people who do not have true hypertension. Originally published in 2013 it was updated in September 2015.

In a recent review with our technical support team I asked them what were the practical questions they were most frequently asked about the guideline and ABPM in general.

I thought I would share the results on our Blog as they may be of interest to other ABPM customers. In no particular order this is what they told me.

Continue reading “24/7 ABPM Guidelines Revisited”

Blood Pressure And Diabetes

Having diabetes can increase your risk of developing high blood pressure and other cardiovascular problems, because diabetes adversely affects the arteries and can cause atherosclerosis – a narrowing of the arteries. This can cause high blood pressure, which if not treated, can lead to further blood vessel damage, stroke, heart failure, heart attack or kidney failure.

High blood pressure can also increase the risk of diabetes complications such as diabetic eye and kidney problems.

What are the symptoms of high blood pressure?

Usually, high blood pressure causes no symptoms. This is why it is so important to have your blood pressure checked on a regular basis, either during a visit to your doctor or diabetic nurse, or through home blood pressure monitoring – using equipment such as A&D’s UA-767S device ideal for consumer home use.

This model makes it easy to track you blood pressure over time and features an Irregular Heartbeat Indicator and World Hypertension Society blood pressure classification index.

Information on how to correctly measure blood pressure can be found on the British Hypertension Society website. At £36 the monitor can be purchased here

Kardia Mobile ECG. What’s in a name?

The AliveCor Mobile ECG is now Kardia Mobile by AliveCor and the AliveECG app is now the Kardia App.

Why change the name? Kardia is more than just a new brand. Users of Kardia and Kardia Mobile will benefit from new features including:

Support for voice memos to provide subjective context to EKG recordings

  • Integration with Apple’s Health app and Google Fit to fuel more robust, personal heart health reports in addition to EKG recordings
  • An optional subscription service (Kardia Premium) to provide personalized reports and a detailed ECG recording history via the Journal
  • All users will have access to a free Kardia Premium trial through September 30, 2016.In addition to these new features, the new Kardia Band for Apple Watch, will enable you to record your ECG and capture a voice memo discreetly from your wrist. Kardia Band is pending 510K clearance and CE mark, and will be available for purchase later in the year.

Kardia by AliveCor lets you take a proactive role in your heart’s health by giving you the ability to record medical-grade EKGs anytime, anywhere, easily. In just 30 seconds, Kardia shows you whether your heart rhythm is normal or if atrial fibrillation (a leading cause of stroke) is detected in your EKG. Kardia delivers accurate results, and makes it easy to share EKG data with your doctor for analysis and diagnosis. Works with Apple iOS and most Android smartphones and tablets. Requires download of the free Kardia app, available on the App Store and Google Play.

The Kardia by AliveCor can be purchased by visiting www.pmsinstruments.co.uk

The right monitor for the job?

All blood pressure monitors are really all the same aren’t they? Which is the most accurate? I’m confused as all BP monitors seem to be the same. What about reliability and durability?

These are some of the questions our sales team are frequently asked and it’s true many digital blood pressure monitors offer similar features and claim to offer similar “clinically validated accuracy”.

But what about durability and reliability?

Continue reading “The right monitor for the job?”

Waiting Room Blood Pressure Monitors Rebooted

The TM-2657P is the latest waiting room blood pressure monitor from A&D Medical. It builds on the speed, reliability and accuracy of the previous TM-2655P, which it replaces, but now features a new ergonomic, modern, compact design.

The new integrated arm rest helps ensure the patient’s arm is comfortable and in the correct position during a measurement. A new antibacterial arm cuff cover is also now fitted as standard with the TM-2657P.

Designed and engineered in Japan, the new TM-2657P has a faster printout speed and offers added optional connectivity features including Bluetooth.

The “Torque Controlled Belt drive Method” (TCBM) cuff mechanism in the TM-2657P provides sophisticated automatic cuff size adjustment, ensuring the arm is positioned correctly for accurate high speed measurement, first time, every time.

With a centrally located simple one button operation, it can be used on children (13 years or above) and adults with either the left or right arm.

After the reading, the results are output to the inbuilt thermal printer with the date, time systolic, diastolic and pulse rate clearly displayed. New printing options also permit the inclusion of a barcode or QR code on the print out.

