Loop recorders can detect irregular heartbeats

Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Implantable loop recorders are sometimes used in medicine for patients who are having palpitations or are fainting or whose hearts sometimes beat in unusual ways. They can also be useful in detecting heart rhythms that may cause strokes. That's what we'll be focusing on today with my guest, Stephanie Loveless. She's a nurse practitioner at Upstate working in neurology. Welcome to "The Informed Patient," Ms. Loveless.

Stephanie Loveless, NP: Thank you for having me, Amber.

Host Amber Smith: You care mostly for patients with neurological issues including stroke. We think of strokes as a neurological disease, but how might the heart be involved in some types of stroke?

Stephanie Loveless, NP: That's actually a great question. If we think back to our anatomy lessons in high school, growing up, the heart is directly connected to the brain by providing it its blood supply. There are essentially four vessels that go from the heart up into the brain to supply the blood. So if there is an irregular heartbeat causing clots to form within the heart, they can then travel up those pipes causing stroke in the brain.

Host Amber Smith: Now what about, I've heard of atrial fibrillation being a risk factor for stroke. Is that what that is?

Stephanie Loveless, NP: Yes. Atrial fibrillation is an irregular heartbeat that 95% of the population can be in and out of without even knowing that we are in and out of that rhythm. So it's a very reckless, reclusive type of a rhythm that we need to be aware of.

For every decade of life we age, we have an increased risk of about 10% of getting or running into atrial fibrillation and / or being symptomatic with that rhythm. The strokes that we find from a rhythm in atrial fibrillation tend to be the ones that leave our patients with the biggest deficits.

Host Amber Smith: You used the term reclusive. Can you explain what you mean by that?

Stephanie Loveless, NP: Reclusive meaning sinister or very hard to pin down, inconsistent. Just because we know that the patient may have had this irregular heartbeat, it may not be back within the next day or two. The heart is very automatistic. Each cell has the ability to kind of taking over the rhythm, and some of them do a better job than others.

Host Amber Smith: So if a person has atrial fibrillation, do they need an implantable loop recorder?

Stephanie Loveless, NP: A lot of our patients that come in with stroke present with symptoms that would have us look into the etiology or reason for which they've had that stroke. One of those etiologies or reasons for having a stroke could be atrial fibrillation. They could still be in the atrial fibrillation on arrival, or they could not be. So it's a process by which we follow protocols to do a series of testing to determine whether or notadditional workup should be done for that patient depending upon the findings of those tests.

Host Amber Smith: So let's talk about who would qualify for an implantable loop recorder. Are there age restrictions or other diseases the person might have that would prevent them from getting one?

Stephanie Loveless, NP: There's not any age restrictions and / or disease that would prevent them from getting an implantable loop recorder. It depends on, again, the location of the stroke, whether it's in a cortical or top of the brain area coming off of a major artery, the left middle cerebral artery or the right middle cerebral artery, for example.

They will benefit patients long term for monitoring for this rhythm. So yes, we've had implantable loops recorder placed in 40-year-old patients up until 85 years young. It kind of depends on the patient, how many other medical issues they have. We are living longer in society, so it's all specific and case-by-case dependent.

Host Amber Smith: How do you describe implantable loop recorders to patients when they're considering one?

Stephanie Loveless, NP: A lot of times, my colleague and I both have the opportunity to sit down and show them a pamphlet that we've got from the device company that we use.We also have the demo of the device itself, showing them the size of it, the weight of it, and how teeny tiny it is. So they're kind of put at ease as far as it's a teeny tiny device. It's gotten smaller as years gone by. The first device, I did a little research, and it was, I think back in 1990 it said, was the first implantable loop recorder, but it was much bigger. So as technology has changed and come along, they've gotten a lot smaller.

But we have a talk about the benefit of wearing it, the duration of wearing it. And it's really a bedside procedure, that if you're inpatient and carry the diagnosis of cryptogenic stroke -- which that etiology really means, we don't know why you had the stroke -- then you are benefited to have this implanted prior to discharge from the hospital.

Host Amber Smith: Where does it get implanted?

Stephanie Loveless, NP: The anatomical position of where the device is implanted, if you're looking at yourself in the mirror and you know where your clavicle is on your chest, we count down four spaces in between the ribs on the left side of your sternum, which is the bone in the middle of your chest, and then we numb that area with lidocaine.

