Is sensible use being made of an inpatient Holter monitoring and transthoracic echocardiogram service within acute medicine?

Transthoracic echocardiograms (TTE) and 24-hour Holter recordings are commonly requested investigations for patients presenting with symptoms thought to be due to underlying cardiac pathology. The objective of this study was to audit the use of inpatient TTE and Holter monitors in acute medical patients under the care of physicians other than cardiologists within a tertiary cardiology referral centre. This was accomplished by a retrospective analysis of 4,623 TTE and 3,145 Holters reported by cardiologists between 8 October 1999 and 3 November 2005. The age range for Holter monitoring was 16-104 years, mean 70 (SD 18) years. The age range for TTE was 16-101 years, mean 68 (SD 17) years. Of the Holters performed, 69.1% were within normal limits. Atrial fibrillation/flutter was the commonest arrhythmia, found in 787 patients (25.0%). A total of 99 patients were referred to a cardiologist; 47 of these patients were permanently paced. Of the TTE requests to assess left ventricular function, 44.8% were normal. A cardiac source of embolism was found in 1.8% of requests to assess for this. TTE requests for infective endocarditis confirmed the diagnosis in 4.1% of patients. Holter investigation and TTE were commonly requested investigations; a large proportion of both, however, were within normal limits. This suggests that more consideration is required before making the request for Holter investigation and TTE, as more appropriate investigations may be available.