The printout will also display (if present) an irregular heartbeat symbol. An irregular heartbeat is defined as a heartbeat that varies by 25% from the average of all heartbeats during the blood pressure measurement.

Like the previous model, the TM-2657P looks set to be popular with GP Practices looking for a clinically validated, easy to use professional waiting room blood pressure monitor.

Does anyone still use Mercury Sphygmomanometers?

The UM-102A is the latest second generation Mercury free sphygmomanometer from Japanese company A&D Medical. It builds on the reliability and accuracy of the previous model, which it replaces, but now features a new ergonomic, modern, lightweight design.

Designed for professional use, it allows clinicians to record accurate blood pressure measurements using the “Gold Standard” Auscultatory measurement technique whilst listening for Korotkoff sounds with a stethoscope.

An extensive range of latex free compatible cuffs, with “quick fit” connectors and inflation bulbs already attached, make swapping cuffs quick and simple.

The adjustable, clear, anti-glare LCD screen is graduated just like Mercury so it is easy to read from any angle.

Sales of new Mercury sphygmomanometers were banned in the UK in 2014, but the UM-102A is an alternative clinically validated modern interpretation of the traditional Mercury sphygmomanometer.

Transcranial Holter and Carotid Stenosis

The Atys Medical TCDx Transcranial Holter is a unique transcranial Doppler with an innovative motorised 1.5MHz Doppler probe. Traditional transcranial Doppler (TCD) requires the patient to be stationary during the recording period with a bulky and uncomfortable headframe that is prone to movement artefacts and loss of signal. The TCDx recorder is small, lightweight and battery operated allowing high resolution digital recording of up to 5 hours duration. Because of the temporal variability in embolization the longer monitoring length is preferable to ensure embolic episodes are not missed.

As the TCDx is portable the patient can engage in normal daily activities and the product can be used in an outpatient setting. An auto search algorithm and automatic self-adjusting probe restores vessel insonation if the signal quality gets weak. Post processing of the recorded TCD signal is automatic and fast using software for emboli detection. Each embolic event is tagged and the operator has full access to both the Doppler spectral signal and audiogram. The Doppler spectral signal is a representation of the Doppler signal in the frequency domain. The Audiogram is the representation of the same Doppler signal but in the time domain.

During set up real time display of the Doppler spectrum and the motorised probe ensures optimum signal quality and positioning on the acoustic window. In symptomatic carotid stenosis, the presence of emboli predicts future transient ischemic attack and stroke risk. Whether they have a similar predictive role in asymptomatic stenosis is under investigations and the TCD-x has been designed to help answer this question.

The applications of the TCD-x are not restricted to carotid plaques. They also include all unstable wall diseases, endocarditis and decompression illness. The TCD-x is also suitable for physiological studies as the time evolution of blood velocity can be analysed.

 

AliveCor ECG APP Update

The latest version of the AliveCor AliveECG app now comes with two new FDA-cleared and CE-marked automated detectors. The latest version of the mobile app instantly detects when an ECG is either Normal or unreadable. The Normal Detector provides added peace of mind allowing patients to go about their regular daily activities knowing that no abnormalities were detected in their ECG.

The Interference Detector goes a step beyond the existing enhanced filter to make sure the ECG is readable and physicians receive only the highest quality recordings.

Now whenever an ECG is taken with the AliveCor Heart Monitor, the AliveECG app will tell users if atrial fibrillation (AF), a leading cause of stroke is present, if the ECG is normal or if there is too much interference and another ECG should be taken. These features allow for the delivery of more efficient clinical decision-making and follow-up, as Doctors are able to focus on reviewing the ECGs that are most important.

At The Heart Of Healthcare Technology

P.M.S (Instruments) Ltd will now be distributing the AliveCor® Heart Monitor, a single-channel ECG (electrocardiogram) recorder. The AliveCor Heart Monitor provides people with suspected or diagnosed heart conditions, and those at risk of heart conditions, the ability to track their heart health anytime, anywhere, at an affordable cost.

As we celebrate our 40th anniversary in business we are well placed to say that  truly unique medical products come along infrequently. The AliveCor® ECG heart monitor is a game changer that looks set to change the way ECG is recorded and the whole management and diagnosis of Atrial Fibrillation.

