Introduction Atrial fibrillation (AF) is a global public health priority. An unsolved problem is how to detect paroxysmal AF. Patients presenting with palpitations are usually monitored for a short period of time with conventional 24 hour Holter monitor or 72 hours cardiac memo. As a result, it is likely that AF is being routinely underdiagnosed and undertreated. This service evaluation reviewed the proportion of patients amongst those who are investigated for palpitations/pre-syncope/syncope by the Cardiology Department in Queen Alexandra hospital (CQAH) with a 24 hours Holter monitor or cardiac memo who have evidence of AF.

Methods Retrospective review of all patients who were investigated with either a 24 hours Holter monitor or 72 hours cardiac memo during August 2019. Clinic letters and discharge summaries were reviewed to assess reason for investigations, findings and outcomes. If a diagnosis of AF, paroxysmal AF or atrial flutter was made, management decision and subsequent anticoagulation was reviewed.

Results A total of 232 patients were assessed with 24 hours Holter (n=122) monitor and Cardiac memo (n=108). Average age 65 years (5-94). In 5% of cases (12/232) no documentation of results was found. 5% (10/220) had new diagnosis of AF.

60% (72/122) of patients investigated with a 24 hours Holter monitor for palpitation (18/122), pre-syncope (5/122) and syncope (15/122) were in sinus rhythm (SR) +/- ectopics. No patients with palpitation or pre-syncope had AF. 4/15 patients with syncope had a new diagnosis of AF (2) or supraventricular tachycardia (2). 34% (42/122) of Holter monitor were done as a result of a documented arrhythmia, 18/42 of which had known AF. 21% (26/122) of Holter monitor were used to investigate TIA/Stroke, 3/26 had new diagnosis of AF.

70% (75/108) of patients investigated with a Cardiac Memo for palpitations (28/108), pre-syncope (13/108) and syncope (15/108) were in SR +/- ectopics. 3/28 with palpitations, 1/13 with pre-syncope, 1/15 with syncope group had new AF. 2/15 with syncope who were in SR had a reveal device implanted subsequently. 34% (37/108) were investigated due to TIA/Stroke, all of which were in SR.

Conclusion The number of patients diagnosed with significant cardiac arrhythmia, for example AF, as a result of conventional 24 hours tape and cardiac memo is low even if patients present with symptoms of palpitations, pre-syncope and syncope.

As a result of this service evaluation we have applied for a £20.000 grant as part of a ‘NHS Joint Working Project’ to introduce novel, prolonged and home-based ECG monitoring to the department. Patients who are referred to CQAH and require investigation of symptoms of palpitation, pre-syncope and syncope will be offered ECG monitoring over up to 3 months with a KardiaMobile 6 lead ECG (by AliveCor) as an alternative to conventional methods described above. A comparison of identification of cardiac arrhythmia, in particularly AF and subsequent management change, will be made.

Conflict of Interest Nil