Once we numb that area with lidocaine, we wait a minute or two and then when thatlittle incision device we use just shows that the skin is firm and like a little pressure but not pain, then we make an incision and place the device underneath the skin.

Host Amber Smith: Are there any wires or cords that come out of the device?

Stephanie Loveless, NP: Luckily not. It's beautiful with what technology can do these days. It's a wireless device. Itsits right underneath the skin and communicates between either an app that the reps can put on the phone to show their rhythm over time, or a device that the patient takes home and puts within 10 feet of where they sleep at night. So if somebody has to sleep in a recliner chair in their living room for one reason or another, that device can sit on a table right by the chair or in their bedside.

The device that's implanted underneath the skin kind of communicates independently on its own with the device, either on your phone or at the bedside. During the overnight hours when you're sleeping -- so it's nothing you'll be responsible for -- it communicates and then transmits to the cardiologist who is actually monitoring that device remotely.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with nurse practitioner Stephanie Loveless, who specializes in neurology, and we're talking about implantable loop recorders.

So once it's in place, can the patient feel it with their fingers below the skin, or can they hear it?

Stephanie Loveless, NP: They can certainly feel it. Yes. It will be noticeable underneath the skin, but not by any way impeding or limiting their activities of daily living or life. Patients ask if they can fly. Yes, you can. They ask if they can swim. Yes, they can. My biggest take home is you can always have an MRI. Don't be told that you can't. A lot of patients will go to the emergency room, and some emergency rooms will say, "well, we couldn't do an MRI, which is a scan of the brain, because the patient has an implantable loop recorder." That's not true. So that's one important take home we like to get across for patient education.

Host Amber Smith: Are there batteries in it that would need to be changed in the future?

Stephanie Loveless, NP: No. The lifetime of the battery that's in the device is up to three and a half to four years. So once it's implanted under the skin, as that implantation process is completed, the rep is with us at the bedside, so it's showing and ensuring that we have the proper signal that will show the proper picture to the cardiologist for the three and a half to four years of the device's battery life.

Now, when the battery life is dead at that three and a half to four year mark, the patient can have a conversation with the cardiologist to make a determination whether they would want that removed or not.

Host Amber Smith: So they may, it may be time to take it out, maybe they don't need it anymore, or maybe they need a replacement?

Stephanie Loveless, NP: The research that I'm aware of so far, we aren't replacing them after the timeframe of the battery life. That's not to say that with all the research being done on a daily basis out in the world, but that may not change tomorrow or down the road.

They can be what they call explanted or removed by the providers that place them, but they don't have to be. They can be with you for the duration. They won't interfere with the rest of things of life.

Host Amber Smith: Now you mentioned a rep. Is that a representative from the company that makes the device? So they're there helping on the insertion?

Stephanie Loveless, NP: They'll bring the device to bedside, and they will talk to the patient and / or family member after the procedure's completed, showing them whether they help them upload the app on the phone, or it's the device that goes home with them.

They will talk to them about where to put it up in the house once they're there. They will tell them just the little idiosyncrasies that come and go with a new device. But there's a supportive 800 number that they provide to patients. They reach out. They're just as involved as we are from the word "go," which is nice.

Host Amber Smith: Now, are there any risks that patients should be aware of? I know you said it doesn't curtail their activities, but are there any precautions that they need? Can they go near a microwave for instance?

Stephanie Loveless, NP: We have been told there are really no restrictions from the ins and outs of daily life, which is nice. so I would say there are no restrictions. Now, if somebody comes across one, you let me know, and then we'll share that.

Host Amber Smith: Now, do I understand correctly, it's cardiologists, the doctors who specialize in the heart, who were the first to implant loop recorders, right?

Stephanie Loveless, NP: That is correct. Cardiology is a phenomenal bunch of providers that work very closely with us. We've had the privilege here at Upstate to work with Dr. Avneet Singh and Dr. Andrew Weinberg. In moving this process to what it is today, Dr. Weinberg assisted credentialing myself, Taylor Weber, the other nurse practitioner, along with Dr. Hesham Masoud and Dr. Aravind Reddy.