It is one of a growing number of products that are using the power of smart phones and tablets and turning them into “medical devices”. The AliveCor® and associated App is a fully CE certified and approved validated medical device which looks set to be a true game changer when it comes to medical products.

Using the AliveECG app from iTunes or Google Play with automatic AF detection, patients and physicians can manage existing conditions with intelligent, personalized features. Tracking of medications, lifestyle choices and ongoing symptoms allows patients to have a better understanding of their health status. Advanced search features and enhanced graphical trends provide a more comprehensive and reliable view of a patient’s overall health.

The AliveCor Heart Monitor, when used with the AliveECG app, becomes an, easy-to-use, cost effective medical device that records high resolution, accurate ECGs and heart rate anywhere, and at any time. A user simply attaches the monitor to their mobile device, downloads the AliveECG app, and records an ECG by resting the monitor on the fingers for 30 seconds.

Users will immediately see their ECG recording on the device screen. ECGs are then stored in the app and on secure, encrypted servers located in the EU. ECGs can also be printed or e-mailed directly from a mobile device.

Medical professionals can also utilize the free web-based Patient Management Provider dashboard provided by AliveCor that allows them to choose to receive and review ECG recordings from their patients once given viewing permission.

Once connected, the patient’s future recordings automatically start showing up. This is a great way of monitoring a patient’s condition remotely from pre-diagnosis to long-term care.

Clinical studies have demonstrated the AliveCor Heart Monitor’s accuracy to be comparable to readings from Lead 1 of a standard ECG machines, but at a fraction of the cost.

The AliveCor system is a cost effective atrial fibrillation screening device and heart monitor which can be used by U.K. and Ireland medical professionals, patients and health conscious individuals, to record, display, store, and transfer single-channel electrocardiogram (ECG) rhythms.

Measurements Made Easy

The demise of the mercury sphygmomanometer in clinical practice has been discussed and debated for over 10 years.

Until recently they could still be sold for professional use in the healthcare sector. However, since 10 April 2014 and the implementation of EU Commission regulation no 847/2012 the sale of mercury-containing sphygmomanometers to the healthcare sector, is now prohibited.

The exception is where new sphygmomanometers will be used in ongoing epidemiological studies or as reference standards in clinical validation studies of mercury-free sphygmomanometers.

Despite this and as recently as December 2013, the MHRA were still recommending that calibrated, non-mercury devices, which are not automatic, should be made available in all clinical areas.

They should be used to check automatic device results and should also be used in clinical conditions where automatic monitors may be inappropriate e.g. arrhythmia, pre-eclampsia or specific vascular disease.

This presents the Practice Manager and Clinician with a potential dilemma. How do they comply with the MHRA guidelines?

Fortunately for Clinicians with the right training and skillset, there are a number of manual devices available which include shock resistant aneroid sphygmomanometers (ERKA Switch) and manual electronic devices like the A&D Medical UM-101A which have the same look and feel as Mercury.

Assuming Clinicians are comfortable using the Auscultation (manual) technique of recording blood pressure with a stethoscope, then a new generation of hybrid devices like the  Omron HBP-1300 are now also available.

These new devices are designed specifically with the professional user in mind. During an automatic measurement if the Irregular Pulse Wave symbol feature is indicated, the user can switch to manual mode and use a stethoscope to verify a reading is accurate without having to change device or cuff.

This is in line with MHRA recommendations.

Conclusion

Mercury sphygmomanometers have not been banned but new ones cannot now be purchased for general clinical use. That doesn’t mean the end of manual readings which in certain clinical situations may be required.

Suitable alternative clinically validated mercury free sphygmomanometers are available, so clinicians do still have a choice.

New hybrid automatic and manual blood pressure monitors specifically designed for the professional market are now available. They offer the advantage of a clinically validated automatic measurement or back up of a manual measurement where circumstances dictate.

Why You Should Use ECG Event Recorders in Primary Care.

The updated NICE clinical guideline CG180 (2014) was published in June 2014. It gives guidance on the management of atrial fibrillation and recommends an ECG should be performed on all patients where atrial fibrillation is suspected where an irregular pulse has been detected, whether symptomatic or not.

It recommends using ambulatory ECG recording in patients with suspected paroxysmal AF as follows:

  • A 24-hour Holter ECG monitor should be used in those with suspected asymptomatic episodes or symptomatic episodes less than 24 hours apart.
  • An event recorder ECG should be used in those with symptomatic episodes more than 24 hours apart.

The National Service Framework for Coronary Heart Disease chapter on cardiac arrhythmias lists three quality requirements relating to patient support, diagnosis and treatment and sudden cardiac death.

So why aren’t more GPs using Event Recorders in Primary Care?

There are two main types of ECG recorders worn by patients in an ambulatory setting away from the

Surgery. They are Holter ECG recorders like the Meditech CardioMera or Event Capture ECG recorders like the Meditech CardioBlue and DCBiomed InstantCheck.

They are generally used to investigate suspected symptoms of arrhythmia including palpitations, light-headedness or syncope (partial or complete loss of consciousness), which have not been detected during a shorter 12 lead, surgery based ECG.

Holter or event recorder

Continuous full disclosure Holter ECG monitors were first used in the 1970s and typically operate for 24-48 hours recording every single heartbeat during this period.

This can mean that upwards of 100,000 beats are recorded over a 24 hour period. They are especially useful if the wearer does not feel or is not aware of the ECG abnormality, and are typically more expensive than event recorders.

In most cases data is now stored digitally either on internal flash memory or on removable SD data cards.

Data is uploaded to a computer where software automatically analyses the recording classifying it by beat type, identifying and labelling specific arrhythmias and in some cases, providing a textual summary for the clinician.

Reports should be customisable and have the ability to be attached to the patient’s clinical notes electronically.

Most Holter analysis software can run on a desktop PC and a separate dedicated PC is not required. This makes the analysis of the recording much quicker.

Event ECG recorders are different and are designed for patients who experience symptoms very infrequently and require monitoring over several days or even weeks.

This type of recorder is usually patient activated by pushing a button, but some can be programmed to record automatically at pre-set intervals or will trigger automatically at the onset of certain arrhythmias.

Some event recorders record post event data only. Others operate in a ‘loop’ memory mode so the device records 30 seconds of pre event and 30 seconds post event data. This is useful should the patient lose consciousness and allows the clinician to view the ECG immediately leading up to the event.

Traditionally, post event recorders would have had an external lead with electrodes fitted to the patient’s chest or be held against the chest to record. Recent advances in technology have seen the development of new recorders, which have built in finger or wrist watch type electrodes, which permit long term monitoring without the discomfort or irritation of a patient lead.

Ambulatory blood pressure monitors. Are you getting good value?

The cost of ABPM monitors has fallen considerably in recent years but purchasers should check that there are no hidden extras and that the supplier is able to offer free technical support, installation training and advice to nurses who generally fit the monitor.

As some manufacturers offer expensive additional warranties or support contracts the true “whole life” running costs including maintenance should be factored in to the purchasing decision.

All modern 24-hour monitors like the Meditech ABPM-04, Meditech ABPM-05 and TM-2430 now use PC-based software and in most instances it is possible to attach the patient’s report to popular clinical management systems, such as EMIS and SystmOne.

Again it is worth checking that this is included and that there are no expensive annual licence fees or dongles required, as well as checking that multiple copies can be installed without additional cost.

An ABPM report should include, as a minimum, daytime and night-time averages, a list of BP data and trend graph on one or 2 sheets of A4 paper.

Normal mean levels for ABPM in adults are slightly lower than surgery readings at 135/85 for daytime average and 120/70 when asleep.

The results can usually be interpreted by suitably qualified clinicians. The latest version of CardioVisions that works with the Meditech ABPM-04 and Meditech ABPM-05 provides additional automatic analysis to the NICE 2011 guidelines and this can save time and ensure consistent reporting.

Ideally, the monitor should be able to use rechargeable batteries to minimise costs. A wide range of cuff sizes should be available but the adult and large adult will probably be used the most popular. Cuff barriers like those from TIDI can help keep cuffs hygienic and prevent soiling.

Most but not all companies will offer additional training if required.

As with any piece of medical equipment used in patient diagnosis, routine calibration and servicing is important. This should only be undertaken by authorised service technicians that have access to original manufacturer parts and test equipment.

With any ABPM this should be available in the UK from the supplier to avoid unnecessary downtime.

As with all things it’s unwise to pay too much but sometimes risky to pay too little.