So the four of us are neurological stroke providers that do have that ability to cross the boundary into cardiology, within reason, to assist giving our patients all that they need to have the best opportunity of not having another stroke from a central source.

Host Amber Smith: Is it common for nurse practitioners to do these procedures?

Stephanie Loveless, NP: I think as a whole, there are some advanced practice providers within the cardiology world that are doing the devices. And we've just been able to expand it out of that discipline to include neurology. So it's a procedure that's beneficial to our patients that in years past we've had trouble getting in a timely matter that didn't delay discharge or hold up a patient. So giving more resources to us to be able to provide that care to the patient gives them the best possible outcomes moving forward, going out into the community. There is an external monitor that patients can wear, but it's not as sophisticated. It's not as sensitive. It's not as forthcoming for providing what we're looking for over the long term.

Host Amber Smith: How do you tell patients to prepare for the procedure? Is there any blood work ahead of time, or any other testing they have to do, or?

Stephanie Loveless, NP: Nope. Nope. A lot of times we have a patient, I actually placed one yesterday. It was a matter of going in and explaining the procedure to the patient, essentially walking them through step by step what we would be doing. They signed consent, so permission for us to make that little incision and then put the device underneath the skin. Sometimes it requires a suture or two thereafter, and then some glue to keep the skin.

And then we'll come in with the heart and vascular team is very helpful. Ashley Hunter is one of the main nurses down there that comes to bedside with us with every procedure and helps us do what we do best. So it's definitely a multidisciplinary and team dedicated process.

Host Amber Smith: Does it start working right away?

Stephanie Loveless, NP: It starts working right away. As I understand it, for example, if you have the implant done and then they go home and then you connect the device then the communications begin.

So that device will be letting the office know the next day if there's any alerts, if there's any arrhythmias. And then they would contact the patient and / or myself or somebody within the neurology team that took care of that patient to ensure their medical management changes.

Host Amber Smith: So if the machine does detect an arrhythmia, or a problematic heart rhythm, will the patient know that? Is there an alarm that they hear?

Stephanie Loveless, NP: Not that I was told. It's a great question. Maybe in the upcoming models there will be. But they do get, typically, a phone call from, like I said, the device team's area. They will let them know that there was atrial fibrillation detected. And then cardiology or ourselves would then change the medical management, typically off of the antiplatelet agents that they were discharged home on to an anticoagulant.

Host Amber Smith: So how much of an emergency might that be? If the patient has alerted that there's been an arrhythmia detected, is that something that has to be dealt with immediately, or do they make an appointment to come in, like, the next day?

Stephanie Loveless, NP: Thankfully, atrial fibrillation could be a rhythm that could cause patients symptoms, including, but not limited to, acutely being short of breath and inability to catch their breath, a rapid heart rate that's irregular. But it's not one of those medical 9 1 1 emergencies where you're running to the emergency department, per se, unless you, with that abnormal breathing, you really had a tough time. But traditionally it's not anything more than a phone call and a change in medications that then work on the blood to keep it thin to prevent another clot from forming and then traveling to the brain, causing another stroke.

Host Amber Smith: What has been the feedback from your patients who've had these implanted so far?

Stephanie Loveless, NP: So far so good. You know, we've been very fortunate to work collaboratively with Dr. Weinberg and Justin Kurtz, who's his nurse practitioner out in the community, who sees our patients for the two-week wound check. So they look at the insertion site and make sure everything is healing nicely. And so far so good. We haven't had any poor responses, so it's just, it gives us another level of security that we're doing what's best for the patients, given they're unfortunance of having a stroke, but hopefully that first stroke was something that they'll recover nicely from and not be living with a deficit and thereby moving forward, preventing them from an additional deficit from this persnickety rhythm that we may have.

Host Amber Smith: That's really encouraging and good to know that there's a way, potentially, to prevent a future stroke. So I really appreciate you making time to tell us about this.

Stephanie Loveless, NP: Thank you for your time, and thank you for letting me educate the community because that's very important.

Host Amber Smith: My guest has been Upstate nurse practitioner, Stephanie Loveless. She specializes in caring for neurology patients. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. If you enjoyed this episode, please tell a friend to listen, too. And you can rate and review "The Informed Patient" podcast on Spotify, Apple Podcasts, YouTube, or wherever you tune in. This is your host, Amber Smith, thanking you for listening.