Undiagnosed OSA increases the risk of high blood pressure

Obstructive Sleep Apnoea (OSA) is a sleep related breathing disorder which occurs if airflow through the nose and mouth is obstructed. Having undiagnosed OSA increases the risk of high blood pressure, and is associated with other serious conditions such as strokes and heart attacks, type II diabetes and depression as well as traffic collisions. OSA affects men, women and children.

A growing amount of evidence suggests that OSA is the most common type of secondary hypertension, however, an estimated 70-90 percent of cases are undiagnosed.

The Meditech apneABP is ideal as an opportunistic outpatient screening tool for OSA and can help diagnose at risk patients prior to referral to specialist sleep labs.

Blood pressure is recorded automatically at pre-set intervals and SP02 data is recorded continuously.

The easy to use CardioVisions software displays 24-hr blood pressure chart, histogram, correlations, blood pressure statistics, oxygen saturation overview, plethysmograph pulse wave, pulse oximetry statistics and activity.

As a result, apneABP gives information not only about blood pressure and general pulse oximetry data, but also about the condition of the arterial system through plethysmograph and pulse wave.

The apneABP e will allow CCGs and GPs to take an active role in OSA screening and referral pathways which is beneficial to the patient, the GP and the sleep clinic.

PMS algorithm for blood pressure measurement

The CG127 2011 NICE Hypertension guidelines includes generic guidance on the measurement of blood pressure, including the key recommendation that 24 hour ambulatory blood pressure measurement be used before anti-hypertensive treatment is initiated. However out of the entire 317 page document, there is only one 6 page section on measuring blood pressure.

This section focuses on the different ways and methods of measuring blood pressure and the different types of devices available. The question is could the selection of the latest devices       streamline the blood pressure measurement process and save time, as well as clinical resources?

Is there a case for developing a suggested PMS algorithm for blood pressure measurement and what form should this take?

Step One Use a Waiting Room BP Monitor

Monitors like the TM-2655P waiting room monitor for patient self-measurement have been available for some time. They are convenient, easy to use and cost effective. They can be effective opportunistic screening devices and may identify patients with undiagnosed Hypertension.

Many also provide additional clinical information such as whether an Irregular Heartbeat is present. Many GP practices utilize them as part of a drop in service as they allow patients to monitor their own BP without making an appointment. This frees up clinicians for other duties. As with any BP monitor, it is important to check the monitor is listed on the BHS web site (www.bhsoc.org). Monitors that measure from the upper arm are recommended.

Step 2 Confirmation with a manual measurement

If it is felt that a reading from a waiting room blood pressure monitor needs clarification, an additional measurement should be taken. The BHS provide “best practice” guidance on the correct way to record blood pressure using an automatic or manual device. Most clinicians will rely on a clinically validated automatic monitor.

Most of these low cost devices like the UA-1010 feature an irregular heartbeat indicator and some have a “Tricheck” feature, which will automatically repeat a measurement three times, in accordance with BHS recommendations.

For patients identified with an irregular heartbeat, non-Mercury manual devices like the UM-101 are available.

Step 3 Use ABPM – The Gold Standard

The cost of ambulatory blood pressure monitors has fallen considerably over the last few years.  Like spirometers and ECG machines, the latest models such as the Meditech ABPM-05 feature software that provides automatic analysis of the results for consistent, time saving reporting to NICE Guidelines.

No More New Mercury Sphygmomanometers

The confusion that has surrounded the use of Mercury in medical devices has been rumbling on for several years. It’s use was restricted in thermometers some years ago but 2014 now finally sees the banning of it in new Mercury sphygmomanometers for environmental reasons.

The sale of Mercury Sphygmomanometers is now banned under EU directive no 847/2012 which also bans the use of Mercury strain gauges.

Alternatives to the Mercury sphygmomanometer and Mercury strain gauge are widely available, in the case of strain gauges they now use Indium Gallium.

The highly popular validated A&D UM-102A offers Auscultatory manual blood pressure measurement without Mercury in a compact design it even looks like a Mercury sphygmomanometer! Hybrid automatic and manual sphygmomanometers like the A&D Medical  UM-211 are also available.

Interestingly enough the directive does allow the use of Mercury as a reference standard for the validation of new blood pressure monitors and for research. So the Gold Standard still lives on since it’s invention over 130 years ago in 1881!